SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe

AIMS

To develop and validate a recalibrated prediction model (SCORE2-Diabetes) to estimate the 10-year risk of cardiovascular disease (CVD) in individuals with type 2 diabetes in Europe.

METHODS AND RESULTS

SCORE2-Diabetes was developed by extending SCORE2 algorithms using individual-participant data from four large-scale datasets comprising 229 460 participants (43 706 CVD events) with type 2 diabetes and without previous CVD. Sex-specific competing risk-adjusted models were used including conventional risk factors (i.e. age, smoking, systolic blood pressure, total, and HDL-cholesterol), as well as diabetes-related variables (i.e. age at diabetes diagnosis, glycated haemoglobin [HbA1c] and creatinine-based estimated glomerular filtration rate [eGFR]). Models were recalibrated to CVD incidence in four European risk regions. External validation included 217 036 further individuals (38 602 CVD events), and showed good discrimination, and improvement over SCORE2 (C-index change from 0.009 to 0.031). Regional calibration was satisfactory. SCORE2-Diabetes risk predictions varied several-fold, depending on individuals' levels of diabetes-related factors. For example, in the moderate-risk region, the estimated 10-year CVD risk was 11% for a 60-year-old man, non-smoker, with type 2 diabetes, average conventional risk factors, HbA1c of 50 mmol/mol, eGFR of 90 mL/min/1.73 m2, and age at diabetes diagnosis of 60 years. By contrast, the estimated risk was 17% in a similar man, with HbA1c of 70 mmol/mol, eGFR of 60 mL/min/1.73 m2, and age at diabetes diagnosis of 50 years. For a woman with the same characteristics, the risk was 8% and 13%, respectively.

CONCLUSION

SCORE2-Diabetes, a new algorithm developed, calibrated, and validated to predict 10-year risk of CVD in individuals with type 2 diabetes, enhances identification of individuals at higher risk of developing CVD across Europe.

Estimating individual lifetime risk of incident cardiovascular events in adults with Type 2 diabetes: an update and geographical calibration of the DIAbetes Lifetime perspective model (DIAL2)

AIMS

The 2021 European Society of Cardiology cardiovascular disease (CVD) prevention guidelines recommend the use of (lifetime) risk prediction models to aid decisions regarding intensified preventive treatment options in adults with Type 2 diabetes, e.g. the DIAbetes Lifetime perspective model (DIAL model). The aim of this study was to update the DIAL model using contemporary and representative registry data (DIAL2) and to systematically calibrate the model for use in other European countries.

METHODS AND RESULTS

The DIAL2 model was derived in 467 856 people with Type 2 diabetes without a history of CVD from the Swedish National Diabetes Register, with a median follow-up of 7.3 years (interquartile range: 4.0-10.6 years) and comprising 63 824 CVD (including fatal CVD, non-fatal stroke and non-fatal myocardial infarction) events and 66 048 non-CVD mortality events. The model was systematically recalibrated to Europe's low- and moderate-risk regions using contemporary incidence data and mean risk factor distributions. The recalibrated DIAL2 model was externally validated in 218 267 individuals with Type 2 diabetes from the Scottish Care Information-Diabetes (SCID) and Clinical Practice Research Datalink (CPRD). In these individuals, 43 074 CVD events and 27 115 non-CVD fatal events were observed. The DIAL2 model discriminated well, with C-indices of 0.732 [95% confidence interval (CI) 0.726-0.739] in CPRD and 0.700 (95% CI 0.691-0.709) in SCID.

CONCLUSION

The recalibrated DIAL2 model provides a useful tool for the prediction of CVD-free life expectancy and lifetime CVD risk for people with Type 2 diabetes without previous CVD in the European low- and moderate-risk regions. These long-term individualized measures of CVD risk are well suited for shared decision-making in clinical practice as recommended by the 2021 CVD ESC prevention guidelines.

Assessing Representativeness of Randomised Controlled Trials using Serious Adverse Events

Context: The applicability of randomised controlled trials of pharmacological agents to older people with frailty/multimorbidity is often uncertain, due to concerns that trials are not representative. However, assessing trial representativeness is challenging and complex. Objectives: We explore an approach assessing trial representativeness by comparing rates of trial Serious Adverse Events (SAEs: most of which reflect hospitalisations/deaths) to rates of hospitalisation/death in routine care (which, in a trial setting, would be SAEs be definition). Study design: Secondary analysis of trial and routine healthcare data. Dataset and population: 483 trials (n=636,267) from clinicaltrials.gov across 21 index conditions. A routine care comparison was identified from SAIL databank (n=2.3M). Instrument: SAIL data were used to derive the expected rate of hospitalisations/deaths by age, sex and index condition. Outcomes: We calculated the expected number of SAEs for each trial compared to the observed number of SAEs (observed/expected SAE ratio). We then re-calculated the observed/expected SAE ratio additionally accounting for comorbidity count in 125 trials for which we accessed individual participant data. Results: For 12/21 index conditions the observed/expected SAE ratio was <1, indicating fewer SAEs in trials than expected given community rates of hospitalisations and deaths. A further 6/21 had point estimates <1 but the 95% CI included the null. The median observed/expected SAE ratio was 0.60 (95% CI 0.56-0.65; COPD) and the interquartile range was 0.44 (0.34-0.55; Parkinson's disease) to 0.88 (0.59-1.33; IBD). Higher comorbidity count was associated with SAEs/hospitalisations and deaths across index conditions. For most trials, the observed/expected ratio was attenuated but remained <1 after additionally accounting for comorbidity count. Conclusion: Trial participants experience fewer SAEs than expected based on age/sex/condition hospitalisation and death rates in routine care, confirming the predicted lack of representativeness. This difference is only partially explained by differences in multimorbidity. Assessing observed/expected SAE may help assess applicability of trial findings to older populations in whom multimorbidity and frailty are common.

Calibrating a network meta-analysis of diabetes trials of sodium glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor analogues and dipeptidyl peptidase-4 inhibitors to a representative routine population: a systematic review protocol

INTRODUCTION

Participants in randomised controlled trials (trials) are generally younger and healthier than many individuals encountered in clinical practice. Consequently, the applicability of trial findings is often uncertain. To address this, results from trials can be calibrated to more representative data sources. In a network meta-analysis, using a novel approach which allows the inclusion of trials whether or not individual-level participant data (IPD) is available, we will calibrate trials for three drug classes (sodium glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP1) receptor analogues and dipeptidyl peptidase-4 (DPP4) inhibitors) to the Scottish diabetes register.

METHODS AND ANALYSIS

Medline and EMBASE databases, the US clinical trials registry (clinicaltrials.gov) and the Chinese Clinical Trial Registry (chictr.org.cn) will be searched from 1 January 2002. Two independent reviewers will apply eligibility criteria to identify trials for inclusion. Included trials will be phase 3 or 4 trials of SGLT2 inhibitors, GLP1 receptor analogues or DPP4 inhibitors, with placebo or active comparators, in participants with type 2 diabetes, with at least one of glycaemic control, change in body weight or major adverse cardiovascular event as outcomes. Unregistered trials will be excluded.We have identified a target population from the population-based Scottish diabetes register. The chosen cohort comprises people in Scotland with type 2 diabetes who either (1) require further treatment due to poor glycaemic control where any of the three drug classes may be suitable, or (2) who have adequate glycaemic control but are already on one of the three drug classes of interest or insulin.

ETHICS AND DISSEMINATION

Ethical approval for IPD use was obtained from the University of Glasgow MVLS College Ethics Committee (Project: 200160070). The Scottish diabetes register has approval from the Scottish A Research Ethics Committee (11/AL/0225) and operates with Public Benefit and Privacy Panel for Health and Social Care approval (1617-0147).

PROSPERO REGISTRATION NUMBER

CRD42020184174.

Cohort profile: the Scottish Diabetes Research Network national diabetes cohort - a population-based cohort of people with diabetes in Scotland

PURPOSE

The Scottish Diabetes Research Network (SDRN)-diabetes research platform was established to combine disparate electronic health record data into research-ready linked datasets for diabetes research in Scotland. The resultant cohort, 'The SDRN-National Diabetes Dataset (SDRN-NDS)', has many uses, for example, understanding healthcare burden and socioeconomic trends in disease incidence and prevalence, observational pharmacoepidemiology studies and building prediction tools to support clinical decision making.

PARTICIPANTS

We estimate that >99% of those diagnosed with diabetes nationwide are captured into the research platform. Between 2006 and mid-2020, the cohort comprised 472 648 people alive with diabetes at any point in whom there were 4 million person-years of follow-up. Of the cohort, 88.1% had type 2 diabetes, 8.8% type 1 diabetes and 3.1% had other types (eg, secondary diabetes). Data are captured from all key clinical encounters for diabetes-related care, including diabetes clinic, primary care and podiatry and comprise clinical history and measurements with linkage to blood results, microbiology, prescribed and dispensed drug and devices, retinopathy screening, outpatient, day case and inpatient episodes, birth outcomes, cancer registry, renal registry and causes of death.

FINDINGS TO DATE

There have been >50 publications using the SDRN-NDS. Examples of recent key findings include analysis of the incidence and relative risks for COVID-19 infection, drug safety of insulin glargine and SGLT2 inhibitors, life expectancy estimates, evaluation of the impact of flash monitors on glycaemic control and diabetic ketoacidosis and time trend analysis showing that diabetic ketoacidosis (DKA) remains a major cause of death under age 50 years. The findings have been used to guide national diabetes strategy and influence national and international guidelines.

FUTURE PLANS

The comprehensive SDRN-NDS will continue to be used in future studies of diabetes epidemiology in the Scottish population. It will continue to be updated at least annually, with new data sources linked as they become available.

Severe mental illness and quality of diabetes care: a retrospective national linked cohort study

ObjectiveTo use a Scottish national linked diabetes care dataset to determine whether annual monitoring of clinical guideline-recommended diabetes care indicators differ by severe mental illness (SMI) status among people with type 2 diabetes (T2D)  during the first year following diabetes diagnosis and thereafter. ApproachWe examined receipt of 9 diabetes care indicators (HbA1c; cholesterol; urinary albumin; serum creatinine; blood pressure; retinopathy screening; foot examination; body mass index; and smoking status) in people with T2D diagnosed 2009-2018, comparing people with a prior hospital record of schizophrenia, bipolar disorder and depression versus no hospital record for any mental illness. We analysed receipt of care in the first year using logistic regression and for the entire follow-up period (until death or 31 December 2018) using generalized linear mixed effects models, adjusting for calendar year, sociodemographic and lifestyle factors and comorbidities (and in the latter, diabetes duration). ResultsWe included 119,508 people with T2D (mean age 59.7 [±13.2 SD]), of which 1701 (1%), 768 (0.5%) and 5211 (3%) had schizophrenia, bipolar disorder and depression, respectively. During the first year, compared to people without mental illness those with each SMI were more likely to receive cholesterol and serum creatinine measurement and, for schizophrenia only, HbA1c measurement, after adjustment for confounding factors. People with depression had higher odds of receiving a smoking review, but lower odds of receiving urinary albumin measurement. Receipt of all other indicators were similar across comparison groups. In the longitudinal analyses, people with schizophrenia had persistently higher odds of receiving HbA1c and people with a SMI had lower odds of receiving retinopathy screening. ConclusionReceipt of care delivered in the primary care setting was generally similar in people with versus without SMI in the short and long term. However, people with SMI were less likely to receive retinopathy screening, highlighting a need for better monitoring of care indicators delivered outside primary care settings.

Thematic analysis of the challenges and options for the Portfolio Committee on Health in reviewing the National Health Insurance Bill

The Portfolio Committee on Health (PCH) obtained public input on the National Health Insurance Bill from a wide array of individuals and organisations between May and September 2021. The record of these submissions collated by the Parliamentary Monitoring Group provided the source material for this article. The concerns, suggestions and other issues raised by respondents were analysed to determine what challenges and options the PCH needs to take seriously as they prepare the Bill for Parliament. Prominent issues raised included concerns about the proposed governance structure, flaws in the funding model, the risk of corruption, the constitutional and human rights at risk, limited access to care for several groups, and the unresolved nature of the medical benefits to be provided under the Bill. Future legal contestation of the Bill on several of these issues has the potential to stop or delay its implementation for a long time. The PCH has some hard decisions to make: whether to address these concerns with quite radical revisions of the bill, to omit problematic elements, or to leave it unchanged, and accept the contestation this will bring.

Lifestyle interventions for type 2 diabetes prevention in children and adolescents of African descent in OECD countries: a systematic review protocol

OBJECTIVES

The objectives of this review are to investigate the effectiveness of lifestyle interventions for type 2 diabetes prevention in children and adolescents of African descent in the Organisation for Economic Co-operation and Development (OECD) member countries and to attempt to ascertain what aspects of these interventions are most effective in this population.

INTRODUCTION

Lifestyle interventions have been shown to prevent or delay the onset of type 2 diabetes;however, the extent to which these interventions are effective for children and adolescents of African descent is not well established. The increasing type 2 diabetes incidence and prevalence in children and adolescents of African descent in some OECD member countries underscores the need to pool available evidence to ascertain the effectiveness of lifestyle interventions for type 2 diabetes prevention in this population.

INCLUSION CRITERIA

Lifestyle interventions to be considered include individual-or group-based lifestyle or behavioral modification interventions aimed at preventing or delaying the onset of type 2 diabetes in children and adolescents of African descent aged 19 years and under in OECD countries. Randomized controlled trials and non-randomized studies that assess the effectiveness of lifestyle interventions for type 2 diabetes prevention will be considered.

METHODS

The databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Social Services Abstracts, Cochrane Central Register of Controlled Trials, and ProQuest Dissertations and Theses Global databases. There will be no language or date limits placed on the search. Two independent reviewers will conduct the title, abstract, and full-text screening, followed by critical appraisal and data extraction. Data will undergo meta-analysis where appropriate, and will otherwise be presented as narrative synthesis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021247267.

The role of the Minister of Health in the National Health Insurance Bill: Challenges and options for the Portfolio Committee on Health

The Portfolio Committee on Health (PCH) is responsible for obtaining public input on the National Health Insurance Bill, reviewing the Bill based on these inputs, and presenting the final Bill to the National Assembly. More than 130 individuals, organisations and institutions requested to make oral presentations, which commenced on 18 May 2021. Drawing on Parliamentary Monitoring Group meeting summaries and the presentations and submissions made by 82 respondents between 18 May and 10 September 2021, we examine governance concerns, especially in relation to the role and powers of the Minister of Health, and respondents' proposals for addressing them, and outline the challenges and options for the PCH in responding to the proposals.

Prevalence and characteristics associated with diabetes mellitus and impaired fasting glucose among people aged 15 to 64 years in rural and urban Rwanda: secondary data analysis of World Health Organization surveillance data

Introduction

diabetes mellitus is an increasing public health burden in developing countries. The magnitude of diabetes association with traditional risk factors for diabetes have been given less attention in rural population. This study aims to determine the prevalence of diabetes and impaired fasting glucose and to assess associated characteristics to hyperglycemia in rural and urban Rwanda.

Methods

this is a secondary analysis of data from a population-based cross-sectional study of 7240 people describing risk factors for non-communicable diseases using the WHO stepwise methods (STEPS). Relative frequencies of variables of interest were compared in rural and urban residence using Pearson chi-square tests. Diabetes and impaired fasting glucose were combined in a single hyperglycemia variable and odds ratios with 95% confidence intervals were used to explore associations between hyperglycemia, socio-demographic and health factors in urban and rural populations.

Results

the prevalence in rural and urban areas was 7.5% and 9.7% (p.005) for diabetes and 5.0% and 6.2% for impaired fasting glucose (p.079) respectively. Obesity (AOR 2.57: CI: 0.86-7.9), high total cholesterol (AOR 3.83: CI: 2.03-7.208), hypertension (AOR 1.18: CI: 0.69-2.00), increasing age were associated with hyperglycemia in urban participants but only high total cholesterol and low high density lipoproteins (HDL) cholesterol were risk factors for hyperglycemia in rural participants.

Conclusion

approximately one in six people in Rwanda have hyperglycemia. The magnitude of the association with traditional risk factors for diabetes differ in rural and urban settings. Different approaches to primary and secondary prevention of diabetes may be needed in rural populations.

709 IMPACT ON HEALTHCARE UTILISATION OF A GENERAL PRACTITIONER-LED MODEL OF CARE FOR PATIENTS WITH FRAILTY

Introduction

Primary care has a significant role to play in the identification and management of frailty. MidMed is a new dedicated GP-led service developed by a large practice in Midlothian for patients living at home with moderate or severe frailty. MidMed comprises a full-time GP performing a comprehensive geriatric assessment (CGA) adapted for primary care. Patients receive direct access to all appointments with the named GP. The aim of this study was to assess the impact of MidMed on healthcare utilisation in this patient group.

Methods

Patients with moderate or severe frailty at the MidMed practice were identified by the electronic Frailty Index (&gt;0.24). After 16 months, patients who had been accepted into MidMed (MidMed group) were compared with those yet to be enrolled and who continued to receive usual care (non-MidMed group). Routinely collected data were used to identify outcomes including unscheduled hospital admissions, primary care consultations, continuity of care, outpatient attendances and mortality. Adjusted rate ratios were estimated using regression models.

Results

510 patients with moderate or severe frailty were identified (290 in MidMed, 220 in non-MidMed). Patients in each group were just as likely to have at least one hospital admission per year but those in MidMed had a reduced risk of further hospital admission compared to the non-MidMed group (adjusted RR 0.46 [95%CI 0.30–0.71]). MidMed was also associated with statistically significant higher usage of primary care (adjusted RR 1.52, [95%CI, 1.30–1.75]) and better continuity of care. There was no difference in mortality or the number of outpatient appointments when adjusted for co-variates.

Conclusion

A GP-led service for frailty is associated with lower risk of hospital readmission and improved continuity of care. Further studies are now required to better understand why use of such primary care services increase and whether this changes over time.

Complex foraging behaviours in wild birds emerge from social learning and recombination of components

Recent well-documented cases of cultural evolution towards increasing efficiency in non-human animals have led some authors to propose that other animals are also capable of cumulative cultural evolution, where traits become more refined and/or complex over time. Yet few comparative examples exist of traits increasing in complexity, and experimental tests remain scarce. In a previous study, we introduced a foraging innovation into replicate subpopulations of great tits, the 'sliding-door puzzle'. Here, we track diffusion of a second 'dial puzzle', before introducing a two-step puzzle that combines both actions. We mapped social networks across two generations to ask if individuals could: (1) recombine socially-learned traits and (2) socially transmit a two-step trait. Our results show birds could recombine skills into more complex foraging behaviours, and naïve birds across both generations could learn the two-step trait. However, closer interrogation revealed that acquisition was not achieved entirely through social learning-rather, birds socially learned components before reconstructing full solutions asocially. As a consequence, singular cultural traditions failed to emerge, although subpopulations of birds shared preferences for a subset of behavioural variants. Our results show that while tits can socially learn complex foraging behaviours, these may need to be scaffolded by rewarding each component. This article is part of a discussion meeting issue 'The emergence of collective knowledge and cumulative culture in animals, humans and machines'.

TP5.2.9 Mortality following major lower extremity amputation in people with and without diabetes in Scotland 2004-2013

Aim

To describe short and longer-term mortality following major lower extremity amputation (LEA) by diabetes status over two time periods.

Methods

A retrospective cohort study of patients who underwent major LEA between 2004 and 2013 was conducted based on linkage of national population-based hospital records and a register of people with diagnosed diabetes. Post-operative mortality was estimated at 30 days, one year and where available, five years. Using logistic regression models, we estimated the odds of death associated with diabetes adjusted for age, sex and socio-economic status within these time points compared to the non-diabetic population stratified by type of diabetes and five-year calendar periods.

Results

There were a total of 5436 people who received an amputation during the study period of whom approximately 40% had diabetes. Overall mortality for the 2004-8 and 2009-13 cohorts respectively was not significantly different at 7.9% and 7.3% at 30 days and 31% and 27% at one year. Almost 64% of the 2004-8 cohort were dead within five years. The only statistically significantly associations between diabetes and mortality were observed within five year follow-up of the 2004-8 cohort with odds ratios (95% CI) compared to the non-diabetic population of 1.62 (1.17, 2.26) for type 1 diabetes and 1.38 (1.14, 1.66) for type 2 diabetes.

Conclusions

An adverse association between diabetes and mortality after LEA only became apparent in longer term follow-up.

Associations of statin adherence and lipid targets with adverse outcomes in myocardial infarction survivors: a retrospective cohort study

OBJECTIVES

To examine associations between statin adherence and lipid target achievement in myocardial infarction (MI) survivors, and their associations with mortality and recurrent MIs.

DESIGN

Retrospective cohort study using linked clinical records within the National Health Service Greater Glasgow and Clyde (NHS GGC) Data Safe Haven.

SETTING

Routine clinical practice in the NHS GGC area between January 2009 and July 2017.

PARTICIPANTS

Patients ≥18 years who experienced a non-fatal MI hospital admission (ICD10: I21, I22) between January 2009 and July 2014 (n=11 031), followed up from the date of MI admission until July 2017 or death, whichever occurred first.

PRIMARY AND SECONDARY OUTCOME MEASURES

Statin adherence was estimated using encashed prescriptions and lipid results from routine biochemistry data. Primary lipid and statin adherence targets were LDL ≤1.8 mmol/L and adherence ≥50%, and were related to all-cause death, deaths due to cardiovascular disease (CVD) (ICD10: I00-I99 as the underlying cause), and recurrent MI in unadjusted models and models adjusting for age, sex, socioeconomic deprivation and year of MI.

RESULTS

Over 4.5 years follow-up, 76% achieved LDL ≤1.8 mmol/L, and 84.5% had average adherence ≥50%. Patients with adherence <50% had an increased risk of not meeting LDL ≤1.8 mmol/L, in adjusted models (OR 2.03, 95% CI 1.78 to 2.31, p<0.0001). In univariable models, not meeting LDL ≤1.8 mmol/L was associated with increased risks of all-cause mortality (HR 1.27, 95% CI 1.16 to 1.39, p<0.0001) and CVD mortality (HR 1.29, 95% CI 1.11 to 1.51, p=0.0013). Adherence <50% was associated with increased risks of all-cause mortality (HR 1.58, 95% CI 1.44 to 1.74, p<0.0001) and CVD mortality (HR 1.60, 95% CI 1.36 to 1.88, p<0.0001). Adjustment for confounders did not abrogate these associations. Neither exposure was associated with recurrent MIs.

CONCLUSIONS

Non-achievement of lipid and adherence targets are associated with increased risks of all-cause and CVD mortality. Further work is required to optimise their use to improve outcomes in clinical practice.

P–720 Prevalence of Female Infertility in the UK Armed Forces

Study question

What is the prevalence of female infertility among UK military personnel and does it differ from the Metropolitan Police Service (MPS) and civilian populations?

Summary answer

Prevalence of self-reported infertility was higher in servicewomen (31.7%) and female MPS officers (36.3%) than in civilian women (24.4%).

What is known already

Arduous employment is associated with numerous potential occupational hazards and behaviours that may be relevant to fertility. These include physical and psychological stress, smoking, alcohol drinking and other lifestyle factors. A preliminarily report in 2016 indicated that UK servicewomen over 30 years of age were more likely to present with fertility problems compared with reported civilian infertility data for age-matched women. Few previous studies have compared infertility prevalence of servicewomen with civilians, and none have compared infertility prevalence with other occupations.

Study design, size, duration

A cross-sectional study was undertaken in 2019 to determine prevalence of infertility. All eligible UK servicewomen (14,650) and MPS officers (8,262) aged 18–60 years were invited to participate with sisters of participants recruited as controls using a snowball technique. Data including pregnancy history, time to each pregnancy and self-reported infertility risk-factors were collected using an online questionnaire. We estimated a sample of 4898 servicewomen would give a precision of 1% around infertility prevalence estimates.

Participants/materials, setting, methods

The questionnaire was developed, piloted and adapted for electronic distribution. The occupational groups were invited by email to complete the questionnaire on three occasions. Prevalence of infertility was defined as the proportion of women at risk of pregnancy who had not become pregnant within 12 months. Only women with pregnancy outcomes, or fully tested for fertility (12 months or more of exposure), were included in the denominator.

Main results and the role of chance

Participants included 4806 (33%) women serving in the UK Armed Forces, 1237 (15%) female MPS officers and 435 (estimated 8%) non-military, non-MPS sisters (biological, half, step or adopted) of both groups. 98.4% of responses were complete. Prevalence of self-reported 12-month infertility was 31.7% (95% CI 29.9–33.5) in servicewomen, 36.3% (95% CI 33.1–39.7) in MPS officers and 24.4% (95% CI 19.6–29.8) in civilian women. Age, history of polycystic ovary syndrome, endometriosis, fibroids, tubal and pelvic surgery, hysterectomy and a short General Health Questionnaire (GHQ 12) score of &gt; 4 (suggesting a minor psychiatric disorder) were associated with infertility and adjusted for in logistic regression models to estimate odds ratios. The adjusted odds ratio (aOR) of infertility in servicewomen was 1.0 (95% CI 0.8–1.2) compared with MPS officers and 1.5 (95% CI 1.1–2.0) in both servicewomen and MPS officers compared with sisters.

Limitations, reasons for caution

The major limitation is the low response rate, particularly in the two control groups, potentially resulting in response bias. Prevalence of infertility could have been further over-estimated if fertile women are more likely to have left the military or MPS. There is scope for residual confounding.

Wider implications of the findings: Further analyses will explore the key risk factors to identify what aspects of these occupations contribute to infertility and which may be modifiable. Future cohort studies would be helpful to extend the understanding of the influence of occupation on infertility.

Trial registration number

Not applicable

REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS

Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").

Administrative Coding in Electronic Health Care Record-Based Research of NAFLD: An Expert Panel Consensus Statement

BACKGROUND AND AIMS

Electronic health record (EHR)-based research allows the capture of large amounts of data, which is necessary in NAFLD, where the risk of clinical liver outcomes is generally low. The lack of consensus on which International Classification of Diseases (ICD) codes should be used as exposures and outcomes limits comparability and generalizability of results across studies. We aimed to establish consensus among a panel of experts on ICD codes that could become the reference standard and provide guidance around common methodological issues.

APPROACH AND RESULTS

Researchers with an interest in EHR-based NAFLD research were invited to collectively define which administrative codes are most appropriate for documenting exposures and outcomes. We used a modified Delphi approach to reach consensus on several commonly encountered methodological challenges in the field. After two rounds of revision, a high level of agreement (>67%) was reached on all items considered. Full consensus was achieved on a comprehensive list of administrative codes to be considered for inclusion and exclusion criteria in defining exposures and outcomes in EHR-based NAFLD research. We also provide suggestions on how to approach commonly encountered methodological issues and identify areas for future research.

CONCLUSIONS

This expert panel consensus statement can help harmonize and improve generalizability of EHR-based NAFLD research.

What factors explain the much higher diabetes prevalence in Russia compared with Norway? Major sex differences in the contribution of adiposity

INTRODUCTION

Compared with many other countries Russia has a high prevalence of diabetes in men and women. However, contrary to what is found in most other populations, the risk is greater among women than men. The reasons for this are unclear.

RESEARCH DESIGN AND METHODS

Prevalence and risk factors for diabetes at ages 40-69 years were compared in two population-based studies: Know Your Heart (KYH) (Russia, 2015-2018, n=4121) and the seventh wave of the Tromsø Study (Tromsø 7) (Norway, 2015-2016, n=17 649). Diabetes was defined by the level of glycated hemoglobin and/or self-reported diabetes and/or diabetes medication use. Marginal structural models were used to estimate the role of key risk factors for diabetes in differences between the studies.

RESULTS

Age-standardized prevalence of diabetes was higher in KYH compared with Tromsø 7 in men (11.6% vs 6.2%) and in women (13.2% vs 4.3%). Age-adjusted ORs for diabetes in KYH compared with Tromsø 7 were 2.01 (95% CI 1.68 to 2.40) for men and 3.66 (95% CI 3.13 to 4.26) for women. Adiposity (body mass index and waist circumference) explained none of this effect for men but explained 46.0% (39.6, 53.8) for women. Addition of smoking and C reactive protein, as further mediators, slightly increased the percentage explained of the difference between studies to 55.5% (46.5, 66.0) for women but only to 9.9% (-0.6, 20.8) for men.

CONCLUSIONS

Adiposity is a key modifiable risk factor that appears to explain half of the almost threefold higher female prevalence of diabetes in Russia compared with Norway, but none of the twofold male difference.

Defining remission of type 2 diabetes in research studies: A systematic scoping review

BACKGROUND

Remission has been identified as a top priority by people with type 2 diabetes. Remission is commonly used as an outcome in research studies; however, a widely accepted definition of remission of type 2 diabetes is lacking. A report on defining remission was published (but not formally endorsed) in Diabetes Care, an American Diabetes Association (ADA) journal. This Diabetes Care report remains widely used. It was the first to suggest 3 components necessary to define the presence of remission: (1) absence of glucose-lowering therapy (GLT); (2) normoglycaemia; and (3) for duration ≥1 year. Our aim is to systematically review how remission of type 2 diabetes has been defined by observational and interventional studies since publication of the 2009 report.

METHODS AND FINDINGS

Four databases (MEDLINE, EMBASE, Cochrane Library, and CINAHL) were searched for studies published from 1 September 2009 to 18 July 2020 involving at least 100 participants with type 2 diabetes in their remission analysis, which examined an outcome of type 2 diabetes remission in adults ≥18 years and which had been published in English since 2009. Remission definitions were extracted and categorised by glucose-lowering therapy, glycaemic thresholds, and duration. A total of 8,966 titles/abstracts were screened, and 178 studies (165 observational and 13 interventional) from 33 countries were included. These contributed 266 definitions, of which 96 were unique. The 2009 report was referenced in 121 (45%) definitions. In total, 247 (93%) definitions required the absence of GLT, and 232 (87%) definitions specified numeric glycaemic thresholds. The most frequently used threshold was HbA1c<42 mmol/mol (6.0%) in 47 (20%) definitions. Time was frequently omitted. In this study, a total of 104 (39%) definitions defined time as a duration. The main limitations of this systematic review lie in the restriction to published studies written in English with sample sizes of over 100. Grey literature was not included in the search.

CONCLUSIONS

We found that there is substantial heterogeneity in the definition of type 2 diabetes remission in research studies published since 2009, at least partly reflecting ambiguity in the 2009 report. This complicates interpretation of previous research on remission of type 2 diabetes and the implications for people with type 2 diabetes. Any new consensus definition of remission should include unambiguous glycaemic thresholds and emphasise duration. Until an international consensus is reached, studies describing remission should clearly define all 3 components of remission.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019144619.

Prescribing Paradigm Shift? Applying the 2019 European Society of Cardiology-Led Guidelines on Diabetes, Prediabetes, and Cardiovascular Disease to Assess Eligibility for Sodium-Glucose Cotransporter 2 Inhibitors or Glucagon-Like Peptide 1 Receptor Agonists as First-Line Monotherapy (or Add-on to Metformin Monotherapy) in Type 2 Diabetes in Scotland

OBJECTIVE

In 2019, the European Society of Cardiology led and released new guidelines for diabetes cardiovascular risk management, reflecting recent evidence of cardiovascular disease (CVD) reduction with sodium-glucose cotransporter 2 inhibitors (SGLT-2is) and some glucagon-like peptide 1 receptor agonists (GLP-1RAs) in type 2 diabetes (T2D). A key recommendation is that all those with T2D who are (antihyperglycemic) drug naïve or on metformin monotherapy should be CVD risk stratified and an SGLT-2i or a GLP-1RA initiated in all those at high or very high risk, irrespective of glycated hemoglobin. We assessed the impact of these guidelines in Scotland were they introduced as is.

RESEARCH DESIGN AND METHODS

Using a nationwide diabetes register in Scotland, we did a cross-sectional analysis, using variables in our register for risk stratification at 1 January 2019. We were conservative in our definitions, assuming the absence of a risk factor where data were not available. The risk classifications were applied to people who were drug naïve or on metformin monotherapy and the anticipated prescribing change calculated.

RESULTS

Of the 265,774 people with T2D in Scotland, 53,194 (20.0% of those with T2D) were drug naïve, and 56,906 (21.4%) were on metformin monotherapy. Of these, 74.5% and 72.4%, respectively, were estimated as at least high risk given the guideline risk definitions.

CONCLUSIONS

Thus, 80,830 (30.4%) of all those with T2D (n = 265,774) would start one of these drug classes according to table 7 and figure 3 of the guideline. The sizeable impact on drug budgets, enhanced clinical monitoring, and the trade-off with reduced CVD-related health care costs will need careful consideration.

North Atlantic climate far more predictable than models imply

Quantifying signals and uncertainties in climate models is essential for the detection, attribution, prediction and projection of climate change^1-3. Although inter-model agreement is high for large-scale temperature signals, dynamical changes in atmospheric circulation are very uncertain⁴. This leads to low confidence in regional projections, especially for precipitation, over the coming decades^5,6. The chaotic nature of the climate system^7-9 may also mean that signal uncertainties are largely irreducible. However, climate projections are difficult to verify until further observations become available. Here we assess retrospective climate model predictions of the past six decades and show that decadal variations in North Atlantic winter climate are highly predictable, despite a lack of agreement between individual model simulations and the poor predictive ability of raw model outputs. Crucially, current models underestimate the predictable signal (the predictable fraction of the total variability) of the North Atlantic Oscillation (the leading mode of variability in North Atlantic atmospheric circulation) by an order of magnitude. Consequently, compared to perfect models, 100 times as many ensemble members are needed in current models to extract this signal, and its effects on the climate are underestimated relative to other factors. To address these limitations, we implement a two-stage post-processing technique. We first adjust the variance of the ensemble-mean North Atlantic Oscillation forecast to match the observed variance of the predictable signal. We then select and use only the ensemble members with a North Atlantic Oscillation sufficiently close to the variance-adjusted ensemble-mean forecast North Atlantic Oscillation. This approach greatly improves decadal predictions of winter climate for Europe and eastern North America. Predictions of Atlantic multidecadal variability are also improved, suggesting that the North Atlantic Oscillation is not driven solely by Atlantic multidecadal variability. Our results highlight the need to understand why the signal-to-noise ratio is too small in current climate models¹⁰, and the extent to which correcting this model error would reduce uncertainties in regional climate change projections on timescales beyond a decade.

Atypical forms of diabetes mellitus in Africans and other non-European ethnic populations in low- and middle-income countries: a systematic literature review

BACKGROUND

Atypical presentations of diabetes mellitus (DM) have been reported in non-European ethnic populations under various names. It is unclear whether those names are used for the same or different clinical phenotypes. Unclear terminology may lead to inappropriate treatment and an underestimation of the burden caused by atypical diabetes phenotypes overlapping with classic types of diabetes. This review aimed to describe the terms used for atypical forms of diabetes and to investigate whether the terms are used for similar or different phenotypes.

METHODS

PubMed and Scopus were searched for relevant publications in French or English available before 15 September 2015 using the terms: "Atypical diabetes", "Malnutrition Related Diabetes Mellitus (MRDM)", "Fibro-calculus pancreatic diabetes (FCPD)", Protein deficient Pancreatic Diabetes (PDPD)", "African diabetes", "Ketosis prone-type 2 diabetes", "tropical diabetes", "Flatbush diabetes", "J-type diabetes". Titles, abstracts screening and quality assessment were performed by two independent authors. Observational studies addressing atypical diabetes in humans aged 14 years and above were included. One author extracted data from selected articles.

RESULTS

22 articles among 350 identified articles were retained for data extraction. Two atypical diabetes phenotypes were identified, each of them with a variety of names but similar definitions. One phenotype occurred in very thin people less than 30 years of age, typically from poor socio-economic backgrounds and requires insulin for life. It differs from type 1 diabetes in the tolerance of high blood glucose without ketosis in the absence of exogenous insulin. The second phenotype resembles type1 diabetes as it presents with ketosis at onset but responds well, as type2 diabetes, to oral hypoglycemic drugs after initial stabilization with insulin. It occurs in individuals who are usually over 30 years of age, with normal or overweight and absence of auto antibodies mainly found in type 1 diabetes.

CONCLUSION

The scarce existing literature used various terms for similar diabetes phenotypes. Agreement on nomenclature for the various forms of diabetes using the above reported characteristics are needed in populations where atypical forms of diabetes exist as well as better characterization of phenotypes and genotypes to inform evidence based treatment.

Representation of people with comorbidity and multimorbidity in clinical trials of novel drug therapies: an individual-level participant data analysis

BACKGROUND

Clinicians are less likely to prescribe guideline-recommended treatments to people with multimorbidity than to people with a single condition. Doubts as to the applicability of clinical trials of drug treatments (the gold standard for evidence-based medicine) when people have co-existing diseases (comorbidity) may underlie this apparent reluctance. Therefore, for a range of index conditions, we measured the comorbidity among participants in clinical trials of novel drug therapies and compared this to the comorbidity among patients in the community.

METHODS

Data from industry-sponsored phase 3/4 multicentre trials of novel drug therapies for chronic medical conditions were identified from two repositories: Clinical Study Data Request and the Yale University Open Data Access project. We identified 116 trials (n = 122,969 participants) for 22 index conditions. Community patients were identified from a nationally representative sample of 2.3 million patients in Wales, UK. Twenty-one comorbidities were identified from medication use based on pre-specified definitions. We assessed the prevalence of each comorbidity and the total number of comorbidities (level of multimorbidity), for each trial and in community patients.

RESULTS

In the trials, the commonest comorbidities in order of declining prevalence were chronic pain, cardiovascular disease, arthritis, affective disorders, acid-related disorders, asthma/COPD and diabetes. These conditions were also common in community-based patients. Mean comorbidity count for trial participants was approximately half that seen in community-based patients. Nonetheless, a substantial proportion of trial participants had a high degree of multimorbidity. For example, in asthma and psoriasis trials, 10-15% of participants had ≥ 3 conditions overall, while in osteoporosis and chronic obstructive pulmonary disease trials 40-60% of participants had ≥ 3 conditions overall.

CONCLUSIONS

Comorbidity and multimorbidity are less common in trials than in community populations with the same index condition. Comorbidity and multimorbidity are, nevertheless, common in trials. This suggests that standard, industry-funded clinical trials are an underused resource for investigating treatment effects in people with comorbidity and multimorbidity.

Associations of autozygosity with a broad range of human phenotypes

In many species, the offspring of related parents suffer reduced reproductive success, a phenomenon known as inbreeding depression. In humans, the importance of this effect has remained unclear, partly because reproduction between close relatives is both rare and frequently associated with confounding social factors. Here, using genomic inbreeding coefficients (FROH) for >1.4 million individuals, we show that FROH is significantly associated (p < 0.0005) with apparently deleterious changes in 32 out of 100 traits analysed. These changes are associated with runs of homozygosity (ROH), but not with common variant homozygosity, suggesting that genetic variants associated with inbreeding depression are predominantly rare. The effect on fertility is striking: FROH equivalent to the offspring of first cousins is associated with a 55% decrease [95% CI 44-66%] in the odds of having children. Finally, the effects of FROH are confirmed within full-sibling pairs, where the variation in FROH is independent of all environmental confounding.

Tool use and social homophily among male bottlenose dolphins

Homophilous behaviour plays a central role in the formation of human friendships. Individuals form social ties with others that show similar phenotypic traits, independently of relatedness. Evidence of such homophily can be found in bottlenose dolphins ( Tursiops aduncus) in Shark Bay, Western Australia, where females that use marine sponges as foraging tools often associate with other females that use sponges. 'Sponging' is a socially learned, time-consuming behaviour, transmitted from mother to calf. Previous research illustrated a strong female bias in adopting this technique. The lower propensity for males to engage in sponging may be due to its incompatibility with adult male-specific behaviours, particularly the formation of multi-level alliances. However, the link between sponging and male behaviour has never been formally tested. Here, we show that male spongers associated significantly more often with other male spongers irrespective of their level of relatedness. Male spongers spent significantly more time foraging, and less time resting and travelling, than did male non-spongers. Interestingly, we found no difference in time spent socializing. Our study provides novel insights into the relationship between tool use and activity budgets of male dolphins, and indicates social homophily in the second-order alliance composition of tool-using bottlenose dolphins.

Cardiovascular disease prevalence and risk factor prevalence in Type 2 diabetes: a contemporary analysis

AIMS

To describe the prevalence of major cardiovascular disease (CVD) and risk factor control in a contemporary population with Type 2 diabetes.

METHODS

We used data from the national registry in Scotland, Scottish Care Information-Diabetes, linked to hospital admissions. Using descriptive statistics and logistic regression we described associations of risk factors with CVD. CVD was defined based on diagnostic codes in primary or secondary care data for ischaemic heart disease, cerebrovascular disease peripheral arterial disease, heart failure, cardiac arrhythmia, hypertensive heart disease and revascularization procedures.

RESULTS

Among 248 400 people with Type 2 diabetes with a median age of 67.5 years (IQR 58.2, 76.1) and median diabetes duration of 7.8 years (3.8, 13.0), 32% had prior CVD (35% of men, 29% of women). Median HbA_1c overall was 55 mmol/mol (7.2%), median SBP was 132 mmHg, median total cholesterol was 4.1 mmol/l and mean BMI was 32 kg/m² _. Overall two-thirds (65% of men, 68% of women) have two or more of the following CVD risk factor thresholds: HbA_1c ≥ 53 mmol/mol (7%), SBP > 130 mmHg or DBP > 80 mmHg, total cholesterol ≥ 5 mmol/l or BMI ≥ 30 kg/m² , or were currently smoking. Overall 84% were taking anti-hypertensives and 75% a statin. Use of metformin was common at 58%, but other diabetes drugs that reduce CVD were rarely used.

CONCLUSIONS

There continues to be a high prevalence of CVD among people with Type 2 diabetes and a high level of unmet need for risk factor control. This implies substantial scope for reducing the excess risk of CVD in diabetes through improved management of known risk factors.