The Implication of Diabetes-Specialized Nurses in Aiming for the Better Treatment and Management of Patients with Diabetes Mellitus: A Brief Narrative Review

Diabetes mellitus (DM) is regarded as one of the most critical public health challenges of the 21st century. It has evolved into a burgeoning epidemic since the last century, and today ranks among the major causes of mortality worldwide. Diabetes specialist nurses (DSNs) are central to good patient care and outcomes including confident self-care management. Evidence shows that DSNs are cost-effective, improve clinical outcomes, and reduce length of stay in hospital. In this brief narrative review, we aim to describe the roles of DSNs and their contribution in the treatment and management of patients with DM. This narrative review describes the importance of DSNs in healthcare practice, in the inpatient and outpatient departments, in the pediatrics department, in managing diabetic foot ulcers, in the treatment and management of gestational diabetes, in prescribing medications for DM and in diabetes self-management education on glycosylated hemoglobin, and cardiovascular risk factors. To conclude, DSNs have a crucial role in the treatment and management of patients with DM and its complications. DSNs have a great impact on diabetes therapy, and hence implementation of DSNs and nurse-led diabetic clinics might be beneficial for the health care system. Finally, having DSNs might significantly contribute to good healthcare practice and support. Even though DSNs are not available in several regions around the globe, and even though this post is still new to several health care institutions, the presence of DSNs recognized and certified by the various healthcare systems would be very useful.

Carnosine supplementation improves glucose control in adults with pre-diabetes and type 2 diabetes: A randomised controlled trial

BACKGROUND AND AIMS

Type 2 diabetes (T2DM) is a major cause of morbidity and mortality globally. Carnosine, a naturally occurring dipeptide, has anti-inflammatory, antioxidant, and anti-glycating effects, with preliminary evidence suggesting it may improve important chronic disease risk factors in adults with cardiometabolic conditions.

METHODS AND RESULTS

In this randomised controlled trial, 43 adults (30%F) living with prediabetes or T2DM consumed carnosine (2 g) or a matching placebo daily for 14 weeks to evaluate its effect on glucose metabolism assessed via a 2-h 75 g oral glucose tolerance test. Secondary outcomes included body composition analysis by dual energy x-ray absorptiometry (DEXA), calf muscle density by pQCT, and anthropometry. Carnosine supplementation decreased blood glucose at 90 min (-1.31 mmol/L; p = 0.02) and 120 min (-1.60 mmol/L, p = 0.02) and total glucose area under the curve (-3.30 mmol/L; p = 0.04) following an oral glucose tolerance test. There were no additional changes in secondary outcomes. The carnosine group results remained significant before and after adjustment for age, sex, and change in weight (all>0.05), and in further sensitivity analyses accounting for missing data. There were no significant changes in insulin levels.

CONCLUSION

This study provides preliminary support for larger trials evaluating carnosine as a potential treatment for prediabetes and the initial stages of T2DM. Likely mechanisms may include changes to hepatic glucose output explaining the observed reduction in blood glucose without changes in insulin secretion following carnosine supplementation.

Shifts in KDIGO CKD risk groups with empagliflozin: Kidney-protection from SGLT2 inhibition across the spectrum of risk

T2D is a well-established risk factor for development and progression of CKD. KDIGO recommends categorization of risk by likelihood of progression to ESKD. Compared to placebo, empagliflozin decreases likelihood of worsening (OR 0.70, 95 % CI 0.62-0.78) and increases likelihood of improvement (OR 1.56, 95 % CI 1.30-1.86) in KDIGO risk category.

Conbercept combined with laser photocoagulation in the treatment of diabetic macular edema and its influence on intraocular cytokines

BACKGROUND

The prevalence of diabetes mellitus (DM) in China is high, and the base is broad. Diabetic retinopathy (DR) is a critical condition affecting the life and health of a nation and its economic development. DR is a common complication of DM.

AIM

To investigate the efficacy of laser photocoagulation combined with intravitreal injection of conbercept for treating macular edema.

METHODS

Overall, 130 patients with diabetic macular edema (DME) hospitalized in The Third People's Hospital of Changzhou from January 2019 to June 2022 were retrospectively included. According to the treatment plan, 130 patients with DME were categorized into an observation and a control group, with 65 patients in each group. The control group received laser photocoagulation, and the observation group received laser photocoagulation with intravitreal injection of conbercept. Observe changes in vision, cytokines in the eye and so on.

RESULTS

The total efficacy rate in the observation group (93.85%) was higher than that in the control group (78.46%) (P < 0.05). In both groups, the best corrected visual acuity correction effect improved after treatment, and the observation group was superior to the control group (P < 0.05). Retinal thickness and central macular thickness improved after treatment, and the observation group was superior to the control group (P < 0.05). The levels of vascular endothelial growth factor, interleukin-6, soluble intercellular adhesion molecule-1, and basic fibroblast growth factor in both groups improved after treatment, and the observation group was superior to the control group (P < 0.05).

CONCLUSION

In patients with macular edema, combining laser photocoagulation and intravitreal injections of conbercept for DME is a more effective and safer strategy to improve vision, and lower intraocular cytokine levels.

2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes

BACKGROUND

The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020.

METHODS

The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria.

RESULTS AND CONCLUSIONS

All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Discovery of novel flavonoid derivatives as potential dual inhibitors against α-glucosidase and α-amylase: virtual screening, synthesis, and biological evaluation

Diabetes mellitus is one of the top ten causes of death worldwide, accounting for 6.7 million deaths in 2021, and is one of the most rapidly growing global health emergencies of this century. Although several classes of therapeutic drugs have been invented and applied in clinical practice, diabetes continues to pose a serious and growing threat to public health and places a tremendous burden on those affected and their families. The strategy of reducing carbohydrate digestibility by inhibiting the activities of α-glucosidase and α-amylase is regarded as a promising preventative treatment for type 2 diabetes. In this study, we investigated the dual inhibitory effect against two polysaccharide hydrolytic enzymes of flavonoid derivatives from an in-house chemical database. By combining molecular docking and structure-activity relationship analysis, twelve compounds with docking energies less than or equal to - 8.0 kcal mol^-1 and containing required structural features for dual inhibition of the two enzymes were identified and subjected to chemical synthesis and in vitro evaluation. The obtained results showed that five compounds exhibited dual inhibitory effects on the target enzymes with better IC₅₀ values than the approved positive control acarbose. Molecular dynamics simulations were performed to elucidate the binding of these flavonoids to the enzymes. The predicted pharmacokinetic and toxicological properties suggest that these compounds are viable for further development as type 2 diabetes drugs.

The functions of Ca2+/calmodulin-dependent protein kinase II (CaMKII) in diabetes progression

The increase in blood glucose causes a myriad of pathways and molecular components to malfunction, leading to diabetes. Diabetes affects each organ differently by activating distinct pathways. It has an impact on the liver, pancreas, kidney (nephropathy), eyes (retinopathy), and nervous system (neuropathy). Understanding the effects of diabetes on each organ is the first step in developing a sustained treatment for the disease. Among the many cellular molecules impacted by diabetes is Ca²⁺/calmodulin-dependent protein kinase II (CaMKII), a complex Ca²⁺/calmodulin-activated serine/threonine-protein kinase. When intracellular [Ca²⁺] rises, it binds to calmodulin (CaM) to produce Ca²⁺/CaM, which activates CaMKIIs. This factor is involved in the pancreas, liver, heart, muscles, and various organs. Thus, Understanding CaMKII action in each organ is critical for gaining a complete picture of diabetic complications. Therefore, this review covers CaMKII's functions in many organs and how it affects and has been affected by diabetes.

Hyperinsulinemia and plasma glucose level independently associated with all-cause and cardiovascular mortality in Chinese people without diabetes-A post-hoc analysis of the 30-year follow-up of Da Qing diabetes and IGT study

AIMS

We aimed to characterize the effect of insulin resistance and plasma glucose on all-cause and cardiovascular disease (CVD) death.

METHODS

A total of 462 individuals without diabetes in the original Da Qing Diabetes and IGT Study were enrolled in the present analysis, and further divided into G1 (low insulin low glucose), G2 (high insulin low glucose), G3 (low insulin high glucose) and G4 (high insulin high glucose) groups according to medians of glucose and insulin level at baseline. The all-cause and CVD death were assessed from 1986 to 2016.

RESULTS

During the 30-year follow-up, compared with G1, G2, G3, and G4 groups were all at increased death risk after adjusting covariates. G2 and G3 were associated with similar risks in both all-cause (G2: HR 1.65, 95%CI 1.02-2.67; G3: HR 1.76, 95%CI 1.11-2.81) and CVD death (G2: HR 2.03, 95%CI 1.01-4.05; G3: HR 1.85, 95%CI 0.93-3.68). The highest risk was observed in G4 (all-cause death: HR 2.32, 95%CI 1.45-3.69; CVD death: HR 2.68, 95%CI 1.35-5.29).

CONCLUSIONS

In this post-hoc study, participants with either high glucose or high insulin were related to increased risk of mortality, implying that strategies targeting eliminating both hyperglycemia and hyperinsulinemia may favor the long-term outcomes.

Photoresponsive polymeric microneedles: An innovative way to monitor and treat diseases

Microneedles (MN) technology is an emerging technology for the transdermal delivery of therapeutics. When combined with photoresponsive (PR) materials, MNs can deliver therapeutics precisely and effectively with enhanced efficacy or synergistic effects. This review systematically summarizes the therapeutic applications of PRMNs in cancer therapy, wound healing, diabetes treatment, and diagnostics. Different PR approaches to activate and control the release of therapeutic agents from MNs are also discussed. Overall, PRMNs are a powerful tool for stimuli-responsive controlled-release therapeutic delivery to treat various diseases.

Design and analysis of crossover trials for investigating high-risk medical devices: A review

During evaluation of new investigational medical devices, the FDA recommends that investigators design a crossover clinical trial, in which the patients are arranged to cross over from one treatment arm to another. The FDA annually receives the premarket applications of investigational medical devices, in which sponsors design and conduct crossover trials as their confirmatory clinical trials for evaluating safety and effectiveness of the devices. This article reviews the use of crossover clinical trial in pivotal clinical trials for high-risk medical devices regulated and approved by the United States Food and Drug Administration (FDA) from 2005 to 2018. As an example, in which a crossover trial was implemented during the regulatory approval process of a new device, the article additionally presents the FDA-approved premarket approval (PMA) submission of the Medtronic MiniMed 530G system, an artificial pancreas device system that mimic a normally functioning pancreas by monitoring glucose levels and administering insulin at a certain threshold maintained by sensing blood glucose levels. The article also reiterates the critical regulatory considerations that the FDA made regarding the design and analysis of crossover trials in its guidance for industry.

Critical questions in diabetes management: What are the most compelling challenges and how can we handle them?

Background

The prevalence of diabetes mellitus is growing worldwide, showing almost a 10-fold increase in the last five decades. Despite advances in the understanding of the disease mechanisms, preventive measures, and treatment options, morbidity and mortality remain high. Moreover, the burden of uncontrolled glycemia and associated complications have a significant impact on healthcare costs. To be ready for the future and emerging issues in the management of diabetes and related disorders, a holistic approach is essential for the prevention of the next generations. So many challenges in the management of diabetes exist globally, which differ according to the health infrastructure, and cultural, economic, and sociodemographic status of the nations.

Conclusions

In this minireview and commentary on previously unaddressed needs relating to the management of diabetes, we discuss the ubiquitous and most compelling challenges and suggest potential solutions in the care of patients with diabetes.

Change in fatty acid composition of plasma triglyceride caused by a 2 week comprehensive risk management for diabetes: A prospective observational study of type 2 diabetes patients with supercritical fluid chromatography/mass spectrometry-based semi-target lipidomic analysis

AIMS/INTRODUCTION

Hypertriglyceridemia is common in patients with diabetes. Although the fatty acid (FA) composition of triglycerides (TGs) is suggested to be related to the pathology of diabetes and its complications, changes in the fatty acid composition caused by diabetes treatment remain unclear. This study aimed to identify short-term changes in the fatty acid composition of plasma triglycerides after diabetes treatment.

MATERIALS AND METHODS

This study was a sub-analysis of a prospective observational study of patients with type 2 diabetes aged between 20 and 75 years who were hospitalized to improve glycemic control (n = 31). A lipidomic analysis of plasma samples on the 2nd and 16th hospital days was conducted by supercritical fluid chromatography coupled with mass spectrometry.

RESULTS

In total, 104 types of triglycerides with different compositions were identified. Most of them tended to decrease after treatment. In particular, triglycerides with a lower carbon number and fewer double bonds showed a relatively larger reduction. The inclusion of FA 14:0 (myristic acid), as a constituent of triglyceride, was significantly associated with a more than 50%, and statistically significant, reduction (odds ratio 39.0; P < 0.001). The total amount of FA 14:0 as a constituent of triglycerides also decreased significantly, and its rate of decrease was the greatest of all the fatty acid constituents.

CONCLUSIONS

A 2 week comprehensive risk management for diabetes resulted in decreased levels of plasma triglycerides and a change in the fatty acid composition of triglycerides, characterized by a relatively large reduction in FA 14:0 as a constituent of triglycerides.

Evaluation of change in metabolome caused by comprehensive diabetes treatment: A prospective observational study of diabetes inpatients with gas chromatography/mass spectrometry-based non-target metabolomic analysis

AIMS/INTRODUCTION

Diabetes patients develop a variety of metabolic abnormalities in addition to hyperglycemia. However, details regarding change in various metabolites after comprehensive diabetes treatment remain unknown. This study aimed to identify the short-term change in metabolome in inpatients who were subject to comprehensive diabetes treatment, using gas chromatography/mass spectrometry-based non-target metabolomics techniques.

MATERIALS AND METHODS

Participants of the present study were randomly recruited from the patients with type 2 diabetes hospitalized due to problems with glycemic control (n = 31) and volunteers without diabetes (n = 30), both of whom were aged between 20 and 75 years. A metabolomic analysis of fasting plasma samples on the 2nd (pre-treatment) and 16th hospital (post-treatment) day with gas chromatography/mass spectrometry using a multiple reaction monitoring mode was carried out.

RESULTS

A principal component analysis showed that metabolome of fasting plasma was different between individuals with and without diabetes. The metabolome of fasting plasma in diabetes patients after treatment was different from that of pre-treatment, as well as individuals without diabetes. Many amino acids (proline, glycine, serine, threonine, methionine, pyroglutamic acid, glutamine and lysine) were significantly increased by >10% after administering the inpatient diabetes treatment. A hierarchical clustering analysis showed that in the case of patients with markedly decreased monosaccharide levels and increased 1,5-anhydroglucitol, the levels of amino acids increased more significantly.

CONCLUSIONS

After a 2-week comprehensive treatment, the plasma levels of various amino acids increased in conjunction with the reduction in monosaccharide levels in poorly controlled type 2 diabetes patients.

Multi-level Diabetes Prevention and Treatment Interventions for Native People in the USA and Canada: a Scoping Review

PURPOSE OF REVIEW

This scoping literature review seeks to answer the question "What is known in the existing literature about multi-level diabetes prevention and treatment interventions for Native people living in the United States and Canada?"

RECENT FINDINGS

Multi-level interventions to prevent and/or treat chronic diseases, such as diabetes, promise to help individuals who experience health disparities related to social determinants of health. As described by the socio-ecological model, such interventions mobilize support through a combination of individual, interpersonal, organizational, community, and policy levels of activity. This review revealed little literature about multi-level diabetes prevention and/or treatment programs for US and Canada-based Native peoples. Ten interventions were identified; all focused on diabetes prevention; eight were specific to youth. Multi-level intervention design elements were largely individual-, school-, and community-based. Only three interventions included environmental or policy-level components.

Managing diabetes in diabetic patients with COVID: where do we start from?

AIMS

COVID-19 has and still is sweeping away the national health systems worldwide. In this review, we sought to determine the evidence base proofs on the antidiabetic treatment capable to reduce the risk of COVID-19-related mortality.

METHODS

We have performed a systematic search of published articles using PubMed, and EMBASE from March 2020 to March 31st, 2021. We excluded editorials, commentary, letters to the editor, reviews, and studies that did not have mortality as an outcome. For metformin and insulin only, we performed a meta-analysis using Cochrane RevMan 5.2.

RESULTS

Among antidiabetic drugs, metformin was the only drug associated with a reduced risk of mortality. Conversely, insulin appears associated with an increased risk. The other classes of drugs were neutral.

CONCLUSIONS

The totality of articles reports retrospective data strongly affected by "channeling bias" so that most of the existing results on each class of drugs are driven by the phenotype of patients likely to receive that specific drug by prescription.

Assessment of risk factors for bone fractures in patients with type 2 diabetes mellitus: A study in Saudi Arabia

BACKGROUND AND AIMS

This study aimed to estimate the prevalence of bone fractures and analyze their associated risk factors in people with and without type 2 diabetes (T2D) in Saudi Arabia.

METHODS

This study was conducted among 1188 people (581 type 2 diabetes) in Prince Sultan Military Medical City, Riyadh, Saudi Arabia. In addition to the demographic variables, glycated hemoglobin (HbA1c), creatinine, estimated glomerular filtration rate (eGFR), use of teriparatide, presence of rheumatoid arthritis, presence of chronic obstructive pulmonary disease (COPD), Bone mineral density (BMD), Trabecular Bone Score (TBS) and Fracture Risk using the Fracture Risk Assessment Tool (FRAX) were also collected.

RESULTS

There were 1188 people (mean age 66.5 ± 8.7yrs) included in this study, of which 1068 (89.9%) were female, and 120 (10.1%) were male. A total of 112 (9.4%) individuals had a fracture history. Female, use of teriparatide, TBS (partially degraded and degraded), FRAX with TBS (MOF), and FRAX with TBS (Hip fx) were identified as independent risk factors for fracture in the whole study population. Teriparatide use and FRAX with TBS (MOF) were observed as independent risk factors for fracture in the non-diabetic population, whereas age, creatinine, eGFR, teriparatide, osteopenia, osteoporosis, TBS (partially degraded, degraded), FRAX with TBS (MOF), FRAX with TBS (Hip fx) were determined as independent risk factors for fracture among patients with diabetes.

CONCLUSION

Patients with T2D were observed to have a higher risk for fractures. The findings of the study highlight the requirement for fracture prevention strategies in patients with diabetes.

FGF21 and Chronic Kidney Disease

The global nephrology community recognizes the increasing burden of kidney disease and its poor health outcomes in the general population. Given this, strategies to establish early diagnosis, improve understanding of the natural course and develop novel therapeutic interventions to slow progression and reduce complications are encouraged. Fibroblast growth factor 21 (FGF21), a member of the endocrine FGF subfamily, has emerged as a master homeostasis regulator of local and systemic lipid, glucose and energy metabolism. In addition, FGF21 should be considered an autonomic and endocrine regulator of stress responses in general. Promising results has been shown in both dysmetabolic animal models and metabolic disease patients after pharmacological administration of FGF21 analogs. The association of FGF21 with renal function has been studied for more than ten years. However, the functional role of FGF21 in the kidney is still poorly understood. This review summarizes the biological effects of FGF21 and discusses what is currently known about this hormone and chronic kidney disease, highlighting important gaps that warrant further research.

Efficacy of i-Port Advance system on patients satisfaction and glycemic control among patients with type 1 diabetes in Saudi Arabia

BACKGROUND AND AIMS

To determine the efficacy of i-Port Advance system on patients satisfaction and glycemic control among patients with type 1 diabetes (T1D).

METHODS

This prospective study was performed among 73 patients with T1D (13-29 years) at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. Demographic data were collected at baseline and clinical characteristics were collected at baseline and 12 weeks. Patients' responses to Morisky Medication Adherence Scale (MMAS-8) and Insulin Delivery Satisfaction Survey (IDSS) were recorded at baseline and 12 weeks after initiating the i-Port Advance system.

RESULTS

At 12 weeks, significant improvement was evident in the IDSS subscales, which comprises the IDSS effective (p = 0.048), burdensome (p = 0.032), and IDSS inconvenient (p = 0.001), with the total baseline IDSS score being 2.6 ± 0.42, and at 12 weeks being 3.7 ± 0.72 (p = 0.037). The MMAS total score at baseline was 4.6 ± 1.2, and at 12 weeks, it increased to 6.4 (p = 0.028). HbA1c level was 8.4% at baseline and decreased to 7.9% (p = 0.001) at 12 weeks. The total daily dose of insulin at baseline registered 0.9 ± 0.13, which declined to 0.8 ± 0.12 (p = 0.048) at 12 weeks. Fasting blood sugar value was 197 ± 23.4 at baseline, which dropped to 182 ± 24.5 at 12 weeks (p = 0.01); and the postprandial glucose at baseline was 195 ± 21.4 and declined to 177 ± 19.2 at 12 weeks (p = 0.01). The hypoglycemic episodes revealed a noteworthy reduction after the i-Port Advance system usage.

CONCLUSION

Use of i-Port Advance system was found to raise the patients' satisfaction levels and lower both the hypoglycemic episodes as well as the HbA1c levels.

Type 2 diabetes and metabolic surgery guidelines and recommendations should urgently be unified

Metabolic surgery has been studied in the last decades as an effective and safe treatment for type 2 diabetes (T2D), and randomized controlled trials generally found surgery superior when compared with medical treatment. In 2016, the DSS-II Joint Statement recognized the importance of metabolic surgery in the treatment of T2D and urged clinicians to discuss, recommend, or at least consider this procedure for their patients. Diabetes societies also cogitate metabolic surgery as an option for T2D patients in their guidelines. However, there are some differences in recommendations that could lead a careful reader to some confusion. This was potentialized in a recent document published by the same DSS-II group concerning prioritization for surgery after the COVID-19 pandemic, in which the criteria suggested for an expedited recommendation that is not exactly evidence-based, and collided substantially with several clinical guidelines worldwide, especially with regard to secondary prevention of cardiovascular disease. A more harmonious discussion and unified guidelines between clinicians and surgeons are needed in order to provide the same message for those who read different articles.

Impact of the FreeStyle Libre flash glucose monitoring system on diabetes- self-management practices and glycemic control among patients with type 2 diabetes in Saudi Arabia: A prospective study

BACKGROUND AND AIMS

To examine the efficacy of FreeStyle Libre Flash Glucose Monitoring System (FGMS) on Diabetes Self-Management Practices (DSMP) and glycemic control among patients with type 2 diabetes (T2D).

METHODS

This prospective study was conducted among 105 patients with T2D (aged 30-70 years), who self-tested their glucose levels by conventional finger-prick method using blood glucose meters (BGM). At baseline visit, FGMS sensors were fixed by a diabetes educator to all patients. At the baseline and at 12 weeks of the study, an interviewer collected the responses of Diabetes Self-Management (DSM) from all the study population using a questionnaire.

RESULTS

At 12 weeks, significant improvements in the DSM subscales were observed, which includes glucose management (P = 0.042), dietary control (P = 0.048), physical activity (P = 0.043), health care use (P = 0.001) and self-care (P = 0.001), compared to the values at baseline. At baseline, when the HbA1c level was 8.2%, at 12 weeks, it dropped to 7.9%. Also, at baseline, when the hypoglycemia frequency was 3.1, it declined to 1.2 episodes/month at 12 weeks. While comparing the blood glucose monitoring through BGM at the baseline (1.92/day), a higher degree of frequency of blood glucose monitoring was evident at 12 weeks (6.84/day), after the patients employed the FreeStyle Libre.

CONCLUSION

After 12 weeks of using the FreeStyle Libre, the frequency of hypoglycemic episodes and the HbA1c levels were dropped, while the practice of DSM and frequency of blood glucose monitoring were improved.

Current State of Diabetes Mellitus Prevalence, Awareness, Treatment, and Control in Latin America: Challenges and Innovative Solutions to Improve Health Outcomes Across the Continent

PURPOSE OF REVIEW

Latin America is the scenario of great inequalities where about 32 million human beings live with diabetes. Through this review, we aimed at describing the current state of the prevalence, awareness, treatment, and control of diabetes mellitus and completion of selected guidelines of care across Latin America and identify opportunities to advance research that promotes better health outcomes.

RECENT FINDINGS

The prevalence of diabetes mellitus has been consistently increasing across the region, with some variation: higher prevalence in Mexico, Haiti, and Puerto Rico and lower in Colombia, Ecuador, Dominican Republic, Peru, and Uruguay. Prevalence assessment methods vary, and potentially underestimating the real number of persons with diabetes. Diabetes unawareness varies widely, with up to 50% of persons with diabetes who do not know they may have the disease. Glycemic, blood pressure, and LDL-C control and completion of guidelines to prevent microvascular complications are not consistently assessed across studies, and the achievement of control goals is suboptimal. On the other hand, multiple interventions, point-of-care/rapid assessment tools, and alternative models of health care delivery have been proposed and tested throughout Latin America. The prevalence of diabetes mellitus continues to rise across Latin America, and the number of those with the disease may be underestimated. However, some local governments are embedding more comprehensive diabetes assessments in their local national surveys. Clinicians and public health advocates in the region have proposed and initiated various multi-level interventions to address this enormous challenge in the region.

A Review of Continuous Glucose Monitoring-Based Composite Metrics for Glycemic Control

We performed a literature review of composite metrics for describing the quality of glycemic control, as measured by continuous glucose monitors (CGMs). Nine composite metrics that describe CGM data were identified. They are described in detail along with their advantages and disadvantages. The primary benefit to using composite metrics in clinical practice is to be able to quickly evaluate a patient's glycemic control in the form of a single number that accounts for multiple dimensions of glycemic control. Very little data exist about (1) how to select the optimal components of composite metrics for CGM; (2) how to best score individual components of composite metrics; and (3) how to correlate composite metric scores with empiric outcomes. Nevertheless, composite metrics are an attractive type of scoring system to present clinicians with a single number that accounts for many dimensions of their patients' glycemia. If a busy health care professional is looking for a single-number summary statistic to describe glucose levels monitored by a CGM, then a composite metric has many attractive features.

Clinical efficacy and predictors of response to dulaglutide in type-2 diabetes

Aim of this retrospective multicenter observational study was to evaluate the efficacy and safety of the glucagon-like peptide-1 receptor agonist (GLP-1 RA) dulaglutide in a type-2 diabetic real-world population and to determine the factors predicting the response in terms of glycated haemoglobin (HbA1c) and other relevant clinical outcomes. Data for efficacy outcomes, adverse events and drug discontinuation were collected from records of patients with type-2 diabetes treated with once-a-week 1.5 mg of dulaglutide for 12 months in routine clinical practice. Initial analysis included 782 patients and 626 had complete follow-up at 6- and 12-months. There was a significant reduction of HbA1c at 6 months (-1 ± 0.8 %, p < 0.0001), which remained stable at 12-months follow-up (-1 ± 0.9 %, p < 0.0001). The percentage of subjects with HbA1c≤7.0 % increased significantly from 7.2 % at baseline to 52.7 % at 6 months to 55.8 % at 12 months. Predictors of the achievement of HbA1c≤7.0 % were low baseline HbA1c and short duration of diabetes. The reduction of HbA1c was associated with reductions of BMI, waist circumference, fasting plasma glucose and blood pressures. Neither sex nor age had significant effects on any clinical or laboratory outcome. The effects of dulaglutide on HbA1c, BMI and SBP tended to be greater in patients who shifted from dipeptidyl peptidase-IV inhibitors (-0.8 ± 0.8 %) than other GLP-1 RA, even if an improvement of HbA1c reduction (-0.5 %) was also seen in those shifting from other GLP-1 RA. This study confirms that addition of dulaglutide 1.5 mg once a week in real word settings has beneficial effects on both clinical and laboratory outcomes in patients with uncontrolled type-2 diabetes. Dulaglutide has a greater effect on HbA1c in patients with higher baseline values and helps achieve a target HbA1c≤7.0 %, more consistently in patients with lower baseline HbA1c and shorter diabetes duration.

The association between type 2 diabetes mellitus and bladder cancer risk among postmenopausal women

INTRODUCTION

Evidence on the association between diabetes and risk of bladder cancer has been controversial. In addition, findings on the associations between duration of diabetes, diabetes treatment, and risk of bladder cancer have been inconsistent.

METHODS

A total of 148,208 participants in Women's Health Initiative study were included. Information on diabetes status, diabetes duration, and treatment was collected both at baseline and during follow-up. Information on potential confounders including age, race/ethnicity, education, occupation, family history of cancer, smoking status, alcohol consumption, total physical activity, body mass index, and daily dietary intake were collected at baseline. Bladder cancer cases were collected and confirmed by a centralized review of pathology reports. Cox proportional hazard models with time-varying covariates were used to examine associations of diabetes status, duration of diabetes, and diabetes treatment with bladder cancer risk.

RESULTS

During a median follow-up of 18.5 years, 865 bladder cancer cases were identified. There were no significant associations of diabetes, duration of diabetes, or diabetes treatment with risk of bladder cancer. Participants with prevalent diabetes did not have significantly higher risk of bladder cancer compared with those without diabetes.

CONCLUSION

Diabetes was not significantly associated with risk of bladder cancer among postmenopausal women.

Current molecular aspects in the development and treatment of diabetes

Diabetes mellitus (DM) leads to microvascular, macrovascular, and neurological complications. Less is understood about the mechanisms of this disease that give rise to weak bones. The many molecular mechanisms proposed to explain the damage caused by chronic hyperglycemia are organ and tissue dependent. Since all the different treatments for DM involve therapeutic activity combined with side effects and each patient represents a unique condition, there is no generalized therapy. The alterations stemming from hyperglycemia affect metabolism, osmotic pressure, oxidative stress, and inflammation. In part, hemodynamic modifications are linked to the osmotic potential of the excess of carbohydrates implicated in the disease. The change in osmotic balance increases as the disease progresses because hyperglycemia becomes chronic. The aim of the current contribution is to provide an updated overview of the molecular mechanisms that participate in the development and treatment of diabetes.

Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus

BACKGROUND

In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM.

METHODS

MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria.

RESULTS AND CONCLUSIONS

In non-pregnant adults, the recommended HbA_1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA_1c is 6.5-7.5%. When HbA_1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-₁RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA_1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m², metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m² or eGFR 30-90 mL/min/1.73 m² with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-₁RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.

Costs of people with diabetes in relation to average glucose control: an empirical approach controlling for year of onset cohorts

OBJECTIVE

To estimate the impact of glycaemic control and time since diabetes diagnosis on care costs incurred by people with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

Random-effects linear regression models were run to test the impact of average glucose control (HbA1c) and time since diabetes diagnosis on total care spending in people with T2DM, adjusting for year of onset and other covariates. Two datasets were linked, Vektis (healthcare costs reimbursed by the Dutch mandatory health insurance) and Zodiac (clinical and sociodemographic data). The sample includes 22,612 observations, grouped in 5653 individuals from the Northern part of the Netherlands, covering 4 years (2008-2011).

RESULTS

A 1% point increase in HbA1c is associated with a 2.2% higher total care costs. However, when treatment modality is included, the results are modified. A 1% point increase (11 mol/mol) in HbA1c is significantly associated with 3.4% higher total care costs for individuals without glucose-lowering treatment. Being treated with insulin is significantly associated with an increase in costs of 30-38% for every additional percentage point of HbA1c, depending on the covariates included. Without controlling for year of onset, an additional year of diabetes duration relates to 2.6% higher care costs, while this is 4.9% controlling for year of onset. The effect of HbA1c and diabetes duration differs between types of costs.

CONCLUSION

HbA1c, insulin treatment and diabetes duration are the main drivers of increasing care costs. The results signal the relevance of controlling for HbA1c together with treatment modality, diabetes duration and year of diagnosis effects.

A mobile health monitoring-and-treatment system based on integration of the SSN sensor ontology and the HL7 FHIR standard

BACKGROUND

Mobile health (MH) technologies including clinical decision support systems (CDSS) provide an efficient method for patient monitoring and treatment. A mobile CDSS is based on real-time sensor data and historical electronic health record (EHR) data. Raw sensor data have no semantics of their own; therefore, a computer system cannot interpret these data automatically. In addition, the interoperability of sensor data and EHR medical data is a challenge. EHR data collected from distributed systems have different structures, semantics, and coding mechanisms. As a result, building a transparent CDSS that can work as a portable plug-and-play component in any existing EHR ecosystem requires a careful design process. Ontology and medical standards support the construction of semantically intelligent CDSSs.

METHODS

This paper proposes a comprehensive MH framework with an integrated CDSS capability. This cloud-based system monitors and manages type 1 diabetes mellitus. The efficiency of any CDSS depends mainly on the quality of its knowledge and its semantic interoperability with different data sources. To this end, this paper concentrates on constructing a semantic CDSS based on proposed FASTO ontology.

RESULTS

This realistic ontology is able to collect, formalize, integrate, analyze, and manipulate all types of patient data. It provides patients with complete, personalized, and medically intuitive care plans, including insulin regimens, diets, exercises, and education sub-plans. These plans are based on the complete patient profile. In addition, the proposed CDSS provides real-time patient monitoring based on vital signs collected from patients' wireless body area networks. These monitoring include real-time insulin adjustments, mealtime carbohydrate calculations, and exercise recommendations. FASTO integrates the well-known standards of HL7 fast healthcare interoperability resources (FHIR), semantic sensor network (SSN) ontology, basic formal ontology (BFO) 2.0, and clinical practice guidelines. The current version of FASTO includes 9577 classes, 658 object properties, 164 data properties, 460 individuals, and 140 SWRL rules. FASTO is publicly available through the National Center for Biomedical Ontology BioPortal at https://bioportal.bioontology.org/ontologies/FASTO .

CONCLUSIONS

The resulting CDSS system can help physicians to monitor more patients efficiently and accurately. In addition, patients in rural areas can depend on the system to manage their diabetes and emergencies.

Variation of carbohydrate intake in diabetic children on carbohydrate counting

AIMS

Carbohydrate counting (CC) is a technique for managing diabetes particularly based on the counting of carbohydrates. It allows diabetic patients to vary their amount of carbohydrates from one meal to another by adjusting their insulin dose. The primary objective was to determine the variation of carbohydrate intake (CI) in children on CC.

METHOD

This was a prospective study conducted between 2014 and 2016. We collected the amount of carbohydrates eaten at each meal by 77 diabetic over a period of 28 days (i.e. 8068 data). We analyzed the number and percentage of significant CI variation rates from one day to another, both for the whole day and for each meal. The CI variation rate was deemed significant if it was greater than or equal to 30%.

RESULTS

The percentage of significant CI variation rates was 30% at the daily level, 34% for breakfast, 44% for lunch and dinner, and 53% for snack. The percentage of significant variation rates varied according to age, treatment and occurrence of events.

CONCLUSION

Children varied their CI significantly from one meal to another more than one in three times. CC offers flexibility and a better quality of life for children using this method.

Protective effect of vitamin E on oxidative stress and sperm apoptosis in diabetic Mice

Background

Generation of free radicals and oxidative stress are a major contributor to diabetes. These factors lead to the development of diabetic testicles disorders.

Objective

In this study, the protective effect of vitamin E on functional disorders associated with diabetes induced oxidative stress in male reproductive systems has been investigated.

Materials and Methods

Thirty-three adult male Mice were divided into control, diabetic, and untreated diabetic groups. Streptozotocin was used to induce diabetes. In the treated group, vitamin E was given to the Mice intraperitoneally for 30 days. Then, animals were anesthetized and sacrificed. Animal testicles were isolated and homogenized in phosphate buffer and used for measuring sperm count, motility and survival of sperm, MDA concentration and antioxidant capacity (TAC). Apoptosis was also performed with the TUNEL test.

Results

The results of reduction (12.03 ± 98.11) TAC, MDA concentration (-28.5 ± 2.58), sperm motility (unstable sperma= 86.4 ± 7.48), sperm count (171.51), Sperm morphology (natural morphology= 49.69 ± 31.93) and abnormal morphology (9.77 ± 49.7) with increased oxidative damage. These changes were statistically significant in comparison with the control group for all variables other than MDA (p= 0.05). Treatment of vitamin E diabetic Mice improved the ability of antioxidants to prevent oxidative damage in the testicles, restore the sperm movement, and increase the number of normal sperm as well as TAC. The level of apoptosis in the treated group has decreased compared to the untreated group.

Conclusion

Vitamin E protects the reproductive system against diabetes mellitus. Therefore, it was concluded that vitamin E may be a suitable agent for protecting the sperm and testicular parameters against undesirable effects of diabetes.

Alteration of layer thickness in the choroid of diabetic patients

IMPORTANCE

Choroidal thickness changes in diabetic retinopathy improve understanding the pathophysiology and managements of this disease.

BACKGROUND

To examine the choroidal layer thickness in diabetes mellitus (DM) patients and normal individuals, and to compare the findings based on medical history of systemic DM treatments, and stage of diabetic retinopathy (DR).

DESIGN

Case control study.

PARTICIPANTS

Two hundred sixty eight eyes of 134 DM patients and age-matched 72 healthy controls of 92 eyes.

METHODS

Central choroidal layer thickness (total, inner, and outer layers) was measured using enhanced depth imaging OCT. DM patients were divided into two groups; the DM treated group (88 cases), and the untreated group (46 cases). These two groups were further classified into four groups; no DR (NDR), mild/moderate non-proliferative DR (mNPDR), severe NPDR and PDR.

MAIN OUTCOME MEASURES

Comparison of subfoveal choroid layer thickness in control and diabetic patient groups.

RESULTS

Choroidal thickness measurements of diabetic eyes had strong correlation between masked raters in choroidal layers, proving high reproducibility. The total and outer choroid thicknesses in mNPDR in the DM untreated group were significantly thinner than normal controls (each P<0.05). Choroidal outer layer thickness of the severe NPDR in the DM untreated group was significantly thicker than normal controls (P<0.05). In the DM treatment group, there were no significant differences from the control group regarding choroidal layer thicknesses and all stages of DR.

CONCLUSIONS AND RELEVANCE

The choroidal thickness significantly changed in the DM untreated group, and the main anatomical changes might result from the outer layer.

Preparation, characterization and in vivo evaluation of pH sensitive, safe quercetin-succinylated chitosan-alginate core-shell-corona nanoparticle for diabetes treatment

The study aims for development of an efficient polymeric carrier for evaluating pharmaceutical potentialities in modulating the drug profile of quercetin (QUE) in anti-diabetic research. Alginate and succinyl chitosan are focused in this investigation for encapsulating quercetin into core-shell nanoparticles through ionic cross linking. The FT-IR, XRD, NMR, SEM, TEM, drug entrapment and loading efficiency are commenced to examine the efficacy of the prepared nanoparticles in successful quercetin delivery. Obtained results showed the minimum particle size of ∼91.58nm and ∼95% quercetin encapsulation efficiently of the particles with significant pH sensitivity. Kinetics of drug release suggested self-sustained QUE release following the non-fickian trend. A pronounced hypoglycaemic effect and efficient maintenance of glucose homeostasis was evident in diabetic rat after peroral delivery of these quercetin nanoparticles in comparison to free oral quercetin. This suggests the fabrication of an efficient carrier of oral quercetin for diabetes treatment.

Diabetes and risk of cancer incidence: results from a population-based cohort study in northern Italy

BACKGROUND

Aim of this study was to compare cancer incidence in populations with and without diabetes by cancer site. Furthermore, we aimed at comparing excess risk of cancer according to diabetes type, diabetes duration and treatment, the latter as regards Type 2 diabetes.

METHODS

By use of the Reggio Emilia diabetes registry we classified the resident population aged 20-84 at December 31^st 2009 into two groups: with and without diabetes. By linking with the cancer registry we calculated the 2010-2013 cancer incidence in both groups. The incidence rate ratios (IRR) by cancer site, type of diabetes, diabetes duration, and as concerns Type 2 diabetes, by treatment regimen were computed using Poisson regression model and non-diabetic group as reference.

RESULTS

The cohort included 383,799 subjects without diabetes and 23,358 with diabetes. During follow-up, we identified 1464 cancer cases in subjects with diabetes and 9858 in the remaining population. Overall cancer incidence was higher in subjects with diabetes than in those without diabetes (IRR = 1.22, 95%CI 1.15-1.29), with similar results focusing on subjects with at least 2-year diabetes duration. Cancer sites driving overall increased risk were liver, pancreas, Colon rectum, and bladder in both sexes, corpus uteri for females. There was also suggestion of an increased risk for kidney cancer in females and a decreased risk for prostate cancer. Excess risk was found in patients with Type 2 diabetes, more marked among insulin users, especially with combined therapy. We observed an increasing risk for diabetes duration up to 10 years from diagnosis (IRR = 1.44, 95%CI 1.29-1.61) and a subsequent decrease to moderate-higher risk (IRR = 1.15, 95%CI 1.04-1.30).

CONCLUSIONS

Our study indicates that the strength of association depends on specific cancer site. Insulin, monotherapy or combined therapy, per se or as an indication of poor blood glucose control, in addition to diabetes duration, may play a role in the association of diabetes and cancer.

Insulin Treatment Attenuates Decline of Muscle Mass in Japanese Patients with Type 2 Diabetes

Sarcopenia is defined as an age-related loss of skeletal muscle mass and strength, and is a major cause of disability and mobility limitations. Recent studies have demonstrated that type 2 diabetes and insulin signaling deficiencies contribute to the progression of sarcopenia, suggesting that a sufficient supply of insulin to the skeletal muscles may be important for the maintenance of muscle function; however, little has been reported regarding whether insulin treatment can protect against sarcopenia. We conducted a retrospective observational study to examine the impact of insulin treatment on the muscle mass of patients with type 2 diabetes. A total of 312 patients (mean age: 64 ± 11 years; 40.8% female; 27.6% treated with insulin) were studied in this retrospective observational study. Skeletal muscle index (SMI) and grip strength (kg) were used to assess sarcopenia. The prevalence of sarcopenia was 18.0%. Insulin treatment was shown to be protective against the annual decline of SMI (standardized β 0.195; p = 0.025) even after adjusting for covariates, including age, gender, duration of diabetes, and body mass index. In a cohort matched by propensity scores, insulin treatment significantly increased the 1-year change in SMI (mean ± SE) compared with non-insulin-treated group (2.40 ± 0.98% vs. -0.43 ± 0.98%; p = 0.050). Our data suggest that insulin treatment could attenuate the progression of sarcopenia in patients with type 2 diabetes.

Practices, perceptions and expectations for carbohydrate counting in patients with type 1 diabetes - Results from an online survey

AIMS

Characterize adult patients with diabetes on intensive insulin therapy in terms of: (a) practices and perceived difficulties relative to carbohydrate counting (CC) and diabetes treatment, and (b) their perceptions and expectations relative to CC.

METHODS

Participants completed a 30-question web-based questionnaire.

RESULTS

Participants with type 1 diabetes (T1D) and using CC as part of their treatment plan (n=180) were included in this analysis. Participants were predominantly women (64%), aged 42±13years old and had diabetes for 22±13years. A large proportion of participants reported being confident in applying CC (78%) and considered precise CC as being important for glycemic control (91%), while only 17% reported finding CC difficult. Despite the low perceived difficulty associated with CC, many specific difficulties were encountered by patients such as the perception that glycemia fluctuates even with appropriate CC and that CC complicates the management of diabetes. A larger proportion of participants with a lower level of education (<university degree) and current or history of depression reported not feeling confident in applying CC. Most respondents believed that new technologies could facilitate CC (57%) and would be interested in such technology (62%).

CONCLUSIONS

Although a majority of participant reported being confident in applying CC, many difficulties and constraints associated with CC have been identified. These results highlight that patients with a lower level of education and with a history or current depression could benefit from specific CC education strategies. Future studies should examine the efficacy of technology tools to facilitate CC.

Consensus recommendations on exploring effective solutions for the rising cost of diabetes

Diabetes remains asymptomatic for a long period of time and its real burden gets noticed only once the complications set in. The number of individuals affected with the disease is also on the rise and more so in the low income countries. This scenario calls for urgent precautionary measures that need to be undertaken to equip ourselves to fight against this chronic disease. Individuals with financial constraints cannot afford to access even the basic treatment facilities and thus stands the most burdened. The International Diabetes Federation calls for 'Eyes on Diabetes' for the society to focus on early screening and early intervention. The rising cost of diabetes results from delayed and denied treatment. The panel discussion organized as a part of 4th Annual global diabetes convention of Jothydev's Professional Education Forum (JPEF, 2016) facilitated a platform to address diabetes as a serious health concern that needs to be given immediate priority by the policymakers as well as public and also to discuss about the feasible measures that will help achieve cost effective and affordable diabetes treatment. This was followed by in-depth literature search and finally a set of recommendations have been arrived at by the key opinion leaders to realize the dream of affordable diabetes care to all deserving individuals.

Validation of an Arabic version of the Diabetes Treatment Satisfaction Questionnaire in Qatar

AIMS

Several instruments evaluate patient-reported outcomes in diabetes mellitus (DM), but almost none are validated for use in Arabic language. The aim of this study is to test the psychometric properties and responsiveness of the Arabic version of the Diabetes Treatment Satisfaction Questionnaire (DTSQs) in Qatar.

METHODS

Ambulatory Arabic speaking DM patients were interviewed at two consecutive time points in Doha, Qatar. The 8-item DTSQs was administered in conjunction with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the World Health Organization Quality of Life Measure (WHOQOL-Bref) to assess convergent validity. Reliability was evaluated by internal consistency and item analysis. Construct validity was evaluated using "known groups" comparisons (including gender, insulin use, and HbA1c). Sensitivity of DTSQs scores to the subject's metabolic conditions was determined.

RESULTS

One hundred subjects (mean age 50.7) participated. Half (54%) were female. The majority (93%) had Type 2 DM, but 39 (42%) were using insulin. Results revealed satisfactory internal consistency. Metabolic measures (fasting blood glucose and AIC) had significant inverse correlations with DTSQs scores (interview 1, Pearson's r=-0.333 and r=-0.401, respectively, p<0.01). Scale criterion and construct validity were found to be satisfactory. Most sub-dimensions of the SF-36 and WHOQOL-Bref were correlated with the DTSQ, indicating a good concurrent validity. As in prior studies, women demonstrated poorer treatment satisfaction.

CONCLUSIONS

The Qatar Arabic DTSQs version was found to be a reliable and valid instrument for the assessment of treatment satisfaction in Arabic diabetes mellitus patients in the country.

Biochemical bone turnover markers in diabetes mellitus - A systematic review

BACKGROUND

Diabetes mellitus is associated with an increased risk of fractures, which is not explained by bone mineral density. Other markers as bone turnover markers (BTMs) may be useful.

AIM

To assess the relationship between BTMs, diabetes, and fractures.

METHODS

A systematic literature search was conducted in August 2014. The databases searched were Medline at Pubmed and Embase. Medline at Pubmed was searched by "Diabetes Mellitus" (MESH) and "bone turnover markers" and Embase was searched using the Emtree by "Diabetes Mellitus" and "bone turnover", resulting in 611 studies. The eligibility criteria for the studies were to assess BTM in either type 1 diabetes (T1D) or type 2 diabetes (T2D) patients.

RESULTS

Of the 611 eligible studies, removal of duplicates and screening by title and abstract lead to 114 potential studies for full-text review. All these studies were full-text screened for eligibility and 45 studies were included. Two additional studies were added from other sources. Among the 47 studies included there were 1 meta-analysis, 29 cross-sectional studies, 13 randomized controlled trials, and 4 longitudinal studies. Both T1D and T2D were studied. Most studies reported fasting BTM and excluded renal disease.

CONCLUSION

Markers of bone resorption and formation seem to be lower in diabetes patients. Bone specific alkaline phosphatase is normal or increased, which suggests that the matrix becomes hypermineralized in diabetes patients. The BTMs: C-terminal cross-link of collagen, insulin-like growth factor-1, and sclerostin may potentially predict fractures, but longitudinal trials are needed. This article is part of a Special Issue entitled Bone and diabetes.

Impact of body weight on antidiabetic treatment and predictors of weight control under real-world conditions: a 2-year follow-up of DiaRegis cohort

AIMS

Treatment strategies for obese patients with type 2 diabetes mellitus aim to increase physical activity, reduce body weight, and improve glucose control using weight-beneficial antidiabetic drugs. The objective of this study was to determine whether these strategies are implemented, and to identify factors predictive of glucose control and body weight management in a large, real-world patient population.

METHODS

The prospective DiaRegis cohort study included 3807 patients with type 2 diabetes in whom the treating physician decided to intensify and optimize treatment because of insufficient glucose control.

RESULTS

Antidiabetic treatment of overweight and obese patients was compared with that of normal-weight patients over a 2-years follow-up period, and multivariate analyses were performed to identify predictors of body weight loss. Among the 3807 participants, 92.5 % were overweight or obese. Normal-weight participants were more often treated with sulfonylureas or insulin, and overweight and obese patients with metformin or glucagon-like peptide (GLP)-1 analogues. Predictors of weight loss were body mass index (BMI) ≥30 kg/m(2) and any reported physical activity.

CONCLUSIONS

DiaRegis study shows that under real-world conditions, antidiabetic drug therapy is performed dependent on body weight. This strategy results in adequate glucose control and moderate weight reductions in overweight and obese patients. Weight loss is affected by treatment with weight-beneficial drugs, but also by any reported physical activity. However, only a small subgroup of patients perform physical activity. Initiation and maintenance of a physically active lifestyle remains a significant challenge for physicians, and patients with type 2 diabetes.

Differential Effect of Glycosylated Hemoglobin Value and Antidiabetic Treatment on the Risk of 30-day Readmission Following a Hospitalization for Acute Heart Failure

INTRODUCTION AND OBJECTIVES

In patients with heart failure and type 2 diabetes, low glycosylated hemoglobin has been related with higher risk of mortality but information regarding morbidity is scarce. We sought to evaluate the association between glycosylated hemoglobin and 30-day readmission in patients with type 2 diabetes and acute heart failure.

METHODS

Glycosylated hemoglobin was measured before discharge in 835 consecutive patients with acute heart failure and type 2 diabetes. Cox regression analysis adapted for competing events was used.

RESULTS

Mean (standard deviation) age was 72.9 (9.6) years and median glycosylated hemoglobin was 7.2% (6.5%-8.0%). Patients treated with insulin or insulin/sulfonylurea/meglitinides were 41.1% and 63.2% of the cohort, respectively. At 30 days post-discharge, 109 (13.1%) patients were readmitted. A multivariate analysis revealed that the effect of glycosylated hemoglobin on the risk of 30-day readmission was differentially affected by the type of treatment (P for interaction<.01). Glycosylated hemoglobin (per 1% decrease) was inversely associated with higher risk in those receiving insulin (hazard ratio = 1.45; 95% confidence interval, 1.13-1.86; P=.003) or insulin/sulfonylurea/meglitinides (hazard ratio = 1.44; 95% confidence interval, 1.16-1.80; P=.001). Conversely, glycosylated hemoglobin (per 1% increase) had no effect in non-insulin dependent diabetes (hazard ratio = 1.01; 95% confidence interval, 0.87-1.17; P=.897) or even a positive effect in patients not receiving insulin/sulfonylurea/meglitinides (hazard ratio = 1.12; 95% confidence interval, 1.03-1.22; P=.011).

CONCLUSIONS

In acute heart failure, glycosylated hemoglobin showed to be inversely associated to higher risk of 30-day readmission in insulin-dependent or those treated with insulin/sulfonylurea/meglitinides. A marginal effect was found in the rest. Whether this association reflects a treatment-related effect or a surrogate of more advanced disease should be clarified in further studies.

Initiation of treatment for incident diabetes: evidence from the electronic health records in an ambulatory care setting

OBJECTIVE

We examined patterns and predictors of initiation of treatment for incident diabetes in an ambulatory care setting in the US.

METHODS

Data were extracted from electronic health records (EHR) for active patients ≥ 35 years in a multispecialty, multiclinic ambulatory care organization with 1000 providers. New onset type 2 diabetes and subsequent treatment were identified using lab, diagnosis, medication prescription, and service use data. Time from the first evidence of diabetes until initial treatment, either medication or education/counseling, was examined using a Kaplan-Meier hazards curve. Potential predictors of initial treatment were examined using multinomial logistic models accounting for physician random effects.

RESULTS

Of 2258 patients with incident diabetes, 55% received either medication or education/counseling (20% received both) during the first year. Of the treated patients, 68% received a treatment within the first four weeks, and 13% after initial 16 weeks. Strong positive predictors (P < 0.01) of combined treatment were younger age, higher fasting glucose at diagnosis, obesity, and visits with an endocrinologist.

CONCLUSIONS

Among insured patients who have a primary care provider in a multispecialty health care system, incident diabetes is treated only half the time. Improved algorithms for identifying incident diabetes from the EHR and team approach for monitoring may help treatment initiation.

Insulin degludec early clinical experience: does the promise from the clinical trials translate into clinical practice--a case-based evaluation

BACKGROUND

Clinical experience of patients is an additional source of information that can inform prescribing decisions for new therapies in practice. In diabetes, for example, patients with recurrent hypoglycemia may be excluded from trials conducted for regulatory purposes. Using insulin degludec (IDeg), a new basal insulin with an ultra-long duration of action as an example, an interim analysis is presented describing whether the decision to prescribe IDeg to patients experiencing treatment-limiting problems on their existing insulin regimes represented good clinical and economic value.

METHODS

Records from the first 51 consecutive patients with diabetes (35 type 1 [T1D] and 16 type 2 [T2D]) switching to insulin degludec from either insulin glargine (IGlar) or insulin detemir (IDet), mostly due to problems with hypoglycemia (39/51, 76.5%), were reviewed at up to 37 weeks. Patients indicated frequency of hypoglycemia and completed a disease-specific questionnaire reporting six measures of confidence and treatment satisfaction. For the largest group of exposed patents, the T1D module of the IMS Core Diabetes Model (CDM) was used to evaluate the cost-effectiveness of the treatment decision.

FINDINGS

HbA1c decreased by 0.5 ± 0.3% points and 0.7 ± 0.3% points for T1D and T2D, respectively. Hypoglycemic events decreased by >90%. Combined mean scores were ≥ 3.7 (1 = much worse, 3 = no change, 5 = much improved) for all six satisfaction and confidence items. In T1D, the treatment decision was highly cost-effective in the CDM lifetime analysis. Even when excluding benefits beyond hypoglycemia reduction, predicted cost per quality-adjusted life-year for IDeg vs IGlar/IDet was £10,754.

INTERPRETATION

These data illustrate the complementary nature of clinical trial and practice data when evaluating the value of therapeutic innovations in diabetes care. There were reductions in patient-reported hypoglycemia, reduced HbA1c, and improved treatment satisfaction in relation to the decision to prescribe IDeg. Initial health economic evaluation suggested that the decision to prescribe IDeg in this phenotypic group of T1D patients represented good value for money.

Patients who showed paradoxical increase in HbA1c levels after intensification of diabetes treatment

OBJECTIVES

When diabetes treatment is started, added, or changed (intensification of treatment) in patients with poor glycemic control, GA (glycated albumin) decreases within a few weeks, while HbA1c increases in some patients, resulting in a discrepancy between changes in GA and HbA1c. In the present study, we investigated the pathophysiology of such discrepancies.

DESIGN AND METHODS

Four diabetic patients with poor glycemic control in whom GA showed a decrease while HbA1c showed an increase at a few weeks after intensification of treatment, resulting in a discrepancy between the time course of HbA1c and that of GA, were studied.

RESULTS

In all patients HbA1c increased during the course before intensification of treatment; GA measured in two patients before the intensification of treatment also increased. After the intensification of treatment, GA decreased in all patients. On the other hand, HbA1c increased even after the intensification of treatment, but it decreased later in these patients.

CONCLUSIONS

In patients in whom HbA1c increased in spite of a decrease in GA after the intensification of diabetes treatment, glycemic control got worsened before the intensification of treatment. In such patients, therapeutic effect may be misinterpreted if glycemic control is evaluated by HbA1c, and thus it is preferable to evaluate glycemic control by fasting plasma glucose, GA and fructosamine in such situations.