Prognostic value of Geriatric-8 for adverse outcomes within 30 days of surgery in older adults with colorectal cancer: A retrospective cohort study

PURPOSE

It is unclear whether the Geriatric-8 (G8) has the accuracy to preselect patients for complete geriatric assessment, and has the ability to predict adverse outcomes in patients with colorectal cancer (CRC). We therefore aimed to determine whether the G8, or other variables present in the medical record, are applicable in predicting 30-day adverse outcomes in older patients undergoing surgery for CRC.

METHODS

We performed a retrospective cohort study involving patients ≥70 years who had surgery for CRC between 2018 and 2020 in a general hospital in the Netherlands. The primary outcome was adverse outcome(s), which is a composite of surgical and non-surgical complications, readmission and mortality, all within 30 days of surgery. The secondary endpoints were the individual components, such as delirium, infection and ileus. We explored potential prognostic factors using multivariable logistic regression analysis. Data were collected from the Dutch ColoRectal Audit (DRCA) and medical records.

RESULTS

The study included 200 patients (mean age 78.9 years: 50% female), with 36.5% having adverse outcomes in the first 30 days of surgery. In neither univariate nor multivariable analysis were G8 scores associated with adverse outcomes. Factors with higher odds of adverse outcomes were male gender, and having cognitive decline or previous delirium.

CONCLUSION

This study confirms that G8 scores have no prognostic value for adverse outcomes, complications and mortality within 30 days of surgery among older adults with CRC. Therefore, the G8 should not be the tool for short-term risk prediction of adverse outcomes in these patients.

Determinants of HbA1c reduction with FreeStyle Libre flash glucose monitoring (FLARE-NL 5)

Aims

To identify factors predicting HbA1c reduction in patients with diabetes mellitus (DM) using FreeStyle Libre Flash Glucose Monitoring (FSL-FGM).

Methods

Data from a 12-month prospective nation-wide FSL registry were used and analysed with multivariable regression. For the present study we included patients with hypoglycaemia unawareness or unexpected hypoglycaemias (n = 566) and persons who did not reach acceptable glycaemic control (HbA1c > 70 mmol/mol (8.5%)) (n = 294). People with other indications for use, such as sensation loss of the fingers or individuals already using FSL-FGM or rtCGM, were excluded (37%).

Results

Eight hundred and sixty persons (55% male with a mean age of 46.7 (±16.4) years) were included. Baseline HbA1c was 65.1 (±14.5) mmol/mol (8.1 ± 1.3%), 75% of the patients had type 1 DM and 37% had microvascular complications. Data concerning HbA1c was present for 482 (56.0%) at 6 months and 423 (49.2%) persons at 12 months. A significant reduction in HbA1c (≥5 mmol/mol (0.5%)) was present in 187 (22%) persons. For these persons, median HbA1c reduction was −9.0 [−13.0, −4.0] mmol/mol (−0.82 [−1.19, −0.37]%) at 6 months and −9.0 [−15.0, −7.0] mmol/mol (−0.82 [−1.37, −0.64]%) at 12 months. In multivariable regression analysis with age, gender and SF-12 physical and mental component scores as covariates, only baseline HbA1c was significant: −0.319 (SE 0.025; p < 0.001; R² = 0.240 for the model). In exploratory analysis among subgroups with different indications for FSL-FGM use (hypoglycaemia unawareness or persistently high HbA1c) and persons with a significant HbA1c decrease over the study period, baseline HbA1c remained the only significant predictor.

Conclusions

Among the variables we analysed in the present study, only high HbA1c at baseline predicts significant HbA1c reduction during FSL-CGM use.

Hypomagnesemia in persons with type 1 diabetes: associations with clinical parameters and oxidative stress

BACKGROUND

Among persons with type 1 diabetes mellitus (T1DM) low concentrations of magnesium have been reported. Previous (small) studies also suggested a relation of hypomagnesemia with (poor) glycaemic control and complications. We aimed to investigate the magnitude of hypomagnesemia and the associations between magnesium with parameters of routine T1DM care in a population of unselected outpatients.

METHODS

As part of a prospective cohort study, initially designed to measure quality of life and oxidative stress, data from 207 patients with a mean age of 45 [standard deviation (SD) 12] years, 58% male, diabetes duration 22 [interquartile range (IQR) 16, 31] years and glycated haemoglobin (HbA1c) of 60 (SD 11) mmol/mol [7.6 (SD 1.0)%] were examined. Hypomagnesemia was defined as a concentration below <0.7 mmol/l.

RESULTS

Mean magnesium concentration was 0.78 (SD 0.05) mmol/l. A deficiency was present in 4.3% of participants. Among these persons, mean concentration was 0.66 (SD 0.03) mmol/l. There was no correlation between magnesium and HbA1c at baseline (r = -0.014, p = 0.843). In multivariable analysis, free thiols (reflecting the degree of oxidative stress) were significantly and negatively associated with magnesium concentrations.

CONCLUSION

In this cohort of T1DM outpatients, the presence of hypomagnesemia was infrequent and, if present, relative mild. Magnesium was not associated with glycaemic control nor with presence of micro- and macrovascular complications. Although these results need confirmation, in particular the negative association of magnesium with free thiols, this suggests that hypomagnesemia is not a relevant topic in routine care for people with T1DM.

Active participation of patients with type 2 diabetes in consultations with their primary care practice nurses - what helps and what hinders: a qualitative study

Background

Patients with type 2 diabetes mellitus (T2DM) receiving primary care regularly visit their practice nurses (PNs). By actively participating during medical consultations, patients can better manage their disease, improving clinical outcomes and their quality of life. However, many patients with T2DM do not actively participate during medical consultations. To understand the factors affecting engagement of patients with T2DM, this study aimed to identify factors that help or hinder them from actively participating in consultations with their primary care PNs.

Methods

Two semi-structured focus groups and 12 semi-structured individual interviews were conducted with patients with T2DM (n = 20) who were undergoing treatment by primary care PNs. All interviews were transcribed verbatim and analyzed using a two-step approach derived from the context-mapping framework.

Results

Four factors were found to help encourage patients to actively participate in their consultation: developing trusting relationships with their PNs, having enough time in the appointment, deliberately preparing for consultations, and allowing for the presence of a spouse. Conversely, four factors were found to hinder patients from participating during consultations: lacking the need or motivation to participate, readjusting to a new PN, forgetting to ask questions, and ineffectively expressing their thoughts.

Conclusion

Patients lacked the skills necessary to adequately prepare for a consultation and achieve an active role. In addition, patients’ keen involvement appeared to benefit from a trusting relationship with their PNs. When active participation is impeded by barriers such as a lack of patient’s skills, facilitators should be introduced at an early stage.

Trial registration

Current Controlled Trials NTR4693 (July 16, 2014).

Laser therapy for onychomycosis in patients with diabetes at risk for foot ulcers: a randomized, quadruple-blind, sham-controlled trial (LASER-1)

BACKGROUND

Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers.

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of the treatment of onychomycosis with local laser therapy.

METHODS

In a single-centre, randomized (1:1), quadruple-blind, sham-controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium-doped yttrium aluminium garnet (Nd-YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1-year follow-up.

RESULTS

From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd-YAG 1064 nm laser is safe.

CONCLUSION

At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.

Use of FreeStyle Libre Flash Monitor Register in the Netherlands (FLARE-NL1): Patient Experiences, Satisfaction, and Cost Analysis

In patients with diabetes mellitus (DM), adequate glucose control is of major importance. When treatment schemes become more complicated, proper self-management through intermittent self-measurement of blood glucose (SMBG), among others, becomes crucial in achieving this goal. In the last decade, continuous glucose monitoring (CGM) has been on the rise, providing not only intermittent information but also information on continuous glucose trends. The FreeStyle Libre (FSL) Flash CGM system is a CGM system mainly used for patients with DM and is designed based on the same techniques as early CGMs. Compared with earlier CGMs, the FSL is factory calibrated, has no automated readings or direct alarms, and is cheaper to use. Although less accurate compared with the gold standard for SMBG, users report high satisfaction because it is easy to use and can help users monitor glucose trends. The Flash Monitor Register in the Netherlands (FLARE-NL) study aims to assess the effects of FSL Flash CGM use in daily practice. The study has a before-after design, with each participant being his or her own control. Users will be followed for at least 1 year. The endpoints include changes in HbA1c, frequency and severity of hypoglycemias, and quality of life. In addition, the effects of its use on work absenteeism rate, diabetes-related hospital admission rate, and daily functioning (including sports performance) will be studied. Furthermore, cost-benefit analysis based on the combination of registered information within the health insurance data will be investigated. Ultimately, the data gathered in this study will help increase the knowledge and skills of the use of the Flash CGM in daily practice and assess the financial impact on the use of the Flash CGM within the Dutch healthcare system.

Healthcare reimbursement costs of children with type 1 diabetes in the Netherlands, a observational nationwide study (Young Dudes-4)

BACKGROUND

Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children. Studies on costs related to T1DM are scarce and focused primarily on the costs directly related to diabetes. We aimed to investigate both the overall healthcare costs and the more specific costs related to the management of diabetes.

METHODS

This is a retrospective and observational, nationwide cohort study of all Dutch children (aged 0-18 years) with T1DM. Data were collected from the national registry for healthcare reimbursement, in which all Dutch insurance companies combine their reimbursement data. In the Netherlands for all Dutch citizens health care is covered by law and all children are treated by hospital-based paediatricians.

RESULTS

We analysed 6710 children distributed over 81 hospitals: 475 children in 6 university hospitals and 6235 children in 75 general hospitals. Total reimbursement for all children with T1DM over the period 2009 to 2011 was € 167,494,732 corresponding to an annual mean of € 55,831,577 of total costs and € 8326 euros per child. When comparing small (between 26 and 54 patients), medium (57-84 patients) and large (88-248 patients) general hospitals, costs per patient were highest in the hospitals with the highest number of T1DM patients. The costs for devices, secondary care and pharmaceutics had most impact on total expenditures. Over the study period, there was a slight decrease in per person costs.

CONCLUSION

The overall health expenditure of a child with T1DM is more than € 8000 per patient per annum. Given the move towards more device-intensive multidisciplinary care for these patients, the costs of treating T1DM in children are likely to increase further in the coming years.

Performance of the FreeStyle Libre Flash glucose monitoring system in patients with type 1 and 2 diabetes mellitus

OBJECTIVE

To evaluate the performance of the FreeStyle Libre Flash continuous glucose monitoring (FSL-CGM) system against established central laboratory methods.

RESEARCH DESIGN AND METHODS

20 subjects (8 type 1 diabetes mellitus, 12 type 2 diabetes mellitus) were analyzed. FSL-CGM sensor measurements (inserted in arm and abdomen) were compared with capillary blood glucose results analyzed with StatStrip as semigold standard. The glucose response after a standardized oral glucose load was measured by FSL-CGM and capillary samples analyzed by perchloric acid hexokinase (PCA-HK) method, StatStrip and FSL test strip (FSLC), and a commonly used CGM system (iPro2).

RESULTS

FSL-CGM arm sensor readings showed 85.5% of paired readings falling within Clarke Error Grid (ISO 15197:2013) zone A when compared with StatStrip. For FSL-CGM abdomen and FSLC, these percentages were 64% and 98%, respectively. The overall correlation of FSL-CGM in the arm and the StatStrip indicates a performance with lower results with the FSL-CGM in the arm than expected based on the StatStrip in the lower glucose ranges, and higher results than expected in the higher ranges. Following a standardized glucose load, a slower rise in glucose level was observed for FSL-CGM arm as compared with PCA-HK, StatStrip, FSLC, and iPro2 during the first 45-60 min after glucose load ingestion.

CONCLUSIONS

Certain matters need attention while using the FSL-CGM in daily life including the observed lower values in the lower ranges, and the underestimation of the effect of a meal on glucose response. These effects of such deviations can partly be overcome by optimizing the available user instructions.

TRIAL REGISTRATION NUMBER

TC5348; results.

Health-related quality of life, rehabilitation and mortality in a nursing home population

BACKGROUND

Health-related quality of life (HRQOL) in nursing home residents is generally low. The purpose of this study was to investigate the associations between HRQOL and two clinically relevant outcome measures, all-cause mortality and successful rehabilitation, in a nursing home population.

METHODS

In an observational prospective cohort study in a nursing home population, HRQOL was assessed with the RAND-36. A total of 184 patients were included, 159 (86%) completed the RAND-36 and were included in the study. A Cox proportional hazard model was used to investigate the independent association between HRQOL, rehabilitation and mortality with adjustment for confounders. Risk prediction capabilities were assessed with Harrell's C statistics and the proportion of explained variance (R2).

RESULTS

The median age (interquartile range) was 79 (75-85) years. The health dimensions vitality (HR 0.88 (95% CI 0.77-0.99)) and mental health (HR 0.86 (95% CI 0.75-0.98)) were inversely associated and role functioningphysical (HR 1.08 (95%CI 1.02-1.15)) was positively associated with mortality. The Harrell's C value and the R2 were ≤ 0.02 and ≤ 0.03 higher in the adjusted models with the dimensions role functioning- physical, mental health or vitality compared with the models without these dimensions. None of the health dimensions or summary scales were related to successful rehabilitation.

CONCLUSION

HRQOL was significantly associated with mortality for three dimensions, but partly in opposite directions. Additional value of HRQOL in mortality prediction is very limited. There were no independent associations between HRQOL and successful rehabilitation. Although HRQOL is an important outcome, this study did not provide evidence for an association between HRQOL and successful rehabilitation.

Effects of intraperitoneal insulin versus subcutaneous insulin administration on sex hormone-binding globulin concentrations in patients with type 1 diabetes mellitus

AIMS

Elevated sex hormone-binding globulin (SHBG) concentrations have been described in patients with type 1 diabetes mellitus (T1DM), probably due to low portal insulin concentrations. We aimed to investigate whether the route of insulin administration, continuous intraperitoneal insulin infusion (CIPII), or subcutaneous (SC), influences SHBG concentrations among T1DM patients.

METHODS

Post hoc analysis of SHBG in samples derived from a randomized, open-labeled crossover trial was carried out in 20 T1DM patients: 50% males, mean age 43 (±13) years, diabetes duration 23 (±11) years, and hemoglobin A1c (HbA1c) 8.7 (±1.1) (72 (±12) mmol/mol). As secondary outcomes, testosterone, 17-β-estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were analyzed.

RESULTS

Estimated mean change in SHBG was -10.3nmol/L (95% CI: -17.4, -3.2) during CIPII and 3.7nmol/L (95% CI: -12.0, 4.6) during SC insulin treatment. Taking the effect of treatment order into account, the difference in SHBG between therapies was -6.6nmol/L (95% CI: -17.5, 4.3); -12.7nmol/L (95% CI: -25.1, -0.4) for males and -1.7nmol/L (95% CI: -24.6, 21.1) for females, respectively. Among males, SHBG and testosterone concentrations changed significantly during CIPII; -15.8nmol/L (95% CI: -24.2, -7.5) and -8.3nmol/L (95% CI: -14.4, -2.2), respectively. The difference between CIPII and SC insulin treatment was also significant for change in FSH 1.2U/L (95% CI: 0.1, 2.2) among males.

CONCLUSIONS

SHBG concentrations decreased significantly during CIPII treatment. Moreover, the difference in change between CIPII and SC insulin therapy was significant for SHBG and FSH among males. These findings support the hypothesis that portal insulin administration influences circulating SHBG and sex steroids.

Uptake and Effects of the e-Vita Personal Health Record with Self-Management Support and Coaching, for Type 2 Diabetes Patients Treated in Primary Care

We studied the use, uptake, and effects of e-Vita, a personal health record, with self-management support and personalized asynchronized coaching, for type 2 diabetes patients treated in primary care. Patients were invited by their practice nurse to join the study aimed at testing use and effects of a personal health record. Patients were followed up for 6 months. Uptake and usage were monitored using log data. Outcomes were self-reported diabetes self-care, diabetes-related distress, and emotional wellbeing. Patients' health status was collected from their medical chart. 132 patients agreed to participate in the study of which less than half (46.1%) did not return to the personal health record after 1st login. Only 5 patients used the self-management support program within the personal health record, 3 of whom asked a coach for feedback. Low use of the personal health record was registered. No statistical significant differences on any of the outcome measures were found between baseline and 6 month follow-up. This study showed minimal impact of implementing a personal health record including self-management support in primary diabetes care. Successful adoption of web-based platforms, as ongoing patient centered care, is hard to achieve without additional strategies aimed at enhancing patient motivation and engaging professionals.

Intraperitoneal versus subcutaneous insulin therapy in the treatment of type 1 diabetes mellitus

BACKGROUND

Continuous intraperitoneal insulin infusion (CIPII), a last-resort type 1 diabetes mellitus (T1DM) treatment, has only been investigated in small or controlled studies. We aimed to investigate glycaemia and quality of life (QoL) with CIPII versus subcutaneous (SC) insulin therapy during usual T1DM care.

METHODS

A prospective, observational case-control study. CIPII-treated cases were matched to SC controls. The primary endpoint was a non-inferiority assessment (pre-defined margin of -5.5 mmol÷mol) of the baseline adjusted difference in HbA1c between groups during a 26-week follow-up. Secondary outcomes included QoL, clinical and biochemical measurements.

RESULTS

In total, 183 patients were analysed (CIPII n = 39 and SC n = 144). The HbA1c difference between treatment groups was -3.0 mmol÷mol (95% CI -5.0, -1.0), being lower in the SC group. Patients using SC insulin therapy spent less percentage of time in hyperglycaemia (-9.3% (95% CI -15.8, -2.8)) and more in euglycaemia (6.9% (95% CI 1.2, 12.5) as compared with CIPII-treated patients. Besides a 3.6 U÷l (95% CI 1.2, 6.0) lower concentration of alanine aminotransferase with CIPII, no biochemical and clinical differences were present. Most QoL scores were lower at baseline among CIPII-treated patients. However, besides lower health status, there were no differences in the baseline-adjusted general and diabetes-specific QoL and treatment satisfaction.

CONCLUSION

Although patients using CIPII had a higher glycaemic profile compared with patients using SC insulin therapy, the HbA1c difference was non-inferior. Overall, health status was lower among CIPII-treated patients, although diabetes-specific QoL and treatment satisfaction was similar to subcutaneously treated patients.

Report of a 7 year case-control study of continuous intraperitoneal insulin infusion and subcutaneous insulin therapy among patients with poorly controlled type 1 diabetes mellitus: favourable effects on hypoglycaemic episodes

AIMS

Continuous intraperitoneal insulin infusion (CIPII) is a last-resort treatment option for patients with type 1 diabetes mellitus (T1DM) who fail to reach adequate glycaemic control with subcutaneous (SC) insulin therapy. Aim was to compare the long-term effects of CIPII and SC insulin therapy among patients with T1DM in poor glycaemic control.

METHODS

Patients in which CIPII was initiated in 2006 were compared with a control group of T1DM patients who continued SC therapy. Linear mixed models were used to calculate differences between the baseline (2006) and final (2013) measurements within and between groups.

RESULTS

A total of 95 patients of which 21 were using CIPII and 74 using SC insulin were included. Within the CIPII group, the number of hypoglycaemic episodes decreased with -5 (95% CI -8 to -3) per 2 weeks while it remained stable among SC patients. Over time, only the number of hypoglycaemic episodes decreased more with CIPII as compared to SC insulin treatment (difference: -6 (95% CI -9 to -4)). There were no differences between treatment groups regarding clinical parameters and quality of life scores over time. Pump or catheter dysfunction led to ketoacidosis in 6 patients: 2 using CIPII and 4 SC insulin.

CONCLUSIONS

After 7 years of follow-up, there is a persistent decline of hypoglycaemic events among CIPII treated T1DM patients. Besides less hypoglycaemic episodes with CIPII therapy, there are no differences between long-term CIPII and SC insulin therapy.

Differences in interpretation of haemoglobin A1c values among diabetes care professionals

BACKGROUND

To assess the expected precision of HbA1c measurements and the magnitude of HbA1c changes eliciting the advice to change treatment among diabetes care professionals.

METHODS

A seven-item questionnaire was sent to participants through a website. The survey focused on physicians and nurses involved in diabetes care.

RESULTS

In total, 104 physicians, 177 diabetes specialist nurses, and 248 primary care nurses responded to the survey. A large number of the nurses (44%) and only a small number of the physicians (4%) were not aware of the inherent uncertainty of HbA1c results. Nurses considered adjusting therapy based on very small changes in HbA1c whereas physicians in general adhere to 0.5% (5.5 mmol÷mol) as a clinically meaningful cut-off point. After therapy adjustment, a very small (0.1%) or no increase in HbA1c was considered to be significant enough to conclude that glucose regulation has worsened by 49% of the nurses and only 13% of the physicians.

CONCLUSION

Significant differences exist in the interpretation of changes in HbA1c results between physicians and nurses. Nurses consider therapy changes based on very small changes in HbA1c, whereas physicians preferably agree to the clinically relevant change of 0.5% (5.5 mmol÷mol). Changing therapy based on relatively small changes in HbA1c might lead to undue adjustments in the treatment of patients with diabetes. There is a clear need for more training for all diabetes care professionals about both the clinical significance and accuracy of HbA1c measurements.

Intraperitoneal insulin infusion: treatment option for type 1 diabetes resulting in beneficial endocrine effects beyond glycaemia

Continuous intraperitoneal insulin infusion (CIPII) is a treatment option for patients with type 1 diabetes mellitus who fail to reach adequate glycaemic control despite intensive subcutaneous (SC) insulin therapy. CIPII has clear advantages over SC insulin administration in terms of pharmacokinetic and pharmacodynamic properties and has been shown to improve glycaemic regulation. Due to the delivery of insulin predominantly in the portal vein, as opposed to systemically, CIPII offers a unique research model to investigate the effects of insulin on endocrine and metabolic parameters in vivo. The aim of the present article is to provide an overview of the literature with respect to the effects of CIPII on glucose management, quality of life, complications and costs, with additional focus on metabolic and endocrine aspects. Finally, future use and research objectives are discussed.

Sex specific association between carnosinase gene CNDP1 and cardiovascular mortality in patients with type 2 diabetes (ZODIAC-22)

INTRODUCTION

Homozygosity for a 5-leucine repeat (5L-5L) in the carnosinase gene (CNDP1) has been associated with a reduced prevalence of diabetic nephropathy in cross-sectional studies in patients with type 2 diabetes, particularly in women. Prospective studies on mortality are not available. This study investigated whether 5L-5L was associated with mortality and progression of renal function loss and to what extent this effect is modified by sex.

METHODS

In a prospective cohort of patients with type 2 diabetes, a Cox proportional hazard model was used to compare 5L-5L with other genotypes regarding (cardiovascular) mortality. Renal function slopes were obtained by within-individual linear regression of the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) equation, and were compared between 5L-5L and other genotypes.

RESULTS

871 patients were included (38% with 5L-5L). After 9.5 years of follow-up, hazards ratios (HR) for all-cause and cardiovascular mortality in 5L-5L versus other genotypes were 1.09 [95% confidence interval (CI) 0.88-1.36] and 1.12 (95% CI 0.79-1.58), respectively. There was a significant interaction between CNDP1 and sex for the association with cardiovascular mortality (p = 0.01), not for all-cause mortality (p = 0.32). Adjusted HR in 5L-5L for cardiovascular mortality was 0.69 (95% CI 0.39-1.23) in men and 1.77 (95% CI 1.12-2.81) in women. The slopes of eGFR-MDRD did not significantly differ between 5L-5L and other genotypes.

CONCLUSIONS

The association between CNDP1 and cardiovascular mortality was sex-specific, with a higher risk in women with 5L-5L genotype. CNDP1 was not associated with all-cause mortality or change in eGFR.

Effect of i.p. insulin administration on IGF1 and IGFBP1 in type 1 diabetes

In type 1 diabetes mellitus (T1DM), low concentrations of IGF1 and high concentrations of IGF-binding protein 1 (IGFBP1) have been reported. It has been suggested that these abnormalities in the GH-IGF1 axis are due to low insulin concentrations in the portal vein. We hypothesized that the i.p. route of insulin administration increases IGF1 concentrations when compared with the s.c. route of insulin administration. IGF1 and IGFBP1 concentrations in samples derived from an open-label, randomized cross-over trial comparing the effects of s.c. and i.p. insulin delivery on glycaemia were determined. T1DM patients were randomized to receive either 6 months of continuous i.p. insulin infusion (CIPII) through an implantable pump (MIP 2007C, Medtronic) followed by 6 months of s.c. insulin infusion or vice versa with a washout phase in between. Data from 16 patients who had complete measurements during both treatment phases were analysed. The change in IGF1 concentrations during CIPII treatment was 10.4 μg/l (95% CI -0.94, 21.7 μg/l; P=0.06) and during s.c. insulin treatment was -2.2 μg/l (95% CI -13.5, 9.2 μg/l; P=0.69). When taking the effect of treatment order into account, the estimated change in IGF1 concentrations was found to be 12.6 μg/l (95% CI -3.1, 28.5 μg/l; P=0.11) with CIPII treatment compared with that with s.c. insulin treatment. IGFBP1 concentrations decreased to -100.7 μg/l (95% CI -143.0, -58.3 μg/l; P<0.01) with CIPII treatment. During CIPII treatment, parts of the GH-IGF1 axis changed compared with that observed during s.c. insulin treatment. This supports the hypothesis that the i.p. route of insulin administration is of importance in the IGF1 system.

Vitamin B12 deficiency and the lack of its consequences in type 2 diabetes patients using metformin

OBJECTIVES

To study vitamin B12 concentrations in patients with type 2 diabetes with and without metformin use and to identify risk factors and consequences of low vitamin B12 concentrations.

RESEARCH DESIGN AND METHODS

This study had a cross-sectional design. During eight weeks all patients with type 2 diabetes visiting the diabetic outpatient clinic of the Isala Clinics in Zwolle were approached for participation. Participation included measurement of haemoglobin, mean corpuscular volume and vitamin B12 levels. Data on neuropathy were retrospectively searched for in the patient records. Vitamin B12 deficiency was defined as serum B12 concentrations <150 pmol/l.

RESULTS

In the total cohort (n=298), the overall prevalence of vitamin B12 concentrations <150 pml/l was 9.7% (95% CI 6.6-13.7%). In type 2 diabetes patients not taking metformin (n=134), the prevalence was 4.4% (95% CI 1.6-9.4%) compared with 14.1% in metformin users (n=164) (95% CI 9.2-20.4%; p=0.006). Each 100 mg step in metformin dose increased (OR=1.081, p=0.014), whereas PPI use lowered (OR=0.322, p=0.037) the odds of having a vitamin B12 deficiency in logistic regression. Nevertheless, metformin use did not predict the chance on having anaemia or neuropathy.

CONCLUSION

Among patients with type 2 diabetes using metformin, the prevalence of vitamin B12 deficiency is higher than compared with patients not using metformin. However, metformin use did not predict the chance of having anaemia or neuropathy.

Copeptin, a surrogate marker for arginine vasopressin, is associated with declining glomerular filtration in patients with diabetes mellitus (ZODIAC-33)

AIM/HYPOTHESIS

Arginine vasopressin (AVP), the hormone important for maintaining fluid balance, has been shown to cause kidney damage in rodent models of diabetes. We investigated the potential role of AVP in the natural course of kidney function decline in diabetes in an epidemiological study.

METHODS

Plasma copeptin, a surrogate for AVP, was measured in baseline samples from patients with type 2 diabetes treated in primary care and included in the Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) cohort.

RESULTS

Samples from 1,328 patients were available; 349 were analysed separately because they used renin-angiotensin-aldosterone system inhibition (RAASi), which influences albumin/creatinine ratio (ACR) and estimated (e)GFR. In the other 979 patients (46% men, age 68 years [58-75], ACR 1.8 mg/mmol [0.9-5.7], eGFR 67 ± 14 ml min(-1) 1.73 m(-2)) baseline copeptin (5.3 pmol/l [3.2-9.5]) was significantly associated with log e [ACR] and eGFR, even after adjustment for sex, age and risk factors for kidney function decline (standardised [std] β 0.13, p < 0.001, std β -0.20, p < 0.001 respectively). Follow-up data were available for 756 patients (6.5 years [4.1-9.6]). Baseline copeptin was associated with increase in ACR (std β 0.09, p = 0.02), but lost significance after adjustment (std β 0.07, p = 0.08). Copeptin was associated with a decrease in eGFR after adjustment (std β -0.09, p = 0.03). The strength of the association of copeptin with change in eGFR was stronger than that of established risk factors for kidney function decline (e.g. BMI, HbA1c). In patients who used RAASi there was a significant association between baseline copeptin and ACR and eGFR, but not with change in ACR and eGFR.

CONCLUSIONS/INTERPRETATION

In patients with diabetes not using RAASi a higher baseline copeptin concentration is significantly associated with higher baseline ACR and lower eGFR values and with a decline in eGFR during follow-up. This last association is independent of, and stronger than, most traditional risk factors for kidney function decline.

Educational disparities in mortality among patients with type 2 diabetes in The Netherlands (ZODIAC-23)

BACKGROUND

Relative mortality differences between educational level in mortality have been reported among diabetic as well as among non-diabetic subjects in Europe, but data on absolute differences are lacking. We studied the effect of educational disparities on mortality in a Dutch prospective cohort of type 2 diabetes mellitus (T2DM) patients.

METHODS

This study was part of the ZODIAC study, a prospective observational study of patients with T2DM. Data on educational level were first collected on 19 May 1998, and from this date on, 858 patients were included in 1998; educational level was known for 656 patients. Vital status was assessed in 2009. The relationship between mortality and educational level was studied using a Cox proportional hazard model, the relative index of inequality (RII), slope index of inequality (SII) and the population attributable risk (PAR). Educational level was divided into four categories; the highest educational level was used as reference.

RESULTS

After a median follow-up time of 9.7 years, 365 out of 858 patients had died. The hazard ratio of primary education for total mortality was 3.02 (95% CI 1.44-6.34). The RII was 2.85 (95% CI 1.21-6.67), the absolute difference in the risk for mortality (SII) was 384 deaths (95% CI 49-719) per 10,000 follow-up years. PAR for patients with the lowest level of education was 51.4%.

CONCLUSIONS

A low educational level had a higher impact on mortality than having a macrovascular complication. Given the substantial differences in mortality between educational levels in T2DM, more understanding of underlying (modifiable) mechanisms is necessary.

What do professionals recommend regarding the frequency of self-monitoring of blood glucose?

BACKGROUND

Patients' adherence to guidelines regarding self-monitoring of blood glucose (SMBG) is limited. However, there are no previous reports about the recommendations that are given in clinical practice concerning SMBG. The aim of this study was to investigate what healthcare providers recommend to insulin-treated patients with diabetes regarding frequency and timing of SMBG.

METHODS

In this cross-sectional descriptive study, primary care assistants, diabetes specialised nurses and doctors in the Netherlands were invited via e-mail to complete an internet survey.

RESULTS

A total of 980 (14%) professionals returned the questionnaire. Insulin pump users and patients with type 1 diabetes (T1DM) on 4 injections a day were advised to perform SMBG daily by 96% and 63% of the professionals, respectively. The majority of the professionals advised these patients to perform 3-4 measurements per day. There was less agreement on the timing (pre- and÷or postprandial). Patients with type 2 diabetes (T2DM) on four injections were advised to perform SMBG less frequently. There was a wide variation in recommendations that were given to patients with T2DM on less intensive insulin regimens.

CONCLUSION

This study investigated SMBG from a professional's perspective. A considerable and relevant variation in the recommendations about the number and timing of SMBG was observed. The most striking differences were found in patients with T2DM on less intensive insulin regimes, also with respect to the frequency of SMBG. Well-designed studies are necessary in order to give a more evidence-based advice on the basic frequency and timing of SMBG.

Time for considering other blood pressure target values in elderly patients with type 2 diabetes?

Although blood pressure control has undoubtedly proven its benefits in reducing the high cardiovascular risk in patients with type 2 diabetes mellitus (T2DM), it still remains unclear whether intensive antihypertensive treatment in old age (> 75 years) is beneficial. Many of the current guidelines recommend a systolic blood pressure (SBP) < 140 mmHg or lower, unless patients are at high risk for possible adverse events such as postural hypotension (1,2). This perspective aims to get a discussion started on the appropriate target SBP value for patients with T2DM aged older than 75 years.We would like to propose the less stringent value of< 160 mmHg in this specific population.

Glycaemic control and the risk of mortality in elderly type 2 diabetic patients (ZODIAC-20)

AIMS

Studies on macrovascular consequences of glucose control in elderly patients (>75 years) with type 2 diabetes mellitus (T2DM) are lacking. The present study aimed to investigate the relationship between HbA(1c) and mortality in this specific population.

METHODS

Between 1998 and 1999, 374 primary care patients with T2DM aged older than 75 years participated in the Zwolle Outpatient Diabetes project Integrating Available Care study, a prospective observational study. Early 2009, data on mortality were collected. Updated means for annually measured HbA(1c) values were calculated after a follow-up time of 10 years. Updated mean HbA(1c) was used as a time-dependent covariate in a Cox proportional hazard model. Main outcome measures were all-cause and cardiovascular disease (CVD) mortality. Analyses were performed in strata according to diabetes duration (<5, 5-11 and ≥11 years).

RESULTS

  In the group with a diabetes duration <5 years, an increase of 1% in the updated mean HbA(1c) level was associated with an increase in all-cause and CVD mortality risk of 51% (95% CI 17-95%) and 72% (95% CI 19-148%), respectively. Glycaemic control was not related to mortality for patients with a diabetes duration ≥5 years.

CONCLUSION

Poor glycaemic control is related to increased all-cause and CVD mortality in patients >75 years with T2DM of short duration (<5 years).

DISCUSSION

Because of the observational study design, our results should be interpreted with caution. Nevertheless, they are suggestive that improving glycaemic control may be beneficial in elderly patients with T2DM, especially in those with recently diagnosed T2DM. Randomised-controlled trials are necessary to investigate whether this holds true.

A polymorphism in the gene encoding carnosinase (CNDP1) as a predictor of mortality and progression from nephropathy to end-stage renal disease in type 1 diabetes mellitus

AIMS/HYPOTHESIS

Homozygosity for a five leucine repeat (5L-5L) in the carnosinase gene (CNDP1) has been found to be cross-sectionally associated with a low frequency of diabetic nephropathy (DN), mainly in type 2 diabetes. We prospectively investigated in patients with type 1 diabetes whether: (1) 5L-5L is associated with mortality; (2) there is an interaction of 5L-5L with DN or sex for prediction of mortality; and (3) 5L-5L is associated with progression to end-stage renal disease (ESRD).

METHODS

In this prospective study in white European patients with type 1 diabetes, individuals with DN were defined by persistent albuminuria ≥ 300 mg/24 h. Controls without nephropathy were defined by persistent (>15 years) normoalbuminuria < 30 mg/24 h. Leucine repeats were assessed with a fluorescent DNA analysis system. Onset of ESRD was defined by need to start chronic dialysis or kidney transplantation.

RESULTS

The study involved 916 patients with DN and 1,170 controls. During follow-up for 8.8 years, 107 patients (14%) with 5L-5L died compared with 182 patients (13.8%) with other genotypes (p = 0.99). There was no significant interaction of 5L-5L with DN for prediction of mortality (p = 0.57), but a trend towards interaction with sex (p = 0.08). In patients with DN, HR for ESRD in 5L-5L vs other genotypes was not constant over time, with increased risk for 5L-5L beyond 8 years of follow-up (p = 0.03).

CONCLUSIONS/INTERPRETATION

CNDP1 polymorphism was not associated with mortality, and nor was there an interaction of this polymorphism with DN for prediction of mortality in patients with type 1 diabetes. CNDP1 polymorphism predicts progression to ESRD in patients with DN, but only late after baseline measurements.

Self-monitoring of blood glucose in tablet-treated type 2 diabetic patients (ZODIAC)

BACKGROUND

Whether self-monitoring of blood glucose (SMBG) improves glycaemic control in patients with type 2 diabetes mellitus (T2DM) not using insulin is questionable. Our aim was to investigate the effects of SMBG in patients with T2DM who were in persistent moderate glycaemic control whilst not using insulin.

METHODS

Patients were eligible when between 18 and 70 years of age, with an HbA1c between 7 and 8.5%, using one or two oral blood glucose lowering agents. Forty-one of the anticipated 52 patients were randomly assigned to receive either SMBG added to usual care, or to continue with usual care for one year. A fasting glucose value and three postprandial glucose values were measured twice weekly (including a Saturday or a Sunday). The primary efficacy parameter was HbA1c. Furthermore, health-related quality of life and treatment satisfaction were assessed using the Short-form 36 Health Survey Questionnaire (SF-36), the Type 2 Diabetes Symptom Checklist (DSC-r), the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and the WHO -Wellbeing Index (WHO-5).

RESULTS

Change in HbA1c between groups was -0.05% (95% CI: -0.51, 0.41; p=0.507). Also, there were no significant changes between groups on the DTSQ , DSC type 2, WHO-5 or SF -36, except for the SF -36 dimension 'health change' which was lower in the SBMG group (mean difference: -12 (95% CI: -20.9, -3.1).

CONCLUSION

On top of the absence of a clinical benefit, tablet-treated T2DM patients experienced some worsening of their health perception. We therefore argue that the use of SMBG in this patient group is questionable, and its unlimited use and promotion should be reconsidered.

Alpha lipoic acid: a new treatment for neuropathic pain in patients with diabetes?

BACKGROUND

Neuropathic pain is difficult to treat. We identified those studies in the literature in which the effectiveness of alpha lipoic acid as a treatment for neuropathic pain was evaluated.

METHODS

Systematic literature review. The databases MEDLINE and EMBASE were searched using the keywords 'lipoic acid', 'thioctic acid', 'diabet*', and the medical subject headings (MeSH ) 'thioctic acid' and 'diabetes mellitus'. Randomised placebo-controlled trials (RCTs) and meta-analyses were selected and assessed for their methodological quality.

RESULTS

Five RCTs and one meta-analysis were found. The Total Symptom Score (TSS) was used as the primary outcome measure. A significant improvement in the TSS was reported in four of the RCTs. An oral or intravenous alpha lipoic dose of at least 600 mg per day resulted in a 50% reduction in the TSS. However, compared with the control group, the TSS reduction in most groups was less than 30%, which is the threshold presumed to be clinically relevant. Four RCTs were of good quality (level of evidence 1b), one RCT had methodological limitations (level 2b), and the methodological quality of the meta-analysis was insufficient for the purposes of this review.

CONCLUSION

Based on the currently available evidence, when given intravenously at a dosage of 600 mg once daily over a period of three weeks, alpha lipoic acid leads to a significant and clinically relevant reduction in neuropathic pain (grade of recommendation A). It is unclear if the significant improvements seen after three to five weeks of oral administration at a dosage of >or= 600 mg daily are clinically relevant.

The relationship between obesity and cancer mortality in type 2 diabetes: a ten-year follow-up study (ZODIAC-21)

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) as well as patients with obesity have increased cancer mortality. In a previous paper we suggested that there was a trend for decreased mortality in obese individuals with T2DM. The aim of the new analyses was to investigate the same relationship after increasing our sample size and extending our follow-up period.

PATIENTS AND METHODS

1353 patients were followed prospectively as part of the ZODIAC study. The cancer mortality rate was evaluated using standardized mortality ratio (SMR) and its association with BMI (kg/m(2)) and obesity (>30 kg/m(2)) with Cox proportional hazard analysis.

RESULTS

After a median follow-up time of 9.8 years, 570 patients had died, of whom 122 died from malignancy. The SMR for cancer mortality was 1.47 (95%CI 1.22-1.76). BMI and obesity were not associated with cancer death.

CONCLUSION

The trend towards an inverse relationship between obesity and cancer mortality as reported previously disappeared after increasing sample size and follow-up to 9.6 years.

eGFR and creatinine clearance in relation to metabolic changes in an unselected patient population

BACKGROUND

It is widely assumed that moderate to severe renal failure (creatinine clearance <60 ml/min; or an MDRD-4 (Modification of Diet in Renal Disease equation) <60 ml/min/1.73 m(2)) is associated with metabolic changes, often needing further assessment and treatment. We investigated whether such abnormalities are already present at earlier stages of kidney disease, as assessed by 24-hour urine sampling and MDRD-4 calculation.

METHODS

A select, retrospective cohort study was conducted. Creatinine clearance was measured by collecting 24-hour urines. The individual eGFRs were calculated with the MDRD-4 formula and patients were then divided by renal function category (<15, 15-30, 30-45, 45-60, 60-90, >90 ml/min(/1.73 m(2))). Per clearance category the number of people with anaemia, hypokalaemia, uraemia and hyperphosphataemia was evaluated.

RESULTS

The median creatinine clearance rate was 67.3 ml/min (quartiles: 42.9-95.8) versus a median MDRD-4-eGFR of 51.6 ml/min/1.73 m(2) (35.8-67.7). Anaemia, hyperkalaemia, hypocalcaemia, and uraemia were found to be present at higher levels of creatinine clearance rate and eGFR than previously reported (p<0.0005). This increased prevalence was more pronounced in elderly subjects, particularly with respect to anaemia (OR 2.71 and 2.02 for MDRD-4 and creatinine clearance respectively, p<0.0005). The same holds for the proportion with uraemia (OR 1.85, p<0.0005) and hypocalcaemia (OR 1.97, p=0.011) for MDRD-4.

CONCLUSION

Metabolic changes in an in- and outpatient hospital population are present at earlier stages than was stated in recent guidelines, especially when creatinine clearance levels are used as indicators. This might have implications for testing and treatment of patients with suspected kidney disease and/or loss of renal function.

Diabetes specialist nurse as main care provider for patients with type 2 diabetes

BACKGROUND

The objective of this study was to determine whether the management of type 2 diabetes (DM2) can be transferred from an internist to a nurse specialised in diabetes (NSD).

METHODS

Ninety-three patients with DM2 referred by their general practitioner were randomised; 84 patients completed the study. The intervention group received care from an NSD who treated glycaemia, blood pressure and lipid profile by protocol. The control group received care from an internist. The primary endpoint was the main decrease in HbA1c. Secondary endpoints included blood pressure, lipid profile, healthcare costs, QOL , and patient satisfaction.

RESULTS

HbA1c, total cholesterol, LDL cholesterol and cholesterol/HDL ratio decreased significantly in both study populations after a follow-up time of 12 months. Cholesterol/HDL ratio decreased by 0.4 and 0.9 in the NSD and control group respectively (p=0.034 for the difference between groups). The decreases (95% confidence interval) in systolic blood pressure were 8.6 mmHg (2.6, 14.7) in the NSD group and 4.0 mmHg (-0.9, 8.9) in the control group, without a significant difference between groups. After one year, 33.3% of the patients in the NSD group achieved an HbA1c level. <7% compared with 2.2%at baseline (p=0.002). Healthcare costs were less and patient satisfaction with the NSD s was significantly better(p<0.001), while maintaining the same QOL .

CONCLUSION

NSD s using treatment protocols are able to provide effective care for patients with DM 2, comparable with the care provided by an internist, with respect to clinical parameters, and superior with respect to healthcare costs and patient satisfaction.

Modification of diet in renal disease and Cockcroft-Gault formulas do not predict mortality (ZODIAC-6)

AIMS

An inverse relationship between estimates of renal function, with formulas such as the Modification of diet in renal disease (MDRD) study equation or the Cockcroft-Gault formula, and mortality has been suggested. These formulas both contain the variables sex, serum creatinine and age and the latter also contains body weight. We investigated whether these formulas predict mortality better than the variables they contain together in patients with Type 2 diabetes.

METHODS

In 1998, 1143 primary care patients with Type 2 diabetes participated in the Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) Study, in the Netherlands. Clinical and laboratory data were collected at baseline. Life status was assessed after 6 years. We used Cox proportional hazard modelling to investigate the association between estimates of renal function (continuous data) and the variables they contain and mortality, adjusting for confounders. Both formulas were compared with models consisting of the variables present in the formulas. Predictability was assessed using Bayesian information criterion (BIC) and Harrell's C statistics.

RESULTS

At follow-up, 335 patients had died. All variables, except sex, influenced mortality. Predictive capability, indicated by lower BIC values and higher Harrell's C values, was up to 10% better for models containing the separate variables as compared with Cockcroft-Gault or MDRD.

CONCLUSIONS

Using estimates of renal function to assess mortality risk decreases predictability as compared with the combination of the risk factors they contain. These formulas, therefore, could be used to estimate renal function; however, they should not be used as a tool to predict mortality risk.

Increased cancer mortality in type 2 diabetes (ZODIAC-3)

BACKGROUND

It is unclear whether there is a relationship between type two diabetes and cancer mortality. It also is unclear whether obesity and body mass index (BMI) are associated with cancer in type 2 diabetes patients.

PATIENTS AND METHODS

In 1998, 1,145 patients with type two diabetes mellitus were enrolled in the Zwolle Outpatient Diabetes project Intergrating Available Care (ZODIAC) study. In this project, general practitioners (GPs) were assisted by hospital-based diabetes specialist nurses. Vital status was assessed in September 2004. The cancer mortality rate was evaluated using standardized mortality ratio (SMR) and its association with BMI (kg/m2) and obesity (>30 kg/m2) with the Cox proportional hazard ratio.

RESULTS

The median follow-up time was 5.8 years. A total of 335 patients had died, of whom 70 died from malignancy. The SMR for cancer mortality was 1.38 (95% CI 1.07-1.75). BMI and obesity were not associated with cancer death.

CONCLUSION

An increased cancer mortality rate was found in type two diabetes mellitus patients but there was no significant association between BMI or obesity and cancer mortality.

Cholesterol in end-stage renal disease: the good, the bad or the ugly?

The incidence of cardiovascular disease is markedly increased in patients with end-stage renal disease (ESRD). High serum cholesterol is widely recognised as a cardiovascular risk factor in the general population. However, in patients with ESRD high concentrations of cholesterol are associated with a better survival. This reverse epidemiology is, amongst others, caused by confounding due to malnutrition and chronic inflammation. In this population, treatment with statins to lower the serum cholesterol remains a matter of debate. In ESRD, LDL cholesterol is modified by increased oxidative stress. These altered LDL particles play a pivotal role in the development of atherosclerosis. Treatment with the antioxidant vitamin E has not equivocally been shown to be beneficial in this population. This review tries to put data from literature on dyslipidaemia and oxidative stress in ESRD in perspective.

[Cinnamon: not suitable for the treatment of diabetes mellitus]

OBJECTIVE

To identify published studies evaluating the effects of cinnamon on glycaemic control.

DESIGN

Literature search.

METHOD

The Medline database was searched using all possible combinations of the words and medical subject headings (MeSH) 'cinnamon', 'diabetes mellitus', 'HbA1C' and 'glucose'. All human or animal studies in which cinnamon was administered as intervention were included.

RESULTS

Several animal studies and 5 randomized placebo-controlled trials in humans were found. Most of the animal studies described beneficial effects of cinnamon on glycaemic control. One placebo-controlled trial in patients with type 2 diabetes found that cinnamon intake was associated with favourable effects on fasting plasma glucose. None of the studies reported an improvement in HbA1C. A study in patients with type 1 diabetes found that cinnamon had no effect.

CONCLUSION

Based on the currently available evidence, cinnamon should not be recommended for the improvement ofglycaemic control.

Intensification of therapy and no increase in body mass index with longer disease duration in type 2 diabetes mellitus (ZODIAC-5)

BACKGROUND

Decreased insulin sensitivity and beta-cell failure are the two key components in the pathogenesis of type 2 diabetes mellitus (T2DM). Secondary treatment failure is often attributed to the development of obesity-related insulin resistance in combination with continued loss of beta-cell function.

OBJECTIVE

Assess metabolic control, body mass index (BMI) and treatment in relationship to diabetes duration to study these mechanisms.

METHODS

Cross-sectional study of 7875 patients with T2DM in primary care in The Netherlands. Clinical data and laboratory results were obtained for the 2005 annual visit. Patients were grouped according to diabetes duration in 2-year intervals. Each step in the traditional treatment sequence was considered as a sign of progression of beta-cell failure.

RESULTS

Complete data regarding duration and treatment were available for 6850 patients (87%). After the initial years following diagnosis, treatment with diet alone decreases and oral hypoglycaemic agents (OHA) are prescribed to an increasing percentage of patients. Treatment with OHA diminishes after approximately 10 years following diagnosis and treatment with insulin increases until approximately two-thirds of patients with diabetes duration of more than 20 years are being treated with insulin. BMI does not increase with longer disease duration.

CONCLUSION

The concept of beta-cell failure as the primary determinant of the chronic progression of T2DM is supported by these results, whereas a deterioration of obesity-related insulin sensitivity as indicator is not supported.

[Measuring the blood pressure in both arms is of little use; longitudinal study into blood pressure differences between both arms and its reproducibility in patients with diabetes mellitus type 2]

OBJECTIVE

To determine the prevalence of inter-arm blood pressure differences > 10 mmHg in patients with diabetes mellitus type 2 (DM2) and to determine whether these differences are consistent over time.

DESIGN

Descriptive.

METHOD

In an evaluation study of 169 DM2 patients from 5 general practices in 2003 and 2004, different methods of oscillatory measurement were used to investigate inter-arm blood pressure differences > 10 mmHg systolic or diastolic. These methods were: one measurement in each arm non-simultaneously (method A), one measurement simultaneously (B) and the mean of two simultaneous measurements (C).

RESULTS

With method A an inter-arm blood pressure difference was found in 33% of patients. This percentage diminished to 9 with method C. In 44% (n = 7) of the patients in whom method C detected a relevant blood pressure difference, this difference was not found with method A. In 79% of patients the inter-arm blood pressure difference was not reproduced after one year.

CONCLUSION

In daily practice, one non-simultaneous blood pressure measurement in each arm (method A) was of little value for identification of patients with inter-arm blood pressure differences. The reproducibility was poor one year later. Bilateral blood pressure measurement is therefore of little value.

[Assessment of renal function according to the NHG protocol 'Diabetes mellitus type 2': risk of overestimating the number of diabetes patients with renal dysfunction]

OBJECTIVE

To evaluate the consequences of the new Dutch College of General Practitioners (NHG) protocol 'Diabetes mellitus type 2', which recommends using either the Cockcroft-Gault (CG) formula or the 'Modification of diet in renal disease' (MDRD) study formula to determine the estimated glomerular filtration rate (eGFR) as an indicator of renal function, in a cohort of patients with type-2 diabetes.

DESIGN

Inventory.

METHOD

The eGFR was calculated using the CG formula, the body-mass index (BMI-)corrected CG formula and the MDRD formula in 6224 patients with type-2 diabetes who entered the 'Zwolle outpatient diabetes project integrating available care' (ZODIAC) study in 2005.

RESULTS

Using the CG and MDRD formulas, 31% and 63% of patients, respectively, had an eGFR of 30-59 ml/min (units for MDRD are ml/ min/1.73 m2) for which referral is advisable. In addition, 1% and 11%, respectively, had an eGFR <30 ml/min (reference: >90 ml/min), for which referral is necessary. Most patients aged >70 years (or > 50 years using the BMI-corrected CG formula) had an eGFR <60 ml/min.

CONCLUSIONS

Reduced eGFR can be a sign of renal dysfunction but, using these formulas, can also be partly explained by advanced age. Therefore other factors should be considered when interpreting the results ofeGFR before it is concluded that the patient has kidney disease and the associated increased risk of cardiovascular disease.

Glucose dysregulation in nondiabetic patients with ST-elevation myocardial infarction: acute and chronic glucose dysregulation in STEMI

BACKGROUND

Admission hyperglycaemia is associated with an increased risk of mortality after myocardial infarction. Whether long-term glucose dysregulation (assessed by HbA1c) is more important than acute hyperglycaemia is unknown. We evaluated the prognostic value of admission glucose and HbA1c levels in nondiabetic patients with ST-segment elevation acute myocardial infarction (STEMI).

METHODS

In 504 unselected, consecutive patients with STEMI, glucose and HbA1c levels were measured on admission. Glucose was categorised as <11.1 mmol/l (n=422) and >or= 11.1 mmol/l (n=82). HbA1c levels were categorised as <6.0% (n=416) and >or=6.0% (n=88). Mean follow-up was 1.6+/-0.6 years.

RESULTS

Patients with hyperglycaemia on admission were comparable with those with normoglycaemia. However,patients with HbA1c >or=6.0%, as compared with those with HbA1c <6%, were older, were more often on beta-blockers and more frequently had multivessel disease. Thirty-day mortality in the subsequent glucose categories (<11.1 mmol/l and >or=11.1 mmol/l) was 4% and 19% (p<0.001) and in the subsequent HbA1c categories (<6% and >or=6%) was 5% and 12% (p=0.03). After multivariable analyses, admission glucose (OR 4.91,95% CI 2.03 to 11.9, p< 0.001) but not HbA1c (OR 1.33, 95%CI 0.48 to 3.71, p=0.58) was significantly associated with 30-day mortality. Among 30-day survivors, neither admission glucose nor HbA1c were predictors of long-term mortality.

CONCLUSION

Elevated admission glucose is an important predictor of 30-day outcome after STEMI, while prior long-term glucose dysregulation is a covariate of other high-risk clinical characteristics. Among 30-day survivors, neither admission blood glucose nor HbA1c were predictors of long-term outcome.

Glycaemic control, health status and treatment satisfaction with continuous intraperitoneal insulin infusion

BACKGROUND

Continuous intraperitoneal insulin infusion(CIPI ) has been in use for over 20 years. High costs and technical problems have prevented its widespread use. In the Netherlands, the Isala Clinics in Zwolle is the centre with the most extensive experience with CIPII . Its use is aimed at improving glycaemic control with less hypoglycaemic events, and thus improving quality of life inpatients with poorly controlled diabetes despite intensified insulin treatment. Our aim was to assess glycaemic control,health status and treatment satisfaction in subjects treated with CIPII within the Isala Clinics.

METHODS

Retrospective longitudinal analysis of clinical data in 48 patients started on CIPII between 1983 and 2005.HbA1c at baseline, after one year, and at present assessment or at the end of pump use were applicable. Cross-sectional assessment of health status, well-being and treatment satisfaction was carried out.

RESULTS

Of 48 patients, 33 were treated with CIPII at the moment of assessment. Five patients died whilston CIPII ; four from diabetes-related causes, none from hypoglycaemia. HbA1c decreased significantly from 9.7 to 8.8% after one year, to 8.6% at long-term follow-up; p<0.01. Less hypoglycaemic events were reported. Short-Form 12-Item Health Survey (SF -12)scores were 37.4 and 47.2 (range 0-100), the Well-Being Index (WHO-5) score was 52.7 (range 0-100) and median treatment satisfaction score was 32 (range 0-36).

CONCLUSION

CIPII leads to improved glycaemic control with less self-reported hypoglycaemic events in patients with poorly controlled diabetes. Treatment satisfaction is high. Mental health status and well-being scores are low, however.

Prognostic value of admission glucose and glycosylated haemoglobin levels in acute coronary syndromes

BACKGROUND

Admission hyperglycaemia is associated with poorer prognosis in patients with an acute coronary syndrome (ACS). Whether hyperglycaemia is more important than prior long-term glucose metabolism, is unknown.

AIM

To investigate the prognostic value of admission glucose and HbA(1c) levels in patients with ACS.

METHODS

We measured glucose and HbA(1c) at admission in 521 consecutive patients with suspected ACS. Glucose was categorized as <7.8 (n = 305), 7.8-11.0 (n = 138) or > or =11.1 mmol/l (n = 78); HbA(1c) as <6.2% (n = 420) or > or =6.2% (n = 101). Mean follow-up was 1.6 +/- 0.5 years.

RESULTS

The diagnosis of ACS was confirmed in 332 patients (64%), leaving 189 (36%) with atypical chest pain. In ACS patients, mortality by glucose category (<7.8, 7.8-11.0 or > or =11.1 mmol) was 9%, 8% and 25%, respectively (p = 0.001); mortality by HbA(1c) category (<6.2% vs. > or =6.2%) was 10% vs. 17%, respectively (p = 0.14). On multivariate analysis, glucose category was significantly associated with mortality (HR 3.0, 95% CI 1.1-8.3), but HbA(1c) category was not (HR 1.5, 95%CI 0.6-4.2).

DISCUSSION

Elevated admission glucose appears more important than prior long-term abnormal glucose metabolism in predicting mortality in patients with suspected ACS.