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IntroductionPersons of South Asian descent have a higher prevalence of type 2 diabetes mellitus (T2DM). The management of T2DM in the South Asian community has required the support of adult children, potentially impacting the quality of life, diabetes-related knowledge, and risk perception among these caregivers.Research design and methodsTo investigate diabetes-related knowledge, quality of life, risk perception, and actual risk of developing diabetes among South Asian young adults whose parents are living with T2DM. A cross-sectional study was conducted (n=150). An online survey was administered. Data were analyzed with descriptive and inferential statistics.ResultsThere was a statistically significant difference in diabetes-related knowledge between males and females (p=0.002).ConclusionFindings highlight the importance of providing gender-specific and culturally tailored diabetes educational interventions.

IntroductionLimited information was available regarding the perioperative outcomes in patients with and without use of metformin. This study aims to evaluate the complications and mortality after major surgery in patients with diabetes who use metformin.Research design and methodsUsing a real-world database of Taiwan’s National Health Insurance from 2008 to 2013, we conducted a matched cohort study of 91 356 patients with diabetes aged >20 years who used metformin and later underwent major surgery. Using a propensity score-matching technique adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 91 356 controls who underwent surgery but did not use metformin were selected. Logistic regression was used to calculate the ORs with 95% CIs for postoperative complications and 30-day mortality associated with metformin use.ResultsPatients who used metformin had a lower risk of postoperative septicemia (OR 0.94, 95% CI 0.90 to 0.98), acute renal failure (OR 0.87, 95% CI 0.79 to 0.96), and 30-day mortality (OR 0.79, 95% CI 0.71 to 0.88) compared with patients who did not use metformin, in both sexes and in every age group. Metformin users who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR 0.60, 95% CI 0.59 to 0.62) and lower medical expenditures (pConclusionsAmong patients with diabetes, those who used metformin and underwent major surgery had a lower risk of complications and mortality compared with non-users. Further randomized clinical trials are needed to show direct evidence of how metformin improves perioperative outcomes.

IntroductionEpidemiological and genetic studies have recorded the association between proinflammatory cytokines and the development of insulin resistance, diabetes, and cardiovascular disease. The role of interleukin 6 (IL-6), NH2-terminal portion pro-brain natriuretic peptide (NT-proBNP) and resistin in the pathogenesis of heart disease in type 2 diabetes mellitus (T2DM) is still a matter of controversy. The current study aimed to evaluate the role of these biomarkers in the development of left ventricular systolic dysfunction and the ability to use them as non-invasive test in the prediction of left ventricular hypertrophy and systolic dysfunction in T2DM.Research design and methods150 participants were included in this case–control study. Patients were divided into two subgroups according to echocardiographic findings: group 1a included 46 patients with type 2 diabetes mellitus and echocardiographic evidence of abnormal systolic function; group 1b included 54 patients with type 2 diabetes mellitus and with normal echocardiogenic study; and group 2 included 50 apparently healthy controls. Routine laboratory investigations such as complete blood count, liver and renal function tests, and lipid profile, serum IL-6, NT-proBNP, and resistin were measured in all participants. Conventional echocardiography was done with special concern on the assessment of left ventricular systolic function (ejection fraction).ResultsThere was a significant increase in the level of resistin, NT-proBNP and IL-6 in group 1a patients compared with group 1b and in healthy controls. Echocardiographic parameters showed a significant increase in left ventricular mass index, left ventricle posterior wall thickness, interventricular septum thickness, and left ventricle mass in group 1a compared with group 1b and the control group. The increased left ventricular mass index was associated with higher levels of IL-6, NT-proBNP and resistin.ConclusionsProinflammatory cytokines had a clear relation with left ventricular systolic dysfunction and hypertrophy and can be used as early non-invasive markers for detection of left ventricular remodeling and systolic dysfunction in patients with T2DM.

ObjectiveTight control of hyperglycemia reduces risk of diabetic retinopathy (DR), but the residual risk remains high. This study aimed to explore relationships between plasma phenylalanine and tyrosine with DR in type 2 diabetes (T2D) and interactions between the two amino acids, and their secondary interaction with renal dysfunction.Research design and methodsWe extracted data of 1032 patients with T2D from tertiary hospital consecutively from May 2015 to August 2016. Binary logistic regression models with restricted cubic spline were used to check potential non-linear associations and to obtain ORs and 95% CIs of variables under study. Addictive interaction was estimated using relative excess risk due to interaction, attributable proportion due to interaction and synergy index. Area under the receiver operating characteristic curve was used to check increased predictive values.ResultsOf 1032 patients, 162 suffered from DR. Copresence of low phenylalanine and low tyrosine increased DR risk (OR 6.01, 95% CI 1.35 to 26.8), while either of them alone did not have a significant effect with significant additive interaction. Presence of diabetic nephropathy further increased the OR of copresence of low phenylalanine and low tyrosine for DR to 25.9 (95% CI 8.71 to 76.9) with a significant additive interaction. Inclusion of phenylalanine and tyrosine in a traditional risk factor model significantly increased area under the curve from 0.81 to 0.83 (95% CI 0.80 to 0.86).ConclusionPlasma low phenylalanine and low tyrosine worked independently and synergistically to increase the risk of DR in T2D. Presence of renal dysfunction further amplified the effect of copresence of low phenylalanine and low tyrosine on DR risk.

IntroductionThis study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs).Research design and methodsA retrospective study included 2011–2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported.ResultsAmong 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (pConclusionsRacial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.

IntroductionTo investigate the associations of 30 min postload plasma glucose (30 mPG) levels during an oral glucose tolerance test (OGTT) with the risk of future diabetes in a general Japanese population.Research design and methodsA total of 2957 Japanese community-dwelling residents without diabetes, aged 40–79 years, participated in the examinations in 2007 and 2008 (participation rate, 77.1%). Among them, 2162 subjects who received 75 g OGTT in a fasting state with measurements of plasma glucose level at 0, 30, and 120 min were followed up for 7 years (2007–2014). Cox’s proportional hazards model was used to estimate HRs and their 95% CIs of each index for the development of type 2 diabetes using continuous variables and quartiles with adjustment for traditional risk factors. The influence of 30 mPG on the predictive ability was estimated with Harrell’s C-statistics, integrated discrimination improvement (IDI), and the continuous net reclassification index (cNRI).ResultsDuring follow-up, 275 subjects experienced type 2 diabetes. Elevated 30 mPG levels were significantly associated with increased risk of developing diabetes (pConclusionsElevated 30 mPG levels were associated with increased risk of diabetes, and inclusion of 30 mPG levels significantly improved the predictive ability for future diabetes, suggesting that 30 mPG may be useful for identifying high-risk populations for type 2 diabetes.

IntroductionThe aim of the study was to identify the sociodemographic and clinical factors associated with death after the first lower-extremity amputation (LEA), minor and major separately, using data from regional health administrative databases.Research design and methodsWe carried out a population-based cohort study including patients with diabetes residing in the Lazio region and undergoing a primary amputation in the period 2012–2015. Each individual was followed up for at least 2 years. Kaplan-Meier analysis was used to evaluate long-term survival; Cox proportional regression models were applied to identify factors associated with all-cause mortality.ResultsThe cohort included 1053 patients, 72% were male, 63% aged ≥65 years, and 519 (49%) died by the end of follow-up. Mortality rates at 1 and 4 years were, respectively, 33% and 65% for major LEA and 18% and 45% for minor LEA. Significant risk factors for mortality were age ≥65, diabetes-related cardiovascular complications, and chronic renal disease for patients with minor LEA, and age ≥75 years, chronic renal disease and antidepressant drug consumption for subjects with major LEA.ConclusionsThe present study confirms the high mortality rates described in patients with diabetes after non-traumatic LEA. It shows differences between minor and major LEA in terms of mortality rates and related risk factors. The study highlights the role of depression as specific risk factor for death in patients with diabetes after major LEA and suggests including its definition and management in strategies to reduce the high mortality rate observed in this group of patients.

IntroductionCompare cost of the interstitial liquid glucose flash monitoring (FM) system (FreeStyle Libre 2) versus self-monitoring of blood glucose (SMBG) in adults with type 1 diabetes mellitus (T1DM) in Spain.Research design and methodsA model was developed to estimate, with the perspective of the Spanish health system, the annual costs associated with glucose monitoring and hypoglycemic events management in T1DM population, with multiple insulin daily doses (MDI). According to published evidence, rate of severe hypoglycemia (SHE) of 4.90 episodes per patient-year was applied. Reduction of SHE (58.6%) was modeled associated with FM use. Published rates of hospital care (20.2%) and subsequent admission (16%) were assumed for SHE. The daily consumption of strips and lancets was 9 in patients with SMBG (before and after 4 daily intakes and at bedtime) and 0.5 for FM users (according to IMPACT trial findings). Annual consumption of 26 FM sensors was considered (1 every 14 days). Unit costs (in € of 2019, excluding VAT) were obtained from literature and national databases. Sensitivity analyses (SA) were carried out to evaluate the model robustness.ResultsThe total annual cost/patient was €4437 for SMBG and €2526 for FM. The use of FM would be associated with an annual savings in the costs of monitoring and managing hypoglycemic events of €1911 per patient-year. In a hypothetical cohort of 1000 patients with T1DM MDI, FM could avoid in 1 year 4900 SHE, 93 hospitalizations for SHE. In addition, the use of FM would generate total savings of up to €1 910 000 per year. In the SA with alternative hypoglycemia events rates and use of strips and lancets, and including non-SHE episodes, savings from €370 000 to €1 760 000 were observed with FM.ConclusionsThe use of the FM system to monitor glucose in adults with T1DM treated with MDI, would reduce hypoglycemic events and would result in cost savings for the health system.

IntroductionTo assess the feasibility of computer-generated educational messaging system in healthcare workers of a tertiary care hospital. The secondary objectives were glycemic control, patient satisfaction and adherence to lifestyle modifications.Research design and methodsSingle-center parallel-group open-labeled randomized controlled trial with computer generated block randomization.SettingHealthcare workers with diabetes working in Christian Medical College Vellore, Tamil Nadu.Participants431 assessed, 341 met the selection criteria, 320 participants were randomized and 161 were taken into intervention arm and 159 in the control arm.InterventionComputer-generated short message service (SMS) based on transtheoretical model of behavioral change, 2 messages per week for 3 months, along with standard of care diabetic care. Messages had educational material regarding healthy eating habits and exercise and these messages were sent twice weekly. The messages were scheduled via an automatic calendar in a way that each subject in the intervention arm received 15 educational messages per month.Control group received only standard of care diabetic care which included dietary advice, exercise regimen and diabetic medications under supervision of their physician every 3 months.Follow-up6 months.Results95.65% of people in the intervention arm (n=154) received regular messages, out of which 93.17% read the messages regularly. 80.12% acted on the messages. 93.17% felt more satisfied with their healthcare.While both groups showed improvement in body mass index (BMI) and hemoglobin A1c (HbA1c), the difference was greater in the intervention with regard to both decrease in BMI (−0.6, pConclusionsSMS-based education system is feasible in improving healthcare among healthcare workers with diabetes. It improves patient satisfaction, adherence and improves healthcare among individuals with diabetes by decreasing their BMI and decreasing HbA1c.

BackgroundThe burden of diabetes and cardiovascular risk is not uniform across the USA, with much of this disparity tracking differences in socioeconomic status, cultural practices and lifestyle. To further evaluate disparities in these disorders, we assessed the prevalence of diabetes, hypertension, and hypercholesterolemia in an Old Order Amish community that is characterized by distinctive sociocultural practices that include a very cohesive social structure and limited use of modern technologies and medications. We compared prevalence of these conditions with that of the overall US population.MethodWe performed a community-wide survey in 5377 Amish individuals aged 18 years and older from the Lancaster County, Pennsylvania, Amish settlement that included a basic physical examination and fasting blood draw during the period 2010–2018. We then compared the prevalence of diabetes, hypertension, and high cholesterol, defined using standard criteria, between the Amish and the European Caucasian subsample of the 2013–2014 US National Health and Nutrition Examination Survey (NHANES).ResultsPrevalence rates for diabetes, hypertension and hypercholesterolemia were 3.3%, 12.7%, and 26.2% in the Amish compared with 13.2%, 37.8% and 35.7% in NHANES (pConclusionThere is substantially lower prevalence of diabetes, hypertension and hypercholesterolemia in the Amish compared with non-Amish Caucasians in the USA. Possible factors contributing to this disparity include higher physical activity levels in the Amish or other protective sociocultural factors, a greater understanding of which could inform risk reduction interventions for these chronic diseases.

IntroductionThe objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population.Research design and methodsData were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region.ResultsAfter increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years.ConclusionsDiabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people.

Digital, Objective Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study. Methods The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes). Results In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend, Ciencias Médicas y de la Salud

ObjectiveThis study explores the clinical characteristics of patients with diabetes with severe covid-19, and the association of diabetes with survival duration in patients with severe covid-19.Research design and methodsIn this single-center, retrospective, observational study, the clinical and laboratory characteristics of 193 patients with severe covid-19 were collected. 48 patients with severe covid-19 had diabetes, and 145 patients (ie, the controls) did not have diabetes. A severe case was defined as including at least one of the following criteria: (1) Respiratory rate >30/min. (2) Oxygen saturation ≤93%. (3) PaO2/FiO2≤300 mm Hg. (4) Patients, either with shock or respiratory failure, requiring mechanical ventilation, or combined with other organ failure, requiring admission to intensive care unit (ICU).ResultsOf 193 patients with severe covid-19, 48 (24.9%) had diabetes. Compared with patients with severe covid-19 without diabetes, patients with diabetes were older, susceptible to receiving mechanical ventilation and admission to ICU, and had higher mortality. In addition, patients with severe covid-19 with diabetes had higher levels of leukocyte count, neutrophil count, high-sensitivity C reaction protein, procalcitonin, ferritin, interleukin (IL) 2 receptor, IL-6, IL-8, tumor necrosis factor α, D-dimer, fibrinogen, lactic dehydrogenase and N-terminal pro-brain natriuretic peptide. Among patients with severe covid-19 with diabetes, more non-survivors were men (30 (76.9%) vs 9 (23.1%)). Non-survivors had severe inflammatory response, and cardiac, hepatic, renal and coagulation impairment. Finally, the Kaplan-Meier survival curve showed a trend towards poorer survival in patients with severe covid-19 with diabetes than patients without diabetes. The HR was 1.53 (95% CI 1.02 to 2.30; p=0.041) after adjustment for age, sex, hypertension, cardiovascular disease and cerebrovascular disease by Cox regression. The median survival durations from hospital admission in patients with severe covid-19 with and without diabetes were 10 days and 18 days, respectively.ConclusionThe mortality rate in patients with severe covid-19 with diabetes is considerable. Diabetes may lead to an increase in the risk of death.

BackgroundPre-diabetes affects one-third of adults in the USA and a subset will progress to type 2 diabetes. Our objective was to determine whether a disease-specific health plan, known as the Diabetes Health Plan (DHP), designed to improve care for persons with pre-diabetes and diabetes also led to lower rates of incident diabetes among adults with pre-diabetes.MethodsWe examined eligibility and claims data from a large payer who offered the DHP to a national sample of employers. We included adult employees and dependents who were continuously covered by the DHP over a 4-year study window. The primary outcome was incident diabetes. We conducted propensity score matching at the employer level to find comparable control employer groups offering standard plans. Using an adjusted logistic regression model at the individual level, we tested the association between DHP employer group status and incident diabetes diagnosis during the 3 years of postbaseline follow-up.FindingsOur analysis included data from 11 965 continuously enrolled adults with pre-diabetes (n=1538 from nine employers offering DHP; n=10 427 from 105 control employers offering standard plans). DHP employees and covered dependents with pre-diabetes had an 8% lower absolute predicted probability of incident diabetes compared with individuals from employer groups offering standard benefit plans (29% predicted probability of incident diabetes for DHP vs 37% for controls, pConclusionsA pre-diabetes-specific health benefit design was associated with lower rates of incident diabetes and represents an area of needed future study.

IntroductionDiabetes prevalence has never been measured in Guyana. We conducted a nationally representative cross-sectional study to estimate the prevalence of diabetes and pre-diabetes, and the association between sex and diabetes.Research design and methodsIn 2016, the Ministry of Public Health led Guyana’s first national STEPS survey among adults aged 18–69 years. Half of the participants were randomly selected for hemoglobin A1c and fasting blood glucose testing. We estimated the prevalence of diabetes and pre-diabetes and measured the association between sex and diabetes prevalence using logistic regression to compute adjusted ORs.ResultsWe included 805 adults (511 women, 294 men, mean age 41.8 (SD 14.4) years). The national prevalence of diabetes was 18.1% (95% CI: 15.4% to 20.8%), with higher rates among women (21.4%, 95% CI: 18.0% to 24.7%) than men (15.1%, 95% CI: 10.9% to 19.3%). Sex-specific diabetes prevalence varied significantly across urban and rural areas (p=0.002 for interaction). In rural areas, diabetes was twice as common among women (24.1%, 95% CI: 20.1% to 28.2%) compared with men (11.8%, 95% CI: 7.7% to 15.9%). After adjusting for prespecified covariates, rural women had double the odds of diabetes compared with rural men (OR 2.1, 95% CI: 1.20 to 3.82). This prevalence pattern was reversed in urban areas (diabetes prevalence, women: 13.9%, 95% CI: 8.7% to 19.0%; men: 22.0%, 95% CI: 12.9% to 31.1%), with urban women having half the odds of diabetes compared with urban men (OR 0.4, 95% CI: 0.20 to 0.99). We estimated that nearly one-third of women and over a quarter of men had diabetes or pre-diabetes.ConclusionsThe burden of diabetes in Guyana is considerably higher than previously estimated, with an unexpectedly high prevalence among women—particularly in rural areas.

ObjectiveWhether participation in structured diabetes self-management education programs (DSME) for participants with diabetes mellitus is associated with a healthy lifestyle in routine care apart from randomized-controlled studies remains unclear and is this studies’ research question.Research design and methodsWe identified 1300 persons with diabetes mellitus drawn from the cross-sectional population-based analysis German Health Update 2014/2015 (GEDA 2014/2015), which integrated the modules of the European Health Interview Survey (EHIS) wave 2. Of those, 816 were ever-DSME participants and 484 never-participants. We conducted multivariable weighted logistic regression analyses for lifestyle differences comparing ever-DSME and never-DSME participants. Lifestyle was defined by physical activity (PA), current smoking, fruit/vegetable consumption and body mass index (BMI). Age, sex, socioeconomic status, living together, limitation due to health problems for at least for 6 months, self-efficacy and attention to one’s health were included as confounders in the regression models.ResultsEver-DSME participants engaged significantly more often in cycling at least 1 day per week (OR 1.62, 95% CI: 1.15–2.30) and performed significantly more often aerobic endurance training of 150 min per week (including walking: OR 1.42, 95% CI: 1.03–1.94, without walking: OR 1.48, 95% CI: 1.08–2.03) compared with never-DSME participants. Ever-DSME participants were significantly more often ex-smoker compared with never-DSME participants (OR 1.39, 95% CI: 1.03–1.88). DSME attendance was not significantly associated with current smoking, BMI and fruit or vegetable consumption.ConclusionDSME participation is associated with a moderately healthier lifestyle particularly for PA even in routine healthcare. Study results emphasize the importance of a broadly dissemination of DSME access for nationwide diabetes healthcare. Future studies should adjust for DSME participation when investigating lifestyle in persons with diabetes.

Introduction Compression neuropathies (CN) in the upper extremity, the most common being carpal tunnel syndrome (CTS) and ulnar nerve entrapment (UNE), are frequent among patients with diabetes mellitus (DM). Earlier studies have shown contradicting results regarding DM as a risk factor for CN. Thus, the aim of the present population-based, longitudinal study was to explore potential associations between DM, CTS, and UNE during long-term follow-up. Research design and methods A total of 30 466 participants aged 46–73 years, included in the population-based Malmö Diet and Cancer Study during 1991–1996, were followed up in Swedish national registries regarding incident CTS and UNE until 2016. Associations between prevalent DM at baseline and incident CTS or UNE were calculated using Cox proportional hazard models, adjusted for baseline confounders, such as sex, age at study entry, smoking, hypertension, use of antihypertensive treatment, alcohol consumption, and body mass index (BMI). HbA1c and fasting plasma glucose levels had been measured at baseline in a subgroup of 5508 participants and were related to incident CTS and UNE in age and sex-adjusted binary logistic regression models. Results A total of 1081 participants developed CTS and 223 participants developed UNE during a median follow-up of 21 years. Participants with incident CTS or UNE had higher prevalence of DM and higher BMI at baseline. Using multivariate Cox regression models, prevalent DM at baseline was independently associated with both incident CTS (HR 2.10; 95% CI 1.65 to 2.70, p

Adult patients with diabetes mellitus (DM) represent one-fifth of all 30-day unplanned hospital readmissions but some may be preventable through continuity of care with better DM self-management. We aim to synthesize evidence concerning the association between 30-day unplanned hospital readmission and patient-related factors, insurance status, treatment and comorbidities in adult patients with DM. We searched full-text English language articles in three electronic databases (MEDLINE, Embase and CINAHL) without confining to a particular publication period or geographical area. Prospective and retrospective cohort and case–control studies which identified significant risk factors of 30-day unplanned hospital readmission were included, while interventional studies were excluded. The study participants were aged ≥18 years with either type 1 or 2 DM. The random effects model was used to quantify the overall effect of each factor. Twenty-three studies published between 1998 and 2018 met the selection criteria and 18 provided information for the meta-analysis. The data were collected within a period ranging from 1 to 15 years. Although patient-related factors such as age, gender and race were identified, comorbidities such as heart failure (OR=1.81, 95% CI 1.67 to 1.96) and renal disease (OR=1.69, 95% CI 1.34 to 2.12), as well as insulin therapy (OR=1.45, 95% CI 1.24 to 1.71) and insurance status (OR=1.41, 95% CI 1.22 to 1.63) were stronger predictors of 30-day unplanned hospital readmission. The findings may be used to target DM self-management education at vulnerable groups based on comorbidities, insurance type, and insulin therapy.

Background: In immune-mediated inflammatory diseases, there is a lack of precise estimates of glucocorticoid dose-response diabetes risk that consider changes in prescribed dose over time and disease activity. Methods: Population-based longitudinal analysis of electronic health records from the UK Clinical Practice Research Datalink, linked to hospital admissions and the mortality registry (1998-2017). We included 100,722 adult patients without prior diabetes history, diagnosed with giant cell arteritis or polymyalgia rheumatica (n=32,593), inflammatory bowel disease (n=29,272), rheumatoid arthritis (n=28,365), vasculitis (n=6,082), or systemic lupus erythematosus (n=4,410). We estimated risks and hazard ratios of type 2 diabetes associated with time-variant daily and total cumulative prednisolone-equivalent glucocorticoid dose using Cox regression methods. Findings: Average patient age was 58·6 years, 65,469 (65·0%) were women and 8,858 (22·6%) had a BMI ≥30 kg/m2. Overall, 8,137 (8·1%) people developed type 2 diabetes after a median follow-up of 4·9 years. At 1 year, the cumulative risk of diabetes increased from 0·9% during periods of non-use to 5·0% when the daily prednisolone-equivalent dose was ≥25·0mg. We found strong dose-dependent associations for all immune-mediated diseases, BMI levels and underlying disease duration, even after controlling for periods of active systemic inflammation. Adjusted hazard ratio [HR] for a

IntroductionMitochondrial DNA copy number (mtDNA-CN) is a measure of mitochondrial dysfunction and is associated with diabetes in experimental models. To explore the temporality of mitochondrial dysfunction and diabetes, we estimated the prevalent and incident association of mtDNA-CN and diabetes.Research design and methodsWe assessed the associations of mtDNA-CN measured from buffy coat with prevalent and incident diabetes, stratified by race, in 8954 white and 2444 black participants in the Atherosclerosis Risk in Communities (ARIC) study, an observational cohort study. Follow-up for incident analyses was complete through visit 6, 2016.ResultsMean age at mtDNA-CN measurement was 57 years and 59% were female. Prevalence of diabetes at time of mtDNA-CN measurement was higher in blacks (563/2444, 23%) than whites (855/8954, 10%). The fully adjusted odds of prevalent diabetes for the 10th vs 90th percentile of mtDNA-CN was 1.05 (95% CI 0.74 to 1.49) among black and 1.49 (95% CI 1.20 to 1.85) among white participants. Over a median follow-up time of 19 years (Q1, Q3: 11, 24 years), we observed 617 incident diabetes cases among 1744 black and 2121 cases among 7713 white participants free of diabetes at baseline. The fully adjusted hazard of incident diabetes for the 10th vs 90th percentile of mtDNA-CN was 1.07 (95% CI 0.84 to 1.38) among black and 0.97 (95% CI 0.86 to 1.10) among white participants.ConclusionsLower mtDNA-CN in buffy coat was associated with prevalent diabetes in white but not black ARIC participants. Lower mtDNA-CN was not associated with incident diabetes over 20 years of follow-up in whites or blacks.

IntroductionAlthough inflammation assessed by elevated C reactive protein (CRP) concentration is known to be associated with risk of cardiovascular disease, its association with microvascular and macrovascular dysfunction in diabetes and non-diabetes remains unclear. We examined the association between CRP and diabetes and associated microvascular and macrovascular dysfunction in sub-Saharan Africans with and without diabetes.Research design and methodsCross-sectional analyses of baseline data from the multicenter RODAM study (Research on Obesity and Diabetes among African Migrants) including 5248 Ghanaians (583 with diabetes, 4665 without diabetes) aged 25–70 years were done. Logistic regression analyses were used to examine the associations between CRP Z-scores and diabetes and microvascular (nephropathy) and macrovascular (peripheral artery disease (PAD)) dysfunction, with adjustments for age, sex, site of residence, smoking, body mass index, systolic blood pressure, and low-density lipoprotein cholesterol.ResultsIn the fully adjusted models, higher CRP concentration was significantly associated with diabetes (adjusted OR 1.13; 95% CI 1.05 to 1.21, p=0.002). In participants with diabetes, higher CRP concentration was associated with PAD (1.19; 1.03 to 1.41, p=0.046) but not nephropathy (1.13; 0.97 to 1.31, p=0.120). Among participants without diabetes, higher CRP concentration was associated with higher odds of PAD (1.10; 1.01 to 1.21, p=0.029) and nephropathy (1.12; 1.04 to 1.22, p=0.004).ConclusionsIn this study, higher CRP concentration was associated with higher odds of diabetes in sub-Saharan Africans. Also, higher CRP concentration was associated with higher odds of nephropathy and PAD in non-diabetes and higher odds of PAD in diabetes. CRP may be an important marker for assessment of risk of diabetes and risk for PAD and nephropathy in sub-Saharan Africans with and without diabetes.

ObjectiveThe role of diabetes as a predictor of mortality after stroke remains uncertain, and there are very few data for pre-diabetes. This study investigated the association of pre-diabetes and diabetes with 30-day and 1-year mortality after ischemic stroke (IS) and primary intracerebral hemorrhage (ICH).Research design and methodsBetween 2006 and 2013, 2076 patients with IS and 586 patients with ICH (median age 79) were admitted to hospital within 24 hours after stroke onset and were treated in a stroke unit, where they underwent measurement of glycated hemoglobin (HbA1c). Diabetes was retrospectively defined based on medical history, diagnosis during hospital stay or HbA1c ≥6.5% (48 mmol/mol). Pre-diabetes was defined as HbA1c of 5.7%–6.4% (39–47 mmol/mol). Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). HRs were used to test the association of pre-diabetes and diabetes with 30-day and 1-year mortality after stroke onset.ResultsAmong patients with IS, 830 had pre-diabetes and 632 had diabetes; 280 died within 30 days and the other 77 within 1 year. Among patients with ICH, 106 had pre-diabetes and 56 had diabetes; 150 died within 30 days and the other 92 within 1 year. In both stroke subtypes, pre-diabetes and diabetes were associated with higher 30-day mortality. In IS, however, the association was limited to patients with prestroke disability and very severe stroke. At NIHSS 25, HR was 1.58 (95% CI 1.07 to 2.35) for pre-diabetes and 1.67 (95% CI 1.14 to 2.46) for diabetes compared with normoglycemia. In ICH, the association was limited to women for pre-diabetes (HR 1.93, 95% CI 1.15 to 3.24) and to men for diabetes (HR 1.78, 95% CI 1.02 to 3.12). Prestroke glycemic status was unrelated to 1-year mortality.ConclusionsBoth pre-diabetes and diabetes predict short-term mortality after acute stroke, but the association varies depending on both prestroke and stroke-related characteristics. These findings may explain the heterogeneous results obtained by previous studies.

ObjectivesSecondhand smoke (SHS) was known as one of the risk factors for type 2 diabetes. So far, some studies revealed the association of SHS exposure and type 2 diabetes, however, no studies to show the relationship of cumulative SHS exposure with type 2 diabetes exist. Therefore, the objectives of this study were to identify subgroups of participants who share similar trajectories in SHS exposure levels in middle age by using latent class growth modeling, and determine the independent association of these SHS exposure level trajectories with risk of incident type 2 diabetes.MethodsIn Korean Genome and Epidemiology Study (2001–2014), 2079 participants aged 40 years and above who received biennially health check-up to follow-up and with available information of SHS exposure were selected. Four distinct trajectory groups (low-stable, moderate to low, moderate, and high to low) were identified for SHS exposure levels using trajectory modeling methods. Multivariable Cox proportional hazards model was used to examine the association of trajectories with risk of type 2 diabetes.ResultsDuring 24 083.3 person-years of follow-up (mean follow-up duration, 11.6 years), 200 incident cases of type 2 diabetes and 640 incident cases of impaired fasting glucose (IFG) were identified. In multivariable Cox model, ‘High to low’ trajectory was significantly associated with risk of type 2 diabetes (OR 1.9; 95% CI 1.3 to 2.8) compared with ‘Low-stable’. For IFG, all trajectories had significantly 30%–30% higher risk of type 2 diabetes compared with the ‘Low-stable’ trajectory.ConclusionsChanges in SHS exposure levels have been shown to associate with subsequent type 2 diabetes risk. Reversing high exposure level of SHS in middle-aged adulthood may still lead to worse progressions of type 2 diabetes than remaining stable exposure level.

Objective(1) To investigate differences in pain severity and its distribution between patients with and without diabetes mellitus (DM) in a population with advanced osteoarthritis (OA). (2) To explore the role of medication used for diabetes in these associations.Research design and methodsThis is a hospital-based cohort study of patients with advanced OA requiring total joint arthroplasty. Interviews and electronic records included: age, gender, occupation, DM (including medication and duration), analgesics used, anthropometry, joints affected by pain and disease duration. Joint pain was scored by the patients using numerical rating scale. Pain severity score was calculated by adding the number of joints affected by pain and the maximum pain score. All analyses were adjusted and/or stratified by gender, age and body mass index.ResultsIn total, 489 patients with painful OA were included. From those, 139 patients had DM (30% males and 28% females, p=0.03). Pain severity, principally the number of joints affected by pain, and analgesic consumption, was higher in males with diabetes compared with males without diabetes (p=0.012 and OR=3.03; 95% CI 1.24 to 7.36, p=0.015, respectively). These associations were not significant in females (p=0.41 and p=0.66). Pain was more severe in males using insulin versus those who did not (p=0.025). Male subjects with diabetes had higher odds of hand pain or knee and hand pain compared with males without diabetes (OR=3.7, 95% CI 1.15 to 12; p=0.028 and OR=5.54; 95% CI 1.43 to 21.5, p=0.013, respectively).ConclusionsMales with diabetes, especially those who require insulin, have more severe joint pain and consume more analgesics than males without diabetes or those who have DM and use other DM medication.

IntroductionTo estimate the prevalence of and trends in diabetes according to sociodemographic indicators and cardiovascular risk factors in a Swiss population.Research design and methodsAnnual cross-sectional study of adults residing in the state of Geneva. We included 9886 participants (51% women; mean age (SD) of 48.9 (13.4) years). Diagnosed diabetes was self-reported; undiagnosed diabetes was defined as having fasting plasma glucose level of ≥7 mmol/L and no previous diagnosis; total diabetes as the sum of diagnosed and undiagnosed diabetes. To assess trends, we grouped survey years into three time periods: 2005–2010, 2011–2014, and 2015–2017. To assess inequalities, we constructed the relative index of inequality (RII) and the slope index of inequality (SII) for education, income, and health insurance subsidy (state program based on socioeconomic disadvantage).ResultsIn total, 683 diabetes cases were identified. In 2015–2017, total diabetes prevalence was 11.8% (8.6%–14.9%) among lowest income participants, and 4.7% (3.4%–5.9%) among highest income participants (pConclusionAmong adults living in Geneva, Switzerland, substantial differences were observed in diabetes prevalence across socioeconomic and cardiovascular risk groups over a 13-year period, and relative and absolute socioeconomic inequalities appeared to have increased.

IntroductionPatients with diabetes in China have low health literacy, which likely leads to poor clinical outcomes. This study aimed to assess the effectiveness of health literacy and exercise interventions on clinical measurements in Chinese adults with type 2 diabetes mellitus (T2DM).Research design and methodsA cluster randomized controlled trial was conducted from February 2015 through April 2017 in Shanghai, China. 799 patients with T2DM aged 18 years or older recruited from eight Community Healthcare Centers were randomized into one control arm and three intervention arms receiving 1-year health literacy intervention, exercise intervention or both as the comprehensive intervention. Propensity score matching was employed to minimize potential imbalance in randomization. The intervention-attributable effects on main clinical outcomes were estimated using a difference-in-difference regression approach.ResultsAfter propensity score matching, 634 patients were included in the analysis. The three intervention groups had decreased hemoglobin A1c (A1c) level after 12 months of intervention. The largest adjusted decrease was observed in the health literacy group (−0.95%, 95% CI: −1.30 to −0.59), followed by the exercise group (−0.81%, 95% CI: −1.17 to −0.45). However, A1c was observed to increase in the health literacy and the comprehensive groups from 12 to 24 months. No obvious changes were observed for other measurements including high-density and low-density lipoprotein cholesterols, and systolic and diastolic blood pressures.ConclusionsHealth literacy and exercise-focused interventions improve glycemic control in Chinese patients with diabetes after 12 months of intervention, and the health literacy intervention shows the greatest effect. Our results suggest that the interventions may have the potential to improve diabetes self-management and reduce diabetes burden in China.Trial registration numberISRCTN76130594.

ObjectiveTo assess the eligibility of patients participating in DISCOVER (a 3-year, prospective, observational study program of 15 992 patients with type 2 diabetes [T2D] initiating a second-line glucose-lowering therapy across 38 countries) for four cardiovascular outcomes trials (CVOTs) of sodium–glucose cotransporter 2 inhibitors (CANagliflozin cardioVascular Assessment Study [CANVAS], Dapagliflozin effect on CardiovascuLAR Events trial [DECLARE-TIMI 58], EMPAgliflozin cardiovascular OUTCOME event trial [EMPA-REG OUTCOME], and eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes trial [VERTIS-CV]).Research design and methodsIn this cross-sectional analysis, baseline characteristics of DISCOVER patients were compared with the inclusion and exclusion criteria of the CVOTs to assess patient eligibility, overall and in four regions (Asia-Pacific, Europe, Latin America, and Middle East and Africa).ResultsOverall, 11 385 patients (71.2%) had sufficient data for the analysis; 56.1% were men. The mean age and time since T2D diagnosis were 57.4 and 5.6 years, respectively. The mean glycated hemoglobin level was 8.3%. DISCOVER patients were younger, and fewer had a history of cardiovascular disease, than those enrolled in the CVOTs. Eligibility varied across the CVOTs; the proportion of eligible DISCOVER patients was highest for DECLARE-TIMI 58 (40.5%), followed by CANVAS (19.9%), VERTIS-CV (7.2%), and EMPA-REG OUTCOME (7.1%); 54.6% of patients were not eligible for any CVOT. Eligibility for each CVOT varied across regions, which was explained by the differing proportions of patients with established cardiovascular disease.ConclusionsIn a large, international population of patients with T2D initiating a second-line glucose-lowering therapy, DECLARE-TIMI 58 was the most inclusive CVOT, suggesting that its study population will be more representative of patients encountered in routine clinical practice than those of CANVAS, EMPA-REG OUTCOME, and VERTIS-CV.

Background Diabetes education is believed to bring about sustained benefits in diabetes mellitus (DM) patient outcomes. These benefits have not been widely studied in an inpatient hospital setting, and as such the aim was to determine whether a hospital diabetes in-service, and specifically diabetes education, results in reduced blood glucose and HbA1c levels after hospital discharge. Methods and materials A cohort review was performed at a large teaching hospital, in Canberra, Australia. Sixty seven patients comprising 35 males and 32 females who were referred upon discharge to the Diabetes Services as having a history of uncontrolled DM from February 1st, 2015 until January 31st, 2016 were evaluated. The retrospective discharge blood glucose level (BGL) was compared to prospective BGL 3 months after hospital discharge. HbA1c was prospectively taken before and 3 months after Diabetes Service education. A between subjects t-Test was used to compare patients' glucose and HbA1c averages. Results The average discharge BGL result was 13.3 mmol/L, compared to the post-discharge result of 11.2 mmol/L, indicating a significant decrease (p =, Highlights What is already known about this subject?Diabetes mellitus education bring about sustained benefits, although these benefits have not been widely studied in an inpatient setting. What are the new findings?This study is the first to measure the benefits associated diabetes mellitus patient education within an Australian inpatient setting. How might these results change the focus of research or clinical practice?Results indicating improvements in glycaemia following education provides justification for broadening the service.