Control of Glucose, Blood Pressure, and Cholesterol among Adults with Diabetes: The Brazilian National Health Survey

ABC (glucose, blood pressure and LDL-cholesterol) goals are basic standards of diabetes care. We aimed to assess ABC control and related factors in a representative sample of Brazilian adults with diabetes. We analyzed 465 adults with known diabetes in the Brazilian National Health Survey. The targets used were <7% for glycated hemoglobin (A1C); <140/90 mmHg for blood pressure; and <100 mg/dL for LDL-C, with stricter targets for the latter two for those with high cardiovascular (CVD) risk. Individual goals were attained by 46% (95% CI, 40.3–51.6%) for A1C, 51.4% (95% CI, 45.7–57.1%) for blood pressure, and 40% (95% CI, 34.5–45.6%) for LDL-C. The achievement of all three goals was attained by 12.5% (95% CI, 8.9–16.2%). Those with high CVD risk attained blood pressure and LDL-C goals less frequently. A1C control improved with increasing age and worsened with greater duration of diabetes. Achievement of at least two ABC goals decreased with increasing BMI and greater duration of diabetes. In sum, about half of those with known diabetes achieved each ABC goal and only a small fraction achieved all three goals. Better access and adherence to treatment and strategies to personalize goals according to specific priorities are of the essence.

Timing of chocolate intake affects hunger, substrate oxidation, and microbiota: A randomized controlled trial

Eating chocolate in the morning or in the evening/at night, may differentially affect energy balance and impact body weight due to changes in energy intake, substrate oxidation, microbiota (composition/function), and circadian-related variables. In a randomized controlled trial, postmenopausal females (n = 19) had 100 g of chocolate in the morning (MC), in the evening/at night (EC), or no chocolate (N) for 2 weeks and ate any other food ad libitum. Our results show that 14 days of chocolate intake did not increase body weight. Chocolate consumption decreased hunger and desire for sweets (P < .005), and reduced ad libitum energy intake by ~300 kcal/day during MC and ~150 kcal/day during EC (P = .01), but did not fully compensate for the extra energy contribution of chocolate (542 kcal/day). EC increased physical activity by +6.9%, heat dissipation after meals +1.3%, and carbohydrate oxidation by +35.3% (P < .05). MC reduced fasting glucose (4.4%) and waist circumference (-1.7%) and increased lipid oxidation (+25.6%). Principal component analyses showed that both timings of chocolate intake resulted in differential microbiota profiles and function (P < .05). Heat map of wrist temperature and sleep records showed that EC induced more regular timing of sleep episodes with lower variability of sleep onset among days than MC (60 min vs 78 min; P = .028). In conclusion, having chocolate in the morning or in the evening/night results in differential effects on hunger and appetite, substrate oxidation, fasting glucose, microbiota (composition and function), and sleep and temperature rhythms. Results highlight that the "when" we eat is a relevant factor to consider in energy balance and metabolism.

Insulin secretion is a strong predictor for need of insulin therapy in patients with new-onset diabetes and HbA1c of more than 10%: A post hoc analysis of the EDICT study

AIM

To identify predictors of response to glucose-lowering therapy in patients with new-onset diabetes and very high HbA1c (>10%).

METHODS

The study included EDICT participants with an initial HbA1c of more than 10% (N = 104). All subjects received a 75-g oral glucose tolerance test (OGTT) before initiation of therapy, and then were randomized to receive: (a) initial triple therapy with metformin, pioglitazone and exenatide versus (b) stepwise conventional therapy with metformin followed by glipizide and then glargine insulin to reduce HbA1c to less than 6.5%. Insulin secretion and insulin resistance were calculated with OGTT-derived indices.

RESULTS

Sixty-one per cent of participants in the conventional therapy group achieved HbA1c of less than 6.5% at 6 months without need of insulin therapy compared with 78% in the triple therapy group (P = NS). Insulin secretion at baseline was the strongest predictor of subjects who did not require insulin therapy; a cut point of CPEP₁₂₀ /CPEP₀ -the ratio between plasma C-peptide concentration at 120 minutes during the OGTT and fasting plasma C-peptide concentration-of more than 1.7 predicted subjects who achieved the treatment target without insulin, irrespective of the fasting plasma glucose (FPG) concentration and whether or not they were started on conventional or triple therapy. Subjects with a CPEP₁₂₀ /CPEP₀ of less than 1.7 plus FPG of 269 mg/dL or less (≤14.9 mmoL/L) also achieved the treatment goal with triple therapy.

CONCLUSION

Insulin secretion in response to a 75-g OGTT predicts the need for insulin therapy at the time of type 2 diabetes (T2D) diagnosis. A cut point of 1.7 of CPEP₁₂₀ /CPEP₀ provides a useful clinical tool to individualize glucose-lowering therapy in patients with new-onset T2D and HbA1c of more than 10%.

Can functional electrical stimulation-assisted cycle ergometry replace insulin infusion in patients? A nested substudy in a randomized controlled trial with 6 months' follow-up

BACKGROUND

Functional electrical stimulation-assisted cycle ergometry (FESCE) can deliver active exercise to critically ill patients, including those who are sedated. Aerobic exercise is known to stimulate skeletal muscle glucose uptake. We asked whether FESCE can reduce intravenous insulin requirements and improve insulin sensitivity in intensive care unit (ICU) patients.

METHOD

We performed an a priori-planned secondary analysis of data from an outcome-based randomized controlled trial (NCT02864745) of FESCE-based early-mobility program vs standard of care in mechanically ventilated patients. We analyzed glucose profile, glucose intake, and insulin requirements during ICU stay in all enrolled patients. In a nested subgroup, we performed hyperinsulinemic (120 mIU/min/m² ) euglycemic clamps at days 0, 7, and 180 (n = 30, 23, and 11, respectively).

RESULTS

We randomized 150 patients 1:1 to receive intervention or standard of care. Seventeen (23%) patients in each study arm had a history of diabetes. During ICU stay, patients received 137 ± 65 and 137 ± 88 g/day carbohydrate (P = .97), and 31 vs 35 (P = .62) of them required insulin infusion to maintain blood glucose 8.61 ± 2.82 vs 8.73 ± 2.67 mM (P = .75, n = 11,254). In those treated with insulin, median daily dose was 53 IU (interquartile range [IQR], 25-95) vs 62 IU (IQR, 26-96) in the intervention and control arm, respectively (P = .44). In the subgroup of patients undergoing hyperglycemic clamps, insulin sensitivities improved similarly and significantly from acute and protracted critical illness to 6 months after discharge.

CONCLUSION

The FESCE-based early-mobility program does not significantly reduce insulin requirements in critically ill patients on mechanical ventilation.

Potential of Beetroot and Blackcurrant Compounds to Improve Metabolic Syndrome Risk Factors

Metabolic syndrome (MetS) is a group of metabolic abnormalities, which together lead to increased risk of coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM), as well as reduced quality of life. Dietary nitrate, betalains and anthocyanins may improve risk factors for MetS and reduce the risk of development of CHD and T2DM. Beetroot is a rich source of dietary nitrate, and anthocyanins are present in high concentrations in blackcurrants. This narrative review considers the efficacy of beetroot and blackcurrant compounds as potential agents to improve MetS risk factors, which could lead to decreased risk of CHD and T2DM. Further research is needed to establish the mechanisms through which these outcomes may occur, and chronic supplementation studies in humans may corroborate promising findings from animal models and acute human trials.

Breastfeeding Success Among Women with Gestational Diabetes Managed by Diet Only Compared with Those Requiring Medications

Objective: Breastfeeding is known to have a positive impact on maternal and neonatal health. Some have suggested that gestational diabetes mellitus (GDM) is associated with lower breastfeeding rates, but it is not known whether rates are further impacted by glucose control in pregnancy. Thus, we examined whether patients with GDM requiring medication (A2 GDM) were more likely to not initiate or discontinue breastfeeding compared with patients with GDM well controlled by diet (A1 GDM). Research Design and Methods: This is a secondary analysis of a prospective cohort study of 600 patients with GDM. Eligible patients were enrolled during their delivery hospitalization and followed prospectively postpartum. The primary outcome was exclusive breastfeeding at hospital discharge and secondary outcomes included breastfeeding rates at 3 months postpartum. Patients classified as A2 GDM were compared with those classified as A1 GDM. Results: Of the 600 patients enrolled, 301 had A2 GDM and 299 had A1 GDM. Patients who needed medication were observed to be older and more likely to be parous and obese. There were no significant differences in labor outcomes or neonatal complications. After adjusting for baseline differences between the two groups, adjusted odds ratios (aORs) for exclusive breastfeeding rates were similar in mothers with A2 GDM compared with those with A1 GDM at hospital discharge (aOR 0.83 [0.54-1.28]) and 3 months postpartum (aOR 0.58 [0.34-1.01]). Additionally, any breastfeeding rates were similar in mothers with A2 GDM compared with those with A1 GDM, both at hospital discharge (aOR 0.72 [0.44-1.16]) and 3 months postpartum (aOR 0.63 [0.34-1.17]). Conclusions: After adjusting for baseline differences, there was no difference in any or exclusive breastfeeding rates at hospital discharge or 3 months postpartum among patients with A2 GDM compared with those with A1 GDM.

Agreement of blood glucose measured with glucose meter in arterial, central venous, and capillary samples in adult critically ill patients

BACKGROUND

The measurement of blood glucose in critically ill patients is still performed in many ICUs with glucose meters and capillary samples. Several prevalent factors in these patients affect the accuracy of the results and should be interpreted with caution. A weak recommendation from the Surviving Sepsis Campaign (SSC) suggests the use of arterial blood rather than capillary blood for point of care testing using glucose meters.

AIMS AND OBJECTIVES

To analyse the agreement between arterial, central venous, and capillary blood samples of glucose values measured by glucose meter in critically ill patients and study potential confounding factors.

DESIGN

Prospective cross-sectional study in a general intensive care unit (ICU). Patients needing insulin treatment (subcutaneous or intravenous) and blood glucose control were included.

METHODS

Standardized collection of blood samples and measurement of glucose values with a glucometer. Agreement was studied by the Bland-Altman method and stratified analysis of disagreement-survival plots was used to study the influence of haematocrit, pH range, SOFA score, capillary refilling time, intravenous insulin infusion, and lactic acid.

RESULTS

A total of 297 measurements from 54 patients were included. The mean arterial blood glucose was 150.42 (range 31-345 mg/dL). In the graphical analysis, there is a poor agreement both in capillary and venous central to arterial samples, but in opposite direction (underestimation of capillary and overestimation of central venous). Factors associated with a reduction in the agreement between arterial and capillary samples were elevated lactate, poor capillary refilling, and hemodynamic failure. Patients without hemodynamic compromise have an acceptable agreement with values for absolute differences of 16 mg/dL for a disagreement of 10%.

CONCLUSIONS

In critically ill patients, the measurement of blood glucose with a glucose meter should be performed with arterial samples whenever possible. Capillary samples do not accurately estimate arterial blood glucose values in patients with shock and/or vasoactive drugs and underestimate the values in the range of hypoglycemia. Venous samples are subject to error because of potential contamination.

RELEVANCE TO CLINICAL PRACTICE

This study adds support to the recommendation of using arterial blood rather than capillary or venous blood when using glucose meters in critically ill patients, especially in those with hemodynamic failure.

Clinical Characteristics and Degree of Glycemic and Cardiovascular Risk Factor Control in Patients with Type 1 Diabetes in Catalonia (Spain)

Background: This study aims to evaluate the clinical characteristics, complications, degree of glycemic control, and cardiovascular risk factor control in patients with type 1 diabetes in Catalonia (Northwest of Spain). Methods: Cross-sectional study using a database including clinical, laboratory, and treatment data. Patients with an ICD10 diagnosis of type 1 diabetes were included, excluding those treated with glucose-lowering agents other than insulin, or treated only with basal insulin two years after diagnosis. Results: 15,008 patients were analysed. Median IQR age was 42 (31–53) years, diabetes duration 11.8 (6.8–16.0) years, 56.5% men. Median (IQR) HbA1c was 7.9% (7.1–8.8). Microvascular complications were present in 24.4% of patients, 43.6% in those with a diabetes duration >19 years. In presence of known cardiovascular disease 69.3% of patients showed an LDL-C concentration >70 mg/dL, 37% had a systolic blood pressure >135 mmHg and 22.4% were smokers. Conclusions: This study provides a reliable snapshot about the clinical situation of a large population of patients with T1D in Catalonia, which is similar to that of other western areas. The lack of adequate control of cardiovascular risk factors in a significant proportion of patients with cardiovascular disease deserves a more detailed analysis and urges the need for improvement strategies.

Integration of Diabetes and Depression Care Is Associated with Glucose Control in Midwestern Federally Qualified Health Centers

BACKGROUND

The 2016 American Diabetes Association position statement emphasized that psychosocial and medical care should be integrated and provided to all people with diabetes.

OBJECTIVE

To determine whether better integration of diabetes and depression care is associated with better glycemic control.

DESIGN

Cross-sectional surveys of Midwestern federally qualified health center (FQHC) leaders and primary care providers (PCPs) in 2016. Responses were linked to FQHC-level data on the percentage of patients with uncontrolled diabetes (glycated hemoglobin ≥ 9%; 75 mmol/mol).

PARTICIPANTS

Midwest Clinicians' Network-affiliated FQHC leaders, and PCPs at the FQHCs.

MAIN MEASURES

Multilevel models were used to determine associations between the percentage of patients with uncontrolled diabetes and FQHC and PCP characteristics; presence of diabetes and behavioral health care services; and PCPs' perception of the stage of integration between diabetes and depression care services based on the transtheoretical model (i.e., pre-contemplation, contemplation, preparation, action, or maintenance).

KEY RESULTS

Response rates were 60% for the FQHC survey (N = 77) and 55% for the PCP survey (N = 538). In adjusted models, FQHCs in which PCPs perceived a higher stage of integration between diabetes and depression care had 3% fewer patients with uncontrolled diabetes per 1-level increase in integration stage (p = 0.01); on-site diabetes self-management education was associated with 7% fewer patients with uncontrolled diabetes (p < 0.01).

CONCLUSIONS

At Midwestern FQHCs, a higher stage of perceived integration of diabetes and depression care was associated with better FQHC-level glycemic control. Future studies are needed to elucidate what defines integration of diabetes and depression care services.

Real-World Effectiveness of Once-Weekly Semaglutide From a US Commercially Insured and Medicare Advantage Population

PURPOSE

Patients managing type 2 diabetes mellitus (T2DM) often require combination therapy to meet their blood glucose control targets. With limited real-world evidence focused on the use of glucagon-like peptide 1 receptor agonist (GLP-1RA) therapies, the objective of this study was to describe the association between semaglutide once weekly (OW) initiation and changes in hemoglobin A_1c (A_1c) levels.

METHODS

This retrospective, descriptive cohort study used the HealthCore Integrated Research Environment (HIRE) to examine commercially insured and Medicare Advantage patients who had T2DM while taking semaglutide OW from December 1, 2017, to April 30, 2019. The first semaglutide OW prescription fill was defined as the study index date. Changes in mean A_1c levels and A_1c target attainment were evaluated among an intention-to-treat (ITT) population (overall group). Furthermore, a persistent population (PP) analysis on the same outcomes was performed that was limited to ITT patients who were observed to continue to use semaglutide OW at the time of the postindex A_1c measurement. In addition, these outcomes were explored in patients stratified based on prior use of GLP-1RA therapy (experienced vs naive) and baseline A_1c values >9% (75 mmol/mol).

FINDINGS

A total of 1888 patients were identified in the overall ITT group. The mean change in the overall ITT group between preindex and postindex A_1c values was -0.9% percentage points (-9.8 mmol/mol) (mean preindex A_1c, 8.2% [66.1 mmol/mol]) and -1.1 percentage points (-12.0 mmol/mol) (mean preindex A_1c, 8.2% [66.1 mmol/mol]) in the PP subgroup (all P < 0.001). Among the subgroup of patients with a baseline A_1c value >9% (75 mmol/mol), percentage point changes in A_1c were -2.2 (-24.0 mmol/mol) and -2.4 (-26.2 mmol/mol) (all P < 0.001). When accounting for prior GLP-1RA use, the GLP-1RA-naive stratum had double the mean reduction in A_1c compared with the GLP-1RA-experienced stratum (-1.2 [-13.1 mmol/mol] vs -0.6 [-6.6 mmol/mol] percentage points).

IMPLICATIONS

Semaglutide OW is associated with clinically and statistically significant A_1C reduction and increases in reaching A₁ targets using real-world data, even in GLP-1RA-experienced patients, despite more frequent use of insulin or sodium glucose transport protein 2 inhibitors in this group. Target A_1c attainment significantly increased overall and within all subgroups and strata, with approximately half of all patients attaining an A_1c value <7% (53 mmol/mol) and three-quarters attaining an A_1c value <8% (64 mmol/mol).

Suboptimal control for patients with type 2 diabetes in the Central Chronic Medicine Dispensing programme in South Africa

BACKGROUND

In South Africa, the Central Chronic Medicine Dispensing and Distribution (CCMDD) programme allows stable patients with non-communicable diseases, including type 2 diabetes mellitus (T2DM), to collect their medication from a pick-up location near their home, thus avoiding long waiting times and travel expenses. The CCMDD programme aims at improving patient retention and adherence through better access to medicines, resulting in better health outcomes.

AIM

We assessed whether patients with T2DM enrolled in CCMDD achieved the recommended targets for glycaemic, blood pressure (BP) and lipid control.

SETTING

City of Tshwane, South Africa.

METHODS

We reviewed the records of 198 T2DM patients enrolled in CCMDD and assessed their control of haemoglobin A1c (HbA1c), BP and lipids.

RESULTS

Most of the records reviewed belonged to women (64.7%), African (89.9%), hypertensive (82.7%) and to patients exclusively on oral antidiabetic agents (98.5%). Patients were, on average, 57.7 (s.d. = 12.1) years old and had participated in the CCMDD programme for, on average, 2 years. The mean HbA1c was 8% (s.d. = 2). Glycaemic control was achieved by only 29.2% of patients, and 49% of patients had HbA1c between 7% and 9%. Ninety-three patients (66%) had achieved the total cholesterol target, 57.4% achieved BP targets and 6.9% had achieved the low-density lipoprotein cholesterol target.

CONCLUSION

A small group of patients achieved the targets for glycaemic, BP and lipid control. Despite improved accessibility to medication, the CCMDD is not synonymous of improved clinical outcomes. Future research should ascertain the factors associated with suboptimal control for these patients.

Reduction of Pressure Pain Sensitivity as Novel Non-pharmacological Therapeutic Approach to Type 2 Diabetes: A Randomized Trial

Background

Autonomic nervous system dysfunction (ANSD) is known to affect glucose metabolism in the mammalian body. Tradition holds that glucose homeostasis is regulated by the peripheral nervous system, and contemporary therapeutic intervention reflects this convention.

Objectives

The present study tested the role of cerebral regulation of ANSD as consequence of novel understanding of glucose metabolism and treatment target in type 2 diabetes (T2D), suggested by the claim that the pressure pain sensitivity (PPS) of the chest bone periosteum may be a measure of cerebral ANSD.

Design

In a randomized controlled trial of 144 patients with T2D, we tested the claim that 6 months of this treatment would reduce PPS and improve peripheral glucose metabolism.

Results

In the active treatment group, mean glycated hemoglobin A1c (HbA1c) declined from 53.8 to 50.5 mmol/mol (intragroup p = 0.001), compared with the change from 53.8 to 53.4 mmol/mol in the control group, with the same level of diabetes treatment but not receiving the active treatment (between group p = 0.036). Mean PPS declined from 76.6 to 56.1 units (p < 0.001) in the active treatment group and from 77.5 to 72.8 units (p = 0.02; between group p < 0.001) in the control group. Changes of PPS and HbA1c were correlated (r = 0.37; p < 0.001).

Conclusion

We conclude that the proposed approach to treatment of T2D is a potential supplement to conventional therapy.

Clinical Trial Registration:

www.clinicaltrials.gov (NCT 03576430).

Does inpatient hyperglycemia predict a worse outcome in COVID-19 intensive care unit patients?

BACKGROUND

We undertook this study to evaluate the association between hyperglycemia and outcomes in patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU).

METHODS

We conducted a multicenter retrospective study involving all adults with COVID-19 admitted to the ICU between March and May 2020. Patients were divided into normoglycemic (average blood glucose <140 mg/dL) and hyperglycemic (average blood glucose ≥140 mg/dL) groups. Outcomes such as mortality, need and duration of mechanical ventilation, and length of hospital and ICU stays were measured.

RESULTS

Among 495 patients, 58.4% were male with a median age of 68 years (interquartile range [IQR]: 58.00-77.00), and baseline average blood glucose was 186.6 (SD ± 130.8). Preexisting diabetes was present in 35.8% of the studied cohort. Combined ICU and hospital mortality rates were 23.8%; mortality and mechanical ventilation rates were significantly higher in the hyperglycemic group with 31.4% vs 16.6% (P = .001) and 50.0% vs 37.2% (P = .004), respectively. Age above 60 years (hazard ratio [HR] 3.21; 95% CI 1.78, 5.78) and hyperglycemia (HR 1.79; 95% CI 1.14, 2.82) were the only significant predictors of in-hospital mortality. Increased risk for hyperglycemia was found in patients with steroid use (odds ratio [OR] 1.521; 95% CI 1.054, 2.194), triglycerides ≥150 mg/dL (OR 1.62; 95% CI 1.109, 2.379), and African American race (OR 0.79; 95% CI 0.65, 0.95).

CONCLUSIONS

Hyperglycemia in patients with COVID-19 is significantly associated with a prolonged ICU length of stay, higher need of mechanical ventilation, and increased risk of mortality in the critical care setting. Tighter blood glucose control (≤140 mg/dL) might improve outcomes in COVID-19 critically ill patients; evidence from ongoing clinical trials is needed.

Fifteen-minute Frequency of Glucose Measurements and the Use of Threshold Alarms: Impact on Mitigating Dysglycemia in Critically Ill Patients

BACKGROUND

The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients.

METHODS

An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%.

RESULTS

At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial.

CONCLUSION

Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND

Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation.

RESULTS

In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness.

CONCLUSION

We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Physical Activity and Plasma Glucose Control among Diabetic Patients Attending Outpatients Clinics in Hanoi, Vietnam

Reaching the recommendation on physical activity (PA) for health is highly important to effectively manage blood glucose in patients with type 2 diabetes (T2D). The aims of this study were to assess the level and pattern of PA among T2D outpatients and to relate PA levels to glucose control. A cross-sectional study was conducted in outpatient clinics in Hanoi, Vietnam. PA levels were reported using the Global Physical Activity Questionnaire (GPAQ) version 2.0. Participants meeting the WHO recommendations on PA for health or not were respectively categorized as “sufficiently active” and “insufficiently active”. FPG < 7.2 mmol/L was defined as controlled plasma glucose. In total, 407 participants with T2D (55% women, mean (SD) age 61.6 (9.7) years) were included. The fraction of T2D outpatients reporting as insufficiently active was 21%. The lowest amount of energy expenditure was from transport activities (travel from and to places). On multivariate logistic regression, being sufficiently active was associated with a two-fold increased likelihood of having better glycemic control. The findings warrant action plans to increase physical activity in general and in specific active transport for T2D patients in Vietnam.

Combination of Metformin and Exercise in Management of Metabolic Abnormalities Observed in Type 2 Diabetes Mellitus

Excess nutrient intake and lack of exercise characterize the problem of obesity and are common factors in insulin resistance (IR). With an increasing number of prediabetic, and type 2 diabetic populations, metformin is still the most prescribed glucose-lowering drug and is often accompanied by recommendations for regular physical exercise. Metformin, by the inhibition of complex 1 of the electron transport chain, and exercise, by increasing energy expenditure, both elicit a low cellular energy state that leads to improvements in glucose control via activation of adenosine 5' monophosphate-activated protein kinase (AMPK). An augmented stimulation of the energy-sensing enzyme AMPK by either of the two modalities leads to an increase in glycogenolysis, glucose uptake, fat oxidation, a decrease in glycogen and protein synthesis, and gluconeogenesis in muscle and the liver, which are remarked as having positive effects on metabolic pathophysiology observed in IR and type 2 diabetes mellitus (T2DM). While both modalities exploit the energy-sensing enzyme AMPK to attain glucose homeostasis, the synergistic effect of these two treatments is not distinctly supported by the literature. Further, an antagonistic dynamic has been observed in cases where metformin and exercise were combined. Reduction of insulin-sensitizing effects of exercise and an overall hindrance of exercise performance and adaptations have been reported and could suggest the possible incongruity of these two modalities. The aim of this review is to elucidate the effect that metformin and exercise have on the management of the metabolic abnormalities observed in T2DM and to provide an insight into the interaction of these two modalities.

Hybrid Closed-Loop System Achieves Optimal Perioperative Glycemia in a Boy With Type 1 Diabetes: A Case Report

The goal in type 1 diabetes (T1D) therapy is to maintain optimal glycemic control under any circumstance. Diabetes technology is in continuous development to achieve this goal. The most advanced Food and Drug Administration- and European Medicines Agency-approved devices are hybrid closed-loop (HCL) systems, which deliver insulin subcutaneously in response to glucose levels according to an automated algorithm. T1D is frequently encountered in the perioperative period. The latest international guidelines for the management of children with diabetes undergoing surgery include specific adjustments to the patient's insulin therapy, hourly blood glucose monitoring, and intravenous (IV) insulin infusion. However, these guidelines were published while the HCL systems were still marginal. We present a case of a 9-year-old boy with long-standing T1D, under HCL system therapy for the last 9 months, and needing surgery for an appendectomy. We agreed with the family, the surgical team, and the anesthesiologists to continue HCL insulin infusion, without further adjustments, hourly blood glucose checks or IV insulin, while monitoring closely. The HCL system was able to keep glycemia within range for the total duration of the overnight fast, the surgery, and the initial recovery, without any external intervention or correction bolus. This is, to the best of our knowledge, the first reported pediatric case to undergo major surgery using a HCL system, and the results were absolutely satisfactory for the patient, his family, and the medical team. We believe that technology is ripe enough to advocate for a "take your pump to surgery" message, minimizing the impact and our interventions. The medical team may discuss this possibility with the family and patients.

Prevalence and impact of chronic dysglycemia in intensive care unit patients-A retrospective cohort study

BACKGROUND

The prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to Swedish intensive care units (ICUs) is unknown. We aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centered outcomes in critically ill patients.

METHODS

In this retrospective observational cohort study, we obtained glycated hemoglobin A1c (HbA1c) in patients admitted to four tertiary ICUs in Sweden between March and August 2016. Based on previous diabetes history and HbA1c we determined the prevalence of chronic dysglycemia. We used multivariable regression analyses to study the association of chronic dysglycemia with the time-weighted average blood glucose concentration, glycemic lability index (GLI), and development of hypoglycemia (co-primary outcomes), and with ICU length of stay, mechanical ventilation duration, renal replacement therapy (RRT) use, vasopressor use, ICU-acquired infections, and mortality (exploratory clinical outcomes).

RESULTS

Of 943 patients, 312 (33%) had chronic dysglycemia. Of these 312 patients, 84 (27%) had prediabetes, 43 (14%) had undiagnosed diabetes and 185 (59%) had known diabetes. Chronic dysglycemia was independently associated with higher time-weighted average blood glucose concentration (P < .001), higher GLI (P < .001), and hypoglycemia (P < .001). Chronic dysglycemia was independently associated with RRT use (adjusted odds ratio 1.97, 95% CI 1.24-3.13, P = .004) but not with other exploratory clinical outcomes.

CONCLUSIONS

In four tertiary Swedish ICUs, measurement of HbA1c showed that one-third of patients had chronic dysglycemia. Chronic dysglycemia was associated with marked derangements in glycemic control, and a greater need for renal replacement therapy.

A Systematic Review of Collective Evidences Investigating the Effect of Diabetes Monitoring Systems and Their Application in Health Care

INTRODUCTION

Diabetes monitoring systems (DMS) are a possible approach for regular control of glucose levels in patients with Type 1 or 2 diabetes in order to improve therapeutic outcomes or to identify and modify inappropriate patient behaviors in a timely manner. Despite the significant number of studies observing the DMS, no collective evidence is available about the effect of all devices.

GOAL

To review and consolidate evidences from multiple systematic reviews on the diabetes monitoring systems and the outcomes achieved.

MATERIALS AND METHODS

Internet-based search in PubMed, EMBASE, and Cochrane was performed to identify all studies relevant to the research question. The data regarding type of intervention, type of diabetes mellitus, type of study, change in clinical parameter(s), or another relevant outcome were extracted and summarized.

RESULTS

Thirty-three out of 1,495 initially identified studies, involving more than 44,100 patients with Type 1, Type 2, or gestational diabetes for real-time or retrospective Continuous Glucose Monitoring (CGMS), Sensor Augmented Pump Therapy (SAPT), Self-monitoring Blood Glucose (SMBG), Continuous subcutaneous insulin infusion (CSII), Flash Glucose Monitoring (FGM), Closed-loop systems and telemonitoring, were included. Most of the studies observed small nominal effectiveness of DMS. In total 11 systematic reviews and 15 meta-analyses, with most focusing on patients with Type 1 diabetes (10 and 6, respectively), reported a reduction in glycated hemoglobin (HbA1c) levels from 0.17 to 0.70% after use of DMS.

CONCLUSION

Current systematic review of already published systematic reviews and meta-analyses suggests that no statistically significant difference exists between the values of HbA1c as a result of application of any type of DMS. The changes in HbA1c values, number and frequency of hypoglycemic episodes, and time in glucose range are the most valuable for assessing the appropriateness and effectiveness of DMS. Future more comprehensive studies assessing the effectiveness, cost-effectiveness, and comparative effectiveness of DMS are needed to stratify them for the most suitable diabetes patients' subgroups.

Dietary inflammatory index score, glucose control and cardiovascular risk factors profile in people with type 2 diabetes

We examined the relationships between the dietary inflammatory index (DII^®), dietary habits and cardiovascular risk factor profiles in people with type 2 diabetes mellitus (T2DM). Energy-adjusted DII (E-DII™) scores were calculated from a Food Frequency Questionnaire in 2568 T2DM patients from different parts of Italy. Analyses were conducted according to quartiles of sex-specific E-DII scores. Higher, more pro-inflammatory, (quartile 4) E-DII scores were associated with overall poor quality of the diet characterised by higher content of refined carbohydrates, added sugars, saturated fat and cholesterol and lower unsaturated fat, fibre and polyphenols compared to quartile 1. Higher E-DII scores also were associated with higher waist circumference (105.4 vs. 103.5 cm; p = 0.002), triglycerides (154.6 vs. 146.1 mg/dL; p = 0.005), diastolic blood pressure (80.05 vs. 78.6 mmHg; p = 0.04) and lower HDL-cholesterol (45.3 vs. 47.4 mg/dL; p = 0.04). In conclusion, E-DII is a potent marker of overall quality of the diet and is associated with an unfavourable cardiovascular risk factor profile.

Targets for blood glucose: What have the trials told us

The challenges of diabetes treatment are to prevent or delay microangiopathic complications and macrovascular disease. Early, effective and sustained glycaemic control is advocated by all diabetes guidelines to mitigate the risks of prolonged hyperglycaemia. The post-hoc analyses of the large randomised glucose intervention trials and the long-term results of these trials have shown clearly that intensive glycaemic control may have more favourable cardiovascular effects when initiated earlier in the course of diabetes, particularly among in patients without cardiovascular disease. Based on the intervention trials a haemoglobin A1c level of less than 7.0% (<53 mmol/mol) is a generally accepted target to reduce microvascular disease and should be initiated early in the course of the diabetes. However, haemoglobin A1c targets should be individualised. Achieving a good glycaemic control without detrimental effect and preferably with benefit to the cardiovascular system and to renal function is an important challenge. When targeting a tight glycaemic control, avoidance of hypoglycaemia is crucial particularly in patients with coronary artery disease and in patients with heart failure. The cardiovascular outcomes trials performed to test the cardiovascular safety of the new glucose-lowering therapies offer compelling evidence in favour of the role of these drugs for cardiovascular prevention. Thus, both the glycaemic target and the choice of therapies should now be defined on an individual basis.

Managing Diabetes During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has affected almost every country in the world and has changed the way we access healthcare. People with pre-existing conditions, such as diabetes, are at high risk of a severe disease course and it is essential that, as well as good hygiene and social distancing measures, blood glucose is carefully monitored, as chronic hyperglycaemia can lead to immune dysfunction. People with diabetes should be encouraged to continue medication prescribed for hypertension, diabetes or dyslipidaemia. Furthermore, patients with diabetes and COVID-19 infection should follow their usual antidiabetic treatment with the exception of sodium-glucose cotransporter-2 inhibitors. As the current pandemic situation has rendered some patients unable to access routine healthcare, telehealth may help those with travel restrictions.

Glucagon for hypoglycaemia treatment in type 1 diabetes

To achieve strict glycaemic control and avoid chronic diabetes complications, individuals with type 1 diabetes (T1D) are recommended to follow an intensive insulin regimen. However, the risk and fear of hypoglycaemia often prevent individuals from achieving the treatment goals. Apart from early insulin suspension in insulin pump users, carbohydrate ingestion is the only option for preventing and treating non-severe hypoglycaemic events. These rescue treatments may give extra calories and cause overweight. As an alternative, the use of low-dose glucagon to counter hypoglycaemia has been proposed as a tool to raise glucose concentrations without adding extra calories. Previously, the commercially available glucagon formulations required reconstitution from powder to a solution before being injected subcutaneously or intramuscularly-making it practical only for treating severe hypoglycaemia. Several companies have developed more stable formulations that do not require the time-consuming reconstitution process before use. As well as treating severe hypoglycaemia, non-severe and impending hypoglycaemia can also be treated with lower doses of glucagon. Once available, low-dose glucagon can be either delivered manually, as an injection, or automatically, by an infusion pump. This review focuses on the role and perspectives of using glucagon to treat and prevent hypoglycaemia in T1D.

Health Literacy and Outcomes of a Community-Based Self-Help Intervention: A Case of Korean Americans With Type 2 Diabetes

BACKGROUND

Although scientific reports increasingly document the negative impact of inadequate health literacy on health-seeking behaviors, health literacy's effect on health outcomes in patients with diabetes is not entirely clear, owing to insufficient empirical studies, mixed findings, and insufficient longitudinal research.

OBJECTIVE

The aim of this study was to empirically examine underlying mechanisms of health literacy's role in diabetes management among a group of Korean Americans with Type 2 diabetes mellitus.

METHODS

Data from a randomized clinical trial of a health literacy-focused Type 2 diabetes self-management intervention conducted during 2012-2016 in the Korean American community were collected at baseline and at 3, 6, 9, and 12 months. A total of 250 Korean Americans with Type 2 diabetes participated (intervention, 120; control, 130). Participants were first-generation Korean American immigrants. Health literacy knowledge was measured with the original Rapid Estimate of Adult Literacy in Medicine and the diabetes mellitus-specific Rapid Estimate of Adult Literacy in Medicine. Functional health literacy was measured with the numeracy subscale of the Test of Functional Health Literacy in Adults and the Newest Vital Sign screening instrument, which also uses numeracy. Primary outcomes included glucose control and diabetes quality of life. Multivariate analyses included latent variable modeling.

RESULTS

A series of path analyses identified self-efficacy and self-care skills as significant mediators between health literacy and glucose control and quality of life. Education and acculturation were the most significant correlates of health literacy.

DISCUSSION

Despite inconsistent findings in the literature, this study indicates that health literacy may indirectly influence health outcomes through mediators such as self-care skills and self-efficacy. The study highlights the importance of health literacy, as well as underlying mechanisms with which health literacy influences processes and outcomes of diabetes self-management.

SGLT2 Inhibitors as Add-On Therapy to Metformin for People with Type 2 Diabetes: A Review of Placebo-Controlled Trials in Asian versus Non-Asian Patients

Metformin remains the first pharmacological choice for treating hyperglycemia in type 2 diabetes (T2DM) in most international guidelines. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are increasingly used as add-on therapy. T2DM pathophysiology is different in Asian and non-Asian (mainly Caucasian) patients. The aim of this systematic review is to compare the efficacy of SGLT2is vs placebo added to metformin in randomized controlled trials (RCTs: range 12-52 weeks) in Asian versus non-Asian patients with T2DM. The primary endpoint is the reduction in glycated hemoglobin (HbA1c) from baseline and key secondary endpoints are reductions in fasting plasma glucose (FPG), body weight (BW) and systolic blood pressure (SBP). Systematic literature search collected 7 RCTs (3 with 2 doses) in Asian patients (10 analyses, n=1164, iSGLT2: canagliflozin, dapagliflozin, ertugliflozin, ipragliflozin, tofogliflozin)) and 10 RCTs (6 with two doses) in non-Asian patients (16 analyses, n=2482, iSGLT2: canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin). Baseline values of HbA1c (7.98±0.19 vs 7.89±0.27%), FPG (8.80 ±0.46 vs 9.11±0.49 mmol/l) and SBP (128.4±1.6 vs 130.2±3.1 mmHg) were not significantly different in Asian vs non-Asian patients, but BW was lower in Asian patients (71.6±4.8 vs 88.0±2.5 kg, p<0.001). The placebo-adjusted weighed mean differences (WMD, 95% CI) were similar in Asian versus non-Asian patients regarding the reductions in HbA1c -0.60 (-0.68, -0.53) % versus -0.54 (-0.59, -0.49) % (p=0.568), FPG -1.37 (-1.53, -1.22) mmol/l vs -1.37 (-1.47, -1.27) mmol/l (p=0.627), BW when expressed in percentage of baseline BW -2.23 (-2.55, -1.90) % vs -2.16 (-2.37, -1.96) % (p=0.324), and SBP -4.53 (-5.53, -3.53) mmHg vs -4.06 (-4.83, -3.29) mmHg) (p=0.223). In conclusion, clinical efficacy of SGLT2i, as an add-on treatment to metformin monotherapy in patients with T2DM, is similar in Asian versus non-Asian patients, despite known ethnic differences in phenotype and pathophysiology of T2DM.

The association between novel glucose indices in parturients with type 1 diabetes mellitus and clinically significant neonatal hypoglycemia

The aim of this study was to determine the association between glucose control indices of parturient with type 1 diabetes (T1DM), treated with an insulin pump and utilizing continuous glucose monitoring (CGM), and clinically significant neonatal hypoglycemia. This was a retrospective cohort study which included 37 pregnant women with T1DM. All women were followed at a single tertiary center and had available CGM data. The association between maternal glucose indices before delivery and the risk for neonatal hypoglycemia requiring IV glucose (clinically significant hypoglycemia) was assessed using logistic regression. Mothers to neonates that experienced clinically significant hypoglycemia had a higher glucose standard deviation (SD) before delivery than did mothers to neonates who did not (25.5 ± 13 mg/dL vs. 14.7 ± 6.7 mg/dl respectively; p = .008). This association persisted after adjustment for maternal age, maternal pregestational body mass index (BMI), gestational age at delivery, neonatal birth weight, large for gestational age (LGA) and gender. This study demonstrates an association between high maternal glucose standard deviation before delivery and the risk for clinically significant neonatal hypoglycemia. Larger studies are needed to confirm these results and further explore the role of intrapartum glucose variability in the prediction and prevention of significant neonatal hypoglycemia.

Rejuvenation of Neutrophil Functions in Association With Reduced Diabetes Risk Following Ten Weeks of Low-Volume High Intensity Interval Walking in Older Adults With Prediabetes - A Pilot Study

Neutrophil dysfunction is a common feature of aging, and is associated with the pathogenesis of many age-related diseases, including type 2 diabetes mellitus (T2DM). Although exercise training improves metabolic health, decreases risk of T2DM, and is associated with improving neutrophil functions, involvement in regular physical activity declines with age. The aim of this study was to determine if neutrophil functions could be improved in association with changes in fitness and metabolic parameters in older adults at risk for T2DM using 10-weeks of low volume high-intensity interval exercise training (HIIT). Ten older (71 ± 5 years) sedentary adults with prediabetes (HbA1c: 6.1 ± 0.3%) completed 10 weeks of a supervised HIIT program. Three 30 min sessions/week consisted of ten 60 s intervals of low intensity [50–60% heart rate reserve (HRR)] separated with similar durations of high intensity intervals (80–90% HRR). Before and after training, glucose and insulin sensitivity, neutrophil chemotaxis, bacterial phagocytosis, reactive oxygen species (ROS) production, and mitochondrial functions were assessed. Exercise-mediated changes in cardiorespiratory fitness (VO_2peak) and neutrophil functions were compared to six young (23 ± 1 years) healthy adults. Following training, significant reductions in fasting glucose and insulin were accompanied by improved glucose control and insulin sensitivity (all p < 0.05). Before exercise training, VO_2peak in the old participants was significantly less than that of the young controls (p < 0.001), but increased by 16 ± 11% following training (p = 0.002) resulting in a 6% improvement of the deficit. Neutrophil chemotaxis, phagocytosis and stimulated ROS production were significantly less than that of the young controls, while basal ROS were higher before training (all p < 0.05). Following training, chemotaxis, phagocytosis and stimulated ROS increased while basal ROS decreased, similar to levels observed in the young controls (all p < 0.05) and reducing the deficit of the young controls between 2 and 154%. In five of the adults with prediabetes, neutrophil mitochondrial functions were significantly poorer than the six young controls before training. Following training, mitochondrial functions improved toward those observed in young controls (all p < 0.05), reducing the deficit of the young controls between 14.3 and 451%. Ten weeks of HIIT in older adults at risk for T2DM reduced disease risk accompanied by improved primary and bioenergetic neutrophil functions. Our results are consistent with a reduced risk of infections mediated by relationships in exercise induced systemic and cellular metabolic features.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02441205, registered on May 12th, 2015.

Altered features of neurotransmitters: NPY, α-MSH, and AgRP in type 2 diabetic patients with hypertension

OBJECTIVE

To investigate the features of neuropeptide Y (NPY), α-melanocyte stimulating hormone (α-MSH), and agouti-related protein (AgRP) in type 2 diabetes mellitus (T2DM) patients with hypertension.

METHODS

Patients with T2DM (n = 384) and healthy volunteers (n = 80) were enrolled into this study. Serum NPY, α-MSH, and AgRP levels were detected using ELISA.

RESULTS

Significantly higher NPY and lower α-MSH and AgRP levels were observed in patients with diabetes compared with those without diabetes, and the mean NPY levels increased, while α-MSH and AgRP levels decreased, with the development of hypertension compared with diabetic patients without hypertension. α-MSH and AgRP levels decreased with an increase in blood pressure in hypertension compared with the non-hypertension patients. Multiple stepwise linear regression analysis showed that NPY, α-MSH, and AgRP levels were closely associated with blood pressure and glucose control. Receiver operating characteristic (ROC) curve analyses indicated that α-MSH may be a better marker compared with NPY and AgRP for regulating glucose and blood pressure and to distinguish between T2DM patients with and without hypertension.

CONCLUSION

NPY, α-MSH, and AgRP might play different roles and be closely related to the occurrence and development of diabetes and hypertension.

Nutrition Therapy, Glucose Control, and Brain Metabolism in Traumatic Brain Injury: A Multimodal Monitoring Approach

The goal of neurocritical care in patients with traumatic brain injury (TBI) is to prevent secondary brain damage. Pathophysiological mechanisms lead to loss of body mass, negative nitrogen balance, dysglycemia, and cerebral metabolic dysfunction. All of these complications have been shown to impact outcomes. Therapeutic options are available that prevent or mitigate their negative impact. Nutrition therapy, glucose control, and multimodality monitoring with cerebral microdialysis (CMD) can be applied as an integrated approach to optimize systemic immune and organ function as well as adequate substrate delivery to the brain. CMD allows real-time bedside monitoring of aspects of brain energy metabolism, by measuring specific metabolites in the extracellular fluid of brain tissue. Sequential monitoring of brain glucose and lactate/pyruvate ratio may reveal pathologic processes that lead to imbalances in supply and demand. Early recognition of these patterns may help individualize cerebral perfusion targets and systemic glucose control following TBI. In this direction, recent consensus statements have provided guidelines and recommendations for CMD applications in neurocritical care. In this review, we summarize data from clinical research on patients with severe TBI focused on a multimodal approach to evaluate aspects of nutrition therapy, such as timing and route; aspects of systemic glucose management, such as intensive vs. moderate control; and finally, aspects of cerebral metabolism. Research and clinical applications of CMD to better understand the interplay between substrate supply, glycemic variations, insulin therapy, and their effects on the brain metabolic profile were also reviewed. Novel mechanistic hypotheses in the interpretation of brain biomarkers were also discussed. Finally, we offer an integrated approach that includes nutritional and brain metabolic monitoring to manage severe TBI patients.

Advances in Medical Nutrition Therapy: Parenteral Nutrition

Parenteral nutrition has evolved tremendously, with parenteral formulas now safer and more accessible than ever. "All-in-one" admixtures are now available, which simplify parenteral nutrition usage and decrease line infection rates alongside other methods of infectious control. Recently published data on the benefits of parenteral nutrition versus enteral nutrition together with the widespread use of indirect calorimetry solve many safety issues that have emerged over the years. All these advances, alongside a better understanding of glycemic control and lipid and protein formulation improvements, make parenteral nutrition a safe alternative to enteral nutrition.

Pasta Consumption and Connected Dietary Habits: Associations with Glucose Control, Adiposity Measures, and Cardiovascular Risk Factors in People with Type 2 Diabetes-TOSCA.IT Study

Background: Pasta is a refined carbohydrate with a low glycemic index. Whether pasta shares the metabolic advantages of other low glycemic index foods has not really been investigated. The aim of this study is to document, in people with type-2 diabetes, the consumption of pasta, the connected dietary habits, and the association with glucose control, measures of adiposity, and major cardiovascular risk factors. Methods: We studied 2562 participants. The dietary habits were assessed with the European Prospective Investigation into Cancer and Nutrition (EPIC) questionnaire. Sex-specific quartiles of pasta consumption were created in order to explore the study aims. Results: A higher pasta consumption was associated with a lower intake of proteins, total and saturated fat, cholesterol, added sugar, and fiber. Glucose control, body mass index, prevalence of obesity, and visceral obesity were not significantly different across the quartiles of pasta intake. No relation was found with LDL cholesterol and triglycerides, but there was an inverse relation with HDL-cholesterol. Systolic blood pressure increased with pasta consumption; but this relation was not confirmed after correction for confounders. Conclusions: In people with type-2 diabetes, the consumption of pasta, within the limits recommended for total carbohydrates intake, is not associated with worsening of glucose control, measures of adiposity, and major cardiovascular risk factors.

Physiological basis of brief vigorous exercise to improve health

This review considers the physiological basis of brief vigorous exercise to improve health, with a focus on cardiorespiratory fitness (CRF) and glycaemic control, and the potential underlying mechanisms involved. We defined 'brief' as a protocol lasting ≤15 min including warm-up, cool-down and recovery, and involving a total of ≤5 min of 'vigorous' exercise, which was classified as meeting or exceeding the lower end of the range for this relative intensity as per the criteria from the American College of Sports Medicine. The physiological mechanisms responsible for the increase in CRF, as measured by maximal oxygen update ( V ̇ O 2 max ), after brief vigorous exercise are unclear and likely depend on various factors including the specific nature of the intervention as well as the time course of the response. Limited available evidence suggests the potential for an increased oxygen extraction by active muscle (i.e. greater arterio-venous oxygen difference), since an increase in V ̇ O 2 max has been reported after several weeks of brief vigorous exercise despite no measurable change in cardiac output. Emerging evidence indicates that brief vigorous exercise can improve glycaemic control, suggesting that this type of exercise could potentially play a role in the prevention and management of type 2 diabetes. The acute response is not well characterized but several studies have shown that several weeks of vigorous exercise improves estimates of insulin sensitivity as determined by various methods including by hyperinsulinaemic-euglycaemic clamp. The physiological mechanisms underlying improved CRF and glycaemic control after brief vigorous exercise, and the broader impact on health, remain fruitful areas of investigation.

Identification of repurposable drugs with beneficial effects on glucose control in type 2 diabetes using machine learning

Despite effective medications, rates of uncontrolled glucose levels in type 2 diabetes remain high. We aimed to test the utility of machine learning applied to big data in identifying the potential role of concomitant drugs not taken for diabetes which may contribute to lowering blood glucose. Success in controlling blood glucose was defined as achieving HgA1c levels < 6.5% after 90-365 days following diagnosis and initiating treatment. Among numerous concomitant drugs taken by type 2 diabetic patients, alpha 1 (α1)-adrenoceptor antagonist drugs were the only group of medications that significantly improved the success rate of glucose control. Searching the published literature, this effect of α1-adrenoceptor antagonists has been shown in animal models, where this class of medications appears to induce insulin secretion. In conclusion, machine learning of big data is a novel method to identify effective antidiabetic effects for potential repurposable medications already on the market for other indications. Because these α1-adrenoceptor antagonists are widely used in men for treating benign prostate hyperplasia (BPH) at age groups exhibiting increased rates of type 2 diabetes, this finding is of potential clinical significance.

Effect of Injection Site Cooling and Warming on Insulin Glargine Pharmacokinetics and Pharmacodynamics

BACKGROUND

In type 1 diabetes (T1D), closed-loop systems provide excellent overnight fasting blood glucose control by adjusting the insulin infusion rate based on corresponding changes in sensor glucose levels. In patients on multiple daily insulin (MDI) injections, such control in overnight glucose levels has not been possible due to the inability to alter the absorption rate of long-acting insulin after injection. In this study, we tested the hypothesis that increases/decreases of fasting glucose levels could be achieved by cooling/warming the skin around the injection site, which would result in lower/higher Glargine absorption rates from its subcutaneous depot.

METHODS

Fourteen subjects with T1D (4 females; age 39.6 ± 16.7 years, HbA1c 7.8 ± 1.1%, BMI 25.4 ± 2.8 kg/m²) on MDI therapy underwent fasting pharmacokinetic and pharmacodynamic studies that started at ~8 am and lasted 240 min on 3 separate days in random order: a control day without warming or cooling of the injection site and two experimental days, one day with injection site warming and the other with cooling.

RESULTS

Cooling the skin around the glargine injection site reduced insulin concentrations by >40% (P < .01 versus the warming study, P = .21 versus the control study), accompanied by a 55 mg/dL increase in serum glucose (P < .01 versus the control study). Conversely, skin warming prevented the fall in serum insulin (P = .2 versus the control study; P < .01 versus the cooling study), resulting in a 40 mg/dL reduction in serum glucose (P < .001 versus the cooling study, P = .11 versus the control study).

CONCLUSIONS

This proof of concept study has shown that cooling and warming the skin around the injection site provides a means to decrease and increase the rate of absorption and action of insulin glargine from its subcutaneous depot.

Effects of sodium-glucose cotransporter (SGLT) inhibitors in addition to insulin therapy on glucose control and safety outcomes in adults with type 1 diabetes: A meta-analysis of randomized controlled trials

Sodium-glucose cotransporter (SGLT) inhibitors added to insulin therapy have been proposed as treatment strategy for type 1 diabetes (T1D). We thus conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy and adverse effects of this combination in T1D. We searched the PubMed, EMBASE, and Cochrane Library databases and ClinicalTrials.gov for RCTs. Statistical analyses were performed using STATA 15. Ten eligible placebo-controlled trials involving 5961 patients were included. Compared with placebo, SGLT inhibitors were associated with a reduction in HbA1c of -0.39% (95% CI, -0.43 to -0.36), an improved mean amplitude of glucose excursion (MAGE) of -14.81 mg/dL (95% CI, -19.08 to -10.54), and a reduction in body weight of -3.47% (95% CI, -3.78 to -3.16), as well as no increased relative risk of hypoglycaemia (1.01; 95% CI, 0.99-1.02) or severe hypoglycaemia (0.91; 95% CI, 0.77-1.07). SGLT inhibitors decreased fasting plasma glucose and insulin requirement but increased the risk of genital infection (3.57; 95% CI, 2.97-4.29) and diabetic ketoacidosis (3.11; 95% CI, 2.11-4.58). However, the very low dose empagliflozin (2.5 mg) did not increase the risk of diabetic ketoacidosis (risk ratio [RR] 0.67; 95% CI, 0.11-3.95). SGLT inhibitors had no effect on overall adverse events, urinary tract infection, or bone fracture but slightly increased the risk of serious adverse events (1.35; 95% CI, 1.16-1.58), severe adverse events (1.84; 95% CI, 1.20-2.84), adverse events leading to discontinuation (1.50; 95% CI, 1.22-1.84), drug-related adverse events (1.78; 95% CI, 1.44-2.19), and diarrhoea (1.54; 95% CI, 1.15-2.05). Although adverse events exist, the available data provide evidence that the combination of SGLT inhibitors with basal insulin treatment is beneficial in patients with T1D.

Overproduction of endothelin-1 impairs glucose tolerance but does not promote visceral adipose tissue inflammation or limit metabolic adaptations to exercise

Endothelin-1 (ET-1) is a potent vasoconstrictor and proinflammatory peptide that is upregulated in obesity. Herein, we tested the hypothesis that ET-1 signaling promotes visceral adipose tissue (AT) inflammation and disrupts glucose homeostasis. We also tested if reduced ET-1 is a required mechanism by which exercise ameliorates AT inflammation and improves glycemic control in obesity. We found that 1) diet-induced obesity, AT inflammation, and glycemic dysregulation were not accompanied by significantly increased levels of ET-1 in AT or circulation in wild-type mice and that endothelial overexpression of ET-1 and consequently increased ET-1 levels did not cause AT inflammation yet impaired glucose tolerance; 2) reduced AT inflammation and improved glucose tolerance with voluntary wheel running was not associated with decreased levels of ET-1 in AT or circulation in obese mice nor did endothelial overexpression of ET-1 impede such exercise-induced metabolic adaptations; 3) chronic pharmacological blockade of ET-1 receptors did not suppress AT inflammation in obese mice but improved glucose tolerance; and 4) in a cohort of human subjects with a wide range of body mass indexes, ET-1 levels in AT, or circulation were not correlated with markers of inflammation in AT. In aggregate, we conclude that ET-1 signaling is not implicated in the development of visceral AT inflammation but promotes glucose intolerance, thus representing an important therapeutic target for glycemic dysregulation in conditions characterized by hyperendothelinemia. Furthermore, we show that the salutary effects of exercise on AT and systemic metabolic function are not contingent on the suppression of ET-1 signaling.

Hospital-acquired complications in intensive care unit patients with diabetes: A before-and-after study of a conventional versus liberal glucose control protocol

BACKGROUND

Critically ill patients with diabetes mellitus (DM) are at increased risk of in-hospital complications and the optimal glycemic target for such patients remains unclear. A more liberal approach to glucose control has recently been suggested for patients with DM, but uncertainty remains regarding its impact on complications.

METHODS

We aimed to test the hypothesis that complications would be more common with a liberal glycemic target in ICU patients with DM. Thus, we compared hospital-acquired complications in the first 400 critically ill patients with DM included in a sequential before-and-after trial of liberal (glucose target: 10-14 mmol/L) vs conventional (glucose target: 6-10 mmol/L) glucose control.

RESULTS

Of the 400 patients studied, 165 (82.5%) patients in the liberal and 177 (88.5%) in the conventional-control group were coded for at least one hospital-acquired complication (P = 0.09). When comparing clinically relevant complications diagnosed between ICU admission and hospital discharge, we found no difference in the odds for infectious (adjusted odds ratio [aOR] for liberal-control: 1.15 [95% CI: 0.68-1.96], P = 0.60), cardiovascular (aOR 1.40 [95% CI: 0.63-3.12], P = 0.41) or neurological complications (aOR: 1.07 [95% CI: 0.61-1.86], P = 0.81), acute kidney injury (aOR 0.83 [95% CI: 0.43-1.58], P = 0.56) or hospital mortality (aOR: 1.09 [95% CI: 0.59-2.02], P = 0.77) between the liberal and the conventional-control group.

CONCLUSION

In this prospective before-and-after study, liberal glucose control was not associated with an increased risk of hospital-acquired infectious, cardiovascular, renal or neurological complications in critically ill patients with diabetes.

Management of Glucose Control in Noncritically Ill, Hospitalized Patients Receiving Parenteral and/or Enteral Nutrition: A Systematic Review

Hyperglycemia is a common occurrence in hospitalized patients receiving parenteral and/or enteral nutrition. Although there are several approaches to manage hyperglycemia, there is no consensus on the best practice. We systematically searched PubMed, Embase, Cochrane Central, and ClinicalTrials.gov to identify records (published or registered between April 1999 and April 2019) investigating strategies to manage glucose control in adults receiving parenteral and/or enteral nutrition whilst hospitalized in noncritical care units. A total of 15 completed studies comprising 1170 patients were identified, of which 11 were clinical trials and four observational studies. Diabetes management strategies entailed adaptations of nutritional regimens in four studies, while the remainder assessed different insulin regimens and administration routes. Diabetes-specific nutritional regimens that reduced glycemic excursions, as well as algorithm-driven insulin delivery approaches that allowed for flexible glucose-responsive insulin dosing, were both effective in improving glycemic control. However, the assessed studies were, in general, of limited quality, and we see a clear need for future rigorous studies to establish standards of care for patients with hyperglycemia receiving nutrition support.

Fecal Enterobacteriales enrichment is associated with increased in vivo intestinal permeability in humans

Type 2 diabetes (T2D) has been linked with increased intestinal permeability, but the clinical significance of this phenomenon remains unknown. The objective of this study was to investigate the potential link between glucose control, intestinal permeability, diet and intestinal microbiota in patients with T2D. Thirty‐two males with well‐controlled T2D and 30 age‐matched male controls without diabetes were enrolled in a case–control study. Metabolic parameters, inflammatory markers, endotoxemia, and intestinal microbiota in individuals subdivided into high (HP) and normal (LP) colonic permeability groups, were the main outcomes. In T2D, the HP group had significantly higher fasting glucose (P = 0.034) and plasma nonesterified fatty acid levels (P = 0.049) compared with the LP group. Increased colonic permeability was also linked with altered abundances of selected microbial taxa. The microbiota of both T2D and control HP groups was enriched with Enterobacteriales. In conclusion, high intestinal permeability was associated with poorer fasting glucose control in T2D patients and changes in some microbial taxa in both T2D patients and nondiabetic controls. Therefore, enrichment in the gram‐negative order Enterobacteriales may characterize impaired colonic permeability prior to/independently from a disruption in glucose tolerance.

Concurrent exercise training on hyperglycemia and comorbidities associated: Non-responders using clinical cutoff points

This study examined the effects of a 20-week concurrent training (CT, ie, resistance plus endurance training) intervention on cardiovascular risk factors, such as body composition, blood pressure, and lipid profile among adult women with hyperglycemia. A secondary aim was to report prevalence of non-responders for the different study outcomes. Physically inactive overweight/obese and hyperglycemic adult women (42 ± 6 years; BMI = 30.9 ± 4.8 kg/m² ) were randomly assigned to a 20-week CT intervention group or a control (non-exercise) group (CG) (n = 14/group). Cardiovascular risk factors for body composition (body mass, waist circumference [WC], fat mass, and lean mass), blood pressure, and lipid profile (total, LDL cholesterol and HDL cholesterol, triglycerides, and fasting glucose) were assessed before and after the 20-week intervention. Our results show that a CT intervention results in a reduction of comorbidities in terms of abdominal obesity and cardiovascular risk in adult women with hyperglycemia by decreasing WC and improving lipid profile in "mean" terms. At the individual level, after CT, some subjects changed their status from a "high" to a "low" cardiovascular risk in terms of WC, while others changed from hypertension to either high blood pressure or normotension, or from high blood pressure to normotension, and others changed from hypercholesterolemia/dyslipidemia to normocholesterolemia. Overall, there were ~30%, 50%, and 20% of individuals in the CT exercise group who showed no change/adverse response for body composition, blood pressure, and lipid profile, respectively, after the 20-week CT intervention.

Fully closed-loop insulin delivery improves glucose control of inpatients with type 2 diabetes receiving hemodialysis

Inpatient diabetes management of those on hemodialysis poses a major challenge. In a post hoc analysis of a randomized controlled clinical trial, we compared the efficacy of fully automated closed-loop insulin delivery vs. usual care in patients undergoing hemodialysis while in hospital. Compared to control patients receiving conventional subcutaneous insulin therapy, those patients receiving closed-loop insulin delivery significantly increased the proportion of time when a continuous glucose monitor was in the target range of 5.6-10.0 mmol/l by 37.6 percent without increasing the risk of hypoglycemia. Thus, closed-loop insulin delivery offers a novel way to achieve effective and safe glucose control in this vulnerable patient population.

Are We Ready to Treat Our Diabetes Patients Using Social Media? Yes, We Are

AIMS

The aim of the study was to evaluate Facebook group as possible communication tool to improve glucose control in adolescents and young people with type 1 diabetes (T1D).

METHODS

This retrospective and cross-sectional study included 728 T1D patients (age 11-25) on continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) treated at the center for insulin pump and glucose sensor in Skopje from January 2012 to December 2017. Data were collected through the electronic medical record system and cross-sectional analysis (telephone, social media (Facebook and Viber) or email). Patients were analyzed in two groups: (a) non-Internet group, with 398 patients treated using standard medical protocol with regular clinic visits; (b) Internet group, with 330 patients who, besides standard medical protocol, were active members of a national closed Facebook group on diabetes. Both the non-Internet and Internet groups had regular visits every 2-3 months. Patients from the Internet group were members of the closed Facebook group "Diabetes Macedonia" and had an opportunity to interact with questions, answers, and comments on diabetes care. An additional analysis was performed of the Internet group on combined use of Facebook and Viber. Average HbA1c levels were compared in both groups.

RESULTS

Each patient from the Facebook group had 1.5 ± 3.5 posts per day. Hba1c was significantly lower in patients from the Internet group (7.1 ± 3.2%; 54 ± 35 mmol/mol) compared to patients from the non-Internet group (7.6 ± 2.8%; 60 ± 31 mmol/mol).

CONCLUSIONS

Social media like Facebook and Viber can be additional communication tool in adolescents and young people with T1D and can significantly lower HbA1c compared to patients without social media use. CSII patients are more likely to use both social media (Facebook and Viber) compared with MDI patients (Facebook only).

Effect of glycaemic control on cardiovascular disease in individuals with type 2 diabetes with pre-existing cardiovascular disease: A systematic review and meta-analysis

The role of intensive glucose control in people with type 2 diabetes and pre-existing cardiovascular disease (CVD) is controversial. The aim of this systematic review and meta-analysis was to determine in a subset of people with type 2 diabetes and pre-existing CVD, the CV effect of intensive glucose control versus standard of care. We searched Medline, the Cochrane library, EMBASE and the National Institutes of Health Trial registration database for randomized controlled trials that evaluated the effect of intensive glucose control versus standard glucose control in people with type 2 diabetes on incident CVD. Data were extracted using a structured form. When data were not available in the publications, authors were contacted. Eight trials involving 8339 participants were included. Among adults with type 2 diabetes and pre-existing CVD, there was no difference in the risk of CV events in those allocated to intensive glucose control compared with those in the standard care arm (relative risk 0.98, 95% confidence interval 0.87-1.09). In conclusion, in people with diabetes and pre-existing CVD, intensive glucose control versus standard care had a neutral effect on incident CV events.

Sweet and Sour: Impact of Early Glycemic Control on Outcomes in Necrotizing Soft-Tissue Infections

Background: Necrotizing soft-tissue infection (NSTI) is a devastating disease associated with high rates of morbidity and mortality. Hyperglycemia is associated with poor wound healing; however, there are no studies evaluating glycemic control outcomes in patients with NSTI. The objective of this study was to examine disease progression and death in patients with NSTI who achieved early glycemic control (EGC) compared with patients that did not. Methods: A retrospective chart review of patients with NSTI was conducted between November 2011 and August 2017. Early glycemic control was defined as a daily average blood glucose concentration ≤150 mg/dL for a minimum of two consecutive days from admission to hospital day three. The primary outcome of this study was a composite of ≤3 debridement procedures by hospital day 14 and survival to discharge. Secondary outcomes were the total number of debridement procedures, amputation, hospital length of stay (LOS), intensive care unit (ICU) LOS, number of hypoglycemic events throughout hospitalization, and discharge disposition. Results: One-hundred five patients were included in the analysis. There were 62% male patients, mean age of 55.3 years, mean weight of 106.9 kg, and 57.1% with diabetes mellitus (DM). The 54 (51.4%) patients with EGC were less likely to have DM (29.6% versus 86.3%; p < 0.001), had a lower median admission glucose concentration (120.5 [97-144] versus 198 [153-295.5] mg/dL; p < 0.001), and had lower median daily glucose values during the first 96 hours after admission (p < 0.001). There was no significant difference in the primary outcome (83.3%% versus 84.3%; p > 0.99) or incidence of hypoglycemia (14.8% versus 23.5%; p = 0.32). Patients with EGC were more likely to return home after discharge (44.4% versus 23.5%; p = 0.039). Conclusion: Overall, there was no difference in composite clinical outcomes between patients with EGC and those without, although more patients who achieved EGC were discharged home. Patients with DM were less likely to achieve EGC.

Renal and Glucose-Lowering Effects of Empagliflozin and Dapagliflozin in Different Chronic Kidney Disease Stages

Objective: The objective of this study was to investigate the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on renal function in different stages of chronic kidney disease (CKD). Design and Methods: We conducted a retrospective cohort study using longitudinal claims data from May 2016-December 2017 from the Chang Gung Research Database. Patients who used one of the three types of SGLT2 inhibitor available at Chang Gung Memorial Hospital, namely empagliflozin 10 mg/tab (Empa10), empagliflozin 25 mg/tab (Empa25), and dapagliflozin 10 mg/tab (Dapa), were included, with the same number of matched non-users. Analysis of variance was used for continuous variables and the chi-square test was applied for categorical variables. Differences in data between two groups were analyzed using an independent t-test, and the basic data before and after treatment were analyzed using generalized estimating equation (GEE). The association among renal function changes was analyzed using a Cox proportional hazards model, with the results presented as unadjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Results: Among the 7,624 SGLT2 inhibitor users, 1,696 patients used Empa10, 2,654 used Empa25, and 3,274 used Dapa. Compared with non-users, dapagliflozin had the lowest risk of estimated glomerular filtration rate (eGFR) decrease over 40% from baseline within 1 year (HR 0.36, 95% CI 0.25-0.51). By using the ICD-10-CM code N179, the acute kidney injury (AKI)-related hospitalization rate was lower in Empa10 and Dapa users than in non-users (HR 0.65, 95% CI 0.49-0.86). Conclusion: Lower risk of eGFR decrease over 40% and AKI-related hospitalization was found in all SGLT2 inhibitor users across the different CKD stages.