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BMJ. 2019 Jan 16;364:l178. doi: 10.1136/bmj.l178.

Nurses, shift work, and diabetes: should late chronotype be considered as a risk factor?

Author information

1
Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, via Fossato di Mortara 46, 44121 Ferrara, Italy.
PMID:
30651292
DOI:
10.1136/bmj.l178
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Conflict of interest statement

Competing interests: None declared.

Publication type

Publication type

3.
BMJ. 2019 Jan 16;364:l177. doi: 10.1136/bmj.l177.

Shift work and diabetes: alcohol consumption as a risk factor.

Author information

1
8000 Aarhus, Denmark.
PMID:
30651233
DOI:
10.1136/bmj.l177
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Conflict of interest statement

Competing interests: None declared.

Publication type

Publication type

4.
Diabet Med. 2019 Jan 24. doi: 10.1111/dme.13909. [Epub ahead of print]

Impact of physical exercise on sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system in people with Type 1 diabetes: a randomized crossover trial.

Author information

1
Diabetes Research Group, Medical School, Swansea University, Swansea, UK.
2
Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UK.
3
Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, Medical University of Graz, Graz, Austria.
4
Sport Science Laboratory, FH Joanneum University of Applied Science, Bad Gleichenberg, Austria.
5
Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
6
Department of Physical Activity and Public Health, Institute of Sports Science, Medical University of Graz, Graz, Austria.
7
Institute of Occupational, Social and Environmental Medicine, University Medical Centre of the University of Mainz, Mainz, Germany.

Abstract

AIMS:

To evaluate the sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system using reference blood glucose levels during moderate-intensity exercise while on either full or reduced basal insulin dose in people with Type 1 diabetes.

METHODS:

Ten participants with Type 1 diabetes [four women, mean ± sd age 31.4 ± 9.0 years, BMI 25.5±3.8 kg/m2 , HbA1c 55±7 mmol/mol (7.2±0.6%)] exercised on a cycle ergometer for 55 min at a moderate intensity for 5 consecutive days at the clinical research facility, while receiving either their usual or a 75% basal insulin dose. After a 4-week washout period, participants performed the second exercise period having switched to the alternative basal insulin dose. During exercise, reference capillary blood glucose values were analysed using the fully enzymatic-amperometric method and compared with the interstitial glucose values obtained. Intermittently viewed continuous glucose monitoring accuracy was analysed according to median (interquartile range) absolute relative difference, and Clarke error grid and Bland-Altman analysis for overall glucose levels during exercise, stratified by glycaemic range and basal insulin dosing scheme (P<0.05).

RESULTS:

A total of 845 glucose values were available during exercise to evaluate intermittently viewed continuous glucose monitoring sensor performance. The median (interquartile range) absolute relative difference between the reference values and those obtained by the sensor across the glycaemic range overall was 22 (13.9-29.7)%, and was 36.3 (24.2-45.2)% during hypoglycaemia, 22.8 (14.6-30.6)% during euglycaemia and 15.4 (9-21)% during hyperglycaemia. Usual basal insulin dose was associated with a worse sensor performance during exercise compared with the reduced (75%) basal insulin dose [median (interquartile range) absolute relative difference: 23.7 (17.2-30.7)% vs 20.5 (12-28.1)%; P<0.001).

CONCLUSIONS:

The intermittently viewed continuous glucose monitoring sensor showed diminished accuracy during exercise. Absolute glucose readings derived from the sensor should be used cautiously and need confirmation by additional finger-prick blood glucose measurements.

PMID:
30677187
DOI:
10.1111/dme.13909
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5.
Diabet Med. 2019 Jan 24. doi: 10.1111/dme.13907. [Epub ahead of print]

Theory-based diabetes self-management education with pre-selection of participants: a randomized controlled trial with 2.5 years' follow-up (ELDES Study).

Author information

1
Julius Centre for Health Sciences and Primary Care, Department of General Practice, University Medical Centre Utrecht, Utrecht University, Utrecht.
2
Leiden University Medical Centre, Department of Public Health and Primary Care/LUMC-Campus The Hague, Eindhoven, The Netherlands.
3
DOH Care Group, Eindhoven, The Netherlands.

Abstract

AIMS:

To evaluate the (cost-)effectiveness of Beyond Good Intentions (BGI), a 12-week group-based, nurse-led self-management programme, in terms of cardiovascular risk factors, self-management and quality of life, after 2.5 years of follow-up in pre-selected individuals with known Type 2 diabetes of up to 5 years' duration.

METHODS:

A parallel randomized controlled trial comparing BGI with usual care, based on a self-management screening questionnaire, was conducted in 43 general practices after pre-selection of participants. After 2.5 years of follow-up, the between-group changes in the abovementioned variables were assessed using analysis of covariance.

RESULTS:

A total of 108 participants (BGI group, n =56; control group, n =52) were included. Changes over time in BMI (-0.4 vs -0.5 kg/m2 ) were similar in the two groups. Median HbA1c [BGI group 47 mmol/mol (6.5%); control group: 49 mmol/mol (6.6%)] and mean systolic blood pressure (BGI group: 132±13 mmHg; control group: 133±14 mmHg) were well controlled at baseline and no intervention effect was found. LDL cholesterol levels decreased from 2.4 to 2.2 mmol/l in the control group and remained stable at 2.6 mmol/l in the intervention group (P=0.032). No intervention effect was found for self-management or quality of life.

CONCLUSION:

In contrast to the first BGI study, we did not observe significant effects of the BGI intervention, despite pre-selection of individuals. In diabetes populations with target levels for HbA1c , systolic blood pressure and LDL cholesterol, no further beneficial effects can be expected from self-management programmes with regard to biomedical factors and quality of life.

PMID:
30677175
DOI:
10.1111/dme.13907
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6.
Diabet Med. 2019 Jan 24. doi: 10.1111/dme.13908. [Epub ahead of print]

Incidence of sight-threatening diabetic retinopathy in people with Type 2 diabetes mellitus and numbers needed to screen: a systematic review.

Author information

1
Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden.
2
Group Practice Asklepion, Barneveld, VU University Medical Centre, Amsterdam, The Netherlands.
3
Department of Ophthalmology, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.

Abstract

AIM:

To investigate the incidence of sight-threatening diabetic retinopathy in Type 2 diabetes mellitus.

BACKGROUND:

In most countries, yearly or biennial screening intervals for diabetic retinopathy in people with Type 2 diabetes are recommended. Fewer screening sessions reduce the effort required of people with Type 2 diabetes and reduce healthcare costs.

METHODS:

We conducted a search of PubMed, Embase, Web of Science and the COCHRANE Library for studies published betweeen 1 January 2000 and 1 January 2017. Eligible studies were those that included general populations of >100 people with Type 2 diabetes mellitus. Additional study population criteria were absence of moderate diabetic retinopathy or more severe diabetic retinopathy than previously at last screening session and at least two successful retinal screening sessions. Outcomes of interest in the included studies were moderate and severe non-proliferative diabetic retinopathy (R2), proliferative diabetic retinopathy (R3) or maculopathy (M1), collectively known as sight-threatening or referable diabetic retinopathy.

RESULTS:

A total of 17 studies were included. In people with Type 2 diabetes without or with only mild diabetic retinopathy at baseline, the average incidence rates of sight-threatening diabetic retinopathy were ~1 per 100 person-years and ~8 per 100 person-years, respectively. The average numbers needed to screen to detect one case of sight-threatening diabetic retinopathy were 175 and 19 in people without and with mild retinopathy at last screening, respectively.

CONCLUSION:

In people with Type 2 diabetes without retinopathy at last screening, the incidence of severe sight-threatening retinopathy at the subsequent screening session was low. In people with mild retinopathy, progression to sight-threatening diabetic retinopathy was nearly 10-fold higher. This review supports lengthening of the screening interval of patients with Type 2 diabetes without retinopathy at last screening session. This article is protected by copyright. All rights reserved.

PMID:
30677170
DOI:
10.1111/dme.13908
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7.
Diabet Med. 2019 Jan 22. doi: 10.1111/dme.13906. [Epub ahead of print]

Clinical utility of ultrasonography-measured visceral adipose tissue depth as a tool in early pregnancy screening for gestational diabetes: a proof-of-concept study.

Author information

1
Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK.
2
Centre for Public Health, Queen's University Belfast, Belfast, UK.

Abstract

AIM:

To examine, in a proof-of-concept study, the ability of visceral adipose tissue depth and subcutaneous fat depth measured in early pregnancy to predict subsequent gestational diabetes, and to assess the performance of these measures as screening tests for gestational diabetes compared with use of the current UK criteria.

METHODS:

A total of 100 women in early pregnancy were recruited from a maternity hospital in Belfast, UK. Visceral adipose tissue depth and subcutaneous fat depth were measured, and each participant underwent a 75-g oral glucose tolerance test at 28 weeks' gestation for the diagnosis of gestational diabetes using WHO 2013 criteria.

RESULTS:

Eighty women completed the study, of whom 15 (19%) developed gestational diabetes. Increasing visceral adipose tissue depth, but not subcutaneous fat depth, was associated with greater gestational diabetes risk after adjusting for confounding factors (odds ratio for a 1-sd rise 2.09, 95% CI 1.06-4.12; P=0.03). Visceral adipose tissue depth ≥4.27 cm had greater sensitivity compared with current National Institute of Health and Care Excellence criteria (87% vs 40%, respectively; P=0.02) and similar specificity (62% vs 74%, respectively; P=0.15) for identifying gestational diabetes.

CONCLUSIONS:

Ultrasonography-measured visceral adipose tissue in early pregnancy is a potential clinical tool for improving sensitivity of selective screening for gestational diabetes, which, compared with universal oral glucose tolerance testing, is likely to reduce by half the numbers requiring this test. Further larger studies are now required for confirmation, including investigation into impact on clinical outcomes. This article is protected by copyright. All rights reserved.

PMID:
30672019
DOI:
10.1111/dme.13906
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8.
Diabet Med. 2019 Jan 22. doi: 10.1111/dme.13905. [Epub ahead of print]

Assessing the severity of Type 2 diabetes using clinical data-based measures: a systematic review.

Author information

1
Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester.
2
NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester.
3
Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester.
4
Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre (MAHSC), Manchester, Manchester.
5
Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester.
6
Division of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton, Brighton.
7
Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, Bristol.
8
Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire.
9
Health eResearch Centre, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester.
10
Department of Public Health and Policy, Institute of Population Health Sciences, University of Liverpool, Liverpool.
11
Primary Care Stratified Medicine (PriSM) group, Division of Primary Care, School of Medicine, University of Nottingham, Nottingham.
12
Keele Cardiovascular Research group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK.

Abstract

AIMS:

To identify and critically appraise measures that use clinical data to grade the severity of Type 2 diabetes.

METHODS:

We searched MEDLINE, Embase and PubMed between inception and June 2018. Studies reporting on clinical data-based diabetes-specific severity measures in adults with Type 2 diabetes were included. We excluded studies conducted solely in participants with other types of diabetes. After independent screening, the characteristics of the eligible measures including design and severity domains, the clinical utility of developed measures, and the relationship between severity levels and health-related outcomes were assessed.

RESULTS:

We identified 6798 studies, of which 17 studies reporting 18 different severity measures (32 314 participants in 17 countries) were included: a diabetes severity index (eight studies, 44%); severity categories (seven studies, 39%); complication count (two studies, 11%); and a severity checklist (one study, 6%). Nearly 89% of the measures included diabetes-related complications and/or glycaemic control indicators. Two of the severity measures were validated in a separate study population. More severe diabetes was associated with increased healthcare costs, poorer cognitive function and significantly greater risks of hospitalization and mortality. The identified measures differed greatly in terms of the included domains. One study reported on the use of a severity measure prospectively.

CONCLUSIONS:

Health records are suitable for assessment of diabetes severity; however, the clinical uptake of existing measures is limited. The need to advance this research area is fundamental as higher levels of diabetes severity are associated with greater risks of adverse outcomes. Diabetes severity assessment could help identify people requiring targeted and intensive therapies and provide a major benchmark for efficient healthcare services.

PMID:
30672017
DOI:
10.1111/dme.13905
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9.
Diabet Med. 2019 Jan 21. doi: 10.1111/dme.13903. [Epub ahead of print]

A comparison between point-of-care testing and venous glucose determination for the diagnosis of diabetes mellitus 6-12 weeks after gestational diabetes.

Author information

1
Department of Medicine, Stellenbosch University, Cape Town, South Africa.
2
Tygerberg Academic Hospital, Cape Town, South Africa.
3
Department of Pathology, Stellenbosch University and the National Health Laboratory Service, Cape Town, South Africa.
4
Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa.

Abstract

AIM:

To evaluate point-of-care-testing (POCT) for the diagnosis of Type 2 diabetes mellitus 6-12 weeks post-partum in women with gestational diabetes (GDM).

METHODS:

Post-partum glucose assessment (75-mg oral glucose tolerance test, OGTT) was performed prospectively in 122 women with GDM (1 November 2015 to 1 November 2017) at Tygerberg Hospital, Cape Town, South Africa. Individuals with known pre-existing diabetes were excluded. The accuracy and clinical utility of POCT (capillary finger-prick) were compared with laboratory plasma glucose (hexokinase and glucokinase methods). The OGTT consisted of two time points (fasting and 2 h) during which concurrent glucose samples (POCT and laboratory) were obtained. Bland-Altman plots and paired analysis were used to assess the analytical accuracy of POCT, whereas its diagnostic performance was determined using positive and negative predictive values to calculate specificity and sensitivity.

RESULTS:

Spearman's ranked correlation analysis indicated a strong association between POCT and laboratory glucose values at both OGTT time points (fasting, r = 0.95, P < 0.0001; 2 h, r = 0.88, P < 0.0001). Thirty-six women were diagnosed with Type 2 diabetes based on gold standard laboratory glucose levels (fasting > 7 mmol/l; 2 h > 11.1 mmol/l). POCT correctly identified Type 2 diabetes in 78% of women (28 of 36) with a positive predictive value of 89.3% and a negative predictive value of 96.7% at the fasting time point. The sensitivity and specificity of POCT to diagnose Type 2 diabetes were 89% (fasting), 85.7% (2 h) and 96.7% (fasting), 98.5% (2 h) respectively. POCT proved less sensitive to diagnose pre-diabetes (69%) but displayed satisfactory specificity (92%) at both time points assessed.

CONCLUSION:

POCT accurately identifies women with Type 2 diabetes 6-12 weeks after GDM.

PMID:
30663133
DOI:
10.1111/dme.13903
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10.
Diabet Med. 2019 Jan 21. doi: 10.1111/dme.13904. [Epub ahead of print]

The challenge of managing Type 1 diabetes in frail older people.

Author information

1
Bournemouth Diabetes& Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, Brighton, UK.
2
Royal Sussex County Hospital, Brighton and Sussex University Hospitals, Brighton, UK.

Abstract

The incidence of Type 1 diabetes is increasing by 2-5% per year and is consistent throughout the first six decades of life [1], with greater numbers reaching older age [2]. Although autonomy to manage Type 1 diabetes is encouraged, problems arise when an individual is less able to make day-to-day decisions regarding their diabetes. Ability to self-manage cannot be readily passed onto family members, and older adults with Type 1 diabetes are increasingly reliant on care from the community. Recurrent admissions occur when older adults forget to take insulin despite input from district nurses, and there can be difficulties surrounding choice of insulin regimen when nutritional intake is poor. This article is protected by copyright. All rights reserved.

PMID:
30663119
DOI:
10.1111/dme.13904
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11.
Diabet Med. 2019 Jan 19. doi: 10.1111/dme.13902. [Epub ahead of print]

Projected number of people with diagnosed Type 2 diabetes in Germany in 2040.

Author information

1
Institute for Biometrics and Epidemiology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.
2
Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany.
3
Hiller Research Unit for Rheumatology, University Hospital Duesseldorf, Düsseldorf, Germany.

Abstract

AIMS:

To project the number of people with Type 2 diabetes in Germany between 2015 and 2040.

METHODS:

Based on data from 65 million insurees of the German statutory health insurance, we projected the age-specific prevalence of diabetes using mathematical relations between prevalence, incidence rate and mortality. We compared several scenarios regarding temporal trends in the incidence and mortality rate. The projected age-specific prevalence was applied to the projected age structure of the German population between 2015 and 2040 to calculate the number of people with Type 2 diabetes.

RESULTS:

Application of current age-specific prevalence estimates to the projected age structure in 2040, although ignoring temporal trends in incidence and mortality, yielded an increase in the number of Type 2 diabetes cases from 6.9 million in 2015 to 8.3 million (+21%) in 2040. More realistic scenarios that account for decreasing mortality rates and different trends in the incidence rates project between 10.7 million (+54%) and 12.3 million (+77%) Type 2 diabetes cases in 2040.

CONCLUSIONS:

For the first time, we projected the number of future Type 2 diabetes cases for the whole adult population in Germany. The results indicate a relative increase in the number of Type 2 diabetes cases of between 54% and 77% from 2015 to 2040. Temporal trends in the incidence rate are the main drivers of this increase. Simply applying current age-specific prevalence to the future age structure probably underestimates the future number of Type 2 diabetes cases.

PMID:
30659656
DOI:
10.1111/dme.13902
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12.
Diabet Med. 2019 Jan 19. doi: 10.1111/dme.13901. [Epub ahead of print]

The 2017 Banting Memorial Lecture The diabetic lower limb - a forty year journey: from clinical observation to clinical science.

Author information

1
Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK.
2
Manchester Royal Infirmary, Manchester, UK.
3
Diabetes Research Institute, University of Miami, Miami, FL, USA.

Abstract

A series of clinical research projects conducted over the past 40 years, all of which were informed by clinical observation or discussions with people with diabetes and staff colleagues are described in this review. A study of necrobiosis lipoidica diabeticorum confirmed that this rare skin complication occurs predominantly in young women with Type 1 diabetes and other microvascular complications. Biopsies of necrobiotic lesions showed destruction of superficial nerve fibres by inflammatory tissue, which likely causes the sensory loss in lesions that is pathognomonic of the condition. The development of corneal confocal microscopy as a new non-invasive surrogate marker of peripheral neuropathy in diabetes is described next and several small studies of the use of this new technique in clinical research are reported. The influence of blood glucose instability on the genesis of neuropathic pain is then explained, with results suggesting that the stability of glycaemic control may be more important than the level of control achieved. Lastly, in neuropathy, studies of gustatory sweating are discussed, including the observation that sweating in the head and neck region is more common in people with end-stage diabetic nephropathy than in those with neuropathy. The disappearance of gustatory sweating after renal transplantation suggests a metabolic cause and for those with troublesome sweating, use of the anticholinergic, anti-muscarinic, topical cream glycopyrrolate is confirmed in a randomized control trial. In the area of diabetic foot research, distended dorsal foot veins were observed to be a clinical sign of sympathetic autonomic neuropathy: raised venous Po2 and Doppler abnormalities of blood flow are highly suggestive of arteriovenous shunting. A series of studies of the abnormalities of pressures and loads under the neuropathic diabetic foot are described: high dynamic plantar pressures are highly predictive of subsequent ulceration in the neuropathic foot. Lastly, a number of recent studies on unsteadiness and gait abnormalities when climbing and descending stairs are described. It is hoped that the art of clinical observation survives in the highly technological 21st century.

PMID:
30659650
DOI:
10.1111/dme.13901
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13.
Diabet Med. 2019 Jan 17. doi: 10.1111/dme.13900. [Epub ahead of print]

Intensification patterns and the probability of HbA1c goal attainment in Type 2 diabetes mellitus: real-world evidence for the concept of 'intensification inertia'.

Author information

1
Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA.
2
Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.
3
Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
4
Chief Medical Officer, Novo Nordisk Inc., Plainsboro, NJ, USA.
5
Health Economics and Outcomes Research, Novo Nordisk Inc., Plainsboro, NJ, USA.
6
Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA.

Abstract

AIMS:

To assess the effects of 'clinical' and 'intensification inertia' by evaluating the impact of different intensification interventions on the probability of HbA1c goal attainment using real-world data.

METHODS:

Electronic health records (Cleveland Clinic, 2005-2016) were used to identify 7389 people with Type 2 diabetes mellitus and HbA1c ≥53 mmol/mol (≥7.0%), despite a stable regimen of two oral antihyperglycaemic drugs for ≥6 months. The participants were stratified by index HbA1c and analysed over a 6-month period for pharmacological intensification, and then for 12 additional months for HbA1c goal attainment (<53 mmol/mol).

RESULTS:

The probability of HbA1c goal attainment (Kaplan-Meier analysis) in the group with index HbA1c 53-63 mmol/mol (7.0-7.9%) was highest with the addition of oral antidiabetic drugs [57.3% (95% CI 52.1, 62.0)] or glucagon-like peptide-1 receptor agonists [56.7% (95% CI 40.4, 68.6)], in the 64-74 mmol/mol (8.0-8.9%) group with the addition of oral antidiabetic drugs [31.9% (95% CI 25.1, 38.1)] or insulin [30.6% (95% CI 18.3, 41.0)], and in the ≥75 mmol/mol (≥9.0%) group with the addition of glucagon-like peptide-1 receptor agonists [53.0% (95% CI 31.8, 67.6)] or insulin [43.5% (95% CI 36.4, 49.8)].

CONCLUSIONS:

Numerical, but not statistically significant, differences in HbA1c goal attainment probability by type of intensification were most marked in people with the highest index HbA1c [≥75 mmol/mol (≥9.0%)]; in this group, injectable therapy showed trends toward greater glycaemic control benefits. Additional research into the phenomenon of intensification inertia is warranted.

PMID:
30653705
DOI:
10.1111/dme.13900
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14.
Diabet Med. 2019 Jan 17. doi: 10.1111/dme.13899. [Epub ahead of print]

Effect of structured self-monitoring of blood glucose, with and without additional TeleCare support, on overall glycaemic control in non-insulin treated Type 2 diabetes: the SMBG Study, a 12-month randomized controlled trial.

Author information

1
Diabetes Research Group, Swansea University, Swansea.
2
Diabetes Centre, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Bangor, UK.
3
Swansea Trials Unit, Swansea University, Swansea, UK.

Abstract

AIM:

To examine the impact of structured self-monitoring of blood glucose, with or without TeleCare support, on glycaemic control in people with sub-optimally controlled Type 2 diabetes.

METHODS:

We conducted a 12-month, multicentre, randomized controlled trial in people with established (>1 year) Type 2 diabetes not on insulin therapy, with sub-optimal glycaemic control [HbA1c ≥58 to ≤119 mmol/mol (≥7.5% to ≤13%)]. A total of 446 participants were randomized to a control group (n =151) receiving usual diabetes care, a group using structured self-monitoring of blood glucose alone (n =147) or a group using structured self-monitoring of blood glucose with additional monthly 'TeleCare' support (n =148). The primary outcome was HbA1c at 12 months.

RESULTS:

A total of 323 participants (72%) completed the study; 116 (77%) in the control group, 99 (67%) in the self-monitoring of blood glucose alone group and 108 (73%) in the self-monitoring of blood glucose plus TeleCare group. Compared to baseline, the mean HbA1c was lower in all groups at 12 months, with reductions of 3.3 mmol/mol (95% CI -5.71 to -0.78) or 0.3% (95% CI -0.52 to -0.07; P=0.01) in the control group, 11.4 mmol/mol (95% CI -14.11 to -8.76) or 1.1% (-1.29 to -0.81; P<0.0001) in the group using self-monitoring of blood glucose alone and 12.8 mmol/mol (95% CI -15.34 to -10.31) or 1.2% (95% CI -1.40 to -0.94; P<0.0001) in the group using self-monitoring of blood glucose plus TeleCare. This represents a reduction in HbA1c of 8.9 mmol/mol (95% CI -11.97 to -5.84) or 0.8% (95% CI -1.10 to -0.54; P≤0.0001) with structured self-monitoring of blood glucose compared to the control group. Participants with lower baseline HbA1c , shorter duration of diabetes and higher educational achievement were more likely to achieve HbA1c ≤53 mmol/mol (7.0%).

CONCLUSIONS:

Structured self-monitoring of blood glucose provides clinical and statistical improvements in glycaemic control in Type 2 diabetes. No additional benefit, over and above the use of structured self-monitoring of blood glucose, was observed in glycaemic control with the addition of once-monthly TeleCare support. (Clinical trial registration no.: ISRCTN21390608).

PMID:
30653704
DOI:
10.1111/dme.13899
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15.
Diabetes. 2019 Jan 23. pii: db180573. doi: 10.2337/db18-0573. [Epub ahead of print]

Genetic Determinants of Glycated Hemoglobin in Type 1 Diabetes.

Author information

1
Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, 00290, Helsinki, Finland.
2
Abdominal Center, Nephrology, University of Helsinki and Helsinki University Hospital, 00290, Helsinki, Finland.
3
Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00290, Helsinki, Finland.
4
Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, ON, M5G 0A4, Canada.
5
Division of Endocrinology and Diabetes, Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, California, USA.
6
Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
7
Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
8
Department of Medicine, Division of Endocrinology and Metabolism, University of Minnesota, Minneapolis, MN, USA.
9
Department of Pediatrics and Medicine, University of Minnesota, Minneapolis, MN, USA.
10
Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA.
11
The Chronic Disease Prevention Unit, National Institute for Health and Welfare, 00271, Helsinki, Finland.

Abstract

Glycated hemoglobin (HbA1c) is an important measure of glycemia in diabetes. HbA1c is influenced by environmental and genetic factors, both in people with and without diabetes. We performed a genome-wide association study (GWAS) for HbA1c in a Finnish type 1 diabetes cohort, FinnDiane. Top results were examined for replication in type 1 diabetes cohorts DCCT/EDIC, WESDR, CACTI, EDC and RASS and a meta-analysis was performed. Three SNPs in high LD on chromosome 13 near relaxin family peptide receptor 2 (RXFP2) were associated with HbA1c in FinnDiane at genome-wide significance (P<5×10-8). The minor alleles of rs2085277 and rs1360072 were associated with higher HbA1c also in the meta-analysis with RASS (P<5×10-8), where these variants had minor allele frequencies ≥1%. Furthermore, these SNPs were associated with HbA1c in a non-diabetic East Asian population (P≤0.013). A weighted genetic risk score created from 55 HbA1c associated variants from the literature was associated with HbA1c in FinnDiane but explained only a small amount of variation. Understanding the genetic basis of glycemic control and HbA1c may lead to better prevention of diabetic complications.

PMID:
30674623
DOI:
10.2337/db18-0573
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17.
Diabetes. 2019 Feb;68(2):258-265. doi: 10.2337/db18-0627.

Type 1 Diabetes in STAT Protein Family Mutations: Regulating the Th17/Treg Equilibrium and Beyond.

Author information

1
Division of Immunology, Transplantation and Infectious Diseases, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy.
2
Vita-Salute San Raffaele University, Milan, Italy.
3
School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, U.K.
4
Biocrystallography Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
5
Division of Immunology, Transplantation and Infectious Diseases, Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy fousteri.georgia@hsr.it.

Abstract

Improvements in the immunological, molecular, and genetic technologies such as next-generation sequencing have led to an exponential increase in the number of monogenic immune dysregulatory syndromes diagnosed, where type 1 diabetes (T1D) forms part of the autoimmune manifestations. Here, we reviewed the mutations in the signal transducer and activator of transcription (STAT) protein family, namely gain-of-function (GOF) mutations in STAT1 and STAT3 as well as STAT5b deficiency, that show strong association to T1D susceptibility. The equilibrium of T-helper 17 (Th17) and regulatory T cells (Tregs) is often found altered in patients affected by STAT GOF mutations. While the increased number of Th17 cells and the concomitant decrease in Treg cells may explain T1D in STAT3 GOF patients, the reduced number of Th17 cells found in those carrying STAT1 GOF mutations added a new level of complexity on the exact role of Th17 in the pathogenesis of T1D. Here, we describe the possible mechanisms through which STAT3 and STAT1 GOF mutations may perturb the fate and function of Th17 and Tregs and explore how this may lead to the development of T1D. We propose that the study of monogenic diseases, and in particular STAT mutations, may not only improve our understanding of the function of the human immune system but also shed light onto the pathogenic mechanisms of T1D and the genetic variants that confer predisposition to the disease.

PMID:
30665954
DOI:
10.2337/db18-0627
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18.
Diabetes. 2019 Feb;68(2):248-257. doi: 10.2337/dbi18-0007.

Sodium-Glucose Cotransporter 2 Inhibition and Diabetic Kidney Disease.

Author information

1
Providence Health Care, Washington State University, Spokane, WA radica.alicic@providence.org.
2
University of Washington School of Medicine, Seattle, WA.
3
College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA.
4
Providence Health Care, Washington State University, Spokane, WA.
5
Kidney Research Institute, University of Washington, Seattle, WA.
6
Institute of Translational Health Sciences, University of Washington, Seattle, WA.

Abstract

Diabetic kidney disease (DKD) is now the principal cause of chronic kidney disease leading to end-stage kidney disease worldwide. As a primary contributor to the excess risk of all-cause and cardiovascular death in diabetes, DKD is a major contributor to the progressively expanding global burden of diabetes-associated morbidity and mortality. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a newer class of antihyperglycemic agents that exert glucose-lowering effects via glycosuric actions. Preclinical studies and clinical trials of SGLT2 inhibitors have consistently demonstrated reduction of albuminuria and preservation of kidney function. In particular, SGLT2 inhibitors lower risk of congestive heart failure, a major cardiovascular complication in DKD. This Perspective summarizes proposed mechanisms of action for SGLT2 inhibitors, integrates these data with results of recent cardiovascular outcomes trials, and discusses clinical applications for patients with DKD. The American Diabetes Association/European Association for the Study of Diabetes Consensus Report published online in October 2018 recommends SGLT inhibitors as preferred add-on therapy for patients with type 2 diabetes and established cardiovascular disease or chronic kidney disease, if kidney function is adequate. Results of the ongoing and just completed clinical trials conducted in patients with established DKD will facilitate further refinement of current guidelines.

19.
Diabetes. 2019 Feb;68(2):241-247. doi: 10.2337/dbi18-0016.

Mitochondrial Stability in Diabetic Retinopathy: Lessons Learned From Epigenetics.

Author information

1
Kresge Eye Institute, Wayne State University, Detroit, MI rkowluru@med.wayne.edu.

Abstract

Diabetic retinopathy remains the leading cause of acquired blindness in working-age adults. While the cutting-edge research in the field has identified many molecular, functional, and structural abnormalities, the exact molecular mechanism of this devastating disease remains obscure. Diabetic environment drives dysfunction of the power generator of the cell and disturbs the homeostasis of mitochondrial dynamic. Mitochondrial DNA (mtDNA) is damaged, the transcription of mtDNA-encoded genes is impaired, and the electron transport chain is compromised, fueling into a vicious cycle of free radicals. The hyperglycemic milieu also alters the epigenetic machinery, and mtDNA and other genes associated with mitochondrial homeostasis are epigenetically modified, further contributing to the mitochondrial damage. Thus, mitochondria appear to have a significant role in the development of diabetic retinopathy, and unraveling the mechanism responsible for their damage as well as the role of epigenetic modifications in mitochondrial homeostasis should identify novel therapeutic targets. This will have a major impact on inhibiting/halting diabetic retinopathy and preventing the loss of vision.

PMID:
30665952
PMCID:
PMC6341304
[Available on 2020-02-01]
DOI:
10.2337/dbi18-0016
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20.
Diabetes. 2019 Feb;68(2):237-238. doi: 10.2337/db19-ti02.

In This Issue of Diabetes.

[No authors listed]
PMID:
30665951
DOI:
10.2337/db19-ti02
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