Effect of diabetes duration on the relationship between glycaemic control and risk of death in older adults with type 2 diabetes

Diabetes specialist nurse support, training and 'virtual' advice reduces district nurse visits and improves outcomes for people with diabetes requiring visits for insulin administration

AIMS

We evaluated the effectiveness of a community diabetes specialist nurse (cDSN) working with district nurses (DNs) to optimise insulin therapy on DN workload and patient outcomes.

METHODS

This was an observational clinical improvement study of outcomes pre- and post-introduction of an intervention within a community diabetes service in an areas of England. Patients were followed up for 6 months. The intervention was a cDSN providing advice and support to DNs in safe diabetes management, with a particular focus on insulin use.

RESULTS

in total, 148 of 224 patients were reviewed; 130 (87.8 %) were available for follow up 6 months after their first review. Comparing pre- to post-intervention outcomes, number of patients with a hypoglycaemic event reduced from 21/129 to 1/128 (X2 = 19.71, p < 0.001) as did the number with a hyperglycaemic event; 53/129 to 23/128 (X2 = 16.48, p < 0.001). Number of DN visits and use of acute hospital services also improved significantly. Estimated cost savings through reduced DN visits, insulin usage, and hospital service use totalled £1.9 million.

CONCLUSIONS

Significant financial savings and reduced patient harms were identified following our intervention in this cohort. Roll-out to other sites in England is a next step.

Effectiveness and safety of insulin glargine 300 U/mL in insulin-naïve individuals according to diabetes duration: Results from the REALI European pooled data analysis

AIM

To evaluate the effectiveness and safety of insulin glargine 300 U/mL (Gla-300) initiation according to diabetes duration (DD).

MATERIALS AND METHODS

We analysed patient-level data from 2381 insulin-naïve individuals with type 2 diabetes (T2D), of whom 2349 (98.7%) were treated with Gla-300 for 24 weeks. Of the 2381 participants, 1048 (44.0%) had a DD of less than 8 years and 1333 (56.0%) had a DD of 8 years or longer. We further analysed the subgroups of participants having a DD of less than 4 years (N = 450), 4-8 years (N = 598), 8-12 years (N = 627) and 12 years or longer (N = 706).

RESULTS

Mean ± standard deviation age was 60.2 ± 9.0 years in participants with a DD less than 8 years and 64.2 ± 8.8 years in those with a DD of 8 years or longer. At 24 weeks of Gla-300 therapy, HbA1c improved with a least-squares (LS) mean change from baseline of -1.88% (95% confidence interval [CI], -1.95 to -1.80) and -1.71% (95% CI, -1.77 to -1.65), respectively, resulting in a LS mean difference between groups of 0.17% (95% CI, 0.07 to 0.26; P = .0005). In the subgroup analysis, LS mean HbA1c reduction from baseline to week 24 was highest in participants with a DD of less than 4 years and lowest in participants with a DD of 12 years or longer. Overall, incidences of symptomatic and severe hypoglycaemia were low, irrespective of DD, without body weight changes.

CONCLUSIONS

Gla-300 was effective and safe in insulin-naïve individuals with T2D, regardless of DD. Improvement in HbA1c was greater when Gla-300 was initiated in participants with a DD of less than 4 years, although the difference between the groups was modest.

Health and Oral Health-Related Quality of Life and the Associated Factors in Diabetic Patients

BACKGROUND

Diabetes mellitus, a chronic multi-systemic disease affecting various organs, may negatively influence health-related quality of life (HRQoL) and oral health-related quality of life (OHRQoL). This study aimed to investigate this association in a cross-sectional sample of Iraqi Kurdish diabetic patients.

METHODS

Two hundred eighty-five type 2 diabetic patients participated in the survey. The EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) and the Oral Health Impact Profile-5 (OHIP-5) instruments were used to measure HRQoL and OHRQoL, respectively.

RESULTS

For the HRQoL, 75%, 64%, 46%, and 20% of the participants reported "some" problems in the fields of pain/discomfort, anxiety/depression, mobility, and interruption in usual activities, respectively. Concerning the OHRQoL, difficulty in chewing, finding less flavor in food, oral/dental pain, uneasiness about appearance, and difficulty in doing usual activities were the most complained fields of OHRQoL in 35%, 30%, 29%, 25%, and 20% of the patients respectively. Women had significantly worse HRQoL and OHRQoL compared to men. There was a positive, directly proportional, and significant correlation between HRQoL and OHRQoL (Pearson correlation test = 0.455, p = 0.000).

CONCLUSION

Sex, income, duration of diabetes, and smoking were the predictive modifying factors for both HRQoL and OHRQoL. From a public health point of view, raising health awareness is urgently needed among Iraqi diabetic patients for better diabetes management, a healthier lifestyle, and regular oral hygiene measurements.

Living well with diabetes in Alaska

Many people with diabetes mellitus experience minimal or no complications. Our objective was to determine the proportion of Alaska Native people who experienced four major complications or mortality and to identify factors that may be associated with these outcomes. We used records in a diabetes registry and clinical and demographic variables in our analyses. We used logistic regression and Cox Proportional Hazards models to evaluate associations of these parameters with death and complications that occurred prior to 2013. The study included 591 Alaska Native people with non-type 1 diabetes mellitus, diagnosed between 1986 and 1992. Over 60% of people in this study remained free of four major diabetes-related complications for the remainder of life or throughout the approximately 20-year study period. Lower BMI, higher age at diagnosis of diabetes, and use of at least one diabetes medication were associated with death and a composite of four complications. A majority of Alaska Native people with DM had none of four major complications over a 20-year period. Lower BMI and use of diabetes medications were associated with higher hazard for some deleterious outcomes. This suggests that goals in care of elders should be carefully individualised. In addition, we discuss several programme factors that we believe contributed to favourable outcomes.

The pattern of diabetic care and glycemic control among the ambulatory diabetic patients in tertiary care settings in Bangladesh

Diabetes mellitus is a major public health concern in Bangladesh. The pattern of diabetic care and control of blood sugar among diabetic patients are not well described. We assessed the pattern of diabetic care among ambulatory diabetic patients attending tertiary care hospitals in Bangladesh, and explored the relationship of glycemic control with behavioral and metabolic risks. Any patient 18 years and older attending the medicine outpatient department (OPD) at randomly selected three government tertiary hospitals in three divisions in Bangladesh were examined by hospital doctors. If a patient who was diagnosed as having diabetes and produced any medical document to support the diagnosis was recruited following an informed consent. Data on socio-demographic characteristics, diabetic care plan and behavioral risks, including tobacco use, physical activity, healthy diet (daily fruits and vegetable consumption) and salt intake were obtained from study participants by recall. Three milliliters of venous blood were tested to determine uncontrolled diabetes by measuring glycated hemoglobin (HbA1C > 7.0), and hyperlipidemia by measuring total cholesterol (> 200 mg/dL), high density lipoprotein/HDL (< 40 Mg/dL, low density lipoprotein/ LDL (> 200 mg/dL), and Triglyceride (> 160 mg/dL). A Total of 465 patients were enrolled. The Mean age was 49 years (SD:11) and 58% were women. Sixty percent patients were on a treatment plan of anti-diabetic drugs (drug), healthy diet (diet) and physical activity (PA), 13.3% diet and drug, 9.7% on drug only, 6.4%  on diet and PA, 3.9% on PA and drug, 1.3% on PA only and 0.9% on diet only. Two- third of the patients (68.6%) had uncontrolled diabetes, which was three times higher, if a patient had diabetes for more than five years than otherwise (OR: 3.31, 95% CI 2.06-5.33), two times higher if a patient did not consume fruits  (OR: 2.28, 1.34-3.87), or three times higher, if a patient did not consume vegetables (OR: 3.70, 95% CI 1.80-7.59) than otherwise, 78% higher, if a patient had taken extra salt in meal than otherwise (OR: 1.78, 95% CI 1.13-2.80) and nine times higher, if a patient had a raised total cholesterol level (> 200 mg/dL) than otherwise (OR: 9.60, 95% CI 2.60-35.40) and three times higher, if a patient had a raised LDL level compared than otherwise (OR: 3.33, 95% CI: 1.93-5.70). Diabetic patients seeking care at tertiary hospitals in Bangladesh follow diverse diabetic care plans and the majority of them do not have diabetes under control. Unhealthy dietary practice and hyperlipidemia among diabetic patients contribute to uncontrolled diabetes. Routine monitoring of blood glucose and enforcing lifestyle modifications could promote effective control of diabetes among diabetic patients in Bangladesh.

Chronic glycemic control influences the relationship between acute perioperative dysglycemia and perioperative outcome

BACKGROUND

The objective of this study was to evaluate the impact of dysglycemia on perioperative outcomes, in patients with and without diabetes, and how prior glycemic control modifies these relationships.

METHODS

Consecutive surgical patients admitted to six South Australian tertiary hospitals between 2017 and 2023 were included. Blood glucose levels within 48 h pre- and post-operatively were assessed in an adjusted analyses against a priori selected covariates. Dysglycemia metrics were hyperglycemia (>10.0 mmol/L), hypoglycemia (<4.0 mmol/L), glycemic variability (standard deviation of mean blood glucose >1.7 mmol/L), and stress hyperglycemic ratio (SHR). The primary outcome was hospital mortality.

RESULTS

Of 52 145 patients, 7490 (14.4%) had recognized diabetes. Inpatient mortality was observed in 787 patients (1.5%), of which 150 (19.1%) had diabetes mellitus. Hyperglycemia was associated with increased mortality in patients with diabetes (odds ratio [OR] = 2.99, 95% CI: 1.63-5.67, p = 0.004) but not in non-diabetics, who instead had an increased odds of intensive care unit (ICU) admission if hyperglycemic (OR = 1.95, 95% CI: 1.40-2.72, p < 0.0001). Glycemic variability was associated with increased mortality in patients with diabetes (OR = 1.46, 95% CI: 1.05-2.01, p < 0.05) but not in non-diabetics. Preoperative glycemic control (HbA1c) attenuated both of these associations in a dose-dependent fashion. Hypoglycemia was associated with increased mortality in non-diabetics (OR = 2.14, 95% CI: 1.92-2.37, p < 0.001) but not in patients with diabetes.

CONCLUSIONS,

In surgical patients with diabetes, prior exposure to hyperglycemia attenuates the impact of perioperative hyperglycemia and glycemic variability on inpatient mortality and ICU admission. In patients without diabetes mellitus, all absolute thresholds of dysglycemia are associated with ICU admission, unlike those with diabetes, suggesting the need to use more relative measures such as the SHR.

Oxidative Stress and Asprosin Levels in Type 2 Diabetic Patients with Good and Poor Glycemic Control

Objectives: HbA1c is the most widely used test as an indicator of glucoregulation in patients with type 2 diabetes mellitus (T2DM). Asprosin and oxidative stress levels can be reduced with good glycemic control (GC) and thus prevented or delayed micro/macro complications in patients with T2DM. The relationship between asprosin, which is thought to affect GC, and oxidative stress parameters such as lipid hydroperoxides (LOOHs), glutathione (GSH), malondialdehyde (MDA), superoxide dismutase (Cu,Zn-SOD), and total antioxidant capacity (TAC) was evaluated in T2DM patients. Materials and Methods: The study was conducted prospectively in 75 healthy people admitted to the hospital for a general health check-up and 150 T2DM patients treated in the diabetes outpatient clinic. The patient's glycemic status measurements were categorized as good glycemic control group (GGC) is defined as HbA1c < 7 and poor glycemic control (PGC) group is defined as HbA1c ≥ 7. Results: The study found a consistent increase in LOOH and MDA levels across the control, GGC, and PGC groups, while GSH, Cu/Zn-SOD, and TAC levels decreased in these respective groups. Additionally, asprosin levels showed a gradual rise in all groups. Positive correlations were observed between asprosin levels and various metabolic and oxidative stress markers, including BMI, WC, FBG, insulin, homeostasis model assessment for insulin resistance (HOMA-IR), DM duration, LOOH, and MDA, while negative correlations were noted with GSH, Cu/Zn-SOD, and TAC specifically in the PGC group. Furthermore, multivariate regression analysis identified HOMA-IR as the primary influencing factor on asprosin levels in PGC patients. Conclusions: Current glycemic dysregulation may lead to increased circulating asprosin and oxidative stress, which cause complications. Since asprosin levels may be an important hormonal factor in determining GC in T2DM, the use of this hormone may be recommended in the future to accelerate therapeutic approaches in T2DM. Early diagnosis and appropriate treatment may delay the development and progression of diabetic complications.

Association between glycated hemoglobin and risk of all-cause mortality in community patients with type 2 diabetes: A prospective cohort study

AIMS/INTRODUCTION

To analyze the association between HbA1c level and the risk of all-cause mortality in community patients with type 2 diabetes mellitus, and to provide a scientific basis for the management of type 2 diabetes mellitus in the community.

MATERIALS AND METHODS

Based on a Zhejiang rural community type 2 diabetes mellitus cohort, a total of 10,310 patients with type 2 diabetes mellitus with complete baseline and follow-up data were selected. The Cox proportional hazards regression model and the restricted cubic spline model were used to evaluate the relationship between the HbA1c level and the risk of all-cause mortality.

RESULTS

During a mean follow-up of 5.5 years, 971 patients died. With HbA1c levels of 6.5-7.0% as the reference, after adjusting for relevant confounding factors, the HR(95%CI) of all-cause mortality with HbA1c levels of <5.5%, 5.5-6.5%, 7.0-8.0%, 8.0-9.0%, and ≥9.0% were 1.53 (1.08-2.15), 0.97 (0.79-1.21), 1.14 (0.92-1.41), 1.44 (1.14-1.83), and 2.08 (1.68-2.58), respectively. The HbA1c level was associated with the risk of all-cause mortality in a "J-shaped" manner. The risk of all-cause mortality was lowest when the HbA1c was 6.5-7.0%, and increased significantly when the HbA1c was ≥ 8.0% and the HbA1c was < 5.5% (P < 0.05). The risk of all-cause death in the HbA1c 5.5-6.5% group and the 7.0-8.0% group was not significant compared with the reference group (P > 0.05).

CONCLUSIONS

The HbA1c levels were associated with the risk of all-cause mortality in type 2 diabetes mellitus in a "J-shaped" manner, a too high or a too low HbA1c level could increase the risk of death. Attention should be paid to the individual evaluation of patients and the setting of appropriate glycemic control goals.

Does type 2 diabetes duration influence the effectiveness of an aerobic exercise intervention: Results from the INTENSITY study

BACKGROUND

Studies suggest that longer durations of T2DM increase the risk of T2DM complications and premature mortality. However, whether T2DM duration impacts the efficacy of an aerobic exercise intervention is unclear.

OBJECTIVE

The purpose of this study was: 1) to compare changes in body composition, cardiorespiratory fitness, and glycemia between individuals with short- and long-duration T2DM after aerobic exercise and 2) to determine whether these changes were associated with changes in glycemia by T2DM duration.

METHODS

A secondary analysis of the INTENSITY study (NCT03787836), including thirty-four adults (≥19 years) with T2DM who participated in 28 weeks of aerobic exercise training for 150 minutes per week at a moderate-to-vigorous intensity (4.5 to 6.0 metabolic equivalents (METs)). Using pre-established cut-points, participants were categorized into two groups 1) short-duration T2DM (<5 years) or 2) long-duration T2DM (≥5 years). Glycemia was measured by glycated hemoglobin (HbA1c), body composition by BodPod, and cardiorespiratory fitness by a measure of peak oxygen consumption (VO2peak). All measurements were performed at baseline, 16 weeks, and 28 weeks.

RESULTS

Participants in the short-duration T2DM group experienced decreases in fat mass (kg) (p = 0.03), HbA1c (p = 0.05), and an increased relative VO2peak (p = 0.01). Those with long-duration T2DM experienced decreases in fat mass (kg) (p = 0.02) and HbA1c (p <0.001) and increased fat-free mass (p = 0.02). No significant differences were observed between groups in any outcomes. Changes in fat mass (r = 0.54, p = 0.02), and body fat percentage (r = 0.50, p = 0.02) were significantly associated with the change in HbA1c in those with a long-duration T2DM only.

CONCLUSION

Our results suggest T2DM duration did not differently impact the efficacy of a 28-week aerobic exercise intervention. However, changes in body composition were associated with better glycemia in individuals with longer T2DM duration only.

Mediation effect of cognitive impairment for the relationship of type 2 diabetes mellitus with mortality among elderly individuals

Objectives

To investigate the potential mediating role of cognitive impairment on the link between type 2 diabetes mellitus (T2DM) and mortality among elderly individuals using data from the National Health and Nutrition Examination Survey (NHANES) database.

Methods

Totally, 1,891 individuals from the NHANES database were included in this cohort study. All-cause mortality was considered study endpoint. Cognitive impairment was assessed by digit symbol substitution test (DSST). Adopted weighted logistic regression analyses to explore the relationship of T2DM with cognitive impairment. Constructed weighted Cox proportional hazard models to investigate the relationship of T2DM with all-cause mortality. We employed distribution-of-the-product method to investigate the mediating effect. RMediation software package was used to calculate the 95% confidence interval (CI) of the distribution-of-the-product. If CI does not contain 0, it suggests a significant mediation effect.

Results

The findings from the weighted logistic regression revealed that individuals with T2DM had a significantly higher likelihood of experiencing cognitive impairment [odds ratio =1.86, 95% CI: 1.39-2.49]. The result showed that T2DM was related to an increased all-cause mortality (hazard ratio=1.37, 95%CI: 1.01-1.87). Importantly, the mediation effect of cognitive impairment on the relationship of T2DM with all-cause mortality is significant (95%CI: 0.06-0.59). The percentage of mediation effect was calculated as 16.2%.

Conclusion

Our study suggested that the presence of cognitive impairment plays a significant role in explaining the link between T2DM and all-cause mortality in older individuals.

Impact of Type 2 Diabetes and Glycated Hemoglobin Levels Within the Recommended Target Range on Mortality in Older Adults With Cognitive Impairment Receiving Care at a Memory Clinic: NCGG-STORIES

OBJECTIVE

To determine the impact of type 2 diabetes and glycated hemoglobin (HbA1c) levels within the recommended target range according to the Japan Diabetes Society/Japan Geriatrics Society Joint Committee on mortality in older adults with cognitive impairment.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included 1,528 and 468 patients aged ≥65 years without and with type 2 diabetes, respectively, who were visiting a memory clinic. The 468 patients with type 2 diabetes were divided into three groups (within, above, and below the target range) based on their HbA1c levels, cognitive function, ability to perform activities of daily living, and medications associated with a high risk of hypoglycemia. The impact of diabetes and HbA1c levels on mortality was evaluated using Cox proportional hazards models.

RESULTS

Over a median follow-up period of 3.8 years, 353 patients (17.7%) died. Compared with individuals without type 2 diabetes, HbA1c levels above (hazard ratio [HR] 1.70, 95% CI 1.08-2.69) and below (HR 2.15, 95% CI 1.33-3.48) the target range were associated with a higher risk of death; however, HbA1c levels within the target range were not (HR 1.02, 95% CI 0.77-1.36).

CONCLUSIONS

HbA1c levels above and below the target range were associated with a higher risk of mortality, whereas patients with HbA1c levels within the target range did not exhibit a higher risk of mortality than individuals without type 2 diabetes. These results provide empirical support for the current target ranges among older adults with cognitive impairment.

Methods to predict heart failure in diabetes patients

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is one of the leading causes of cardiovascular disease and powerful predictor for new-onset heart failure (HF).

AREAS COVERED

We focus on the relevant literature covering evidence of risk stratification based on imaging predictors and circulating biomarkers to optimize approaches to preventing HF in DM patients.

EXPERT OPINION

Multiple diagnostic algorithms based on echocardiographic parameters of cardiac remodeling including global longitudinal strain/strain rate are likely to be promising approach to justify individuals at higher risk of incident HF. Signature of cardiometabolic status may justify HF risk among T2DM individuals with low levels of natriuretic peptides, which preserve their significance in HF with clinical presentation. However, diagnostic and predictive values of conventional guideline-directed biomarker HF strategy may be non-optimal in patients with obesity and T2DM. Alternative biomarkers affecting cardiac fibrosis, inflammation, myopathy, and adipose tissue dysfunction are plausible tools for improving accuracy natriuretic peptides among T2DM patients at higher HF risk. In summary, risk identification and management of the patients with T2DM with established HF require conventional biomarkers monitoring, while the role of alternative biomarker approach among patients with multiple CV and metabolic risk factors appears to be plausible tool for improving clinical outcomes.

Effect of delay in treatment intensification in people with type 2 diabetes and suboptimal glycaemia after basal insulin initiation: A real-world observational study

AIM

Despite global recommendations for type 2 diabetes mellitus treatment to maintain optimal glycaemic targets, a significant proportion of people remain in suboptimal glycaemic control. Our objective was to investigate the impact of intensification delay after basal insulin (BI) initiation on long-term complications in people with suboptimal glycaemia.

MATERIALS AND METHODS

We conducted a retrospective cohort study in individuals with type 2 diabetes mellitus initiated on BI. Those with suboptimal glycaemia (glycated haemoglobin ≥7% or ≥53 mmol/mol) within 12 months of BI initiation were divided into early (treatment intensified within 5 years), or late (≥5 years) intensification groups. We estimated the age-stratified risks of micro- and macrovascular complications among these groups compared with those with optimal glycaemia (glycated haemoglobin <7%).

RESULTS

Of the 13 916 people with suboptimal glycaemia, 52.5% (n = 7304) did not receive any treatment intensification. In those aged <65 years, compared with the optimal glycaemia group late intensification was associated with a 56% higher risk of macrovascular complications (adjusted hazard ratio 1.56; 95% confidence intervals 1.08, 2.26). In elderly people (≥65 years), late intensification was associated with a higher risk of cardiovascular-related death (1.62; 1.03, 2.54) and a lower risk of microvascular complications (0.26; 0.08, 0.83).

CONCLUSIONS

Those who had late intensification were at an increased risk of cardiovascular death if they were ≥65 years and an increased risk of macrovascular complications if they were <65 years. These findings highlight the critical need for earlier intensification of treatment and adopting personalized treatment strategies to improve patient outcomes.

[Conservative Treatment and Secondary Prevention of PAD (Peripheral Artery Disease)]

The immediate and long-term success of endovascular and surgical revascularization crucially depends on the conservative treatment of the PAD. The "gentle, preserving" treatment should be understood as he absolutely basic therapy for every PAD patient, because conservative treatment adresses the "big five" of atherosclerotic risk factors. This article presents both the full spectrum of pharmacological and non-pharmacological strategies.

[Conservative therapy and secondary prevention of PAD]

Today, peripheral artery disease (PAD) is treated with the most modern endovascular and open surgical revascularisation procedures. But the short and long-term success of these interventions is decisively determined by the conservative therapy of PAD, which therefore represents the absolute basic therapy of every PAD. Conservative treatment addresses the "Big Five" of atherosclerosis risk factors: smoking, lack of exercise and overweight, diabetes, hypertension, and hyperlipidemia. Despite the knowledge that PAD as a peripheral manifestation of the systemic atherosclerosis needs the same risk factor management as e.g., coronary heart disease, not even every second PAD patient in Germany receives the required therapy. This paper presents the spectrum of both drug and non-drug strategies and focuses on aspects such as platelet inhibition and anticoagulation regimes, lipid-lowering options as well as the benefits and necessity of exercise programs to promote collaterals and improve quality of life by extending the pain-free walking distance. Proven strategies to overcome smoking addiction, use and purpose of vasoactive substances are highlighted as well as the potential risks of diabetic foot syndrome for limb salvage and prevention of wounds.

The Association of Dyslipidemia and Atherogenic Indices With Glycemic Control in Diabetic Dyslipidemia Patients: A Real-World Landscape

BACKGROUND

Dyslipidemia is an important comorbid factor of type 2 diabetes mellitus (T2DM) that increases the risk of cardiovascular diseases. This study aimed to assess the pattern of dyslipidemia and atherogenic indices and determine its relation with glycemic control.

METHODS

A cross-sectional study enrolled 382 patients with diabetic dyslipidemia. The socio-demographics data, clinical features, and laboratory parameters were collected. The baseline lipid parameters such as total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and glycated hemoglobin (HbA1C) were measured. Atherogenic indices such as TC/HDL-C ratio, TG/HDL-C ratio, LDL-C/HDL-C ratio, non-HDL-C/HDL-C and atherogenic index of plasma (AIP) [log10 (TG/HDL-C)] were calculated. T2DM patients were classified into three groups based on the degree of glycemic control: Good glycemic control (HbA1C<7%), fair control (HbA1C 7-8%), and poor control (HbA1C>8%).

RESULTS

The population's mean age was 48.60±6.15 years, with 145 (38%) males. We found mixed dyslipidemia as the most prevalent (36.1%) form of dyslipidemia in our patients. The most common pattern in atherogenic indices was AIP (94.2%). HbA1c was positively correlated with duration of diabetes (r=0.253, p<0.001). In multivariate logistic regression analysis, duration of diabetes (>10 years) was significantly associated with poor glycemic control with an odds ratio (OR) of 2.31(95% CI; 1.25-4.24, p=0.007).

CONCLUSION

The present study indicated that neither the pattern of dyslipidemia nor the atherogenic indices were markers of poor glycemic control among South Indian patients attending our tertiary care institute. However, duration of diabetes was significantly associated with poor glycemic control.

Intensified glycemic control by HbA1c for patients with coronary heart disease and Type 2 diabetes: a review of findings and conclusions

The occurrence and development of coronary heart disease (CHD) are closely linked to fluctuations in blood glucose levels. While the efficacy of intensified treatment guided by HbA1c levels remains uncertain for individuals with diabetes and CHD, this review summarizes the findings and conclusions regarding HbA1c in the context of CHD. Our review showed a curvilinear correlation between regulated level of HbA1c and therapeutic effectiveness of intensified glycemic control among patients with type 2 diabetes and coronary heart disease. It is necessary to optimize the dynamic monitoring indicators of HbA1c, combine genetic profiles, haptoglobin phenotypes for example and select more suitable hypoglycemic drugs to establish more appropriate glucose-controlling guideline for patients with CHD at different stage of diabetes.

Chronic kidney disease in primary care: risk of cardiovascular events, end stage kidney disease and death

BACKGROUND

The prevalence of chronic kidney disease (CKD) is increasing globally. Early diagnosis in primary care may have a role in ensuring proper intervention. We aimed to determine the prevalence and outcome of CKD in primary care.

METHODS

We performed an observational cohort study in primary care in Copenhagen (2001-2015). Outcomes were stroke, myocardial infarction (MI), heart failure (HF), peripheral artery disease (PAD), all-cause- and cardiovascular mortality. We combined individuals with normal kidney function and CKD stage 2 as reference. We conducted cause-specific Cox proportional regressions to calculate the hazard ratios for outcomes according to CKD group. We explored the associations between kidney function and the outcomes examined using eGFR as a continuous variable modelled with penalised splines. All models were adjusted for age, gender, diabetes, hypertension, existing CVD, heart failure, LDL cholesterol and use of antihypertensive treatment.

RESULTS

We included 171,133 individuals with at least two eGFR measurements of which the majority (n = 157,002) had eGFR > 60 ml/min/1.73m² at index date, and 0.05% were in CKD stage 5. Event rates were low in eGFR > 60 ml/min/1.73m² but increased in those with higher stages of CKD. In adjusted analyses we observed an increase in hazard rates for every outcome with every increment in CKD stage. Compared to the reference group, individuals in CKD stage 4 had double the hazard rate of PAD, MI, cardiovascular and all-cause mortality.

CONCLUSIONS

Our data from a large primary care cohort demonstrate an early increase in the risk of adverse outcomes already at CKD stage 3. This underlines the importance of studying early intervention in primary care.

Associations between Plasma Essential Metals Levels and the Risks of All-Cause Mortality and Cardiovascular Disease Mortality among Individuals with Type 2 Diabetes

Epidemiological evidence regarding the possible link between multiple essential metals levels and all-cause mortality and cardiovascular disease (CVD) mortality among type 2 diabetes (T2D) patients is sparse. Here, we aimed to evaluate the longitudinal associations between 11 essential metals levels in plasma and all-cause mortality and CVD mortality among T2D patients. Our study included 5278 T2D patients from the Dongfeng-Tongji cohort. LASSO penalized regression analysis was used to select the all-cause and CVD mortality-associated metals from 11 essential metals (iron, copper, zinc, selenium, manganese, molybdenum, vanadium, cobalt, chromium, nickel, and tin) measured in plasma. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: With a median follow-up of 9.8 years, 890 deaths were documented, including 312 deaths of CVD. LASSO regression models and the multiple-metals model revealed that plasma iron and selenium were negatively associated with all-cause mortality (HR: 0.83; 95%CI: 0.70, 0.98; HR: 0.60; 95%CI: 0.46, 0.77), whereas copper was positively associated with all-cause mortality (HR: 1.60; 95%CI: 1.30, 1.97). Only plasma iron has been significantly associated with decreased risk of CVD mortality (HR: 0.61; 95%CI: 0.49, 0.78). The dose-response curves for the association between copper levels and all-cause mortality followed a J shape (P_{for nonlinear} = 0.01). Our study highlights the close relationships between essential metals elements (iron, selenium, and copper) and all-cause and CVD mortality among diabetic patients.

The Association Between Diabetes Duration and Domain-Specific Cognitive Impairment: A Population-Based Study

BACKGROUND

Diabetes is a risk factor for cognitive impairment, and disease duration is associated with geriatric decline and functional disabilities.

OBJECTIVE

This study aimed to examine the association of diabetes duration with domain-specific cognitive impairment in elderly.

METHODS

A total of 3,142 participants from the National Health and Nutrition Examination Survey (NHANES) from the period between 2011 and 2014 were included. We assessed cognitive function using the Digit Symbol Substitution Test (DSST), the CERAD Word Learning (CERAD-WL) test, the CERAD Delayed Recall (CERAD-DR) test and animal fluency (AF) test.

RESULTS

After adjusting for age, sex, race/ethnicity, education level, and annual household income, we found that diabetes with a duration longer than 20 years were at 3.32-fold increased risk of DSST impairment (OR = 3.32, 95% CI: 1.95 to 5.67), 1.72-fold increased risk of CERAD-WL impairment (OR = 1.72, 95% CI: 1.13 to 2.62), and 1.76-fold increased risk of AF impairment (OR = 1.76, 95% CI: 1.23 to 2.53), compared with those with no diabetes. Associations were generally stronger in women than in men. Participants with diabetes, who were diagnosed at 50-59 years old were at increased risk of DSST impairment, CERAD-WL impairment, CERAD-DR impairment, and AF impairment per 5 years longer duration of diabetes.

CONCLUSION

Longer diabetes duration was associated with the increased risk of cognitive impairment, especially in processing speed and attention. The presence of chronic kidney disease was associated with the increased risk of DSST impairment.

Sociodemographic and behavioural risk factors associated with low awareness of diabetes mellitus medication in Indonesia: Findings from the Indonesian Family Life Survey (IFLS-5)

Introduction

Low awareness of the necessity of taking medication is common among patients with diabetes mellitus (DM) due to their lack of understanding of the disease. Therefore, it is essential to determine the underlying risks influencing low awareness to design effective intervention strategies. This study aims to evaluate the association of sociodemographic and behavioural factors with low awareness to take medication among patients with DM in Indonesia.

Method

Retrospective data were obtained from the Indonesian Family Life Survey (IFLS-5), a national cross-sectional population-based survey among respondents with DM aged ≥15 years. DM status was confirmed by HbA1c testing, while sociodemographic and other health-related information was obtained from self-reported data. Gender, age, educational level, marital status, economic status, comorbidity, religiosity, residence and health insurance status were considered sociodemographic, whereas blood glucose monitoring status, sleeping problems, depression status, having a general medical check-up, satisfaction with healthcare needs and happiness status were considered behavioural risk factors. Awareness of DM medication was determined by self-reported responses to the question asked by the surveyor. Logistic regression analysis was used to evaluate the association between sociodemographic and behavioural factors and low awareness of DM medication. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

Result

Most of the 706 respondents were female (58.8%) and aged 55-65 years (28.8%). Most of them showed low awareness of diabetes medication (87.7%). Irregular blood glucose monitoring (OR: 23.61, 95% CI 11.46-48.65; p < 0.001), without any comorbidity (OR: 2.03, 95% CI 1.05-3.90; p = 0.034), never had any general medical check-up (OR: 2.52, 95% CI 1.12-5.36; p = 0.016), 26-35 years of age (OR: 4.96, 95% CI 1.06-23.19; p = 0.042), 36-45 years of age (OR: 5.04, 95% CI 1.17-21.69; p = 0.030) and having no health insurance coverage (OR: 2.08, 95% CI 1.12-3.87; p = 0.021) were significantly associated with low awareness of diabetes medication.

Conclusion

Healthcare professionals should regularly evaluate blood glucose level, perform routine medical check-ups, prioritise patient satisfaction by providing appropriate care, involve patients in decision-making by determining their needs and then tailor an intervention to meet the need for, and improve their awareness of, DM medication.

Therapeutic Effects of Switching to Anagliptin from Other DPP-4 Inhibitors in T2DM Patients with Inadequate Glycemic Control: A Non-interventional, Single-Arm, Open-Label, Multicenter Observational Study

INTRODUCTION

The effects of switching DPP-4 inhibitors in type 2 diabetes mellitus (T2DM) patients are being widely studied. However, information of which factors affect the therapeutic response is limited. We evaluated the difference in HbA1c lowering effect by comorbidity and other variables after switching to anagliptin in patients with T2DM inadequately controlled by other DPP-4 inhibitors.

METHODS

In a multicenter, open-label, single-arm, prospective observational study, patients with T2DM, HbA1c ≥ 7.0% who have taken DPP-4 inhibitors other than anagliptin, either alone or in combination (DPP-4 inhibitors + metformin/sulfonylurea (SU)/thiazolidinedione (TZD)/insulin), for at least 8 weeks were enrolled. After the switch to anagliptin, HbA1c and available clinical characteristics were determined.

RESULTS

The change in HbA1c levels from baseline to week 12 and 24 was - 0.40% and - 0.42% in all patients. However, comparing the subgroups without and with comorbidities, the change in HbA1c levels at weeks 12 and 24 was - 0.68% and - 0.89% vs. - 0.27% and 0.22%, respectively. In addition, the proportion of patients achieving HbA1c < 7% from baseline to week 12 and 24 was increased to 70% and 70% vs. 20% and 24%, respectively. Duration of T2DM and different subtype classes of DPP-4 inhibitor did not significantly contribute to the change in HbA1c.

CONCLUSION

In patients with T2DM poorly controlled by other DPP-4 inhibitors, HbA1c levels were significantly decreased after switching to anagliptin. Given that the change in HbA1c was greater in patients without comorbidities than in patients with comorbidities, switching to anagliptin before adding other oral hypoglycemic agents (OHAs) may be an option in patients without comorbidities.

Serum protease-activated receptor (PAR-1) levels as a potential biomarker for diagnosis of inflammation in type 2 diabetic patients

BACKGROUND

Inflammation is a prominent clinical manifestation in type 2 diabetes mellitus (T₂DM) patients, often associated with insulin resistance, metabolic dysregulation, and other complications.

AIM OF THE STUDY

The present study has been designed to check the serum levels of PAR-1 and correlate with various clinical manifestations and inflammatory cytokines levels in type 2 diabetic subjects.

MATERIAL AND METHODS

The study population was divided into two groups, healthy volunteers (n = 15): normal glycated hemoglobin (HbA1c) (4.26 ± 0.55) and type 2 diabetic subjects (n = 30): HbA1c levels (7.80 ± 2.41). The serum levels of PAR-1 (ELISA method) were studied in both groups and correlated with demographic parameters age, weight, body mass index (BMI), and conventional inflammation biomarkers like C-reactive protein (CRP), interleukin 6 (IL-6), interleukin 8 (IL-8), and tumour necrosis factor-alpha (TNF-α).

RESULTS

The demographic variables including the body weight (77.38 ± 10.00 vs. controls 55.26 ± 6.99), BMI (29.39 ± 3.61 vs. controls 25.25 ± 4.01), glycemic index HbA1c (7.80 ± 2.41 vs. controls 4.26 ± 0.55) were found to be statistically increased in T₂DM subjects than the healthy control group. The levels of various inflammatory biomarkers and PAR-1 were significantly elevated in T₂DM groups in comparison to healthy volunteers. The univariate and multivariate regression analysis revealed that elevated PAR-1 levels positively correlated with increased body weight, BMI, HbA1c, and inflammatory cytokines.

CONCLUSION

Our findings indicate that the elevated serum PAR-1 levels serve as an independent predictor of inflammation in T₂DM subjects and might have prognostic value for determining T₂DM progression.

Association of hemoglobin A1c time in range with risk for diabetes complications

INTRODUCTION

We assessed the association between hemoglobin A1c time in range (A1c TIR), based on unique patient-level A1c target ranges, with risks of developing microvascular and macrovascular complications in older adults with diabetes.

RESEARCH DESIGN AND METHODS

We used a retrospective observational study design and identified patients with diabetes from the Department of Veterans Affairs (n=397 634). Patients were 65 years and older and enrolled in Medicare during the period 2004-2016. Patients were assigned to individualized A1c target ranges based on estimated life expectancy and the presence or absence of diabetes complications. We computed A1c TIR for patients with at least four A1c tests during a 3-year baseline period. The association between A1c TIR and time to incident microvascular and macrovascular complications was studied in models that included A1c mean and A1c SD.

RESULTS

We identified 74 016 patients to assess for incident microvascular complications and 89 625 patients to assess for macrovascular complications during an average follow-up of 5.5 years. Cox proportional hazards models showed lower A1c TIR was associated with higher risk of microvascular (A1c TIR 0% to <20%; HR=1.04; 95%) and macrovascular complications (A1c TIR 0% to <20%; HR=1.07; 95%). A1c mean was associated with increased risk of microvascular and macrovascular complications but A1c SD was not. The association of A1c TIR with incidence and progression of individual diabetes complications within the microvascular and macrovascular composites showed similar trends.

CONCLUSIONS

Maintaining stability of A1c levels in unique target ranges was associated with lower likelihood of developing microvascular and macrovascular complications in older adults with diabetes.

Connections between Orthopedic Conditions and Oxidative Stress: Current Perspective and the Possible Relevance of Other Factors, Such as Metabolic Implications, Antibiotic Resistance, and COVID-19

The general opinion in the literature is that these topics remain clearly understudied and underrated, with many unknown aspects and with controversial results in the respective areas of research. Based on the previous experience of our groups regarding such matters investigated separately, here we attempt a short overview upon their links. Thus, we summarize here the current state of knowledge regarding the connections between oxidative stress and: (a) orthopedic conditions; (b) COVID-19. We also present the reciprocal interferences among them. Oxidative stress is, of course, an interesting and continuously growing area, but what exactly is the impact of COVID-19 in orthopedic patients? In the current paper we also approached some theories on how oxidative stress, metabolism involvement, and even antibiotic resistance might be influenced by either orthopedic conditions or COVID-19. These manifestations could be relevant and of great interest in the context of this current global health threat; therefore, we summarize the current knowledge and/or the lack of sufficient evidence to support the interactions between these conditions.

Differential effects of treatment targets on risks of adverse outcomes according to diabetes duration, age and complications: Can these characteristics be used to individualize diabetes treatment? The Rio de Janeiro type 2 diabetes cohort

AIMS

To investigate interactions between more/less strict treatment targets (HbA1c, systolic blood pressure, LDL-cholesterol) and clinical characteristics (age, diabetes duration and presence of complications) for occurrence of cardiovascular/microvascular complications and mortality in type 2diabetes.

METHODS

690 individuals were followed-up for 10 years (median). Interactions between treatment targets, estimated as mean values during the first 2-years, and clinical characteristics were tested in multivariable Cox regressions adjusted for other risk factors. Hazard ratios (HRs) were estimated in stratified analyses for cardiovascular/microvascular outcomes and mortality.

RESULTS

During follow-up, 214 patients had a cardiovascular event (175 MACEs); and 265 died (132 cardiovascular deaths); there were 206 renal, 161 retinopathy and 181 peripheral neuropathy events. There were interactions between treatment parameters and clinical characteristics, in most of them the HRs were higher in older individuals, in those with longer diabetes durations and with complications, particularly for the cardiovascular outcomes and mortality. For microvascular outcomes the opposite was observed. For cardiovascular mortality, the HRs of higher HbA1c were 1.31 (1.08-1.58) and 1.09 (0.88-1.34), respectively with longer/shorter diabetes duration (p-for-interaction 0.11); and 1.43 (1.14-1.79) and 1.02 (0.85-1.23) in older/younger individuals (p-for-interaction 0.019).

CONCLUSIONS

Our findings do not support less strict treatment targets for older individuals, with longer diabetes duration or with complications, particularly for cardiovascular and mortality prevention.

Overtreatment and undertreatment in a sample of elderly people with diabetes

AIMS

In older adults with type 2 diabetes (T2D), overtreatment remains prevalent and undertreatment ignored. The main objective is to estimate the prevalence and examine factors associated with potential overtreatment and undertreatment.

METHOD

Observational study conducted within an administrative database of older adults with T2D who registered in 2018 at the Portuguese Diabetes Association. Participants were categorized either as potentially overtreated (HbA1c ≤ 7.5%), appropriately on target (HbA1c ≥7.5 to ≤9%), or potentially undertreated (HbA1c > 9%).

RESULTS

The study included 444 participants: potential overtreatment and undertreatment were found in 60.5% and 12.6% of the study population. Taking the patients on target as a comparator, the group of potentially overtreated showed to be more men (61.3% vs 52.2%), less-obese (34.1% vs 39.2), higher cardiovascular diseases (13.7% vs 11%), peripheral vascular diseases (16.7% vs 12.8%), diabetic foot (10% vs 4.5%), and severe kidney disease (5.2% vs 4.5%). Conversely, the potentially undertreated participants were more women (64.2% vs 47.7%), obese (49% vs 39.2%), had more dyslipidemia (69% vs 63.1%), peripheral vascular disease (14.2% vs 12.8%), diabetic foot (8.9% vs 4.5%), and infections (14.2% vs 11.9%). The odds of potential overtreatment were mostly decreased by 59% of women, 73.5% in those with retinopathy, and 86.3% in insulin, 65.4% sulfonylureas, and 66.8% in SGLT2 inhibitors users. Contrariwise, an increase in the odds of potential undertreatment was more than 4.8 times higher in insulin, and more than 3.1 times higher in sulfonylureas users.

CONCLUSION

Potential overtreatment and undertreatment in older adults with T2D in routine clinical practice should guide the clinicians to balance the use of newer oral antidiabetic agents considering its safety profile regarding hypoglycemia.

All-cause mortality prediction models in type 2 diabetes: applicability in the early stage of disease

AIMS

The rate of all-cause mortality is twofold higher in type 2 diabetes than in the general population. Being able to identify patients with the highest risk from the very beginning of the disease would help tackle this burden.

METHODS

We tested whether ENFORCE, an established prediction model of all-cause mortality in type 2 diabetes, performs well also in two independent samples of patients with early-stage disease prospectively followed up.

RESULTS

ENFORCE's survival C-statistic was 0.81 (95%CI: 0.72-0.89) and 0.78 (95%CI: 0.68-0.87) in both samples. Calibration was also good. Very similar results were obtained with RECODe, an alternative prediction model of all-cause mortality in type 2 diabetes.

CONCLUSIONS

In conclusion, our data show that two well-established prediction models of all-cause mortality in type 2 diabetes can also be successfully applied in the early stage of the disease, thus becoming powerful tools for educated and timely prevention strategies for high-risk patients.

American Diabetes Association Framework for Glycemic Control in Older Adults: Implications for Risk of Hospitalization and Mortality

OBJECTIVE

The 2021 American Diabetes Association (ADA) guidelines recommend different A1C targets in older adults that are based on comorbid health status. We assessed risk of mortality and hospitalizations in older adults with diabetes across glycemic control (A1C <7%, 7 to <8%, ≥8%) and ADA-defined health status (healthy, complex/intermediate, very complex/poor) categories.

RESEARCH DESIGN AND METHODS

Prospective cohort analysis of older adults aged 66-90 years with diagnosed diabetes in the Atherosclerosis Risk in Communities (ARIC) study.

RESULTS

Of the 1,841 participants (56% women, 29% Black), 32% were classified as healthy, 42% as complex/intermediate, and 27% as very complex/poor health. Over a median 6-year follow-up, there were 409 (22%) deaths and 4,130 hospitalizations (median [25th-75th percentile] 1 per person [0-3]). In the very complex/poor category, individuals with A1C ≥8% (vs. <7%) had higher mortality risk (hazard ratio 1.76 [95% CI 1.15-2.71]), even after adjustment for glucose-lowering medication use. Within the very complex/poor health category, individuals with A1C ≥8% (vs. <7%) had more hospitalizations (incidence rate ratio [IRR] 1.41 [95% CI 1.03-1.94]). In the complex/intermediate group, individuals with A1C ≥8% (vs. <7%) had more hospitalizations, even with adjustment for glucose-lowering medication use (IRR 1.64 [1.21-2.24]). Results were similar, but imprecise, when the analysis was restricted to insulin or sulfonylurea users (n = 663).

CONCLUSIONS

There were substantial differences in mortality and hospitalizations across ADA health status categories, but older adults with A1C <7% were not at elevated risk, regardless of health status. Our results support the 2021 ADA guidelines and indicate that <7% is a reasonable treatment goal in some older adults with diabetes.

Diabetes duration and glycaemic control as predictors of cardiovascular disease and mortality

AIMS

To assess the associations of diabetes duration and glycaemic control (defined by plasma glycated haemoglobin [HbA1c] level) with the risks of cardiovascular disease (CVD) and all-cause mortality and to determine whether the addition of either or both to the established CVD risk factors can improve predictions.

MATERIALS AND METHODS

A total of 435 679 participants from the UK Biobank without CVD at baseline were included. Cox models adjusting for classic risk factors (sociodemographic and anthropometric characteristics, lipid profiles and medication use) were used, and predictive utility was determined by the C-index and net reclassification improvement (NRI).

RESULTS

Compared with participants without diabetes, participants with longer diabetes durations and poorer glycaemic control had a higher risk of fatal/nonfatal CVD. Among participants with diabetes, the fully-adjusted hazard ratios (HRs) for diabetes durations of 5 to <10 years, 10 to <15 years and ≥15 years were 1.15 (95% confidence interval [CI] 0.99, 1.34), 1.50 (95% CI 1.26, 1.79) and 2.22 (95% CI 1.90, 2.58; P-trend <0.01), respectively, compared with participants with diabetes durations <5 years. In addition, those with the longest disease duration (≥15 years) and poorer glycaemic control (HbA1c ≥64 mmol/mol [8%]) had the highest risk of fatal/nonfatal CVD (HR 3.12, 95% CI 2.52, 3.86). Among participants with diabetes, the addition of both diabetes duration and glycaemic control levels significantly improved both the C-index (change in C-index +0.0254; 95% CI 0.0111, 0.0398) and the overall NRI for fatal/nonfatal CVD (0.0992; 95% CI 0.0085, 0.1755) beyond the use of the classic risk factors.

CONCLUSIONS

Both longer diabetes duration and poorer glycaemic control were associated with elevated risks of CVD and mortality. Clinicians should consider not only glycaemic control but also diabetes duration in CVD risk assessments for participants with diabetes.

Assessment of suspected adverse drug reactions in elderly patients with diabetes mellitus based on a Portuguese spontaneous reporting database: analysis of reporting from 2008 to 2018

BACKGROUND

Age is one of the most important risk factors in the development of diabetes mellitus and certain drug classes indicated for this condition may be associated with clinically important adverse drug reactions (ADRs). The aim of this study was to analyze the suspected ADRs in older patients with diabetes mellitus, reported to the Portuguese Pharmacovigilance System from 2008 to 2018.

RESEARCH DESIGN AND METHODS

A retrospective analysis of suspected ADRs reports was performed, involving patients aged ≥65 years.

RESULTS

Of a total of 751 reports collected, 439 were considered serious, 199 led to hospitalization and in 19 of them occurred a fatal outcome. Most of them were observed in females (n = 393) and involved patients belonging mainly to the age group 65-74 years (n = 405). Taking into account a total of 2134 suspected ADRs, the most frequent were hypoglycemia (2.67%) and lactic acidosis (2.62%). The drugs specifically indicated for glycemic control were the most frequently involved in ADRs.

CONCLUSIONS

Most of the ADRs were reported as serious and were mainly associated to drugs in diabetes mellitus. In addition, the majority of them, such as hypoglycemia, are preventable, highlighting the importance to identify possible factors that determine this occurrence, especially in the elderly.

Pre-operative glycaemic control and long-term survival in diabetic patients after coronary artery bypass grafting

OBJECTIVES

We analysed the Veteran Affairs data to evaluate the association of pre-operative glycated haemoglobin (HbA1c) and long-term outcome after isolated coronary artery bypass grafting (CABG).

METHODS

Veterans with diabetes mellitus and isolated CABG (2006-2018) were divided into 4 groups (I: HbA1c <6.5%, II: HbA1c 6.5-8, III 8-10% and IV: HbA1c >10%). The relationship of pre-operative HbA1c and long-term survival was evaluated with a multivariable Cox proportional hazards model and reported as hazard ratios (HR). The cumulative incidence of secondary end-points [myocardial infarction (MI) and repeat revascularization (percutaneous intervention)] for each group was modelled as competing events with cause-specific Cox proportional hazards models.

RESULTS

Overall, 16 190 patients (mean age 64.9 years, male 98%; insulin dependent 53%) with diabetes mellitus underwent isolated CABG. We observed 19.4%, 45.4%, 27% and 8.2% patients in groups I, II, III and IV, respectively. Patients with HbA1c >10% were the youngest (mean age 60.9 years) and had high rates of Insulin dependence (78%). In patients with HbA1c >10%, improvement in levels was observed in 76%. The median follow-up observed was 5.8 (3.2-8.8) years. Compared to the study mean HbA1c (7.3%), mortality rate increased with HbA1c levels >8%, and especially with pre-operative HbA1c levels >9%. Compared to patients with HbA1c <8%, HbA1c 8-10% and >10% were associated with increased MI (HR 1.24 and HR 1.39, respectively) and need for reintervention (HR 1.20 and HR 1.24, respectively).

CONCLUSIONS

In patients undergoing CABG, pre-operative HbA1c >8% is associated with the increased risk of mortality and adverse cardiac events.

Association Between Bariatric Surgery and Major Adverse Diabetes Outcomes in Patients With Diabetes and Obesity

IMPORTANCE

There are high-quality randomized clinical trial data demonstrating the effect of bariatric surgery on type 2 diabetes remission, but these studies are not powered to study mortality in this patient group. Large observational studies are warranted to study the association of bariatric surgery with mortality in patients with type 2 diabetes.

OBJECTIVE

To determine the association between bariatric surgery and all-cause mortality among patients with type 2 diabetes and severe obesity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based matched cohort study included patients with type 2 diabetes and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) 35 or greater who underwent bariatric surgery from January 2010 to December 2016 in Ontario, Canada. Multiple linked administrative databases were used to define confounders, including age, baseline BMI, sex, comorbidities, duration of diabetes diagnosis, health care utilization, socioeconomic status, smoking status, substance abuse, cancer screening, and psychiatric history. Potential controls were identified from a primary care electronic medical record database. Data were analyzed in 2020.

EXPOSURE

Bariatric surgery (gastric bypass and sleeve gastrectomy) and nonsurgical management of obesity provided by the primary care physician.

MAIN OUTCOMES AND MEASURES

The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality and nonfatal morbidities. Groups were compared through a multivariable Cox proportional Hazards model.

RESULTS

A total of 6910 patients (mean [SD] age at baseline, 52.04 [9.45] years; 4950 [71.6%] women) were included, with 3455 patients who underwent bariatric surgery and 3455 match controls and a median (interquartile range) follow-up time of 4.6 (3.22-6.35) years. In the surgery group, 83 patients (2.4%) died, compared with 178 individuals (5.2%) in the control group (hazard ratio [HR] 0.53 [95% CI, 0.41-0.69]; P < .001). Bariatric surgery was associated with a 68% lower cardiovascular mortality (HR, 0.32 [95% CI, 0.15-0.66]; P = .002) and a 34% lower rate of composite cardiac events (HR, 0.68 [95% CI, 0.55-0.85]; P < .001). Risk of nonfatal renal events was also 42% lower in the surgical group compared with the control group (HR, 0.58 [95% CI, 0.35-0.95], P = .03). Of the groups that had the highest absolute benefit associated with bariatric surgery, men had an absolute risk reduction (ARR) of 3.7% (95% CI, 1.7%-5.7%), individuals with more than 15 years of diabetes had an ARR of 4.3% (95% CI, 0.8%-7.8%), and individuals aged 55 years or older had an ARR of 4.7% (95% CI, 3.0%-6.4%).

CONCLUSIONS AND RELEVANCE

These findings suggest that bariatric surgery was associated with reduced all-cause mortality and diabetes-specific cardiac and renal outcomes in patients with type 2 diabetes and severe obesity.

Correlation Between Extracutaneous Microvascular Complications and Diabetic Foot Ulcers in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetes is a metabolic disease that is taking an epidemic proportion around the world. The occurrence of microvascular complications and diabetic foot ulcer is associated with an increased mortality and morbidity incidence, which is the most serious complication of this disease, which significantly reduce the quality of patient life.

OBJECTIVE

The aim of the study was to determine the correlation of extracutaneous microvascular complications with diabetic foot ulcer in patients with type 2 diabetes.

METHOD

The study was prospective, and included 160 patients with type 2 diabetes. It was conducted at the University Clinical Center of the Republic of Srpska in the period from January 2016 until December 2019. The respondents were adults, of both sexes, suffering from type 2 diabetes, in whom complications of this disease are present. Glycemic control was established based on a target HbA1c value of 7%.

RESULTS

Of the 160 patients in the study, 53.8% were men and 46.2% were women. The average age of the patients was 70.11%±10.05 years. Extracutaneous microvascular complications were present in 85 patients (53.1%); of which 30.2% had well-regulated glycemia (HbA1c≤7.0%), while 61.5% (p<0.001) had unregulated glycemia (HbA1c≥7.0). Polyneuropathy was present in 23.3% of patients with HbA1c≤7.0%, while 41.0% of patients had HbA1c≥7.0% (p<0.043). Nephropathy with HbA1c≤7.0% was present in 36.8% of cases compared to patients with HbA1c≥7.0 in whom the prevalence was 36.8% (p<0.004). Out of total, 25.6% had retinopathy with HbA1c≤7.0%, while in 41.9% of patients with HbA1c≥7.0% (p <0.067). Diabetic ulcer foot was present in 13 patients with HbA1c≥7 (11.1%) compared to patients with HbA1c≤7.0% where there was no occurrence of this complication 0.0% (p<0.021). At the same time, 5.6% of patients had a diabetic foot ulcer with polyneuropathy (p=0.010), 4.4% had neuropathy (p=0.058) and 5.6% had retinopathy (p=0.014).

CONCLUSION

The high incidence of extracutaneous microvascular complications and diabetic foot ulcer in patients with type 2 diabetes requires a multidisciplinary approach of medical professionals that includes prevention of risk factors and good regulation of glycemia.

Real-World Improvements in Hypoglycemia in an Insulin-Dependent Cohort With Diabetes Mellitus Pre/Post Tandem Basal-Iq Technology Remote Software Update

OBJECTIVE

Software updatable insulin pumps, such as the t:slim X2 pump from Tandem Diabetes Care, enable access to new technology as soon as it is commercialized. The remote software update process allows for minimal interruption in therapy compared to purchasing a new pump; however, little quantitative data exist on the software update process or on pre/post therapeutic outcomes. We examined real-world usage and impact of a remote software updatable predictive low-glucose suspend (PLGS) technology designed to reduce hypoglycemic events in people with insulin-dependent diabetes.

METHODS

Approximately 15,000 U.S. Tandem pump users remotely updated their t:slim X2 software to Basal-IQ PLGS technology since its commercial release. We performed a retrospective analysis of users who uploaded at least 21 days of pre/post PLGS update usage data to the Tandem t:connect web application between August 28, 2018, and October 21, 2019 (N = 6,170). Insulin delivery and sensor-glucose values were analyzed per recent international consensus and American Diabetes Association guidelines. Software update performance was also assessed.

RESULTS

Median software update time was 5.36 minutes. Overall glycemic outcomes for pre and post software update showed a decrease in sensor time <70 mg/dL from 2.14 to 1.18% (-1.01; 95% confidence interval [CI], -0.97, -1.05; P<.001), with overall sensor time 70 to 180 mg/dL increasing from 57.8 to 58.5% (0.64; 95% CI, 0.04, 1.24; P<.001). These improvements were sustained at 3, 6, and 9 months after the update.

CONCLUSION

Introduction of a software updatable PLGS algorithm for the Tandem t:slim X2 insulin pump resulted in sustained reductions of hypoglycemia.

ABBREVIATIONS

ADA = American Diabetes Association; CGM = continuous glucose monitoring; CI = confidence interval; PLGS = predictive low-glucose suspend; SG = sensor glucose; T1D = type 1 diabetes; T2D = type 2 diabetes; TIR = time-in-range.

Body Composition and the Components of Metabolic Syndrome in Type 2 Diabetes: The Roles of Disease Duration and Glycemic Control

PURPOSE

Data about body compositional changes throughout the course of type 2 diabetes (T2D) are limited and inconsistent. We investigated the roles of the disease duration and glycemic control in T2D-associated changes of body composition and the components of metabolic syndrome (MetS).

PATIENTS AND METHODS

A total of 25 non-diabetic controls and 92 individuals aged 20-60 years with T2D were included in a case-control study conducted at King Faisal Specialist Hospital, Saudi Arabia. Based on disease duration (newly diagnosed: within the first year and long duration: ≥5 years) and glycemic control (glycated hemoglobin [HbA1C] level ≤7%), the patients were divided into the following groups: newly diagnosed and controlled (N&C, n=25), newly diagnosed and uncontrolled (N&U, n=17), old and controlled (O&C, n=25), and old and uncontrolled (O&U, n=25). Blood samples were collected to assess fasting blood glucose level, HbA1C level, and lipid profile. Anthropometric data were evaluated, and body composition was assessed using a bio-impedancemetry analyzer. Nonparametric tests and multivariable logistic regression analyses were performed.

RESULTS

Compared to the control group, the fat mass (FM) was significantly higher in all groups; furthermore, the fat mass/fat-free mass (FM/FFM) ratio was significantly higher in the N&C. The N&U and O&U groups showed significantly higher percentages of all components of MetS. Among all selected independent factors, only age increased the likelihood of MetS diagnosis by 7% (OR: 1.07; 95% CI: 1.004-1.149; P<0.05). Besides, age, gender, adherence to diet regimen, and T2D duration showed lower odds of increased FM/FFM ratio.

CONCLUSION

This study provided evidence about the impact of T2D on body composition and the other components of MetS. Thus, further characterization of T2D contributes to defining the etiology of the disease to detect and treat poor cardiometabolic health.

Phenotyping individuals with newly-diagnosed type 2 diabetes at risk for all-cause mortality: a single centre observational, prospective study

BACKGROUND

Type 2 diabetes (T2D) shows a high mortality rate, dependent on disease duration, comorbidities and glucose control over time. Data on patients with short disease duration are scanty.

METHODS

We prospectively followed a cohort of newly-diagnosed T2D patients referring to a single diabetes centre, treated according to the international guidelines and checked every 6-12 months. All-cause mortality and major cardiovascular (CV) events were registered.

RESULTS

289 patients out of 3019 consecutive first attendances matched inclusion criteria and were included in the observation. Mean follow-up was 51.2 months. At 31 December 2018, 253 patients were alive and 36 deceased. At baseline, deceased individuals were older, with lower eGFR and lower uric acid, higher prevalence of atrial fibrillation. During the follow-up, 18 non-fatal CV events were adjudicated; patients with incident CV disease (CVD) differed at baseline for sex, previous history of CVD and retinopathy, higher use of secretagogues and lower use of metformin. At multivariate analysis, age and previous CVD were the only independent determinants of all-cause mortality and incident CVD, respectively. In deceased individuals, eGFR slope was markedly unstable and ΔeGFR at the end of the follow-up was higher (p < 0.001), and predicted mortality.

CONCLUSION

Newly-diagnosed T2D patients followed according to the best clinical practice show a mortality rate similar to that reported in more complicated patients with longer disease duration; none of the clinical and biochemical variables commonly measured at baseline can predict mortality or incident CVD; early metformin use seems to be associated with no risk of prevalent or incident retinopathy.