IFCC recommendation on reporting results for blood glucose

Impact on result interpretation of correct and incorrect selection of veterinary glucometer canine and feline settings

Veterinary glucometers should be correctly coded for the patient species; however, coding errors occur in clinical settings and the impact of such errors has not been characterized. We compared glucose concentrations in 127 canine and 37 feline samples using both canine and feline settings on a veterinary glucometer (AlphaTrak; Zoetis). All samples were measured first on the canine setting and then measured using the feline setting. Glucose concentration was also measured using a central laboratory biochemical analyzer (Cobas c311; Roche). Three data comparisons for each species were investigated: incorrectly coded glucometer vs. correctly coded glucometer, correctly coded glucometer vs. Cobas c311, and incorrectly coded glucometer vs. Cobas c311. For each comparison, the following analyses were conducted: Spearman rank correlation coefficient, Bland-Altman difference plot analysis, mountain plot analysis, and Deming regression. For clinical context, Clarke error grids were constructed. There was high positive correlation for all comparisons with both species. For all comparisons, mean difference was low (-0.7 to 0.5 mmol/L for canine samples, 1.0-2.0 mmol/L for feline samples). Incorrect glucometer coding resulted in proportional bias for canine samples and positive constant bias for feline samples, and individual differences could be large (-4.44 mmol/L for one dog, 6.16 mmol/L for one cat). Although the glucometer should be used per the manufacturer's recommendation, coding errors are unlikely to have severe adverse clinical consequences for most patients based on error grid analysis.

Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey data

BACKGROUND

The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodemographic variation in these activities across LMICs.

METHODS

We performed a pooled, cross-sectional analysis of individual-level data from nationally representative, population-based surveys conducted in 44 LMICs between October, 2009, and May, 2019. Our sample included all participants older than 25 years who did not have diabetes and were not pregnant. We defined the population at high risk of diabetes on the basis of either the presence of impaired fasting glucose (or prediabetes in countries with a haemoglobin A1c available) or overweight or obesity, consistent with the WHO Package of Essential Noncommunicable Disease Guidelines for type 2 diabetes management. We estimated the proportion of survey participants that were at high risk of developing diabetes based on this definition. We also estimated the proportion of the population at high risk that reported each of four fundamental diabetes prevention activities: physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening, overall and stratified by World Bank income group. Finally, we used multivariable Poisson regression models to evaluate associations between sociodemographic characteristics and these activities.

FINDINGS

The final pooled sample included 145 739 adults (86 269 [59·2%] of whom were female and 59 468 [40·4%] of whom were male) across 44 LMICs, of whom 59 308 (40·6% [95% CI 38·5-42·8]) were considered at high risk of diabetes (20·6% [19·8-21·5] in low-income countries, 38·0% [37·2-38·9] in lower-middle-income countries, and 57·5% [54·3-60·6] in upper-middle-income countries). Overall, the reach of diabetes prevention activities was low at 40·0% (38·6-41·4) for physical activity counselling, 37·1% (35·9-38·4) for weight loss counselling, 42·7% (41·6-43·7) for dietary counselling, and 37·1% (34·7-39·6) for blood glucose screening. Diabetes prevention varied widely by national-level wealth: 68·1% (64·6-71·4) of people at high risk of diabetes in low-income countries reported none of these activities, whereas 49·0% (47·4-50·7) at high risk in upper-middle-income countries reported at least three activities. Educational attainment was associated with diabetes prevention, with estimated increases in the predicted probability of receipt ranging between 6·5 (3·6-9·4) percentage points for dietary fruit and vegetable counselling and 21·3 (19·5-23·2) percentage points for blood glucose screening, among people with some secondary schooling compared with people with no formal education.

INTERPRETATION

A large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide.

FUNDING

Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program and the EU's Research and Innovation programme Horizon 2020.

Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus

BACKGROUND

Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association.

CONTENT

Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed.

SUMMARY

The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.

The Clinical Presentation of Puumala Hantavirus Induced Hemorrhagic Fever with Renal Syndrome Is Related to Plasma Glucose Concentration

Puumala hantavirus (PUUV) causes a hemorrhagic fever with renal syndrome characterized by thrombocytopenia, increased capillary leakage, and acute kidney injury (AKI). As glucosuria at hospital admission predicts the severity of PUUV infection, we explored how plasma glucose concentration associates with disease severity. Plasma glucose values were measured during hospital care in 185 patients with PUUV infection. They were divided into two groups according to maximum plasma glucose concentration: P-Gluc < 7.8 mmol/L (n = 134) and P-Gluc ≥ 7.8 mmol/L (n = 51). The determinants of disease severity were analyzed across groups. Patients with P-Gluc ≥7.8 mmol/L had higher hematocrit (0.46 vs. 0.43; p < 0.001) and lower plasma albumin concentration (24 vs. 29 g/L; p < 0.001) than patients with P-Gluc < 7.8 mmol/L. They presented with higher prevalence of pulmonary infiltrations and pleural effusion in chest radiograph, higher prevalence of shock and greater weight change during hospitalization. Patients with P-Gluc ≥ 7.8 mmol/L were characterized by lower platelet count (50 vs. 66 × 10⁹/L; p = 0.001), more severe AKI (plasma creatinine 272 vs. 151 µmol/L; p = 0.001), and longer hospital treatment (8 vs. 6 days; p < 0.001) than patients with P-Gluc < 7.8 mmol/L. Plasma glucose level is associated with the severity of capillary leakage, thrombocytopenia, inflammation, and AKI in patients with acute PUUV infection.

Early versus late initiation of GH replacement in adult-onset hypopituitarism

INTRODUCTION

Adult-onset growth hormone deficiency (AGHD) is usually the last deficiency to be substituted in hypopituitarism. In children with documented GH deficiency, treatment without delay is crucial for achieving optimal effects on growth and development. In adults, it is not known whether a delay in treatment initiation influences biochemical response and the favourable physiological effects resulting from GH replacement therapy (GHRT).

METHODS

A total of 1085 GH-deficient adults from KIMS (Pfizer International Metabolic Database) were included, adequately replaced with all pituitary hormones except for GH at baseline. Patients were stratified by sex and age (20-50 years and ≥50 years) and subsequently divided into two groups below and above the median duration of unsubstituted AGHD for that subgroup. The median time of unsubstituted GHD for the total cohort was 2.53 years (P5 = 0.35, P95 = 24.42).

RESULTS

Beneficial effects of 4 years of GHRT were observed on lipids and quality of life in all subgroups. A decrease in waist circumference was observed only in older (>50 years) patients. There was no difference in IGF-I SDS and in GH dose required to normalize IGF-I in patients with a duration of unsubstituted AGHD above or below the median. No relevant differences were found between the groups for anthropometric measures, cardiovascular risk factors and quality of life scores.

CONCLUSION

In contrast to GHD in children and adolescents, no difference could be established in treatment response between early or late initiation of GHRT in AGHD in terms of required GH dose, IGF-I, metabolic health and quality of life.

Evaluation of the Freestyle Optium Neo H point-of-care device for measuring blood glucose concentrations in sick calves

Background

Data on the performance of a glucometer in calves with different diseases are currently lacking.

Objective

The primary objective of this study was to evaluate the reliability of a point of care glucometer in calves affected by different diseases relative to a traditional bench‐top autoanalyzer.

Animals

One hundred ninety‐six calves with different disorders in a referral hospital.

Methods

Prospective study. Venous blood samples were used for the determination of glucose concentrations in blood and plasma using the Freestyle Optium Neo H and autoanalyzer, respectively. Data were subjected to Passing‐Bablok regression and Bland‐Altman plots. The Freestyle Optium Neo H was the test method and the autoanalyzer was the reference method. The diagnostic performance of the glucometer relative to the autoanalyzer was assessed using 3 different plasma glucose concentrations.

Results

The Passing‐Bablok regression for the glucometer against the reference method revealed the presence of both proportional bias (1.12; 95% confidence interval [CI], 1.07‐1.18) and constant bias (−11.25; 95% CI, −16.0 to −7.70). The glucometer yielded 92.2%‐100% sensitivity and 86.4%‐96% specificity for the assessing glucose concentration based on different concentration thresholds.

Conclusions and Clinical Importance

The Freestyle Optium Neo H showed proportional and constant biases relative to the reference method. The glucometer showed poor performance according to criteria recommended by the International Standards Organization and the American Society for Veterinary Clinical Pathology. However, the glucometer determined hypoglycemia with high sensitivity and specificity therefore it might be used to diagnose hypoglycemia in calves with different diseases until calf‐specific POC glucometers are developed.

Pre-/analytical factors affecting whole blood and plasma glucose concentrations in loggerhead sea turtles (Caretta caretta)

Blood glucose is vital for many physiological pathways and can be quantified by clinical chemistry analyzers and in-house point-of-care (POC) devices. Pre-analytical and analytical factors can influence blood glucose measurements. This project aimed to investigate pre-analytical factors on whole blood and plasma glucose measurements in loggerhead sea turtles (Caretta caretta) by evaluating the effects of storage (refrigeration) up to 48h after sampling and of packed cell volume (PCV) on whole blood glucose analysis by POC glucometer (time series n = 13); and by evaluating the effects of storage (room temperature and refrigeration) on plasma glucose concentrations using a dry slide chemistry analyzer (DCA) at various conditions: immediate processing and delayed plasma separation from erythrocytes at 24h and 48h (time series n = 14). The POC glucometer had overall strong agreement with the DCA (CCC = 0.76, r = 0.84, C_b = 0.90), but consistently overestimated glucose concentrations (mean difference: +0.4 mmol/L). The POC glucometer results decreased significantly over time, resulting in a substantial decline within the first 2h (0.41±0.47 mmol/L; 8±9%) that could potentially alter clinical decisions, thereby highlighting the need for immediate analysis using this method. The effects of PCV on glucose could not be assessed, as the statistical significance was associated with one outlier. Storage method significantly affected plasma glucose measurements using DCA, with room temperature samples resulting in rapid decreases of 3.57±0.89 mmol/L (77±9%) over the first 48h, while refrigerated samples provided consistent plasma glucose results over the same time period (decrease of 0.26±0.23 mmol/L; 6±5%). The results from this study provide new insights into optimal blood sample handling and processing for glucose analysis in sea turtles, show the suitability of the POC glucometer as a rapid diagnostic test, and confirm the reliability of plasma glucose measurements using refrigeration. These findings emphasize the need to consider pre-/analytical factors when interpreting blood glucose results from loggerhead sea turtles.

Diagnosis of Gestational Diabetes Mellitus with Point-of-Care Methods for Glucose versus Hospital Laboratory Method Using Isotope Dilution Gas Chromatography-Mass Spectrometry as Reference

BACKGROUND

In Sweden, both glucose analyzers in accredited laboratories and point-of-care glucose devices are used for gestational diabetes mellitus (GDM) diagnosis. The aim of this study was to compare the diagnostic performance of the HemoCue Glucose 201+ (HC201+) and RT (HC201RT) systems with that of the hospital central laboratory hexokinase method (CL) based on lyophilized citrate tubes, using the isotope dilution gas chromatography-mass spectrometry (ID GC-MS) as reference.

METHODS

A 75 g oral glucose tolerance test was performed on 135 women screened positive for GDM. Diagnosis was based on the World Health Organization 2013 diagnostic thresholds for fasting (n = 135), 1 h (n = 135), 1 h (n = 135), 1 h (.

RESULTS

Significantly more women were diagnosed with GDM by HC201+ (80%) and CL (80%) than with the reference (65%, P < 0.001) based on fasting and/or 2 h thresholds, whereas the percentage diagnosed by HC201RT (60%) did not differ significantly from the reference. In Bland-Altman analysis, a positive bias was observed for HC201+ (4.2%) and CL (6.1%) and a negative bias for HC201RT (-1.8%). In the surveillance error grid, 95.9% of the HC201+ values were in the no-risk zone as compared to 98.1% for HC201RT and 97.5% for CL.

CONCLUSIONS

A substantial positive bias was found for CL measurements resulting in overdiagnosis of GDM. Our findings suggest better performance of HC201RT than HC201+ in GDM diagnosis. The results may have possible implications for GDM diagnosis in Sweden and require further elucidation.

Phenotypic and genotypic differences between Indian and Scandinavian women with gestational diabetes mellitus

OBJECTIVE

Gestational diabetes mellitus (GDM) is a transient form of diabetes characterized by impaired insulin secretion and action during pregnancy. Population-based differences in prevalence exist which could be explained by phenotypic and genetic differences. The aim of this study was to examine these differences in pregnant women from Punjab, India and Scandinavia.

METHODS

Eighty-five GDM/T2D loci in European and/or Indian populations from previous studies were assessed for association with GDM based on Swedish GDM criteria in 4018 Punjabi Indian and 507 Swedish pregnant women. Selected loci were replicated in Scandinavian cohorts, Radiel (N = 398, Finnish) and STORK/STORK-G (N = 780, Norwegian).

RESULTS

Punjabi Indian women had higher GDM prevalence, lower insulin secretion and better insulin sensitivity than Swedish women. There were significant frequency differences of GDM/T2D risk alleles between both populations. rs7178572 at HMG20A, previously associated with GDM in South Indian and European women, was replicated in North Indian women. The T2D risk SNP rs11605924 in the CRY2 gene was associated with increased GDM risk in Scandinavian but decreased GDM risk in Punjabi Indian women. No other overlap was seen between GDM loci in both populations.

CONCLUSIONS

Gestational diabetes mellitus is more common in Indian than Swedish women, which partially can be attributed to differences in insulin secretion and action. There was marked heterogeneity in the GDM phenotypes between the populations which could only partially be explained by genetic differences.

Improvements in Body Composition after 4 Years of Growth Hormone Treatment in Adult-Onset Hypopituitarism Compared to Age-Matched Controls

BACKGROUND/AIMS

It is unknown whether long-term growth hormone replacement therapy (GHRT) affects body composition in an age- or sex-dependent manner. We aimed to study the effects of 4 years of GHRT on body composition in a large cohort of patients with hypopituitarism compared to a reference population matched by age and sex.

METHODS

A total of 964 GH-deficient adults from KIMS (Pfizer International Metabolic Database) with adult-onset hypopituitarism, adequately replaced with all pituitary hormones except for GH at baseline were included. A random sample of the general population (2,301 subjects) from a similar time period was used as reference. Patients and controls were grouped by sex in 5 age cohorts of 10 years. Main outcome measures were changes in BMI and waist circumference after 4 years of GHRT.

RESULTS

In younger patients (28-47 years), 4 years of GHRT resulted in a BMI increase similar to that observed in the reference population, but older patients (48-67 years) had significantly less BMI increase than age-matched healthy controls. Significant differences were seen in waist circumference in patients of all age cohorts who showed virtually no change after 4 years of GHRT compared to approximately 4 cm of increase in the reference population.

CONCLUSION

Four years of GHRT resulted in improvements in BMI and waist circumference in patients with adult-onset hypopituitarism compared to age-matched controls observed during the same follow-up time. Despite these beneficial effects on body composition, BMI and waist circumference remained higher in patients on GHRT compared to healthy controls.

Adipose tissue and body composition in women six years after gestational diabetes: factors associated with development of type 2 diabetes

Factors differentiating women at highest risk of progression to type 2 diabetes mellitus (T2DM) after gestational diabetes mellitus (GDM) are incompletely known. Our aim was to characterize adipose tissue and body composition in relation to glucose metabolism in women with a history of GDM and to identify factors associated with development of T2DM. We examined glucose tolerance (OGTT), insulin sensitivity (HOMA-IR), body composition (anthropometry, air displacement plethysmography), and blood chemistry in 39 women 6 years after GDM. An adipose tissue biopsy was obtained to assess the size, number, and lipolytic activity of adipocytes, and adipokine release and density of immune cells and blood vessels in adipose tissue. Normal glucose tolerance (NGT) was identified in 31 women and impaired glucose metabolism (IGM) in 8. Women with IGM had higher BMI/fat mass, and related expected adipose tissue features, than women with NGT. Ethnicity was similar in the groups, but numerically there was a higher proportion of European women in the NGT group and a higher proportion of non-European women in the IGM group. BMI was the best discriminator of NGT versus IGM (multivariable logistic regression: OR = 1.34, P < 0.01). Waist-to-height ratio and adipocyte volume were most strongly associated with HOMA-IR (multivariable linear regression: R² = 0.656, P < 0.001). After adjustment for BMI/ethnicity, women with IGM had increased serum adipocyte fatty acid-binding protein, weight gain after index pregnancy, and a lower proportion of fat-free mass. These factors, together with high BMI, abdominal fat distribution, and enlarged adipocytes, may increase the risk of progression to T2DM after GDM.

Pregnancy to postpartum transition of serum metabolites in women with gestational diabetes

CONTEXT

Gestational diabetes is commonly linked to development of type 2 diabetes mellitus (T2DM). There is a need to characterize metabolic changes associated with gestational diabetes in order to find novel biomarkers for T2DM.

OBJECTIVE

To find potential pathophysiological mechanisms and markers for progression from gestational diabetes mellitus to T2DM by studying the metabolic transition from pregnancy to postpartum.

DESIGN

The metabolic transition profile from pregnancy to postpartum was characterized in 56 women by mass spectrometry-based metabolomics; 11 women had gestational diabetes mellitus, 24 had normal glucose tolerance, and 21 were normoglycaemic but at increased risk for gestational diabetes mellitus. Fasting serum samples collected during trimester 3 (gestational week 32±0.6) and postpartum (10.5±0.4months) were compared in diagnosis-specific multivariate models (orthogonal partial least squares analysis). Clinical measurements (e.g., insulin, glucose, lipid levels) were compared and models of insulin sensitivity and resistance were calculated for the same time period.

RESULTS

Women with gestational diabetes had significantly increased postpartum levels of the branched-chain amino acids (BCAAs) leucine, isoleucine, and valine, and their circulating lipids did not return to normal levels after pregnancy. The increase in BCAAs occurred postpartum since the BCAAs did not differ during pregnancy, as compared to normoglycemic women.

CONCLUSIONS

Postpartum levels of specific BCAAs, notably valine, are related to gestational diabetes during pregnancy.

Bedside Blood Glucose Monitoring in Critically Ill Patients: Comparison Between Arterial and Capillary Glucose

BACKGROUND

Critically ill patients are at high risk of hypoglycemia and are particularly vulnerable to unrecognized hypoglycemia. Close blood glucose monitoring is therefore crucial. There are several options to conduct frequent blood glucose measurement and a number of conditions in intensive care unit patients may affect the accuracy of blood glucose measurement. The aim of the study was to compare the accuracy of capillary glucose by bedside glucometer with arterial samples by bedside glucometer and arterial samples by blood gas analyzer in critically ill patients through a prospective case-control study.

MATERIALS AND METHODS

Arterial and capillary samples from 60 patients were taken simultaneously and were tested immediately at the bedside. Results of the paired measurements were compared and expressed as a correlation coefficient.

RESULTS

Capillary glucose in the study group and control group were 9.73 ± 2.28mmol/L and 8.9 ± 1.86mmol/L, respectively; mean arterial glucose measured by glucometer in the study group and control group were 9.25 ± 2.05mmol/L and 8.4 ± 1.89mmol/L, respectively; and mean arterial glucose measured by blood gas analyzer in the study group and control group were 8.41 ± 1.9mmol/L and 8.24 ± 1.5mmol/L, respectively. Correlation between capillary values and arterial values measured by glucometer was less in the study group (r = 0.936, P < 0.001 and r = 0.973, P < 0.001). Correlation between capillary values measured by glucometer and arterial values measured by blood gas analyzer was also less in the study group (r = 0.897, P = 0.001 and r = 0.964, P < 0.001).

CONCLUSIONS

Capillary blood glucose monitoring is reliable only in a selected group of critically ill patients.

HbA1c as a predictor of diabetes after gestational diabetes mellitus

AIM

We wanted to investigate third-trimester HbA1c as a predictor of diabetes after gestational diabetes mellitus (GDM).

METHODS

Women with GDM were followed up prospectively for five years from pregnancy to detect the development of diabetes. The ability of HbA1c to predict diabetes was evaluated with receiver-operating characteristic (ROC) curves and logistic regression analysis.

RESULTS

By five years, 73 of 196 women had been diagnosed with diabetes. An optimal cut-off point for HbA1c of 36mmol/mol (5.4%) could predict diabetes with 45% sensitivity and 92% specificity. For HbA1c ≥39mmol/mol (≥5.7%), sensitivity, specificity, and positive predictive value were 30%, 97%, and 91%, respectively. In logistic regression analysis, adjusting for the diagnostic glucose concentration during pregnancy, HbA1c levels in the upper quartile (≥36mmol/mol) were associated with a 5.5-fold increased risk of diabetes.

CONCLUSION

Third-trimester HbA1c levels in the pre-diabetes range revealed women with post-partum diabetes with high specificity and high positive predictive value. HbA1c testing could be used as a strategy to select high-risk women for lifestyle interventions aimed at prevention of diabetes starting during pregnancy. The results should encourage further validation in other populations using new diagnostic criteria for GDM.

A community-based primary prevention programme for type 2 diabetes mellitus integrating identification and lifestyle intervention for prevention: a cluster randomised controlled trial

Background

Prevention of type 2 diabetes mellitus (T2DM) is a global priority; however, there is a lack of evidence investigating how to effectively translate prevention research into a primary care setting.

Objectives

(1) To develop and validate a risk score to identify individuals at high risk of T2DM in the UK; and (2) to establish whether or not a structured education programme targeting lifestyle and behaviour change was clinically effective and cost-effective at preventing progression to T2DM in people with prediabetes mellitus (PDM), identified through a risk score screening programme in primary care.

Design

A targeted screening study followed by a cluster randomised controlled trial (RCT), with randomisation at practice level. Participants were followed up for 3 years.

Setting

A total of 44 general practices across Leicestershire, UK. The intervention took place in the community.

Participants

A total of 17,972 individuals from 44 practices identified through the risk score as being at high risk of T2DM were invited for screening; of these, 3449 (19.2%) individuals attended. All received an oral glucose tolerance test. PDM was detected in 880 (25.5%) of those screened. Those with PDM were included in the trial; of these, 36% were female, the average age was 64 years and 16% were from an ethnic minority group.

Intervention

Practices were randomised to receive either standard care or the intervention. The intervention consisted of a 6-hour group structured education programme, with an annual refresher and regular telephone contact.

Main outcome measures

The primary outcome was progression to T2DM. The main secondary outcomes were changes in glycated haemoglobin concentrations, blood glucose levels, cardiovascular risk, the presence of metabolic syndrome, step count and the cost-effectiveness of the intervention.

Results

A total of 22.6% of the intervention group did not attend the education and 29.1% attended all sessions. A total of 131 participants developed T2DM (standard care,n = 67; intervention,n = 64). There was a 26% reduced risk of T2DM in the intervention arm compared with standard care, but this did not reach statistical significance (hazard ratio 0.74, 95% confidence interval 0.48 to 1.14;p = 0.18). There were statistically significant improvements in glycated haemoglobin concentrations, low-density lipoprotein cholesterol levels, psychosocial well-being, sedentary time and step count in the intervention group. The intervention was found to result in a net gain of 0.046 quality-adjusted life-years over 3 years at a cost of £168 per patient, with an incremental cost-effectiveness ratio of £3643 and a probability of 0.86 of being cost-effective at a willingness-to-pay threshold of £20,000.

Conclusions

We developed and validated a risk score for detecting those at high risk of undiagnosed PDM/T2DM. We screened > 3400 people using a two-stage screening programme. The RCT showed that a relatively low-resource pragmatic programme may lead to a reduction in T2DM and improved biomedical and psychosocial outcomes, and is cost-effective.

Limitations

Only 19% of those invited to screening attended, which may limit generalisability. The variation in cluster size in the RCT may have limited the power of the study.

Future work

Future work should focus on increasing attendance to both screening and prevention programmes and offering the programme in different modalities, such as web-based modalities. A longer-term follow-up of the RCT participants would be valuable.

Trial registration

Current Controlled Trials ISRCTN80605705.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Erroneous inflation of diabetes prevalence: Are there global implications?

Comparison of the prevalence of type 2 diabetes mellitus (T2DM) in adults aged 25-64 years in selected Pacific Island countries using whole blood and plasma glucose cut-off points. Unit records of STEPwise approach to Surveillance (STEPS) surveys obtained from Fiji, Samoa, and Tonga Ministries of Health; T2DM prevalence recalculated using whole blood and plasma cut-off points. Shaded bars indicate T2DM prevalence based on correct glucose cut-off points for the glucose meter used (fasting blood glucose [FBG] ≥6.1 mmol/L for early surveys^1,3,5 ; fasting plasma glucose [FPG] ≥7.0 mmol/L for later surveys),^2,4,6 whereas open bars show T2DM prevalence based on incorrect glucose cut-off points (FPG ≥6.1 mmol/L for later surveys).^2,4,6 Highlights Incorrect glucose cut-off points were applied to the Fiji 2011, Samoa 2013, and Tonga 2012 STEPS surveys. This doubled the actual T2DM prevalences compared to using the correct glucose cut-off points. The errors occurred due to modern glucose meters producing measurements in plasma-equivalent concentrations from whole blood samples. The incorrect whole blood glucose cut-off (≥6.1mmol/L) was applied instead of the correct plasma glucose cut-off (≥7.0mmol/L). This error likely affects other Pacific states, and may have global ramifications.

Seasonal Pattern in the Diagnosis of Gestational Diabetes Mellitus in Southern Sweden

Aim. The aim of this study was to examine seasonal patterns in glucose tolerance and in the diagnosis of gestational diabetes mellitus (GDM). Methods. Altogether, 11 538 women underwent a 75-g oral glucose tolerance test (OGTT) in the twenty-eighth week of pregnancy during the years 2003-2005 in southern Sweden. GDM was defined by the 2-h capillary glucose concentration in the OGTT (≥8.9 mmol/L). Chi-squared test, analysis of variance, and regression analyses were used for statistical evaluations. Results. The seasonal frequency of GDM ranged from 3.3% in spring to 5.5% in summer (p < 0.0001). Mean 2-h glucose concentrations followed the same seasonal trend, with a difference of 0.15 mmol/L between winter and summer (p < 0.0001). The 2-h glucose level increased by 0.009 mmol/L for every degree increase in temperature (p < 0.0001). In regression analysis, summer (June-August) was associated with increased 2-h glucose level (p < 0.001) and increased frequency of GDM compared to the other seasons (odds ratio 1.51, 95% confidence interval 1.24-1.83, and p < 0.001). Conclusions. Our findings suggest seasonal variation in the 2-h glucose concentration in the OGTT and in the proportion of women diagnosed with GDM, with a peak in the summer.

The relative importance of maternal body mass index and glucose levels for prediction of large-for-gestational-age births

Background

The risk of gestational diabetes mellitus (GDM) increases substantially with increasing maternal body mass index (BMI). The aim of the present study was to evaluate the relative importance of maternal BMI and glucose levels in prediction of large-for-gestational-age (LGA) births.

Method

This observational cohort study was based on women giving birth in southern Sweden during the years 2003–2005. Information on 10 974 pregnancies was retrieved from a population-based perinatal register. A 75-g oral glucose tolerance test (OGTT) was performed in the 28 week of pregnancy for determination of the 2-h plasma glucose concentration. BMI was obtained during the first trimester. The dataset was divided into a development set and a validation set. Using the development set, multiple logistic regression analysis was used to identify maternal characteristics associated with LGA. The prediction of LGA was assessed by receiver-operating characteristic (ROC) curves, with LGA defined as birth weight > +2 standard deviations of the mean.

Results

In the final multivariable model including BMI, 2-h glucose level and maternal demographics, the factor most strongly associated with LGA was BMI (odds ratio 1.1, 95 % confidence interval [CI] 1.08–1.30). Based on the total dataset, the area under the ROC curve (AUC) of 2-h glucose level to predict LGA was 0.54 (95 % CI 0.48–0.60), indicating poor performance. Using the validation database, the AUC for the final multiple model was 0.69 (95 % CI 0.66–0.72), which was identical to the AUC retrieved from a model not including 2-h glucose (0.69, 95 % CI 0.66–0.72), and larger than from a model including 2-h glucose but not BMI (0.63, 95 % CI 0.60–0.67).

Conclusions

Both the 2-h glucose level of the OGTT and maternal BMI had a significant effect on the risk of LGA births, but the relative contribution was higher for BMI. The findings highlight the importance of concentrating on healthy body weight in pregnant women and closer monitoring of weight during pregnancy as a strategy for reducing the risk of excessive fetal growth.

Evaluation of an Electrochemical Point-of-Care Meter for Measuring Glucose Concentration in Blood from Periparturient Dairy Cattle

BACKGROUND

The Precision Xtra(®) meter is a promising low cost electrochemical point-of-care unit for measuring blood glucose concentration ([gluc]) in cattle blood. The meter uses an algorithm that assumes the intra-erythrocyte [gluc] equals the plasma [gluc] on a molal basis, and that the hematocrit is similar in humans and cattle.

OBJECTIVES

The primary objective was to determine the accuracy of the meter for measuring plasma [gluc] in dairy cattle. Secondary objectives were to characterize the influence of hematocrit and sample temperature on the measured value for [gluc].

ANIMALS

A total of 106 periparturient Holstein-Friesian cattle.

METHODS

Blood and plasma samples (1,109) were obtained and Deming regression and Bland-Altman plots were used to determine the accuracy of the meter against the reference method (plasma hexokinase assay). Multivariable regression and linear regression were used to determine the effect of hematocrit and sample temperature on the plasma [gluc] measured by the meter.

RESULTS

Intra-erythrocyte [gluc] was 18% of plasma [gluc] on a molar basis. Sample temperature had a significant linear effect on plasma [gluc] as measured by the meter for 3/5 plasma samples when measured [gluc] > 160 mg/dL.

CONCLUSIONS AND CLINICAL IMPORTANCE

The meter utilizes an algorithm that is optimized for human blood and is inaccurate when applied to bovine blood. Until a cattle-specific algorithm is developed, we recommend using plasma as the analyte instead of blood and calculating plasma [gluc] using the equation: [gluc] = 0.66 × [gluc]p-meter + 15, where [gluc]p-meter is the value reported by the meter. If blood is measured, then we recommend using the equation: [gluc] = 0.90 × [gluc]b-meter + 15.

Towards normalized birthweight in gestational diabetes mellitus

INTRODUCTION

The objective was to describe pregnancy outcomes in gestational diabetes mellitus (GDM) in comparison with general population in Sweden.

MATERIAL AND METHODS

A population-based retrospective study using University hospital records and Swedish Medical Birth Register was carried out on pregnant women with well-monitored GDM (n = 870) and pregnancies in the Swedish Medical Birth Register (n = 1 553 420). Data from GDM pregnancies was compared to pregnancies in the whole of Sweden during 1995-2010. The main outcome measures were age, first bodyweight in and weight gain during pregnancy, birthweight, gestational length, percentage of cesarean deliveries.

RESULTS

First maternal bodyweight during the GDM pregnancy was higher than in the general population, 72.4 ± 17.4 kg (n = 837) vs. 67.3 ± 12.6 kg (n = 1 383 000; p < 0.0001). Women with GDM gained less weight during pregnancy 9.9 ± 5.8 kg (n = 703) compared to the general population, 13.2 ± 5.7 kg (n = 482 860; p < 0.0001). Mean birthweight in GDM pregnancies was 3564 ± 500 g (n = 743) compared to 3580 ± 483 g for the general population (n = 1 316 364; p = ns). Gestational length was slightly shorter, 39.4 weeks in the GDM pregnancies (n = 683) vs. 39.5 weeks (n = 1 319 876; p = 0.02) in the general population and the percentage of cesarean deliveries higher in the GDM pregnancies at 18.4% (n = 712) vs. 13.3% (n = 1 322 242; p < 0.0001).

CONCLUSIONS

Though many studies have shown an increased risk of macrosomia in GDM pregnancies, remaining even after ambitious management programs, we show no difference in birthweight. This may be due to a combination of intense efforts to achieve good metabolic control during pregnancy and shorter pregnancy duration. Preventing unduly large babies is crucial to minimize adverse pregnancy outcomes.

High prevalence of prediabetes in a Swedish cohort of severely obese children

OBJECTIVE

In this cohort of severely obese children and adolescents in Sweden we investigate the prevalence of impaired fasting glucose (IFG), impaired glucose tolerance, (IGT) and silent type 2 diabetes (T2D), in relation to insulin resistance, insulin secretion, disposition index and cardio respiratory fitness.

METHODS

A total of 134 obese children and adolescents [57 females, 77 males, age 13.7 ± 2.7, body mass index (BMI) standard deviation score (SDS) 3.6 ± 0.6] consecutively referred to the National Childhood Obesity Centre performed an oral glucose tolerance test (OGTT), frequently sampled intravenous glucose tolerance test (fs-IVGTT), dual X-ray absorptiometry (DEXA), bicycle ergometer test and fasting levels of glucose, insulin and c-peptide were obtained and homeostatic model of insulin resistance (HOMA-IR) was calculated.

RESULTS

Isolated impaired fasting glucose (i-IFG) were present in 35.8 and 6% had isolated IGT. Combined IGT and IFG were present in 14.2%. The subjects with combined IGT/IFG had significantly lower acute insulin response (AIR) compared with subjects who had normal glucose metabolism or i-IFG (p < 0.05). Among the prepubertal children (n = 24), 25% (6/24) had i-IFG and 25% (6/24) had IGT/IFG and it was predominantly males. Disposition index was the major determinant of 2-h glucose levels (β = -0.49, p = 0.0126). No silent diabetes was detected.

CONCLUSION

In this cohort of severely obese children and adolescents the prevalence of prediabetes was very high. IFG was two times higher in this cohort of severely obese children than in a recently published unselected cohort of obese children in Sweden. In spite of the high prevalence of prediabetes, no subjects with silent diabetes were found.

Role of HbA1c in post-partum screening of women with gestational diabetes mellitus

Aim

To compare the performance of HbA1c with established glucose criteria during an oral glucose tolerance test (OGTT) and to assess HbA1c as a screening test for undiagnosed diabetes and pre-diabetes after gestational diabetes mellitus (GDM).

Methods

Glucose homeostasis was re-evaluated 1–5 years after delivery in 140 women with previous GDM, by means of OGTT and simultaneous HbA1c measurement. Glucose tolerance was defined according to World Health Organisation criteria. HbA1c ≥6.5% (≥48 mmol/mol) was used for diabetes diagnosis and HbA1c ≥5.7% (≥39 mmol/mol) to define abnormal glucose homeostasis.

Results

HbA1c had low sensitivity (14.3%) and high specificity (99.1%) in diabetes diagnosis. Sensitivity and specificity of HbA1c to detect abnormal glucose tolerance were 29.5% and 95.2%, respectively. The consistency in classifying abnormal glucose tolerance between HbA1c and OGTT criteria was 59% (κ = 0.227) and the area under the receiver operating characteristic curve was 0.708. The combined use of HbA1c and fasting glucose criteria showed similar performance to that of fasting glucose criteria alone. The latter identified 63% of the women with pre-diabetes or diabetes in the study cohort. However, by lowering the cut-point of HbA1c to ≥5.0% (≥31 mmol/mol), an additional proportion (27%) with isolated post-glucose load hyperglycaemia was identified.

Conclusion

Proposed thresholds of HbA1c had low diagnostic sensitivity. Combined with a fasting glucose test, the performance was no better than with using a fasting glucose test alone. Combining a fasting glucose test with a lower HbA1c cut-point may be an alternative approach for selection of women for an OGTT.

•

We compare the performance of HbA1c with established glucose criteria during an oral glucose tolerance test (OGTT).

•

We also assess HbA1c as a screening test for undiagnosed diabetes and pre-diabetes after gestational diabetes mellitus.

•

Proposed thresholds of HbA1c had low diagnostic sensitivity relative to OGTT.

•

Combining HbA1c with a fasting glucose test the performance was no better than using a fasting glucose test alone.

•

Combining a fasting glucose test with a lower HbA1c cut-point may be an option for selection of women for an OGTT.

Accuracy evaluation of a new real-time continuous glucose monitoring algorithm in hypoglycemia

BACKGROUND

The purpose of this study was to evaluate the performance of a new continuous glucose monitoring (CGM) calibration algorithm and to compare it with the Guardian(®) REAL-Time (RT) (Medtronic Diabetes, Northridge, CA) calibration algorithm in hypoglycemia.

SUBJECTS AND METHODS

CGM data were obtained from 10 type 1 diabetes patients undergoing insulin-induced hypoglycemia. Data were obtained in two separate sessions using the Guardian RT CGM device. Data from the same CGM sensor were calibrated by two different algorithms: the Guardian RT algorithm and a new calibration algorithm. The accuracy of the two algorithms was compared using four performance metrics.

RESULTS

The median (mean) of absolute relative deviation in the whole range of plasma glucose was 20.2% (32.1%) for the Guardian RT calibration and 17.4% (25.9%) for the new calibration algorithm. The mean (SD) sample-based sensitivity for the hypoglycemic threshold of 70 mg/dL was 31% (33%) for the Guardian RT algorithm and 70% (33%) for the new algorithm. The mean (SD) sample-based specificity at the same hypoglycemic threshold was 95% (8%) for the Guardian RT algorithm and 90% (16%) for the new calibration algorithm. The sensitivity of the event-based hypoglycemia detection for the hypoglycemic threshold of 70 mg/dL was 61% for the Guardian RT calibration and 89% for the new calibration algorithm. Application of the new calibration caused one false-positive instance for the event-based hypoglycemia detection, whereas the Guardian RT caused no false-positive instances. The overestimation of plasma glucose by CGM was corrected from 33.2 mg/dL in the Guardian RT algorithm to 21.9 mg/dL in the new calibration algorithm.

CONCLUSIONS

The results suggest that the new algorithm may reduce the inaccuracy of Guardian RT CGM system within the hypoglycemic range; however, data from a larger number of patients are required to compare the clinical reliability of the two algorithms.

A home-based method for the detection of impaired glucose tolerance in hypertensive primary care patients

OBJECTIVE

The aim of this project was to compare an oral glucose tolerance test (OGTT) partly performed in the patient's home (OGTTh) with a clinic-obtained OGTT with regard to the ability of the tests to identify patients with impaired glucose tolerance (IGT) and type 2 diabetes mellitus (DM-2).

DESIGN

A method comparison.

SETTING

The study was completed at two primary health care centres.

SUBJECTS

Fifty-one patients with hypertension aged 50-79 years completed both OGTT tests.

MAIN OUTCOME MEASURES

Values for capillary P-glucose obtained two hours after a glucose load were compared between the two OGTT tests. Fasting plasma glucose (fP-glucose) and HbA1c were also measured.

RESULTS

Thirty-seven patients were classified in the same group (normal/IGT/DM-2) by the two tests. The index of validity based on the test's ability to identify normal or pathological values (≥ 8.9 mmol/l) was 0.75. The value for kappa was 0.66 with a sensitivity of 0.54 and a specificity of 0.82.

CONCLUSION

OGTTh may be a useful screening method for IGT in risk groups such as hypertensive patients.

Impaired fasting glucose prevalence in two nationwide cohorts of obese children and adolescents

Objective:

Impaired fasting glucose (IFG), a pre-stage to type 2 diabetes in adults, is also present in obese children. A large variation of the occurrence has been recorded, but the true prevalence is unknown due to lack of larger representative cohort studies. This study was implemented to investigate the prevalence of IFG in two nationwide cohorts of obese children and to find factors that affect the risk of IFG.

Design:

A cross-sectional study based on data collected from two nationwide registers of obese children in Germany and Sweden, respectively.

Subjects:

Subjects included were 2–18 years old. 32 907 subjects with fasting glucose were eligible in Germany and 2726 in Sweden. Two cutoff limits for IFG were used: 5.6–6.9 mmol l⁻¹ according to the American Diabetes Association (ADA) and 6.1–6.9 mmol l⁻¹according to the World Health Organization (WHO). Variables collected were gender, age and degree of obesity. Logistic regression was used to calculate odds ratios.

Results:

The total prevalence of IFG among obese children in the German cohort according to the ADA was 5.7% and according to the WHO it was 1.1%. In Sweden, the corresponding prevalence was 17.1% and 3.9%, respectively. IFG risk was correlated with increasing age, male sex and degree of obesity.

Conclusions:

IFG is highly prevalent among obese children. Age and degree of obesity are positively correlated with the risk of having IFG. There are large regional differences. After adjustments, obese children in Sweden, due to unknown reasons, have a 3.4- to 3.7-fold higher risk of having IFG than obese children in Germany.

Population response to information on reversibility of Type 2 diabetes

AIMS

Following publication of the Counterpoint Study (on the reversibility of Type 2 diabetes using a very low energy diet), the extent of public interest prompted the authors to make available, on a website, general information about reversing diabetes. Shortly thereafter, individuals began to feed back their personal experiences of attempting to reverse their diabetes. We have collated this information on the effects of energy restriction in motivated individuals with Type 2 diabetes that has been achieved outside a research setting.

METHODS

Emails, letters and telephone communications received between July 2011 and September 2012 were evaluated (n = 77: 66 men, 11 women). Median diabetes duration was 5.5 years (3 months-28 years). Reversal of diabetes was defined as achieving fasting capillary blood glucose < 6.1 mmol/l and/or, if available, HbA1c less than 43 mmol/mol (6.1%) off treatment.

RESULTS

Self-reported weight fell from 96.7 ± 17.5 kg at baseline to 81.9 ± 14.8 kg after weight loss (P < 0.001). Self-reported fasting blood glucose levels fell from 8.3 mmol/l (5.9-33.0) to 5.5 mmol/l (4.0-10.0) after the weight loss period (P < 0.001). Diabetes reversal was considered to have occurred in 61% of the population. Reversal of diabetes was observed in 80, 63 and 53% of those with > 20, 10-20 and < 10 kg weight loss, respectively. There was a significant correlation between degree of weight loss and reported fasting glucose levels (Rs -0.38, P = 0.006). Reversal rates according to diabetes duration were: short (< 4 years) = 73%, medium (4-8 years) = 56% and long (> 8 years) = 43%.

CONCLUSION

These data demonstrate that intentional weight loss achieved at home by health-motivated individuals can reverse Type 2 diabetes. Diabetes reversal should be a goal in the management of Type 2 diabetes.

Hypertension and low HDL cholesterol were associated with reduced kidney function across the age spectrum: a collaborative study

PURPOSE

To determine if the associations among established risk factors and reduced kidney function vary by age.

METHODS

We pooled cross-sectional data from 14,788 nondiabetics aged 40 to 100 years in 4 studies: Cardiovascular Health Study, Health, Aging, and Body Composition Study, Multi-Ethnic Study of Atherosclerosis, and Prevention of Renal and Vascular End-Stage Disease cohort.

RESULTS

Hypertension and low high-density lipoprotein (HDL) cholesterol were associated with reduced cystatin C-based estimated glomerular filtration rate (eGFR) across the age spectrum. In adjusted analyses, hypertension was associated with a 2.3 (95% confidence interval [CI], 0.1, 4.4), 5.1 (95% CI, 4.1, 6.1), and 6.9 (95% CI, 3.0, 10.4) mL/min/1.73 m(2) lower eGFR in participants 40 to 59, 60 to 79, and at least 80 years, respectively (P for interaction < .001). The association of low HDL cholesterol with reduced kidney function was also greater in the older age groups: 4.9 (95% CI, 3.5, 6.3), 7.1 (95% CI, 6.0, 8.3), 8.9 (95% CI, 5.4, 11.9) mL/min/1.73 m(2) (P for interaction < .001). Smoking and obesity were associated with reduced kidney function in participants under 80 years. All estimates of the potential population impact of the risk factors were modest.

CONCLUSIONS

Hypertension, obesity, smoking, and low HDL cholesterol are modestly associated with reduced kidney function in nondiabetics. The associations of hypertension and HDL cholesterol with reduced kidney function seem to be stronger in older adults.

HLA-DQB1 genotypes and islet cell autoantibodies against GAD65 and IA-2 in relation to development of diabetes post partum in women with gestational diabetes mellitus

AIMS

To study HLA-DQB1 genes and islet cell autoantibodies against glutamic acid decarboxylase 65 (GADA) and insulinoma antigen-2 (IA-2A) in relation to diabetes post partum in mothers with diagnosed gestational diabetes mellitus (GDM).

METHODS

During 2003-2004, women undergoing a 75 g oral glucose tolerance test (OGTT) during pregnancy were invited to participate in the Mamma Study. Cut-off level defining GDM was a 2-h capillary blood glucose of 7.8 mmol/L. 1-2 years after delivery a 75 g OGTT was performed, GADA and IA-2A were measured and HLA-DQB1 genes analysed. Data were available for 452 mothers with previous GDM and 168 randomly selected control subjects.

RESULTS

HLA-DQB1*0602 was negatively associated with GDM (p=0.033) and with development of diabetes post partum (p=0.017), whereas high risk HLA were not associated with GDM or with diabetes. The presence of GADA post partum was positively associated with diabetes post partum (p=0.0009), but not with impaired glucose tolerance.

CONCLUSIONS

Mothers with GDM and HLA-DQB1*0602 were less likely to develop diabetes after pregnancy, and type 1 diabetes associated high risk HLA genes did not predict type 1 diabetes post partum. Additionally, GADA were positively associated with diabetes development.

Evaluation of the analytical performance of the coulometry-based Optium Omega blood glucose meter

BACKGROUND

The goal of diabetes treatment is maintaining near normoglycemia based on self-monitoring of blood glucose (SMBG). In this study, an evaluation of the analytical performance of the coulometry-based Optium Omega™ glucose meter designed for SMBG has been carried out.

METHODS

The assessment of precision and between-lot variability was based on glucose measurements in ethylene-diaminetetraacetic acid venous blood samples. Glucose concentrations measured in 289 fresh capillary blood samples using the Omega glucose meter and the Biosen C_line analyzer were compared.

RESULTS

Within-run imprecision coefficient of variation for the lower and higher glucose concentrations amounted to 5.09 and 2.1%, respectively. The relative lot-dependent differences found for the lower and higher glucose concentrations were equal to 6.8 and 2.6%, respectively. The glucose meter error calculated for various concentration ranges amounted from 2.22 to 4.48%. The glucose meter error met the accuracy criteria recommended by the International Organization for Standardization and the American Diabetes Association. The Passing-Bablok agreement test and error grid analysis with 96% of results in zone A indicated good concordance of results, including glucose concentrations below 100 mg/dl.

CONCLUSIONS

The evaluated Optium Omega glucose meter fits the analytical requirements for its use in blood glucose monitoring in diabetes patients.

Evaluation of the relationship between capillary and venous plasma glucose concentrations obtained by the HemoCue Glucose 201+ system during an oral glucose tolerance test

In 55 women with previous gestational diabetes mellitus, simultaneous capillary and venous plasma glucose concentrations were measured at 0, 30 and 120 min during a 75 g oral glucose tolerance test (OGTT). The aims of the study were to examine the relationship between capillary and venous glucose measurements, and to establish equations for the conversion of capillary and venous glucose concentrations using the HemoCue Glucose 201+ system. Additionally, the correlation between the capillary and venous glucose concentrations with the diagnostic cut-off limits proposed by the World Health Organization (WHO) in 1999 was evaluated. Capillary glucose concentrations were consistently higher than venous glucose concentrations at all time points of the OGTT (p < 0.001), and the correlations between the measurements were statistically highly significant (p < 0.001). The differences between the samples were greatest in the non-fasting state as revealed by the 95% prediction intervals (mmol/L) in Bland-Altman plots; ± 0.54 at 0 min, ± 2.01 at 30 min, and ± 1.35 at 120 min. Equivalence values for capillary plasma glucose concentrations derived from this study tended to be higher than those proposed by the WHO as diagnostic cut-off limits. Stratifying subjects by glucose tolerance status according to the WHO criteria revealed disagreements related to glucose values close to the diagnostic cut-off points. The study findings highlight the uncertainty associated with derived equivalence values. However, capillary plasma glucose measurements could be suitable for diagnostic purposes in epidemiological studies and when translating results on a group basis.

Comparison of point-of-care testing glucose results from intensive care patients measured with network-ready devices

BACKGROUND

Fast and reliable glycemic control is of tremendous importance in intensive care units. Point-of-care devices used in professional care have to be precise and of low variability, and their connectivity has to outrange the abilities of home-care equivalents. In particular, the meter's efficiency should be tested not only with spiked blood samples from healthy donors but also with blood from intensive care unit patients because of their special matrix conditions as low hematocrit, oxygen pressure variability, or medication.

METHODS

Four types of network-ready glucose meters were tested. Data, obtained from native or maltose/xylose-spiked intensive care patients' blood, were compared (oxygen, hematocrit, glucose, and maltose and xylose dependencies) with those from a YSI 2300 STAT Plus™ glucose and lactate analyzer (YSI Life Sciences, Yellow Springs, OH). According to ISO 15197 (2003) acceptance of glucose meter results was determined. Quality control results were investigated considering a new calculation type in German guidelines.

RESULTS

Three of the meters fulfill the overall acceptance criterions. Two of the meters achieved accuracies above 93% in all oxygen, hematocrit, and glucose subgroups. Maltose generates deviations leading to accuracies from 71.1% to 100%, and xylose causes accuracies of 33.3% to 100%.

CONCLUSIONS

State of the art for manufacturing small network point-of-care testing glucose meters has reached a new level of precision, but the devices still have to be handled with care, and in particular the staff of an intensive care unit still needs knowledge about possible interferences.

Ceylon cinnamon does not affect postprandial plasma glucose or insulin in subjects with impaired glucose tolerance

Previous studies on healthy subjects have shown that the intake of 6 g Cinnamomum cassia reduces postprandial glucose and that the intake of 3 g C. cassia reduces insulin response, without affecting postprandial glucose concentrations. Coumarin, which may damage the liver, is present in C. cassia, but not in Cinnamomum zeylanicum. The aim of the present study was to study the effect of C. zeylanicum on postprandial concentrations of plasma glucose, insulin, glycaemic index (GI) and insulinaemic index (GII) in subjects with impaired glucose tolerance (IGT). A total of ten subjects with IGT were assessed in a crossover trial. A standard 75 g oral glucose tolerance test (OGTT) was administered together with placebo or C. zeylanicum capsules. Finger-prick capillary blood samples were taken for glucose measurements and venous blood for insulin measurements, before and at 15, 30, 45, 60, 90, 120, 150 and 180 min after the start of the OGTT. The ingestion of 6 g C. zeylanicum had no significant effect on glucose level, insulin response, GI or GII. Ingestion of C. zeylanicum does not affect postprandial plasma glucose or insulin levels in human subjects. The Federal Institute for Risk Assessment in Europe has suggested the replacement of C. cassia by C. zeylanicum or the use of aqueous extracts of C. cassia to lower coumarin exposure. However, the positive effects seen with C. cassia in subjects with poor glycaemic control would then be lost.

Investigating interferences of a whole-blood point-of-care creatinine analyzer: comparison to plasma enzymatic and definitive creatinine methods in an acute-care setting

BACKGROUND

Although measurement of whole-blood creatinine at the point of care offers rapid assessment of renal function, agreement of point-of-care (POC) results with central laboratory methods continues to be a concern. We assessed the influence of several potential interferents on POC whole-blood creatinine measurements.

METHODS

We compared POC creatinine (Nova StatSensor) measurements with plasma enzymatic (Roche Modular) and isotope dilution mass spectrometry (IDMS) assays in 119 hospital inpatients. We assessed assay interference by hematocrit, pH, pO(2), total and direct bilirubin, creatine, prescribed drugs, diagnosis, red blood cell water fraction, and plasma water fraction.

RESULTS

CVs for POC creatinine were 1.5- to 6-fold greater than those for plasma methods, in part due to meter-to-meter variation. Regressioncomparison of POC creatinine to IDMS results gave a standard error (S(y|x)) of 0.61 mg/dL (54 μmol/L), whereas regression of plasma enzymatic creatinine to IDMS was S(y|x) 0.16 mg/dL (14 μmol/L). By univariate analysis, bilirubin, creatine, drugs, pO(2), pH,plasma water fraction, and hematocrit were not found to contribute to method differences. However, multivariate analysis revealed that IDMS creatinine, red blood cell and plasma water fractions, and hematocrit explained 91.8% of variance in POC creatinine results.

CONCLUSIONS

These data suggest that whole-blood POC creatinine measurements should be used with caution. Negative interferences observed with these measurements could erroneously suggest adequate renal function near the decision threshold, particularly if estimated glomerular filtration rate is determined. Disparity between whole-blood and plasma matrices partially explains the discordance between whole-blood and plasma creatinine methods.

Prevalence of impaired glucose tolerance and diabetes after gestational diabetes mellitus comparing different cut-off criteria for abnormal glucose tolerance during pregnancy

OBJECTIVE

To determine the prevalence of diabetes and impaired glucose tolerance after gestational diabetes mellitus in relation to different categories of glucose tolerance during pregnancy.

DESIGN

Prospective study.

SETTING

Four delivery departments and three hospitals in southern Sweden took part in recruitment and follow-up.

POPULATION

Women undergoing a 75g oral glucose tolerance test during pregnancy delivering in 2003-2005.

METHODS

At first follow-up, one to two years after delivery, 29% of eligible women with abnormal glucose tolerance during pregnancy had an oral glucose tolerance test - 160 with gestational diabetes and 309 with gestational impaired glucose tolerance - in addition to 167 control women. Cut-off levels defining gestational diabetes and impaired glucose tolerance were two-hour capillary blood glucose levels of 9.0 and 7.8mmol/l or plasma glucose 10.0 and 8.6mmol/l, respectively.

MAIN OUTCOME MEASURES

Frequency of abnormal test results at follow-up.

RESULTS

Diabetes was diagnosed in 11% and impaired glucose tolerance in 24% of women with gestational diabetes vs. 4 and 23% in those with gestational impaired glucose tolerance, respectively. Combining women with abnormal test results during pregnancy revealed diabetes or impaired glucose tolerance in 29% as compared to 10% among controls; the odds ratio (95% confidence interval) for having abnormal test results was 3.3 (1.8-5.9) in a multivariate logistic regression analysis.

CONCLUSIONS

Lowering the cut-off level for gestational diabetes to include the category of impaired glucose tolerance would identify a high percentage of women with diabetes and impaired glucose tolerance postpartum, who constitute target groups for intervention and/or diabetes prevention.

Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus

BACKGROUND

Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence-Based Laboratory Medicine Committee of the American Association for Clinical Chemistry jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association.

CONTENT

In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (HbA(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of HbA(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed.

SUMMARY

The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.

Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus

BACKGROUND

Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially.

APPROACH

An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence Based Laboratory Medicine Committee of the AACC jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association.

CONTENT

In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (Hb A(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of Hb A(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed.

SUMMARY

The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.

New plasma separation glucose oxidase-based glucometer in monitoring of blood with different PO2 levels

BACKGROUND

The PalmLab glucometer is a newly designed plasma separation glucose oxidase (GO)-based glucometer. Past studies have shown that the accuracy of GO-based glucometers is compromised when measurements are taken in patients with high PO(2) levels. We performed a two-arm study comparing the fitness of the PalmLab blood glucometer with that of a standard glucose analyzer in monitoring blood glucose levels in pediatric patients, especially when arterial partial pressure of oxygen (PO(2)) was high.

METHODS

In the first arm of the study, arterial blood samples from pediatric patients were measured by the PalmLab blood glucometer and the YSI 2302 Plus Glucose/Lactate analyzer. In the second arm of the study, venous blood samples from adult volunteers were spiked with glucose water to prepare three different levels of glucose (65, 150, and 300mg/dL) and then oxygenated to six levels of PO(2) (range, 40-400mmHg). The biases of the PalmLab glucometer were calculated.

RESULTS

A total of 162 samples were collected in the first arm of the study. Results of linear regression showed that the coefficient of determination (R(2)) between PalmLab glucometer and standard glucose analyzer was 0.9864. Error grid analysis revealed that all the results were within Zone A (clinically accurate estimate zone). The biases between the two systems were low at different PO(2) levels. In the second arm of the study, the results were also unaffected by changes in PO(2).

CONCLUSION

The PalmLab glucometer provides accurate results in samples with high PO(2) and is suitable for measuring arterial glucose levels in pediatric patients.

Does green tea affect postprandial glucose, insulin and satiety in healthy subjects: a randomized controlled trial

Background

Results of epidemiological studies have suggested that consumption of green tea could lower the risk of type 2 diabetes. Intervention studies show that green tea may decrease blood glucose levels, and also increase satiety. This study was conducted to examine the postprandial effects of green tea on glucose levels, glycemic index, insulin levels and satiety in healthy individuals after the consumption of a meal including green tea.

Methods

The study was conducted on 14 healthy volunteers, with a crossover design. Participants were randomized to either 300 ml of green tea or water. This was consumed together with a breakfast consisting of white bread and sliced turkey. Blood samples were drawn at 0, 15, 30, 45, 60, 90, and 120 minutes. Participants completed several different satiety score scales at the same times.

Results

Plasma glucose levels were higher 120 min after ingestion of the meal with green tea than after the ingestion of the meal with water. No significant differences were found in serum insulin levels, or the area under the curve for glucose or insulin. Subjects reported significantly higher satiety, having a less strong desire to eat their favorite food and finding it less pleasant to eat another mouthful of the same food after drinking green tea compared to water.

Conclusions

Green tea showed no glucose or insulin-lowering effect. However, increased satiety and fullness were reported by the participants after the consumption of green tea.

Trial registration number

NCT01086189

Effects of Curcuma longa (turmeric) on postprandial plasma glucose and insulin in healthy subjects

Background

Previous animal studies have shown that Curcuma (C.) longa lowers plasma glucose. C. longa may thus be a promising ingredient in functional foods aimed at preventing type 2 diabetes. The purpose of the study is to study the effect of C. longa on postprandial plasma glucose, insulin levels and glycemic index (GI) in healthy subjects.

Methods

Fourteen healthy subjects were assessed in a crossover trial. A standard 75 g oral glucose tolerance test (OGTT) was administered together with capsules containing a placebo or C. longa. Finger-prick capillary and venous blood samples were collected before, and 15, 30, 45, 60, 90, and 120 min after the start of the OGTT to measure the glucose and insulin levels, respectively.

Results

The ingestion of 6 g C. longa had no significant effect on the glucose response. The change in insulin was significantly higher 30 min (P = 0.03) and 60 min (P = 0.041) after the OGTT including C. longa. The insulin AUCs were also significantly higher after the ingestion of C. longa, 15 (P = 0.048), 30 (P = 0.035), 90 (P = 0.03), and 120 (P = 0.02) minutes after the OGTT.

Conclusions

The ingestion of 6 g C. longa increased postprandial serum insulin levels, but did not seem to affect plasma glucose levels or GI, in healthy subjects. The results indicate that C. longa may have an effect on insulin secretion.

Trial registration number

NCT01029327

Simple pharmacometric tools for oral anti-diabetic drug development: competitive landscape for oral non-insulin therapies in type 2 diabetes

The objectives were to develop a translational model that will help select doses for Phase-3 trials based on abbreviated Phase-2 trials and understand the competitive landscape for oral anti-diabetics based on efficacy, tolerability and ability to slow disease progression. Data for eight anti-diabetics with temporal profiles for fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) from 12 publications were digitized. The monotherapy data consisted of FPG and HbA1c profiles that were modeled using a transit compartment model. Evaluation of the competitive landscape utilized HbA1c literature data for 11 drugs. For the safety metric, tolerability issues with anti-diabetic drug classes were tabulated. For disease progression, the coefficient of failure method was used for assessing data from two long-term trials. The transit rate constants were remarkably consistent across 12 trials and represent system-specific/drug-independent parameters. The competitive landscape analysis showed that the primary efficacy metric fell into two groups of DeltaHbA1c: >0.8% or approximately 0.8%. On the safety endpoints, older agents showed some tolerability issues while the new agents were relatively safe. Among the different drug classes, only the thiazolidinediones appeared to slow disease progression but may also increase heart failure risk. In conclusion, the ability of system-specific parameters to predict HbA1c provides a tool to predict the expected efficacy profile from abbreviated dose-finding trials. To be commercially viable, new drugs should improve DeltaHbA1c by about 0.8% or more and possess safety profiles similar to newer anti-diabetic agents. Thus, this study proposes a suite of simple yet powerful tools to guide type-2-diabetes drug development.

The pituitary gland and age-dependent regulation of body composition

CONTEXT

The prevalence of obesity is increased in hypopituitarism. In the general population, body mass index (BMI) and waist circumference increase with advancing age. It remains uncertain whether age-related changes in pituitary function contribute to the changes in body composition associated with advancing years.

OBJECTIVE

Our objective was to study the relationship between pituitary function, body composition, and age in a large cohort of patients with hypopituitarism and a matched reference population.

DESIGN, SETTING, AND PARTICIPANTS

A total of 3632 GH-deficient adults with hypopituitarism, adequately replaced with all pituitary hormones except for GH, from the prospective KIMS database (Pfizer International Metabolic Database) were included in present analysis. A random sample of the general population (3427 subjects) was used as reference. Patients and controls were grouped by gender in five age cohorts of 10 yr from 28 yr onward.

MAIN OUTCOME MEASURES

Differences in BMI and waist circumference were evaluated.

RESULTS

Patients had a significantly higher BMI and waist circumference than controls, with larger differences at younger age. With advancing age, an increase in BMI and waist circumference was seen in controls but was virtually absent in the patients with adult-onset GH deficiency and hypopituitarism.

CONCLUSION

Patients with hypopituitarism have more excess body fat than age-matched controls, especially in the youngest age groups. The normal increase in fat mass with advancing age is not seen in adult-onset GH-deficient hypopituitarism, suggesting a potential role for the normal pituitary gland as an age-dependent regulator of body composition in adult life.

Age and cystatin C in healthy adults: a collaborative study

BACKGROUND

Kidney function declines with age, but a substantial portion of this decline has been attributed to the higher prevalence of risk factors for kidney disease at older ages. The effect of age on kidney function has not been well described in a healthy population across a wide age spectrum.

METHODS

The authors pooled individual-level cross-sectional data from 18 253 persons aged 28-100 years in four studies: the Cardiovascular Health Study; the Health, Aging and Body Composition Study; the Multi-Ethnic Study of Atherosclerosis and the Prevention of Renal and Vascular End-Stage Disease cohort. Kidney function was measured by cystatin C. Clinical risk factors for kidney disease included diabetes, hypertension, obesity, smoking, coronary heart disease, cerebrovascular disease, peripheral arterial disease and heart failure.

RESULTS

Across the age range, there was a strong, non-linear association of age with cystatin C concentration. This association was substantial, even among participants free of clinical risk factors for kidney disease; mean cystatin C levels were 46% higher in participants 80 and older compared with those <40 years (1.06 versus 0.72 mg/L, P < 0.001). Participants with one or more risk factors had higher cystatin C concentrations for a given age, and the age association was slightly stronger (P < 0.001 for age and risk factor interaction).

CONCLUSIONS

There is a strong, non-linear association of age with kidney function, even in healthy individuals. An important area for research will be to investigate the mechanisms that lead to deterioration of kidney function in apparently healthy persons.