Determinants of early chronic kidney disease in patients with recently diagnosed type 2 diabetes mellitus: a retrospective study from the Taiwan Diabetes Registry

BACKGROUND

We tried to identify the risk factor associate with early chronic kidney disease (CKD) in recently diagnosed type 2 diabetes mellitus patients by utilizing real-world data from Taiwan Diabetes Registry.

MATERIALS AND METHODS

Patients with type 2 diabetes mellitus recently diagnosed within 1 year. We divided the study participants into control group and early CKD group. Early CKD was defined as either CKD stage G1 with albuminuria, CKD stage G2 with albuminuria, or CKD stage G3a regardless of albuminuria (Urine-albumin to creatinine ratio (UACR) ≥ 3 mg/mmol). Control group was defined as CKD G1 or CKD G2 without albuminuria. Logistic regression analyses were used to compare differences in clinical characteristics between the subgroups. Linear regression models were employed to examine the factors predicting estimated glomerular filtration rate (eGFR) and UACR.

RESULTS

Total 2217 patients with recently diagnosed type 2 diabetes mellitus were included. 1545 patients were assigned to control group and 618 patients were assigned to the early CKD group. Age (odds ratio (OR) 1.215, 95% confidence interval [CI] 1.122-1.316), systolic blood pressure (OR 1.203, 95% CI 1.117-1.296), glycated hemoglobin (OR 1.074, 95% CI 1.023-1.129) and triglyceride (OR 2.18, 95% CI 1.485-3.199) were found to be significant risk factors. Further, presence of bidirectional association between UACR and eGFR was found.

CONCLUSIONS

We reported factors associated with early CKD in recently diagnosed type 2 diabetes mellitus patients. Variables that associated with eGFR and UACR were identified respectively, included a mutual influence between UACR and eGFR.

Disparities in prevalence and treatment of diabetes, cardiovascular and chronic kidney diseases - Recommendations from the taskforce of the guideline workshop

There is a mounting clinical, psychosocial, and socioeconomic burden worldwide as the prevalence of diabetes, cardiovascular disease (CVD), and chronic kidney disease (CKD) continues to rise. Despite the introduction of therapeutic interventions with demonstrated efficacy to prevent the development or progression of these common chronic diseases, many individuals have limited access to these innovations due to their race/ethnicity, and/or socioeconomic status (SES). However, practical guidance to providers and healthcare systems for addressing these disparities is often lacking. In this article, we review the prevalence and impact of healthcare disparities derived from the above-mentioned chronic conditions and present broad-based recommendations for improving access to quality care and health outcomes within the most vulnerable populations.

Multi-Ancestry Polygenic Risk Score for Coronary Heart Disease Based on an Ancestrally Diverse Genome-Wide Association Study and Population-Specific Optimization

BACKGROUND

Predictive performance of polygenic risk scores (PRS) varies across populations. To facilitate equitable clinical use, we developed PRS for coronary heart disease (CHD; PRSCHD) for 5 genetic ancestry groups.

METHODS

We derived ancestry-specific and multi-ancestry PRSCHD based on pruning and thresholding and continuous shrinkage priors (polygenic risk score for CHD developed using ancestry-based continuous shrinkage methods) applied to summary statistics from the largest multi-ancestry genome-wide association study meta-analysis for CHD to date, including 1.1 million participants from 5 major genetic ancestry groups. Following training and optimization in the Million Veteran Program, we evaluated the best-performing PRSCHD in 176 988 individuals across 9 diverse cohorts.

RESULTS

Multi-ancestry polygenic risk score for CHD developed using pruning and thresholding methods and polygenic risk score for CHD developed using ancestry-based continuous shrinkage methods outperformed ancestry-specific Polygenic risk score for CHD developed using pruning and thresholding methods and polygenic risk score for CHD developed using ancestry-based continuous shrinkage methods across a range of tuning values. Two best-performing multi-ancestry PRSCHD (ie, polygenic risk score for CHD developed using pruning and thresholding methods optimized using a multi-ancestry population and polygenic risk score for CHD developed using ancestry-based continuous shrinkage methods optimized using a multi-ancestry population) and 1 ancestry-specific (PRSCSxEUR) were taken forward for validation. Polygenic risk score for CHD developed using pruning and thresholding methods (PT) optimized using a multi-ancestry population demonstrated the strongest association with CHD in individuals of South Asian genetic ancestry and European genetic ancestry (odds ratio per 1 SD [95% CI, 2.75 [2.41-3.14], 1.65 [1.59-1.72]), followed by East Asian genetic ancestry (1.56 [1.50-1.61]), Hispanic/Latino genetic ancestry (1.38 [1.24-1.54]), and African genetic ancestry (1.16 [1.11-1.21]). Polygenic risk score for CHD developed using ancestry-based continuous shrinkage methods optimized using a multi-ancestry population showed the strongest associations in South Asian genetic ancestry (2.67 [2.38-3.00]) and European genetic ancestry (1.65 [1.59-1.71]), lower in East Asian genetic ancestry (1.59 [1.54-1.64]), Hispanic/Latino genetic ancestry (1.51 [1.35-1.69]), and the lowest in African genetic ancestry (1.20 [1.15-1.26]).

CONCLUSIONS

The use of summary statistics from a large multi-ancestry genome-wide meta-analysis improved the performance of PRSCHD in most ancestry groups compared with single-ancestry methods. Despite the use of one of the largest and most diverse sets of training and validation cohorts to date, improvement of predictive performance was limited in African genetic ancestry. This highlights the need for larger Genome-wide association study datasets of underrepresented populations to enhance the performance of PRSCHD.

Birthweight and risk of diabetes in later life

Compared with normative birthweight persons, individuals with a lower birthweight had a higher chance of developing type 2 diabetes at a younger age, a lower body mass index at diagnosis, a lesser family history of diabetes and greater probability of comorbidities.

Guideline Development for Medical Device Technology: Issues for Consideration

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Data from network meta-analyses can inform clinical practice guidelines and decision-making in diabetes management: perspectives of the taskforce of the guideline workshop

In recent years, several novel agents have become available to treat individuals with type 2 diabetes (T2D), such as sodium-glucose cotransporter-2 inhibitors (SGLT-2i), tirzepatide, which is a dual glucose-dependent insulinotropic polypeptide receptor agonist (GIP RA)/glucagon-like peptide-1 receptor agonist (GLP-1 RA), and finerenone, a non-steroidal mineralocorticoid receptor antagonist (MRA) that confers significant renal and cardiovascular benefits in individuals with (CKD). New medications have the potential to improve the lives of individuals with diabetes. However, clinicians are challenged to understand the benefits and potential risks associated with these new and emerging treatment options. In this article, we discuss how use of network meta-analyses (NMA) can fill this need.

Precision subclassification of type 2 diabetes: a systematic review

BACKGROUND

Heterogeneity in type 2 diabetes presentation and progression suggests that precision medicine interventions could improve clinical outcomes. We undertook a systematic review to determine whether strategies to subclassify type 2 diabetes were associated with high quality evidence, reproducible results and improved outcomes for patients.

METHODS

We searched PubMed and Embase for publications that used 'simple subclassification' approaches using simple categorisation of clinical characteristics, or 'complex subclassification' approaches which used machine learning or 'omics approaches in people with established type 2 diabetes. We excluded other diabetes subtypes and those predicting incident type 2 diabetes. We assessed quality, reproducibility and clinical relevance of extracted full-text articles and qualitatively synthesised a summary of subclassification approaches.

RESULTS

Here we show data from 51 studies that demonstrate many simple stratification approaches, but none have been replicated and many are not associated with meaningful clinical outcomes. Complex stratification was reviewed in 62 studies and produced reproducible subtypes of type 2 diabetes that are associated with outcomes. Both approaches require a higher grade of evidence but support the premise that type 2 diabetes can be subclassified into clinically meaningful subtypes.

CONCLUSION

Critical next steps toward clinical implementation are to test whether subtypes exist in more diverse ancestries and whether tailoring interventions to subtypes will improve outcomes.

Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine

Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.

Plasma aryl hydrocarbon receptor associated with epicardial adipose tissue in men: a cross-sectional study

BACKGROUND

Epicardial adipose tissue (EAT) is a type of ectopic fat with endocrine and paracrine functions. Aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor that responds to environmental stimuli. AhR expression is associated with obesity. In this cross-sectional study, we aimed to determine the relationship between circulating AhR concentrations and EAT.

METHODS

A total of 30 men with obesity and 23 age-matched men as healthy controls were enrolled. Plasma AhR concentrations were determined at fasting. The EAT thickness was measured on the free wall of the right ventricle from the basal short-axis plane by magnetic resonance imaging.

RESULTS

The participants with obesity had a higher plasma AhR level than the controls (81.0 ± 24.5 vs. 65.1 ± 16.4 pg/mL, P = 0.010). The plasma AhR level was positively correlated with EAT thickness (correlation coefficient = 0.380, P = 0.005). After adjusting for fasting glucose levels, plasma AhR levels were still significantly associated with EAT thickness (95% CI 0.458‒5.357, P = 0.021) but not with body mass index (P = 0.168).

CONCLUSION

Plasma AhR concentrations were positively correlated with EAT thickness on the free wall of the right ventricle in men. Further investigations are needed to evaluate the causal effects and underlying mechanisms between AhR and EAT.

A risk stratification model modified from the U.S. guideline could be applied in an Asian population with or without ASCVD

AIM

This study aimed to evaluate the performance of a modified US (MUS) model for risk prediction of cardiovascular (CV) events in Asian patients and compare it to European and Japanese models.

MATERIAL AND METHODS

The MUS model, based on the US ACC/AHA 2018 lipid treatment guideline, was employed to stratify patients under primary or secondary prevention. Two multi-center prospective observational registry cohorts, T-SPARCLE and T-PPARCLE, were used to validate the scoring system, and the primary outcome was the time to first occurrence/recurrence of major adverse cardiac events (MACEs). The MUS model's performance was compared to other models from Europe and Japan.

RESULTS

A total of 10,733 patients with the mean age of 64.2 (SD: 11.9) and 36.5% female were followed up for a median of 5.4 years. The MUS model was validated, with an AUC score of 0.73 (95% CI 0.68-0.78). The European and Japanese models had AUC scores ranging from 0.6 to 0.7. The MUS model categorized patients into four distinct CV risk groups, with hazard ratios (HRs) as follows: very high-vs. high-risk group (HR=1.91, 95% CI 1.53-2.39), high-vs. moderate-risk group (HR=2.08, 95% CI 1.60-2.69), and moderate-vs. low-risk group (HR=3.14, 95% CI 1.63-6.03). After adjusting for the MUS model, a history of ASCVD was not a significant predictor of adverse cardiovascular outcomes within each risk group.

CONCLUSION

The MUS model is an effective tool for risk stratification in Asian patients with and without ASCVD, accurately predicting MACEs and performing comparably or better than other established risk models. Our findings suggest that patient management should focus on background risk factors instead of solely on primary or secondary prevention.

A Multi-Ancestry Polygenic Risk Score for Coronary Heart Disease Based on an Ancestrally Diverse Genome-Wide Association Study and Population-Specific Optimization

Background

Predictive performance of polygenic risk scores (PRS) varies across populations. To facilitate equitable clinical use, we developed PRS for coronary heart disease (PRSCHD) for 5 genetic ancestry groups.

Methods

We derived ancestry-specific and multi-ancestry PRSCHD based on pruning and thresholding (PRSP+T) and continuous shrinkage priors (PRSCSx) applied on summary statistics from the largest multi-ancestry genome-wide meta-analysis for CHD to date, including 1.1 million participants from 5 continental populations. Following training and optimization of PRSCHD in the Million Veteran Program, we evaluated predictive performance of the best performing PRSCHD in 176,988 individuals across 9 cohorts of diverse genetic ancestry.

Results

Multi-ancestry PRSP+T outperformed ancestry specific PRSP+T across a range of tuning values. In training stage, for all ancestry groups, PRSCSx performed better than PRSP+T and multi-ancestry PRS outperformed ancestry-specific PRS. In independent validation cohorts, the selected multi-ancestry PRSP+T demonstrated the strongest association with CHD in individuals of South Asian (SAS) and European (EUR) ancestry (OR per 1SD[95% CI]; 2.75[2.41-3.14], 1.65[1.59-1.72]), followed by East Asian (EAS) (1.56[1.50-1.61]), Hispanic/Latino (HIS) (1.38[1.24-1.54]), and weakest in African (AFR) ancestry (1.16[1.11-1.21]). The selected multi-ancestry PRSCSx showed stronger associacion with CHD in comparison within each ancestry group where the association was strongest in SAS (2.67[2.38-3.00]) and EUR (1.65[1.59-1.71]), progressively decreasing in EAS (1.59[1.54-1.64]), HIS (1.51[1.35-1.69]), and lowest in AFR (1.20[1.15-1.26]).

Conclusions

Utilizing diverse summary statistics from a large multi-ancestry genome-wide meta-analysis led to improved performance of PRSCHD in most ancestry groups compared to single-ancestry methods. Improvement of predictive performance was limited, specifically in AFR and HIS, despite use of one of the largest and most diverse set of training and validation cohorts to date. This highlights the need for larger GWAS datasets of AFR and HIS individuals to enhance performance of PRSCHD.

Systematic review of precision subclassification of type 2 diabetes

Heterogeneity in type 2 diabetes presentation, progression and treatment has the potential for precision medicine interventions that can enhance care and outcomes for affected individuals. We undertook a systematic review to ascertain whether strategies to subclassify type 2 diabetes are associated with improved clinical outcomes, show reproducibility and have high quality evidence. We reviewed publications that deployed 'simple subclassification' using clinical features, biomarkers, imaging or other routinely available parameters or 'complex subclassification' approaches that used machine learning and/or genomic data. We found that simple stratification approaches, for example, stratification based on age, body mass index or lipid profiles, had been widely used, but no strategy had been replicated and many lacked association with meaningful outcomes. Complex stratification using clustering of simple clinical data with and without genetic data did show reproducible subtypes of diabetes that had been associated with outcomes such as cardiovascular disease and/or mortality. Both approaches require a higher grade of evidence but support the premise that type 2 diabetes can be subclassified into meaningful groups. More studies are needed to test these subclassifications in more diverse ancestries and prove that they are amenable to interventions.

Association of Major Adverse Cardiac Events and Beta-Blockers in Patients with and without Atherosclerotic Cardiovascular Disease: Long-Term Follow-Up Results of the T-SPARCLE and T-PPARCLE Registry in Taiwan

Beta-blockers are widely used, but the benefit is now challenged in patients at risk of atherosclerotic cardiovascular disease (ASCVD) in the present coronary reperfusion era. We aimed to identify the risk factors of a major adverse cardiac event (MACE) and the long-term effect of beta-blockers in two large cohorts in Taiwan. Two prospective observational cohorts, including patients with known atherosclerosis cardiovascular disease (T-SPARCLE) and patients with at least one risk factor of ASCVD but without clinically evident ASCVD (T-PPARCLE), were conducted in Taiwan. The primary endpoint is the time of first occurrence of a MACE (cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, and cardiac arrest with resuscitation). Between December 2009 and November 2014, with a median 2.4 years follow-up, 11,747 eligible patients (6921 and 4826 in T-SPARCLE and T-PPARCLE, respectively) were enrolled. Among them, 273 patients (2.3%) met the primary endpoint. With multivariate Cox PH model analysis, usage of beta-blocker was lower in patients with MACE (42.9% vs. 52.4%, p < 0.01). In patients with ASCVD, beta-blocker usage was associated with lower MACEs (hazard ratio 0.72; p < 0.001), but not in patients without ASCVD. The event-free survival of beta-blocker users remained higher during the follow-up period (p < 0.005) of ASCVD patients. In conclusion, in ASCVD patients, reduced MACE was associated with beta-blocker usage, and the effect was maintained during a six-year follow-up. Prescribing beta-blockers as secondary prevention is reasonable in the Taiwanese population.

Prediction of the risk of developing end-stage renal diseases in newly diagnosed type 2 diabetes mellitus using artificial intelligence algorithms

OBJECTIVES

Type 2 diabetes mellitus (T2DM) imposes a great burden on healthcare systems, and these patients experience higher long-term risks for developing end-stage renal disease (ESRD). Managing diabetic nephropathy becomes more challenging when kidney function starts declining. Therefore, developing predictive models for the risk of developing ESRD in newly diagnosed T2DM patients may be helpful in clinical settings.

METHODS

We established machine learning models constructed from a subset of clinical features collected from 53,477 newly diagnosed T2DM patients from January 2008 to December 2018 and then selected the best model. The cohort was divided, with 70% and 30% of patients randomly assigned to the training and testing sets, respectively.

RESULTS

The discriminative ability of our machine learning models, including logistic regression, extra tree classifier, random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), and light gradient boosting machine were evaluated across the cohort. XGBoost yielded the highest area under the receiver operating characteristic curve (AUC) of 0.953, followed by extra tree and GBDT, with AUC values of 0.952 and 0.938 on the testing dataset. The SHapley Additive explanation summary plot in the XGBoost model illustrated that the top five important features included baseline serum creatinine, mean serum creatine within 1 year before the diagnosis of T2DM, high-sensitivity C-reactive protein, spot urine protein-to-creatinine ratio and female gender.

CONCLUSIONS

Because our machine learning prediction models were based on routinely collected clinical features, they can be used as risk assessment tools for developing ESRD. By identifying high-risk patients, intervention strategies may be provided at an early stage.

Unhealthy lifestyle associated with increased risk of macro- and micro-vascular comorbidities in patients with long-duration type 2 diabetes: results from the Taiwan Diabetes Registry

BACKGROUND

Unhealthy lifestyle has been associated with obesity and type 2 diabetes. Whereas its association with vascular complications in patients with long-duration of type 2 diabetes is still uncertain.

METHODS

A total of 1188 patients with long-duration of type 2 diabetes from the Taiwan Diabetes Registry (TDR) data were analyzed. We stratified the severity of unhealthy lifestyle via scoring three factors (sleep duration <7 or >9 h, sit duration ≥ 8h, and meal numbers ≥ with night snack) and analyzed their associations with the development of vascular complications using logistic regression analysis. Besides, we also included 3285 patients with newly diagnosed type 2 diabetes as the comparison.

RESULTS

Increased numbers of factors that stand for unhealthy lifestyle were significantly associated with the development of cardiovascular disease, peripheral arterial occlusion disease (PAOD) and nephropathy in patients with long-duration of type 2 diabetes. After adjusting multiple covariables, having ≥ 2 factors of unhealthy lifestyle remained significant associations with cardiovascular disease and PAOD, with an odds ratio (OR) of 2.09 (95% confidence interval [CI] 1.18-3.69) and 2.68 (95% CI 1.21-5.90), respectively. Among individual factor for unhealthy lifestyle behaviors, we revealed that eating ≥ 4 meals per day with night snack increased the risk of cardiovascular disease and nephropathy after multivariable adjustment (OR of 2.60, 95% CI 1.28-5.30; OR of 2.54, 95% CI 1.52-4.26, respectively). Whereas sit duration for ≥ 8 h per day increased the risk of PAOD (OR of 4.32, 95% CI 2.38-7.84).

CONCLUSION

Unhealthy lifestyle is associated with increased prevalence of macro- and micro-vascular comorbidities in Taiwanese patients with long-duration type 2 diabetes.

Brain-derived neurotrophic factor associated with kidney function

BACKGROUND

We examined the relationship between brain-derived neurotrophic factor (BDNF) and chronic kidney disease (CKD).

METHODS

First, a cross-sectional study was conducted in 480 participants without known diabetes. An oral glucose tolerance test (OGTT) was administered after overnight fasting, and blood samples were collected at 0, 30, and 120 min. Second, a total of 3003 participants were enrolled for the case-control genetic analysis. After assigning them to a case or a control group based on age and CKD status, we investigated the association between BDNF gene variants and susceptibility to CKD.

RESULTS

A higher fasting serum BDNF quartile was significantly associated with a lower prevalence of CKD (P value for trend  < 0.001). Based on the receiver operating characteristic analysis, the fasting BDNF level had a larger area under the curve for differentiating CKD (0.645, 95% CI 0.583‒0.707) than the BDNF levels at both 30 min (0.547, 95% CI 0.481‒0.612) and 120 min (0.598, 95% CI 0.536‒0.661). A significantly lower CKD prevalence (odds ratio = 0.30, 95% CI 0.12‒0.71) was observed in the highest quartile of fasting BDNF level than that in the lowest quartile, whereas no interquartile differences were observed for BDNF levels determined at 30 or 120 min during the OGTT. Furthermore, BDNF-associated variants, including rs12098908, rs12577517, and rs72891405, were significantly associated with CKD.

CONCLUSIONS

The BDNF level at fasting, but not at 30 and 120 min after glucose intake, was an independent indicator of CKD. In addition, significant associations were observed between three BDNF gene variants and CKD.

Toward better diabetes care: Exploration and implementation

Approximately 40 years ago, I was fortunate enough to step into the field of diabetes. When I had my fellowship training in the USA, I learned how to ask a good scientific question and conduct clinical research. With collaboration with my mentors, Prof. Gerald R Reaven and Prof. Ida Chen, we participated in many clinical trials. We established the Taiwan Diabetes Registry (TDR) to track long-term changes in diabetes profiles. The ultimate purpose of medical research is to provide benefits to patients. Using electronic medical records and point-of-care glucometers, we reduced inpatients' hyperglycemia and hypoglycemia greatly, which was also reflected by the reduction in hospital stays and readmission rates. With the advent of new technology and medications, we have to ponder where we are on the journey toward better diabetes care. We rigorously advocate diabetes care, hold many symposia and publish updated guidelines. We successfully hosted the congress of the 11th International Diabetes Federation Western Pacific Region & 8th Asian Association for the Study of Diabetes Scientific Meeting 2016 at Taipei, Taiwan. As the era of precision medicine is coming, Taiwan could be considered as one of the best places to run precision medicine. The Taiwan Precision Medicine Initiative has enrolled more than half a million residents, and is currently conducting genotyping and data analysis. In conclusion. I witnessed the early days of simple and few choices for diabetes management to the current various modalities in diabetes care. As these new technologies have become available, patients will always remain at the center of the care model with warmth and humility.

A Randomized Controlled Trial of R-Form Verapamil Added to Ongoing Metformin Therapy in Patients with Type 2 Diabetes

CONTEXT

There is a medical need for effective insulin-independent antidiabetic drugs that can promote pancreatic β-cell function and have a low risk of hypoglycemia in type 2 diabetes mellitus (T2DM) patients. R-form verapamil (R-Vera), which is able to enhance the survival of β-cells and has higher cardiovascular safety margin compared with racemic verapamil, was developed as a novel approach for T2DM treatment.

OBJECTIVE

This randomized, double-blind, placebo-controlled clinical trial was designed to evaluate the efficacy and safety of 3 dosages of R-Vera added to ongoing metformin therapy in T2DM patients who had inadequate glycemic control on metformin alone.

METHODS

Participants were randomly assigned in an equal ratio to receive R-Vera 450, 300, or 150 mg per day, or matching placebo, in combination with metformin. The primary endpoint was change in hemoglobin A1c (HbA1c) after 12 weeks of treatment.

RESULTS

A total of 184 eligible participants were randomized to receive either R-Vera or placebo plus metformin. At week 12, significant reductions in HbA1c were observed for R-Vera 300 mg/day (-0.36, P = 0.0373) and 450 mg/day (-0.45, P = 0.0098) compared with placebo. The reduction in HbA1c correlated with decreasing fasting plasma glucose levels and improved HOMA2-β score. Treatment with R-Vera was well tolerated with no hypoglycemic episodes occurring during the trial.

CONCLUSION

Addition of R-Vera twice daily to ongoing metformin therapy significantly improved glycemic control in T2DM patients. The favorable efficacy and safety profile of R-Vera 300 mg/day can be considered as the appropriate dose for clinical practice.

Aryl hydrocarbon receptor deficiency augments dysregulated microangiogenesis and diabetic retinopathy

Diabetic retinopathy (DR) is a pathophysiologic vasculopathic process with obscure mechanisms and limited effective therapeutic strategies. Aryl hydrocarbon receptor (AhR) is an important regulator of xenobiotic metabolism and an environmental sensor. The aim of the present study was to investigate the role of AhR in the development of DR and elucidate the molecular mechanism of its downregulation. DR was evaluated in diabetes-induced retinal injury in wild type and AhR knockout (AhR-/-) mice. Retinal expression of AhR was determined in human donor and mice eyes by immunofluorescence since AhR activity was examined in diabetes. AhR knockout (AhRKO) mice were used to induce diabetes with streptozotocin, high-fat diet, or genetic double knockout with diabetes spontaneous mutation (Leprdb) (DKO; AhR-/-×Leprdb/db) for investigating structural, functional, and metabolic abnormalities in vascular and epithelial retina. Structural molecular docking simulation was used to survey the pharmacologic AhR agonists targeting phosphorylated AhR (Tyr245). Compared to diabetic control mice, diabetic AhRKO mice had aggravated alterations in retinal vasculature that amplified hallmark features of DR like vasopermeability, vascular leakage, inflammation, blood-retinal barrier breakdown, capillary degeneration, and neovascularization. AhR agonists effectively inhibited inflammasome formation and promoted AhR activity in human retinal microvascular endothelial cells and pigment epithelial cells. AhR activity and protein expression was downregulated, resulting in a decrease in DNA promoter binding site of pigment epithelium-derived factor (PEDF) by gene regulation in transcriptional cascade. This was reversed by AhR agonists. Our study identified a novel of DR model that target the protective AhR/PEDF axis can potentially maintain retinal vascular homeostasis, providing opportunities to delay the development of DR.

Medical school grades may predict future clinical competence

BACKGROUND

In real-world medical education, there is a lack of reliable predictors of future clinical competencies. Hence, we aim to identify the factors associated with clinical competencies and construct a prediction model to identify "improvement required" trainees.

METHODS

We analyzed data from medical students who graduated from National Yang-Ming University with clerkship training and participated in the postgraduate year (PGY) interview at Taipei Veterans General Hospital. Clinical competencies were evaluated using grades of national objective structured clinical examination (OSCEs). This study used data from medical students who graduated in July 2018 as the derivation cohort (N = 50) and those who graduated in July 2020 (n = 56) for validation.

RESULTS

Medical school grades were associated with the performance of national OSCEs (Pearson r = 0.34, p = 0.017), but the grades of the structured PGY interviews were marginally associated with the national OSCE (Pearson r = 0.268, p = 0.06). A prediction model was constructed to identify "improvement required" trainees, defined: trainees with the lowest 25% of scores in the national OSCEs. According to this model, trainees with the lowest 25% medical school grades predicted a higher risk of the "improvement required" clinical performance (Q1-Q3 vs Q4 = 15% vs 60%, odds ratio = 8.5 [95% confidence interval = 1.8-39.4], p = 0.029). In the validation cohort, our prediction model could accurately classify 76.7% "improvement required" and "nonimprovement required" students.

CONCLUSION

Our study suggests that interventions for students with unsatisfactory medical school grades are warranted to improve their clinical competencies.

Effect of 1PC111, a Fixed-Dose Combination of Pitavastatin and Ezetimibe, Versus Pitavastatin or Ezetimibe Monotherapy on Lipid Profiles in Patients With Hypercholesterolemia or Mixed Dyslipidemia: A Randomized, Double-blind, Multicenter, Phase III Study

PURPOSE

This study aimed to show that the efficacy of 1PC111 is superior to that of either ezetimibe or pitavastatin alone (monotherapy) for the treatment of hypercholesterolemia.

METHODS

This was a multicenter, randomized, double-blind, Phase III study. Patients with hypercholesterolemia or mixed dyslipidemia were randomized to receive 1PC111 (which was a fixed-dose combination of pitavastatin 2 mg and ezetimibe 10 mg), pitavastatin 2 mg, or ezetimibe 10 mg daily for 12 weeks. The primary end point was the difference in the percent change in LDL-C from baseline to week 12 between the 1PC111 and each monotherapy group. The secondary end points were the percent change in other lipid profiles from baseline to each visit. All patients were assessed for adverse events until end of study.

FINDINGS

A total of 388 patients were randomly assigned to the 1PC111 (n = 128), pitavastatin (n = 132), or ezetimibe (n = 128) group. Generally, baseline characteristics were similar among the 3 groups. A statistically significant decrease in the LDL-C level at week 12 was observed in the 1PC111 group (-50.50% [14.9%]) compared with either the pitavastatin (-36.11% [11.4%]; P < 0.001) or ezetimibe (-19.85% [12.4%]; P < 0.001) group. Also, there was a statistically significant difference between 1PC111 and each monotherapy group in the reduction in total cholesterol, non-HDL-C, and apolipoprotein B levels. Moreover, there was a trend toward more efficient lowering of LDL-C levels in elderly patients (age ≥65 years) than in younger patients (age <65 years) by 1PC111 treatment. In patients given a class I recommendation for atherosclerotic cardiovascular disease prevention, the percentage of patients achieving the LDL-C target of <100 mg/dL at week 12 was significantly higher in the 1PC111 group than in both monotherapy groups (P < 0.001). Overall, the incidence of adverse events was similar among 3 groups.

IMPLICATIONS

1PC111 was more effective in improving lipid profiles and achieving the LDL-C goal than pitavastatin or ezetimibe alone for hypercholesterolemia treatment. Furthermore, 1PC111 may provide more benefit in treating elderly patients.

CLINICALTRIALS

gov identifier: NCT04643093. (Clin Ther. 2022;44:XXX-XXX) © 2022 Elsevier HS Journals, Inc.

A multi-layer functional genomic analysis to understand noncoding genetic variation in lipids

A major challenge of genome-wide association studies (GWASs) is to translate phenotypic associations into biological insights. Here, we integrate a large GWAS on blood lipids involving 1.6 million individuals from five ancestries with a wide array of functional genomic datasets to discover regulatory mechanisms underlying lipid associations. We first prioritize lipid-associated genes with expression quantitative trait locus (eQTL) colocalizations and then add chromatin interaction data to narrow the search for functional genes. Polygenic enrichment analysis across 697 annotations from a host of tissues and cell types confirms the central role of the liver in lipid levels and highlights the selective enrichment of adipose-specific chromatin marks in high-density lipoprotein cholesterol and triglycerides. Overlapping transcription factor (TF) binding sites with lipid-associated loci identifies TFs relevant in lipid biology. In addition, we present an integrative framework to prioritize causal variants at GWAS loci, producing a comprehensive list of candidate causal genes and variants with multiple layers of functional evidence. We highlight two of the prioritized genes, CREBRF and RRBP1, which show convergent evidence across functional datasets supporting their roles in lipid biology.

Newly diagnosed diabetes based on an oral glucose tolerance test predicts cardiovascular outcomes in patients with coronary artery disease: An observational study

Diabetes is prevalent in patients with coronary artery disease (CAD). Using the oral glucose tolerance test (OGTT), abnormal glucose regulation can be detected early in CAD patients without known diabetes. In the present study, we assessed the impact of abnormal glucose regulation on the long-term cardiovascular outcomes of patients with established CAD. Patients hospitalized for a scheduled angiography due to angina were enrolled in Taichung Veterans General Hospital. Fasting plasma glucose (FPG) and 2-hour postload glucose (2hPG) were assessed using the OGTT. Hemoglobin A1c (HbA1c) and other biochemical analyses were assessed using fasting blood samples. During a median follow-up period of 4.6 years, a composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke was recorded as the primary endpoint. In 682 enrolled patients who completed the follow-up, there were 16 myocardial infarction events, 12 stroke events, and 58 deaths as composite endpoints. According to FPG and 2hPG, patients with newly diagnosed diabetes had a 2-fold higher risk for the composite endpoint than those in the normal glucose group (hazard ratio [HR], 2.011; 95% confidence interval (CI), 1.101-3.673; P = .023); however, prediabetes was not significantly associated with the composite endpoint (HR, 1.452; 95% CI, 0.788-2.675; P = .232). On the other hand, patients with diabetes diagnosed by FPG and HbA1c did not have a significantly higher risk for the composite endpoint than those in the normal glucose group (HR, 1.321; 95% CI, 0.686-2.545; P = .405). A 2hPG ≥7.8 mmol/L was a significant predictor for the composite endpoint (odds ratio, 1.743; 95% CI, 1.060-2.863; P = .028) after adjusting for age, sex, and estimated glomerular filtration rate. Diabetes, but not prediabetes, detected via OGTT is associated with a significantly increased risk for the composite endpoint in patients with established CAD. The 2hPG provided a greater predictive power for the composite endpoint than fasting glucose and HbA1c.

Updates for hyperglycemia in pregnancy: the ongoing journey for maternal-neonatal health

We summarize updates of hyperglycemia in pregnancy as well as debate of diagnosis of criteria of gestational diabetes. We also point out several unsovled issues of gestataional diabetes that remain further investigations.

A single-center, cross-sectional study of cross-professional faculties' perception to virtual class under different scenarios: A stepwise approach

BACKGROUND

Virtual teaching in medical education is rising with the increased need caused by the recent pandemic. However, evaluations of the perception of clinical teachers across professions for setting a virtual class in different teaching scenarios are limited. This study aims to identify cross-professional clinical teachers' perception of virtual classes and the acceptability of the virtual class-specific checklist for setting a virtual class.

METHODS

We conducted a cross-sectional study to investigate clinical teachers' need to set and teach a virtual class and then designed a virtual class-specific checklist with five essential steps and a related training program in July 2021. After the training, 186 participants were randomly enrolled in October 2021 to evaluate their perceptions about setting virtual classes and the acceptability of the virtual class-specific checklist using an online assessment questionnaire.

RESULTS

In our institution, the number of faculty-led virtual classes has recently been on the increase. Our study revealed that most teachers agreed that virtual classes could break space and time limitations, but that the Internet environment could affect the fluency of the virtual class. They further agreed that the essential five steps in the checklist should vary depending on the type of teaching scenario. Most clinical teachers, with the exception of those who teach in the operating room, considered the operating room as the most difficult scenario for setting virtual classes.

CONCLUSION

Faculty training for setting virtual classes is essential, and the essential virtual class-specific five steps are suitable for different teachers and teaching scenarios. However, the virtual class-specific checklist should be further adjusted according to the limitations caused by emerging innovative virtual teaching technology.

Brain-Derived Neurotrophic Factor Reduces Long-Term Mortality in Patients With Coronary Artery Disease and Chronic Kidney Disease

Objectives

Chronic kidney disease (CKD) is a risk factor for coronary artery disease (CAD). We examined the effects of circulating brain-derived neurotrophic factor (BDNF) on long-term mortality in patients with CAD and CKD.

Materials and Methods

We enrolled patients with established CAD in the present study. Serum BDNF and estimated glomerular filtration rate (eGFR) were assessed after overnight fasting. All-cause mortality served as the primary endpoint.

Results

All 348 enrolled patients were divided into four groups according to their median BDNF level and CKD status, defined according to eGFR <60 mL/min/1.73 m². Forty-five patients reached the primary endpoint during the median follow-up time of 6.0 years. Kaplan-Meier survival analysis indicated that the group with low BDNF and CKD had a significantly higher mortality rate than the other three groups (log-rank test p < 0.001). Compared to the high BDNF without CKD group, the low BDNF with CKD group had a hazard ratio (HR) of 3.186 [95% confidence interval (CI): 1.482–6.846] for all-cause mortality according to the multivariable Cox proportional hazard regression analysis after adjusting for age and urine albumin-creatinine ratio (p = 0.003). Furthermore, there was a significantly interactive effect between BDNF and CKD status on the risk of the primary endpoint (odds ratio = 6.413, 95% CI: 1.497–27.47 in the multivariable logistic regression model and HR = 3.640, 95% CI: 1.006–13.173 in the Cox regression model).

Conclusion

We observed a synergistic effect between low serum BDNF levels and CKD on the prediction of all-cause mortality in patients with CAD.

Glycemic control was associated with nonprostate cancer and overall mortalities in diabetic patients with prostate cancer

BACKGROUND

Diabetes mellitus (DM) can worsen the prognosis or survival in prostate cancer (PC) patients. We investigated whether glycemic control impacts mortality in PC patients with existing diabetes.

METHODS

All PC patients with or without preexisting DM were enrolled from 2006 to 2017. Mean hemoglobin A1c (HbA1c) values (<7%, 7%-9%, ≥9%) were used to represent glycemic control. Major outcomes included all-cause, PC-specific, and non-PC mortalities. Statistical analyses were performed using Cox regression models with adjusted mean HbA1c and other related confounders.

RESULTS

A total of 831 PC patients were enrolled (non-DM group, n = 690; DM group with a record of mean HbA1c values, n = 141). Results showed that the DM group with mean HbA1c level ≥ 9% (n = 14) had significantly increased risk for all-cause and non-PC mortality (hazard ratio [HR], 3.09; 95% CIs, 1.15-8.32; p=0.025 and HR, 5.49; 95% CIs, 1.66-18.16; p = 0.005, respectively), but not for PC-specific mortality (HR, 1.03; 95% CIs, 0.13-8.44; p = 0.975), compared with the non-DM group.

CONCLUSION

Our findings indicate that PC patients with DM who had a mean HbA1c level ≥ 9% had higher risks of all-cause and non-PC mortality compared with non-DM subjects. Further large and long-term studies are needed to verify the effect of glycemic control in PC patients with DM.

Assessment of diabetic small-fiber neuropathy by using short-wave infrared hyperspectral imaging

Among patients with type 2 diabetes mellitus (T2DM), the association between hyperspectral imaging (HSI) examination and diabetic neuropathy (DN) is ascertained using HSI of the feet using four types of spectral difference measurements. DN was evaluated by traditional Michigan Neuropathy Screening Instrument (MNSI), evaluation of painful neuropathy (ID-Pain, DN4) and sudomotor function by measuring electrochemical skin conductance (ESC). Of the 120 T2DM patients and 20 healthy adults enrolled, T2DM patients are categorized into normal sudomotor (ESC >60 μS) and sudomotor dysfunction (ESC ≤ 60 μS) groups. Spectral difference analyses reveal significant intergroup differences, whereas traditional examinations cannot distinguish between the two groups. HSI waveform reflectance gradually increases with disease severity, at 1400 to 1600 nm. The area under the curve (AUC) of receiver operating characteristic (ROC) analysis for abnormal ESC is ≥0.8 for all four HSI methods. HSI could be an objective, sensitive, rapid, noninvasive and remote approach to identify early small-fiber DN.

Community-based multiple screening for metabolic syndrome by innovative theory: A longitudinal study

The purpose of this research is to elucidate whether metabolic syndrome affects the rate of adoption of a new multiple cancer screening programme, based on the Diffusion of Innovation theory. The time to attend the screening programme, conducted in Keelung, Taiwan, within 10 years was assessed by innovativeness (innovators, early adaptors, early majority, late majority and laggard) using data from 79,303 residents, with the information on metabolic syndrome accrued from routine adult health check-ups. The median time of adopting the programme and the relative rates of early adoption by metabolic syndrome and its severity score were estimated. The results show that the estimated times to adopt the programme ranged from 3 months for innovators to 10 years for the laggard. The rate of early adoption was 34% higher for participants without metabolic syndrome than for those with the disease, and the gradient relationship of disease severity was noted. The adjusted median time to adopt innovativeness was 0.82 years earlier for participants who were disease-free than those with the disease. Meanwhile, the adjusted median time was wider by up to 2.25 years for those with severe disease. The study suggests that innovation should prioritise the potential risk of the metabolic syndrome population.

Enhancing the learning and transfer of preprocedural communication skills during clerkship using audio-visual material: a prospective case-controlled study over 2 years

OBJECTIVE/DESIGN/SETTING

This study aims to develop preprocedural communication-specific framework that emphasises the use of audiovisual materials and compares its acceptability by trainees with a regular module.

TRAINEES

Between October 2018 and July 2021, 96 medical clerks were enrolled and randomly divided into regular and intervention groups. Another 48 trainees whose did not join the framework-based training but complete self-assessments were enrolled as the control group.

INTERVENTIONS

In the intervention training module, the key steps of preprocedural communication-specific skills were structuralised into a framework using the acronym of OSCAR.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study compared the acceptability of trainees for two modules by measuring the degree of increase in the end-of-rotation and follow up (4 weeks later) competency from baseline by trainees' self-assessments and physician assessments after serial trainings.

RESULTS

In comparison with regular group trainees, greater degree of improvements (framework-1 statement: 111%±13% vs 27%±5%, p<0.001; framework-2 statement: 77%±9% vs 48%±2%, p<0.05; skill-1 statement: 105%±9% vs 48%±3%, p<0.001); skill-2 statement: 71%±11% vs 50%±9%, p<0.05) were noted in the framework-related and skill-related statement 1-2 (the familiarity and confidence to use the framework and skills) than those of intervention group. At the end-of-rotation stage, the trainees ability to use the 'A-step: using audiovisual materials' of the OSCAR was significantly improved (229%±13%, p<0.001), compared with other steps. In the intervention group, the degree of improvement of the end-of-rotation data of trainees' self-assessment from baseline was significantly correlated with the degree of the improvement in physicians' assessment data in the aspects of skills, framework and steps in framework (R=0.872, p<0.01; R=0.813, p<0.001; R=0.914, p<0.001).

CONCLUSIONS

The OSCAR framework-based intervention module is well accepted by medical clerks and motivates them to integrate the acquired skills in clinical practice, which leads to trainees' primary care patients being satisfied with their preprocedural communication.

Comparison of OSCE performance between 6- and 7-year medical school curricula in Taiwan

BACKGROUND

The year 2013 marks a watershed in the history of medical education in Taiwan. Following Taiwan's Taskforce of Medical School Curriculum Reform recommendations, the medical school curriculum was reduced from 7 to 6 years. This study aimed to analyze the impact of medical school curriculum reform on medical students' performance in objective structured clinical examinations (OSCEs).

METHODS

We retrospectively analyzed the OSCE records at Taipei Veterans General Hospital (Taipei VGH), one of Taiwan's largest tertiary medical centers, between November 2016 and July 2020. The eligibility criteria were medical students receiving a full one-year clinical sub-internship training at Taipei VGH and in their last year of medical school. All medical students received a mock OSCE-1 at the beginning of their sub-internship, a mock OSCE-2 after six months of training, and a national OSCE at the end of their sub-internship. The parameters for performance in OSCEs included "percentage of scores above the qualification standard" and "percentage of qualified stations."

RESULTS

Between November 2016 and July 2020, 361 undergraduates underwent clinical sub-internship training at Taipei VGH. Among them, 218 were taught under the 7-year curriculum, and 143 were instructed under the 6-year curriculum. Based on baseline-adjusted ANCOVA results, medical students under the 7-year curriculum had a higher percentage of scores above the qualification standard than those under the 6-year curriculum at the mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 33.8% [95% CI 32.0-35.7] vs. 28.2% [95% CI 25.9-30.4], p < 0.001), and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001). Moreover, medical students in the 7-year curriculum had a higher percentage of qualified stations in mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001) and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 91.9% [95% CI 90.1-93.8] vs. 86.1% [95% CI 83.8-88.3], p = 0.001). After clinical sub-internship training, there were no differences in the percentage of scores above the qualification standard (7-year curriculum vs. 6-year curriculum: 33.5% [95% CI 32.2-34.9] vs. 34.6 [95% CI 32.9-36.3], p = 0.328) and percentage of qualified stations (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 88.1-90.7] vs. 90.2% [95% CI 88.6-91.8], p = 0.492).

CONCLUSIONS

At the beginning of the sub-internship, medical students under the 7-year curriculum had better OSCE performance than those under the 6-year curriculum. After the clinical sub-internship training in Taipei VGH, there was no difference in the national OSCE score between the 6- and 7-year curricula. Our study suggests that clinical sub-internship is crucial for the development of clinical skills and performance in the national OSCE.

Distinct associations of self-monitoring of blood glucose with glycemic control and hypoglycemia between groups of recently diagnosed and long-term follow-up type 2 diabetes: The Taiwan Diabetes Registry

BACKGROUND

We investigated the uses and frequency of self-monitoring of blood glucose (SMBG) with glycemic control and hypoglycemia in two groups of type 2 diabetes (T2D) (recently diagnosed and long-term follow-up) using real-world data in Taiwan (the Taiwan Diabetes Registry).

METHODS

Patients with T2D recently diagnosed within 6 months (n = 3297, mean age 54.4 ± 13.9 years) and T2D patients with long-term follow-up (n = 1201, mean age 65.5 ± 12.1 years, mean diabetes duration 14.3 ± 7.8 years) from the Taiwan Diabetes Registry were analysed. All patients were interviewed by certified diabetes educators. Information about SMBG and hypoglycemia was recorded. Demography, personal history, and laboratory data were obtained from electronic medical records. Logistic regression analyses were used to examine the associations of SMBG with glycated haemoglobin (HbA1c) <7% and hypoglycemia.

RESULTS

Mean HbA1c values were 8.4 ± 2.5 and 7.6 ± 1.4%, respectively, in the recently diagnosed and long-term follow-up T2D groups. The self-reported rates of hypoglycemic events within 3 months were 10.5% and 19.0%, respectively. SMBG was associated with higher odds of HbA1c <7% (OR 1.21, 95% CI 1.01-1.44) in patients with recently diagnosed T2D, but with lower odds of HbA1c <7% in T2D patients with long-term follow-up (OR 0.60, 95% CI 0.44-0.82). In both study populations, SMBG was independently associated with hypoglycemia (OR 3.90 [95% CI 2.99-5.08] and OR 3.93 [95% CI 2.73-5.66], respectively). The aforementioned findings were consistent across the strata of SMBG frequency.

CONCLUSION

We reported different associations between SMBG and glycemic control in patients recently diagnosed with T2D and in T2D patients with long-term follow-up. SMBG was associated with higher detection of hypoglycemic episodes in both study populations.

The dawn phenomenon in type 2 diabetes: its association with glucose excursions and changes after oral glucose-lowering drugs

Background:

We investigated the association between glucose excursions and the dawn phenomenon, and the effects of oral-glucose lowering drugs on the dawn phenomenon in patients with type 2 diabetes (T2D).

Methods:

We conducted a post hoc analysis using data from a previous randomized trial. Patients with T2D on metformin monotherapy were randomized to receive add-on acarbose or glibenclamide for 16 weeks. Ambulatory continuous glucose monitoring (CGM) was conducted before randomization and at the end of the study. Using the CGM data, we assessed glucose excursions as indicated by mean amplitude of glycemic excursions (MAGE). The magnitude of the dawn phenomenon was calculated as the difference between the nocturnal nadir (0:00 to 6:00 a.m.) and prebreakfast glucose level.

Results:

A total of 50 patients with T2D [mean age 53.5 ± 8.2 years, mean glycated hemoglobin (HbA1c) 8.4 ± 1.2%] were analyzed. There was an independent association between MAGE and the dawn phenomenon [β coefficient 0.199, 95% confidence interval (CI) 0.074–0.325, p = 0.003]. HbA1c improved significantly after treatment with acarbose or glibenclamide. However, only treatment with acarbose significantly improved glucose excursions. The dawn phenomenon decreased significantly only in patients treated with acarbose (from 35.9 ± 15.7–28.3 ± 16.5 mg/dl, p = 0.037), but not in those treated with glibenclamide (from 35.9 ± 20.6–34.6 ± 17.0 mg/dl, p = 0.776).

Conclusion:

Glucose excursions were independently associated with the dawn phenomenon in patients with T2D on metformin monotherapy. Both glucose excursions and the dawn phenomenon improved after treatment with acarbose, but not after treatment with glibenclamide.

Similar cardiovascular outcomes in patients with diabetes and established or high risk for coronary vascular disease treated with dulaglutide with and without baseline metformin

OBJECTIVE

Recent European Guidelines for Diabetes, Prediabetes and Cardiovascular Diseases introduced a shift in managing patients with type 2 diabetes at high risk for or established cardiovascular (CV) disease by recommending GLP-1 receptor agonists and SGLT-2 inhibitors as initial glucose-lowering therapy. This is questioned since outcome trials of these drug classes had metformin as background therapy. In this post hoc analysis, the effect of dulaglutide on CV events was investigated according to the baseline metformin therapy by means of a subgroup analysis of the Researching Cardiovascular Events with a Weekly Incretin in Diabetes (REWIND) trial.

RESEARCH DESIGN AND METHODS

Patients in REWIND (n = 9901; women: 46.3%; mean age: 66.2 years) had type 2 diabetes and either a previous CV event (31%) or high CV risk (69%). They were randomized (1:1) to sc. dulaglutide (1.5 mg/weekly) or placebo in addition to standard of care. The primary outcome was the first of a composite of nonfatal myocardial infarction, nonfatal stroke, and death from cardiovascular or unknown causes. Key secondary outcomes included a microvascular composite endpoint, all-cause death, and heart failure. The effect of dulaglutide in patients with and without baseline metformin was evaluated by a Cox regression hazard model with baseline metformin, dulaglutide assignment, and their interaction as independent variables. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by a Cox regression model with adjustments for factors differing at baseline between people with vs. without metformin, identified using the backward selection.

RESULTS

Compared to patients with metformin at baseline (n = 8037; 81%), those without metformin (n = 1864; 19%) were older and slightly less obese and had higher proportions of women, prior CV events, heart failure, and renal disease. The primary outcome occurred in 976 (12%) participants with baseline metformin and in 281 (15%) without. There was no significant difference in the effect of dulaglutide on the primary outcome in patients with vs. without metformin at baseline [HR 0.92 (CI 0.81-1.05) vs. 0.78 (CI 0.61-0.99); interaction P = 0.18]. Findings for key secondary outcomes were similar in patients with and without baseline metformin.

CONCLUSION

This analysis suggests that the cardioprotective effect of dulaglutide is unaffected by the baseline use of metformin therapy.

Towards living guidelines on cardiorenal outcomes in diabetes: A pilot project of the Taskforce of the Guideline Workshop 2020

In June 2020, the Taskforce of the Guideline Workshop 2019 convened via teleconferencing to initiate a pilot project that demonstrates the various processes and considerations involved in developing high-quality, evidence-based clinical practice guidelines for the medical management of individuals with type 2 diabetes (T2D) and its associated comorbidities, including cardiovascular disease (CVD) and chronic kidney disease (CKD). The goal of the pilot project was to create evidence-based guidelines for use of sodium-glucose transport protein 2 inhibitors (SGLT2-I) when managing very high risk T2D patients, evidenced by the presence of both CVD and CKD. For this purpose the Taskforce represented a guideline panel and made use of synthesized evidence from an ongoing BMJ Rapid Recommendations project on SGLT2-I and GLP-1 receptor agonists. Results from the Taskforce pilot project demonstrated the value, feasibility and utility of using a step-wise approach to identifying and grading evidence and then developing actionable recommendations for utilizing SGLT2-I in this at-risk T2D population. This report describes the various steps involved in the process and explains how it can be utilized to rapidly develop recommendations in a format that is easy to use and can be quickly updated as new evidence becomes available, also within the emerging concept of living guidelines.

Implementation of an Electronic National Early Warning System to Decrease Clinical Deterioration in Hospitalized Patients at a Tertiary Medical Center

The National Early Warning Score (NEWS) is an early warning system that predicts clinical deterioration. The impact of the NEWS on the outcome of healthcare remains controversial. This study was conducted to evaluate the effectiveness of implementing an electronic version of the NEWS (E-NEWS), to reduce unexpected clinical deterioration. We developed the E-NEWS as a part of the Health Information System (HIS) and Nurse Information System (NIS). All adult patients admitted to general wards were enrolled into the current study. The “adverse event” (AE) group consisted of patients who received cardiopulmonary resuscitation (CPR), were transferred to an intensive care unit (ICU) due to unexpected deterioration, or died. Patients without AE were allocated to the control group. The development of the E-NEWS was separated into a baseline (October 2018 to February 2019), implementation (March to August 2019), and intensive period (September. to December 2019). A total of 39,161 patients with 73,674 hospitalization courses were collected. The percentage of overall AEs was 6.06%. Implementation of E-NEWS was associated with a significant decrease in the percentage of AEs from 6.06% to 5.51% (p = 0.001). CPRs at wards were significantly reduced (0.52% to 0.34%, p = 0.012). The number of patients transferred to the ICU also decreased significantly (3.63% to 3.49%, p = 0.035). Using multivariate analysis, the intensive period was associated with reducing AEs (p = 0.019). In conclusion, we constructed an E-NEWS system, updating the NEWS every hour automatically. Implementing the E-NEWS was associated with a reduction in AEs, especially CPRs at wards and transfers to ICU from ordinary wards.

The Clinical Influence after Implementation of Convolutional Neural Network-Based Software for Diabetic Retinopathy Detection in the Primary Care Setting

Deep learning-based software is developed to assist physicians in terms of diagnosis; however, its clinical application is still under investigation. We integrated deep-learning-based software for diabetic retinopathy (DR) grading into the clinical workflow of an endocrinology department where endocrinologists grade for retinal images and evaluated the influence of its implementation. A total of 1432 images from 716 patients and 1400 images from 700 patients were collected before and after implementation, respectively. Using the grading by ophthalmologists as the reference standard, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to detect referable DR (RDR) were 0.91 (0.87-0.96), 0.90 (0.87-0.92), and 0.90 (0.87-0.93) at the image level; and 0.91 (0.81-0.97), 0.84 (0.80-0.87), and 0.87 (0.83-0.91) at the patient level. The monthly RDR rate dropped from 55.1% to 43.0% after implementation. The monthly percentage of finishing grading within the allotted time increased from 66.8% to 77.6%. There was a wide range of agreement values between the software and endocrinologists after implementation (kappa values of 0.17-0.65). In conclusion, we observed the clinical influence of deep-learning-based software on graders without the retinal subspecialty. However, the validation using images from local datasets is recommended before clinical implementation.

Postchallenge glucose increment was associated with hemoglobin glycation index in subjects with no history of diabetes

We investigated the association between postchallenge glucose increment and hemoglobin glycation index (HGI), the difference between observed and predicted glycated hemoglobin (HbA1c), in subjects with no history of diabetes. We enrolled 1381 subjects who attended our outpatient clinic for an oral glucose tolerance test (OGTT) to screen for diabetes. HGI was defined as observed HbA1c minus predicted HbA1c. The predicted HbA1c was calculated by entering fasting plasma glucose (FPG) level into an equation [HbA1c(%)=FPG(mg/dL)*0.029+2.9686] determined from an HbA1c versus FPG regression analysis using data from an independent cohort of 2734 subjects with no history of diabetes. The association between 2-hour glucose increment and HGI was analyzed using linear regression analyses with adjustment of relevant parameters. Overall, the proportions of subjects with normal glucose tolerance, pre-diabetes, and newly diagnosed diabetes were 42.3%, 41.3%, and 16.4%, respectively. Compared with subjects who had an HGI≤0, subjects with an HGI>0 had a lower FPG (95.0±13.3 vs 98.5±15.3 mg/dL, p<0.001) but a higher 2-hour plasma glucose (151.1±52.8 vs 144.6±51.4 mg/dL, p=0.027) and 2-hour glucose increment (56.1±46.1 vs 46.1±45.0 mg/dL, p<0.001). The 2-hour glucose increment after an OGTT was independently associated with HGI (β coefficient 0.003, 95% CI 0.002 to 0.003, p<0.001). Our findings suggested that postchallenge glucose increment was independently associated with HGI in subjects with no history of diabetes.

Therapeutic Potential of Tpl2 (Tumor Progression Locus 2) Inhibition on Diabetic Vasculopathy Through the Blockage of the Inflammasome Complex

OBJECTIVE

Diabetic retinopathy, one of retinal vasculopathy, is characterized by retinal inflammation, vascular leakage, blood-retinal barrier breakdown, and neovascularization. However, the molecular mechanisms that contribute to diabetic retinopathy progression remain unclear. Approach and Results: Tpl2 (tumor progression locus 2) is a protein kinase implicated in inflammation and pathological vascular angiogenesis. Nε-carboxymethyllysine (CML) and inflammatory cytokines levels in human sera and in several diabetic murine models were detected by ELISA, whereas liquid chromatography-tandem mass spectrometry analysis was used for whole eye tissues. The CML and p-Tpl2 expressions on the human retinal pigment epithelium (RPE) cells were determined by immunofluorescence. Intravitreal injection of pharmacological inhibitor or NA (neutralizing antibody) was used in a diabetic rat model. Retinal leukostasis, optical coherence tomography, and H&E staining were used to observe pathological features. Sera of diabetic retinopathy patients had significantly increased CML levels that positively correlated with diabetic retinopathy severity and foveal thickness. CML and p-Tpl2 expressions also significantly increased in the RPE of both T1DM and T2DM diabetes animal models. Mechanistic studies on RPE revealed that CML-induced Tpl2 activation and NADPH oxidase, and inflammasome complex activation were all effectively attenuated by Tpl2 inhibition. Tpl2 inhibition by NA also effectively reduced inflammatory/angiogenic factors, retinal leukostasis in streptozotocin-induced diabetic rats, and RPE secretion of inflammatory cytokines. The attenuated release of angiogenic factors led to inhibited vascular abnormalities in the diabetic animal model.

CONCLUSIONS

The inhibition of Tpl2 can block the inflammasome signaling pathway in RPE and has potential clinical and therapeutic implications in diabetes-associated retinal microvascular dysfunction.

Generation of three induced pluripotent stem cell lines from type 2 diabetic patients with ocular complications

Retinopathy is a well-known ocular complication that occurs in patients with type 2 diabetes (T2D). Recent evidence also indicates that diabetic patients have an increased prevalence of dry eye syndrome. However, the etiologies of both diabetic retinopathy (DR) and dry eye disease are complex, and their associations with T2D remains to be fully understood. Patient-derived human induced pluripotent stem cells (hiPSCs) enable the generation of disease-specific retinal tissues such as retinal pigment epithelium and lacrimal gland to model disease pathogenesis. Here, we describe the establishment of three hiPSC lines from T2D patients with PDR or dry eye disease.

Prognostic effect of high-density lipoprotein cholesterol level in patients with atherosclerotic cardiovascular disease under statin treatment

In patients with atherosclerotic cardiovascular disease (ASCVD) under statin treatment, the influence of on-treatment level of high-density lipoprotein cholesterol (HDL-C) on cardiovascular (CV) events is controversial. Statin-treated patients were selected from the Taiwanese Secondary Prevention for patients with AtheRosCLErotic disease (T-SPARCLE) Registry, a multicenter, observational study of adult patients with ASCVD in Taiwan. Low HDL-C was defined as < 40 mg/dL for men and < 50 mg/dL for women. The primary outcome was a composite CV events including CV death, myocardial infarction (MI), stroke or cardiac arrest with resuscitation. A total of 3731 patients (mean age 65.6 years, 75.6% men) were included. Patients with on-treatment low HDL-C (44%, mean HDL-C 34.9 ± 6.8 mg/dL) were younger and with more diabetes and higher body weight. The mean follow-up time was 2.7 years. We used restricted cubic spline curves to examine the potential non-linear association between HDL-C and adverse outcomes. Decreased HDL-C levels were associated with a significantly increased risk of CV events in women (< 49 mg/dL in women) but not in men (< 42 mg/dL in men). However, the protective effect of elevated HDL-C levels was more prominent in men than in women. In ASCVD patients with statin therapy, low on-treatment HDL-C was common in Taiwan and associated with an increased risk of CV events in women. Higher HDL-C levels provided more protective effect in men than in women.

The Association between the Participation of Quality Control Circle and Patient Safety Culture

Promoting patient safety culture (PSC) is a critical issue for healthcare providers. Quality control circles program (QCCP) can be used as an effective tool to foster long-lasting improvements on the quality of medical institution. The effect of QCCP on PSC is still unknown. This was a retrospective study conducted with matching data. A safety attitudes questionnaire (SAQ) was used for the evaluation of PSC. The association between all scores of six subscales of SAQ and the participation QCCP were analyzed with both the Mann-Whitney and Kruskal-Wallis tests. A total of 2718 valid questionnaires were collected. Most participants of QCCP were females (78.9%), nurses (52.6%), non-supervisors (92.2%), aged <40 years old (64.8%), degree of specialist or university graduates (78%), and with work experience of <10 years (61.6%). Of all participants, the highest scores were in the dimension of safety climate (74.11 ± 17.91) and the lowest scores in the dimension of working conditions (68.90 ± 18.84). The participation of QCCP was associated with higher scores in four dimensions, namely: teamwork climate (p = 0.006), safety climate (p = 0.037), perception of management (p = 0.009), and working conditions (p = 0.015). The participation or not of QCCP had similar results in the dimension of job satisfaction and stress recognition. QCCP was associated with SAQ in subjects with the following characteristics: female, nurse, non-supervisor, aged >50 years old, higher education degrees and with longer working experiences in the hospital. In this first study on the association between each dimension of SAQ and the implementation of QCCP, we found that QCCP interventions were associated with better PSC. QCCP had no benefits in the dimensions of job satisfaction and stress recognition.

Use of Facebook by Academic Medical Centers in Taiwan During the COVID-19 Pandemic: Observational Study

Background

The battle against COVID-19 remains ongoing, and social media has played an important role during the crisis for both communication and health promotion, particularly for health care organizations. Taiwan’s success during the COVID-19 outbreak is well known and the use of social media is one of the key contributing factors to that success.

Objective

This nationwide observational study in Taiwan aimed to explore the use of Facebook by academic medical centers during the COVID-19 pandemic.

Methods

We conducted a nationwide observational study of all Facebook fan page posts culled from the official accounts of all medical centers in Taiwan from December 2019 to April 2020. All Facebook posts were categorized into either COVID-19–related posts or non–COVID-19–related posts. COVID-19–related posts were split into 4 categories: policy of Taiwan’s Center for Disease Control (TCDC), gratitude notes, news and regulations from hospitals, and education. Data from each post was also recorded as follows: date of post, headline, number of “likes,” number of messages left, number of shares, video or non-video post, and date of search.

Results

The Facebook fan pages of 13 academic medical centers, with a total of 1816 posts, were analyzed. From January 2020, the percentage of COVID-19 posts increased rapidly, from 21% (January 2020) to 56.3% (April 2020). The trends of cumulative COVID-19 posts and reported confirmed cases were significantly related (Pearson correlation coefficient=0.93, P<.001). Pages from private hospitals had more COVID-19 posts (362 versus 289), as well as more video posts (72 posts, 19.9% versus 36 posts, 12.5%, P=.011), when compared to public hospitals. However, Facebook pages from public hospitals had significantly more “likes,” comments, and shares per post (314, 5, 14, respectively, P<.001). Additionally, medical centers from different regions displayed different strategies for using video posts on Facebook.

Conclusions

Social media has been a useful tool for communication during the COVID-19 pandemic. This nationwide observational study has helped demonstrate the value of Facebook for academic medical centers in Taiwan, along with its engagement efficacy. We believe that the experience of Taiwan and the knowledge it can share will be helpful to health care organizations worldwide during our global battle against COVID-19.

Inherited causes of clonal haematopoiesis in 97,691 whole genomes

Age is the dominant risk factor for most chronic human diseases; yet the mechanisms by which aging confers this risk are largely unknown.¹ Recently, the age-related acquisition of somatic mutations in regenerating hematopoietic stem cell populations leading to clonal expansion was associated with both hematologic cancer ^2–4 and coronary heart disease⁵, a phenomenon termed ‘Clonal Hematopoiesis of Indeterminate Potential’ (CHIP).⁶ Simultaneous germline and somatic whole genome sequence analysis now provides the opportunity to identify root causes of CHIP. Here, we analyze high-coverage whole genome sequences from 97,691 participants of diverse ancestries in the NHLBI TOPMed program and identify 4,229 individuals with CHIP. We identify associations with blood cell, lipid, and inflammatory traits specific to different CHIP genes. Association of a genome-wide set of germline genetic variants identified three genetic loci associated with CHIP status, including one locus at TET2 that was African ancestry specific. In silico-informed in vitro evaluation of the TET2 germline locus identified a causal variant that disrupts a TET2 distal enhancer resulting in increased hematopoietic stem cell self-renewal. Overall, we observe that germline genetic variation shapes hematopoietic stem cell function leading to CHIP through mechanisms that are both specific to clonal hematopoiesis and shared mechanisms leading to somatic mutations across tissues.

Associations of fear of hypoglycemia with second-line use of insulin secretagogues or insulin and subsequent glycemic control in patients with type 2 diabetes: An analysis using data from the DISCOVER study

BACKGROUND

Associations of fear of hypoglycemia with prescription of second-line insulin secretagogues (IS) or insulin and subsequent glycemic control in patients with type 2 diabetes were analysed using data from the DISCOVER study-a large, prospective, observational study.

METHODS

Patients with type 2 diabetes initiating a second-line treatment after a first-line oral therapy were enrolled. Fear of hypoglycemia was assessed using baseline Hypoglycemia Fear Survey (HFS) worry score. Glycemic control was assessed using glycated haemoglobin (HbA1c) levels at 6-month and 1-year follow-up, and HbA1c change from baseline was analysed. To examine the association of baseline HFS worry scores with second-line use of IS or insulin, a hierarchical logistic model with country as random effect was used.

RESULTS

A total of 6217 patients were analysed. The mean HFS worry score was 6.9 ± 11.4, while patients in the upper quartile had an HFS worry score ≥9. We divided patients into three groups according to their baseline HFS worry score (0, 1-8, ≥9). HFS worry score was associated with the use of first-line IS, but not the second-line treatment. Compared to treatments with no IS and insulin, a better HbA1c response to second-line IS or insulin was noted in patients with a baseline HFS worry score of 0 or 1-8, but not in patients with a baseline HFS worry score ≥9.

CONCLUSION

HFS worry score was associated with the use of first-line IS and glycemic response to second-line IS or insulin in patients with type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02322762. Registered 23 December 2014.

A Strategic Imperative for Promoting Hospital Branding: Analysis of Outcome Indicators

Background

Optimizing the use of social media to promote hospital branding is important in the present digital era. In Taiwan, only 51.1% of hospitals have official Facebook fan pages. The numbers of likes for these hospitals are also relatively low.

Objective

Our objective was to establish a special branding team for social media operation, led by top administrators of our hospital. Here we present our strategic imperative for promoting hospital branding as well as an analysis of its effectiveness.

Methods

Led by top administrators, the branding team was formed by 11 divisions to create branding strategies. From 2016 to 2018, the team implemented action plans. All information unique to the hospital was posted on Facebook, as well as on the hospital’s official website. To determine the plans’ efficiencies, we obtained reference data from Google Analytics, and we compared Facebook Insights reports for 2016 with those for 2017 and 2018.

Results

One of the branding team’s main missions was to establish branding strategies and to integrate segmental branding messages. In each quarter we regularly monitored a total of 52 action plan indicators, including those for process and outcome, and discussed the results at team meetings. We selected 4 main performance outcome indicators to reflect the effectiveness of the branding efforts. Compared with 2016, the numbers of likes posted on the Facebook fan page increased by 61.2% in 2017 and 116.2% in 2018. Similarly, visits to the hospital website increased by 4.8% in 2017 and 33.1% in 2018. Most Facebook fan page and website viewers were in 2 age groups: 25 to 34 years, and 35 to 44 years. Women constituted 60.42% (14,160/23,436) of Facebook fans and 59.39% (778,992/1,311,605) of website viewers. According to the Facebook Insights reports, the number of likes and post sharing both increased in 2017 and 2018, relative to 2016. Comment messages also increased from 2016 to 2018 (P=.02 for the trend). The most common theme of posts varied over time, from media reports in 2016, to innovative services in both 2017 and 2018. Likes for innovative services posts increased from 2016 through 2018 (P=.045 for the trend). By the end of 2018, we recorded 23,436 cumulative likes for posts, the highest number among medical centers in Taiwan.

Conclusions

We achieved the largest number of Facebook fans among all medical centers in Taiwan. We would like to share our experience with other hospitals that might be interested in engaging in social media for future communications and interactions with their patients.

The Relationship Between Abdominal Body Composition and Metabolic Syndrome After a Weight Reduction Program in Adult Men with Obesity

PURPOSE

To assess the relationship between changes in abdominal adipose tissue and metabolic syndrome (MetS) in men with obesity after a weight reduction program (WRP).

PATIENTS AND METHODS

Adult men with obesity and MetS were recruited for this prospective single-arm intervention study. Participants consumed an energy-restricted diet of 1200 kcal/day and performed 50-mins aerobic exercise daily for 12 weeks. Changes in the components of MetS were recorded. Changes in subcutaneous abdominal fat area (SAFA) and intra-abdominal fat area (IAFA) at the umbilicus level were determined using magnetic resonance imaging.

RESULTS

A total of 30 men (mean age, 42.3 ± 10.0 years; body mass index, 33.7 ± 4.1 kg/m²) were included in this study. A moderate (8.0%) weight reduction occurred. Reversion of MetS was observed in 15 (50%) participants after the WRP. There was significant reduction in SAFA (68.3 ± 20.2 vs. 51.5 ± 18.6 cm²; P < 0.001) and IAFA (96.3 ± 15.6 vs. 86.0 ± 16.5 cm²; P < 0.001); the magnitude of reduction was greater for SAFA than for IAFA (-16.8 ± 7.7 vs. -10.3 ± 8.3 cm²; P < 0.001). Multivariate logistic regression analysis showed a reduction in IAFA to be an independent factor to decrease the risk of persistent MetS after WRP by adjustment for age, baseline IAFA, and change in SAFA (odds ratio = 0.25, 95% confidence interval: 0.07-0.95, P = 0.041). Reduction in SAFA was not significantly associated with the reversion of MetS (P = 0.411).

CONCLUSION

Reduction in IAFA via a 12-week WRP may help reverse MetS in men with obesity and MetS.

Influence of Diabetic Retinopathy on the Relationship Between Body Mass Index and Mortality in Patients with Poorly Controlled Type 2 Diabetes

PURPOSE

An "obesity paradox" has been observed in patients with type 2 diabetes. However, the optimal body mass index (BMI) for survival may be influenced by the stage of diabetes. We examined the relationship between BMI and mortality in patients with type 2 diabetes and the influence of diabetic retinopathy (DR).

PATIENTS AND METHODS

This is a retrospective cohort composing patients with type 2 diabetes who were admitted due to poor glucose control. Presence of DR was confirmed by ophthalmologists. The primary outcome was all-cause mortality. The association between BMI and mortality was assessed using a Cox proportional hazards model with adjustment for age, sex, and traditional risk factors.

RESULTS

A total of 2053 patients were enrolled. Over median follow-up of 6.7 years, there were 1060 deaths. Patients were classified into five categories based on admission BMI (kg/m²): <18.5, 18.5‒23, 23‒25, 25‒27 (reference), 25‒30 and >30. Mortality risk was significantly higher in the <18.5 kg/m², 18.5-23 kg/m², and 23-25 kg/m² categories than in the reference category (P <0.001). The similar obesity paradox was observed in the subgroup of patients without DR. However, in patients with DR, only patients with BMI <18.5 kg/m² had significantly increased mortality than those in the reference category. The presence of DR significantly modified the shape of the association between BMI and mortality (P = 0.019).

CONCLUSION

The obesity paradox exists in patients with poorly controlled type 2 diabetes. The presence of DR appears to significantly influence the shape of the association between BMI and mortality.

Accountability and utilization of diabetes care from 2005 to 2014 in Taiwan

BACKGROUND/PURPOSE

Diabetes mellitus (DM) prevalence has been rapidly increasing in Taiwan and globally. Team care for DM has been provided through diabetes shared-care networks in Taiwan more than 20 years.

METHODS

The study analyzed the National Health Insurance (NHI) claims data from 2005 to 2014 to better understand diabetes care accountability and utilization in Taiwan.

RESULTS

The completion rate of annual check-ups for various metabolic measurements increased significantly, which indicates improvement in diabetes management quality. The average annual visits and drug cost for each patient increased enormously from 2005 to 2014. The annual number of outpatient department/inpatient department (OPD/IPD) patients with diabetes undergoing dialysis increased. The number of OPD visits in patients with diabetes was 1.9 times higher than that in all patients in general. IPD cost appeared to increase, whereas both drug cost and the average length of hospitalization per patient decreased. Endocrine and metabolic diseases were still the leading cause of OPD expenses. The leading cause of IPD expenses was respiratory diseases. An increasing trend was noted in the medical cost for patients with microvascular instead of macrovascular complications. OPD care for patients with diabetes was rather evenly distributed since 2009. Regarding IPD care, medical centers and regional hospitals each hospitalized 37% of the diabetic outpatients in 2014.

CONCLUSION

Accountability of diabetes care in Taiwan improved significantly till 2014. The ongoing fight against DM and tracing, examining and learning from the overall outcomes in future decades is still required.