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Background: Diabetes control is poor globally and leads to burdensome microvascular and macrovascular complications. We aimed to assess post hoc between-group differences in sustained risk factor control and macrovascular and microvascular endpoints at 6.5 years in the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomized trial. Methods and findings: This parallel group individual randomized clinical trial was performed at 10 outpatient diabetes clinics in India and Pakistan from January 2011 through September 2019. A total of 1,146 patients with poorly controlled type 2 diabetes (HbA1c ≥8% and systolic BP ≥140 mm Hg and/or LDL-cholesterol ≥130 mg/dl) were randomized to a multicomponent quality improvement (QI) strategy (trained nonphysician care coordinator to facilitate care for patients and clinical decision support system for physicians) or usual care. At 2.5 years, compared to usual care, those receiving the QI strategy were significantly more likely to achieve multiple risk factor control. Six clinics continued, while 4 clinics discontinued implementing the QI strategy for an additional 4-year follow-up (overall median 6.5 years follow-up). In this post hoc analysis, using intention-to-treat, we examined between-group differences in multiple risk factor control (HbA1c <7% plus systolic BP <130 mm Hg and/or LDL-cholesterol <100 mg/dl) and first macrovascular endpoints (nonfatal myocardial infarction, nonfatal stroke, death, revascularization [angioplasty or coronary artery bypass graft]), which were coprimary outcomes. We also examined secondary outcomes, namely, single risk factor control, first microvascular endpoints (retinopathy, nephropathy, neuropathy), and composite first macrovascular plus microvascular events (which also included amputation and all-cause mortality) by treatment group and whether QI strategy implementation was continued over 6.5 years. At 6.5 years, assessment data were available for 854 participants (74.5%; n = 417 [intervention]; n = 437 [usual care]). In terms of sociodemographic and clinical characteristics, participants in the intervention and usual care groups were similar and participants at sites that continued were no different to participants at sites that discontinued intervention implementation. Patients in the intervention arm were more likely to exhibit sustained multiple risk factor control than usual care (relative risk: 1.79; 95% confidence interval [CI], 1.45, 2.20), p < 0.001. Cumulatively, there were 233 (40.5%) first microvascular and macrovascular events in intervention and 274 (48.0%) in usual care patients (absolute risk reduction: 7.5% [95% CI: −13.2, −1.7], p = 0.01; hazard ratio [HR] = 0.72 [95% CI: 0.61, 0.86]), p < 0.001. Patients in the intervention arm experienced lower incidence of first microvascular endpoints (HR = 0.68 [95% CI: 0.56, 0.83), p < 0.001, but there was no evidence of between-group differences in first macrovascular events. Beneficial effects on microvascular and composite vascular outcomes were observed in sites that continued, but not sites that discontinued the intervention. Conclusions: In urban South Asian clinics, a multicomponent QI strategy led to sustained multiple risk factor control and between-group differences in microvascular, but not macrovascular, endpoints. Between-group reductions in vascular outcomes at 6.5 years were observed only at sites that continued the QI intervention, suggesting that practice change needs to be maintained for better population health of people with diabetes. Trial registration: ClinicalTrials.govNCT01212328. Nikhil Tandon and colleagues explore the impact of a quality improvement strategy for patients with type 2 diabetes 6.5 years after its implementation for the CARRS randomised trial. Author summary: Why was this study done?: Data on whether improvements in diabetes care goal achievement can be sustained (>5 years) with quality improvement (QI) strategies are lacking from low- and middle-income countries (LMICs). Prior studies of QI strategies to improve care goal achievement among people with diabetes from high-income countries reported modest benefits in blood glucose, blood pressure, and lipids, but the effects of these improvements on reducing vascular complications and deaths related to diabetes are unknown. What did the researchers do and find?: In the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomised trial of 1,146 patients with type 2 diabetes attending 10 diverse diabetes clinics in India and Pakistan, the QI strategy was associated with benefits on diabetes care goals (HbA1c <7% plus systolic BP <130 mm Hg and/or LDL-cholesterol <100 mg/dl) at 2.5 years after randomization. Four clinics discontinued implementation, while 6 clinics continued to implement the QI strategy for an additional 4 years. This report assesses whether benefits were sustained and reduced vascular complications and deaths associated with diabetes at 6.5 years. Patients receiving the QI strategy, compared to those receiving usual care, experienced sustained benefits on diabetes care goals and less microvascular endpoints (eye, kidney, and nerve diseases) at 6.5 years after randomization. Total macrovascular and microvascular events were also lower in those receiving the QI strategy, and this was only observed at sites that continued implementation of the QI strategy for 6.5 years. What do these findings mean?: These findings add to our knowledge of the long-term effects of multicomponent QI strategies in sustaining multiple risk factor control and reducing combined vascular events compared to usual care in resource-limited settings. In view of these findings, clinical decision support and trained nonphysician health workers may be important QI strategies to consider integrating into India's healthcare system to improve diabetes care quality and reduce morbidity and mortality. One limitation of the study is that the tertiary care facilities included in the CARRS trial may not be generalizable across LMICs. [ABSTRACT FROM AUTHOR]

Background: Collaborative care (CC) is a multicomponent team-based approach to providing mental health care with systematic integration into outpatient medical settings. The 12-month INDEPENDENT CC intervention improved joint disease control measures in patients with both depression and diabetes at 12 and 24 months following randomization. Objective: This study investigated the durability of intervention effects on patient outcomes at 36 months following randomization. Participants: Adult patients with poorly controlled T2D and depression in India randomized to CC or usual care. Design: Post hoc analyses of between-group differences in patient outcomes at 36 months post-randomization (N = 331) and maintenance of outcomes from 12 to 36 months (N = 314). Main Measures: We evaluated combined risk factor improvement since baseline, defined as ≥ 50.0% reduction in Symptom Checklist Depression Scale (SCL-20) scores along with reduction of at least 0.5 percentage point hemoglobin A1C, 5 mmHg systolic blood pressure, or 10 mg/dL low-density lipoprotein cholesterol. Improvements in single risk factors were also examined. Key Results: There were no between-group differences in improvements since baseline in multiple or single risk factors at 36 months. Patients in the CC group with improved outcomes at 12 months were more likely to maintain a ≥ 50.0% reduction since baseline in SCL-20 scores (CC [54.9%] vs. UC [40.9%]; RR: 1.27 [95% CI: 1.04, 1.56]) and 0.5 percentage point reduction since baseline in hemoglobin A1C (CC [31.9%] vs. UC [19.5%]; RR: 1.64 [95% CI: 1.11, 2.41]) at 36 months. Conclusions: While improvements since baseline in patient outcomes did not differ between the collaborative care and usual care groups at 36 months, patients who received CC were more likely to maintain improvements in depressive symptoms and glucose levels at 36 months if they had achieved these improvements at the end of active intervention. Trial Registration Number: NCT02022111 [ABSTRACT FROM AUTHOR]

The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) study found a 35% reduction in major adverse cardiovascular events for people with human immunodeficiency virus who received daily pitavastatin. However, how this evidence will change practice is far from certain. Here, we outline evidence gaps and political and healthcare delivery challenges that will need to be addressed for REPRIEVE to offer public health benefits in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Aims: To determine whether obesity‐associated metabolites are associated with type 2 diabetes (T2DM) risk among South Asians. Materials and Methods: Serum‐based nuclear magnetic resonance imaging metabolomics data were generated from two South Asian population‐based prospective cohorts from Karachi, Pakistan: CARRS1 (N = 4017) and CARRS2 (N = 4802). Participants in both cohorts were followed up for 5 years and incident T2DM was ascertained. A nested case‐control study approach was developed to select participants from CARRS1 (Ncases = 197 and Ncontrols = 195) and CARRS2 (Ncases = 194 and Ncontrols = 200), respectively. First, we investigated the association of 224 metabolites with general obesity based on body mass index and with central obesity based on waist‐hip ratio, and then the top obesity‐associated metabolites were studied in relation to incident T2DM. Results: In a combined sample of the CARRS1 and CARRS2 cohorts, out of 224 metabolites, 12 were associated with general obesity and, of these, one was associated with incident T2DM. Fifteen out of 224 metabolites were associated with central obesity and, of these, 10 were associated with incident T2DM. The higher level of total cholesterol in high‐density lipoprotein (HDL) was associated with reduced T2DM risk (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.53, 0.86; P = 1.2 × 10−3), while higher cholesterol esters in large very‐low‐density lipoprotein (VLDL) particles were associated with increased T2DM risk (OR 1.90, 95% CI 1.40, 2.58; P = 3.5 × 10−5). Conclusion: Total cholesterol in HDL and cholesterol esters in large VLDL particles may be an important biomarker in the identification of early development of obesity‐associated T2DM risk among South Asian adults. [ABSTRACT FROM AUTHOR]

This study examines the determinants of health and mortality associated with undiagnosed diabetes among a nationally representative sample of US adults. Data are from the National Health and Nutrition Examination Survey between 2011 and 2012 and 2019–2020. Diabetes status is categorized into three groups: undiagnosed diabetes, diagnosed diabetes, and no diabetes. Multiple logistic regression is used to estimate the association between undiagnosed diabetes and three domains of risk factors, including sociodemographic and health behavioral and clinical factors. Cox proportional hazards models are performed to compare excess mortality risk between the three groups. Young adults, racial minorities, the foreign-born, and individuals with limited access to health care are more likely to be unaware of their diabetes. Moreover, adults without a family history of diabetes and chronic conditions have a higher chance of undiagnosed diabetes. No health behavioral factors are found to be associated with undiagnosed diabetes. Adults with undiagnosed diabetes have a lower risk of all-cause and cardiovascular disease mortality compared to those with diagnosed diabetes, but a higher risk of all-cause mortality than those with no diabetes. Targeted public health approaches should address sociodemographic and clinical factors to reduce the burden of undiagnosed diabetes. [ABSTRACT FROM AUTHOR]

To compare the outcomes of trans-abdominal ultrasound (TAS) guided approach and uterine sound-sparing approach (USSA) during copper intrauterine device (IUD) insertion A randomised open-label clinical trial (Clinical Trials.Gov: NCT03383432) included multiparous women requesting Copper IUD insertion for birth control were invited to participate. The eligible women were randomised into two groups (44 women in each group); group I (TAS-guided IUD insertion) and group II: USSA. The primary outcome was to measure the satisfaction score of IUD insertion in both methods. Secondary outcomes included the easiness score (ES), the difference in pain scores during IUD insertion, the duration of insertion, and the successful device placement after one week and one month evaluated by transvaginal ultrasound (TVS). Eighty-eight women were analysed in both groups. The VAS for satisfaction was significantly higher in the USSA group than the TAS-guided group (7.80 ± 1.27 vs. 5.45 ± 1.42, p =.0001). There was significantly lower VAS of pain scores during IUD insertion in the USSA group as compared with the TAS-guided IUD (p =.001). A lower ES and a significantly shorter duration of IUD insertion were also determined among the USSA group (p =.0001). USSA is associated with higher satisfaction and less pain during insertion than the TAS-guided IUD insertion approach. However, both techniques have optimal intra-uterine device positioning. [ABSTRACT FROM AUTHOR]

Objective: We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (ESKD).Research Design and Methods: This was a nationwide, retrospective study of adults (≥18 years old) with diabetes/ESKD, from the United States Renal Data System registry, between 2013 and 2017. Primary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1,000 person-years. Event rates and risk factors were adjusted for patient age, sex, race/ethnicity, dialysis modality, comorbidities, treatment regimen, and U.S. region.Results: Among 521,789 adults with diabetes/ESKD (median age 65 years [interquartile range 57-73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, respectively, the risks decreased with age and were lowest in older patients (≥75 vs. 18-44 years old: incidence rate ratio 0.35, 95% CI 0.33-0.37, and 0.03, 0.02-0.03), women (1.09, 1.06-1.12, and 1.44, 1.35-1.54), and those with smoking (1.36, 1.28-1.43, and 1.71, 1.53-1.91), substance abuse (1.27, 1.15-1.42, and 1.53, 1.23-1.9), retinopathy (1.10, 1.06-1.15, and 1.36, 1.26-1.47), and insulin therapy (vs. no therapy; 0.60, 0.59-0.63, and 0.44, 0.39-0.48). For hypoglycemia, specifically, additional risk was conferred by Black race (1.11, 1.08-1.15) and amputation history (1.20, 1.13-1.27).Conclusions: In this nationwide study of patients with diabetes/ESKD, hypoglycemic crises were threefold more common than hyperglycemic crises, greatly exceeding national reports in nondialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected. [ABSTRACT FROM AUTHOR]

Interhospital fragmentation of care, when a patient is readmitted to a different hospital than they were initially discharged from, occurs in 20-25% of readmissions[1] and is associated with poor outcomes, including 20% higher in-hospital mortality.[1]-[3] Previous studies have examined the impact of interhospital care fragmentation on specific populations, including post-operative[3] and heart failure patients.[2] Older adults, especially those who migrate seasonally,[4] may be at particular risk for fragmented readmissions. METHODS We analyzed the 2018 National Readmissions Database (NRD).[5] We included patients >= 65 years old with 30-day readmissions and excluded interhospital transfers and January admissions, as those could represent readmissions from December 2017. [Extracted from the article]

Objectives: Subclinical atherosclerotic disease is an emerging risk factor for cognitive function among older adults, though less is known about the association between abdominal aortic calcification (AAC) and cognitive function. This study aimed to examine the cross‐sectional association of AAC with cognitive function in a nationally representative sample of population in the U.S. Methods: A total of 1,209 older adults (60 years or older) in the 2013‐2014 National Health and Nutrition Examination Survey were included. AAC was obtained with dual‐energy X‐ray absorptiometry. Cognitive function was examined using the CERAD Word Learning subtest (memory), Digit Symbol Substitution Test (executive function/processing speed), and Animal Fluency Test (language). Test‐specific and global cognition z‐scores were created based on means and standard deviations of cognitive tests. Multivariable linear regression models were used to examine the associations of presence of AAC and severity of AAC with cognition z‐scores. Results: Adjusted for covariates, presence of AAC was associated with poorer global cognition (beta (β) = −0.17, 95% confidence interval (CI): −0.28, −0.06), memory (β = −0.20, 95% CI: −0.31, −0.09), and language ability (β = −0.15, 95% CI: −0.29, −0.01). More severe AAC was associated with poorer cognitive function. The associations were significant among participants <75 years. Discussion: The presence of AAC and greater severity of AAC, were associated with poorer cognitive function, particularly among older adults <75 years. Future research is expected to assess whether lowering global vascular risk can slow cognitive decline. Key points: Abdominal aortic calcification (AAC) was associated with poorer cognitive function among older adults.AAC appears to be a marker of global vascular risk that is associated with poor cognitive function and may stimulate clinicians to be attentive to risk of cognitive decline in patients with existing AAC.Future research is expected to assess whether lowering global vascular risk can slow cognitive decline. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness and safety of repeat misoprostol versus expectant management in women with first‐trimester incomplete miscarriage who have been initially treated with misoprostol. Methods: The study was an open‐labeled randomized controlled trial including women with an incomplete first‐trimester miscarriage after administration of misoprostol. The participants were randomly assigned to vaginal misoprostol or expectant management using a computer‐generated table of random numbers. The primary outcome was the number of women with a complete miscarriage at 1 week. Results: Eighty‐eight women (44 women in each group) were analyzed. The rate of complete miscarriage at 1 week was significantly higher in the misoprostol group than the expectant management group—29 (69.0%) versus 7 (16.7%) (P < 0.001), respectively. Women in the misoprostol group were more satisfied (7.00 ± 0.77 vs 4.57 ± 1.61, P < 0.001) but reported more pain (7.95 ± 1.85 vs 5.26 ± 1.08, P < 0.001) than women in the expectant group. The misoprostol group reported more adverse effects than the expectant management group (P < 0.001). Conclusion: In women with an incomplete first‐trimester miscarriage who were initially treated with misoprostol, repeat administration of misoprostol was more effective than expectant management for achieving complete miscarriage at 1 week. However, misoprostol was associated with more adverse effects. Registration site and number: Clinicaltrials.gov: NCT03148561. Synopsis: Misoprostol treatment is more effective than expectant management in achieving complete miscarriage for women with an incomplete first‐trimester miscarriage initially treated by misoprostol. [ABSTRACT FROM AUTHOR]

Introduction: The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined.Methods: A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008-2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18-64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020.Results: In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= -16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment.Conclusions: Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures. [ABSTRACT FROM AUTHOR]

Background Diabetes is the leading cause of lower extremity nontraumatic amputation globally, and diabetic foot osteomyelitis (DFO) is usually the terminal event before limb loss. Although guidelines recommend percutaneous bone biopsy (PBB) for microbiological diagnosis of DFO in several common scenarios, it is unclear how frequently PBBs yield positive cultures and whether they cause harm or improve outcomes. Methods We searched the PubMed, EMBASE, and Cochrane Trials databases for articles in any language published up to December 31, 2019, reporting the frequency of culture-positive PBBs. We calculated the pooled proportion of culture-positive PBBs using a random-effects meta-analysis model and reported on PBB-related adverse events, DFO outcomes, and antibiotic adjustment based on PBB culture results where available. Results Among 861 articles, 11 studies met inclusion criteria and included 780 patients with 837 PBBs. Mean age ranged between 56.6 and 71.0 years old. The proportion of males ranged from 62% to 86%. All studies were longitudinal observational cohorts, and 10 were from Europe. The range of culture-positive PBBs was 56%–99%, and the pooled proportion of PBBs with a positive culture was 84% (95% confidence interval, 73%–91%). There was heterogeneity between studies and no consistency in definitions used to define adverse events. Impact of PBB on DFO outcomes or antibiotic management were seldom reported. Conclusions This meta-analysis suggests PBBs have a high yield of culture-positive results. However, this is an understudied topic, especially in low- and middle-income countries, and the current literature provides very limited data regarding procedure safety and impact on clinical outcomes or antibiotic management. [ABSTRACT FROM AUTHOR]

Importance: Mental health comorbidities are increasing worldwide and worsen outcomes for people with diabetes, especially when care is fragmented.Objective: To assess whether collaborative care vs usual care lowers depressive symptoms and improves cardiometabolic indices among adults with diabetes and depression.Design, Setting, and Participants: Parallel, open-label, pragmatic randomized clinical trial conducted at 4 socioeconomically diverse clinics in India that recruited patients with type 2 diabetes; a Patient Health Questionnaire-9 score of at least 10 (range, 0-27); and hemoglobin A1c (HbA1c) of at least 8%, systolic blood pressure (SBP) of at least 140 mm Hg, or low-density lipoprotein (LDL) cholesterol of at least 130 mg/dL. The first patient was enrolled on March 9, 2015, and the last was enrolled on May 31, 2016; the final follow-up visit was July 14, 2018.Interventions: Patients randomized to the intervention group (n = 196) received 12 months of self-management support from nonphysician care coordinators, decision support electronic health records facilitating physician treatment adjustments, and specialist case reviews; they were followed up for an additional 12 months without intervention. Patients in the control group (n = 208) received usual care over 24 months.Main Outcomes and Measures: The primary outcome was the between-group difference in the percentage of patients at 24 months who had at least a 50% reduction in Symptom Checklist Depression Scale (SCL-20) scores (range, 0-4; higher scores indicate worse symptoms) and a reduction of at least 0.5 percentage points in HbA1c, 5 mm Hg in SBP, or 10 mg/dL in LDL cholesterol. Prespecified secondary outcomes were percentage of patients at 12 and 24 months who met treatment targets (HbA1c <7.0%, SBP <130 mm Hg, LDL cholesterol <100 mg/dL [<70 mg/dL if prior cardiovascular disease]) or had improvements in individual outcomes (≥50% reduction in SCL-20 score, ≥0.5-percentage point reduction in HbA1c, ≥5-mm Hg reduction in SBP, ≥10-mg/dL reduction in LDL cholesterol); percentage of patients who met all HbA1c, SBP, and LDL cholesterol targets; and mean reductions in SCL-20 score, Patient Health Questionnaire-9 score, HbA1c, SBP, and LDL cholesterol.Results: Among 404 patients randomized (mean [SD] age, 53 [8.6] years; 165 [40.8%] men), 378 (93.5%) completed the trial. A significantly greater percentage of patients in the intervention group vs the usual care group met the primary outcome (71.6% vs 57.4%; risk difference, 16.9% [95% CI, 8.5%-25.2%]). Of 16 prespecified secondary outcomes, there were no statistically significant between-group differences in improvements in 10 outcomes at 12 months and in 13 outcomes at 24 months. Serious adverse events in the intervention and usual care groups included cardiovascular events or hospitalizations (4 [2.0%] vs 7 [3.4%]), stroke (0 vs 3 [1.4%]), death (2 [1.0%] vs 7 [3.4%]), and severe hypoglycemia (8 [4.1%] vs 0).Conclusions and Relevance: Among patients with diabetes and depression in India, a 12-month collaborative care intervention, compared with usual care, resulted in statistically significant improvements in a composite measure of depressive symptoms and cardiometabolic indices at 24 months. Further research is needed to understand the generalizability of the findings to other low- and middle-income health care settings.Trial Registration: ClinicalTrials.gov Identifier: NCT02022111. [ABSTRACT FROM AUTHOR]

We tested the hypothesis that 17α-hydroxyprogesterone caproate (17α-OHP-C) may decrease preterm delivery (PTD) in women with placenta praevia. This was a randomised controlled trial included 114 women with placenta praevia (between 24 and 28 weeks). They were randomly assigned to group I (17α-OHP-C) who received weekly injection of 17α-OHP-C (250 mg/IM) till completing 37 weeks' gestation or group II (Non 17α-OHP-C). The percentage of placenta praevia patients went into PTD in the 17α-OHP-C group was significantly less in comparison to the PTD in the Non 17α-OHP-C group (∼37% vs. 63.5%, p = .004). Furthermore, the mean gestational age was significantly longer (36.7 ± 0.7 vs. 34.9 ± 1.2 weeks, p < .000), the mean number of bleeding attacks was significantly less and the mean birth weight was significantly higher (2841 ± 159 vs. 2561 ± 168 g, p < .000). In conclusion, maintenance tocolysis with intramuscular 17α-OHP-C in placenta praevia women appears beneficial in decreasing the number of bleeding attacks, the percentage of PTD and the neonatal ICU admission.IMPACT STATEMENTWhat is already known on this subject? Over the last two decades, a large number of studies indicated that placenta praevia is a major risk factor for preterm labour and prematurity with its neonatal complications. Increasing caesarean section rates had proportionally increased the incidence of placenta praevia.What do the results of this study add? Up to now, the effective and safe tocolytic agent among these patients is not established. The results of this study (prospective, randomised and controlled with calculated sample size) added a considerable support for hydroxyprogesterone caproate as an effective, safe and cheap tocolytic agent with excellent patient compliance.What are the implications of these findings for clinical practice and/or further research? Our findings may prompt researchers to conduct a large multicentre study to evaluate the prophylactic use of hydroxyprogesterone caproate to decrease preterm labour due to placenta praevia. [ABSTRACT FROM AUTHOR]

Objective: To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities.Research Design and Methods: We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars.Results: Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care.Conclusions: Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of adjunctive use of vaginal progesterone after McDonald cerclage on the rate of second-trimester abortion in singleton pregnancy.Methods: A randomized controlled trial at Woman's Health Hospital, Assiut University, Egypt, between April 2017 and March 2019 enrolled women eligible for McDonald cerclage. After cerclage, participants were randomly assigned to receive progesterone (400 mg pessary) once daily until 37 weeks or no progesterone. The primary outcome was rate of abortion before 28 weeks. Secondary outcomes included gestational age at delivery, preterm delivery, mean birthweight, Apgar score, and admission to the neonatal intensive care unit (NICU).Results: The rate of spontaneous abortion was higher in the no-progesterone group (P=0.016). Mean gestational age and mean birthweight was higher in the progesterone group (P<0.001 and P=0.002, respectively). The frequency of preterm neonates, neonates with Apgar score less than 7, and admission to NICU was higher in the progesterone group than in the no-progesterone group (P=0.005, P=0.008, and P=0.044, respectively).Conclusion: Adjunctive use of vaginal progesterone after McDonald cerclage was found to decrease the frequency of second-trimester abortion and to improve perinatal outcomes in singleton pregnancy. Clinicaltrials.gov: NCT02846909. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of prophylactic bilateral uterine artery ligation (BUAL) in reducing the incidence of postpartum hemorrhage (PPH) during cesarean delivery among women at risk of uterine atony.Methods: A randomized clinical trial at Cairo University Maternity Hospital, Egypt, from December 2017 to December 2018. Women at risk of uterine atony undergoing scheduled or emergency cesarean were randomized to two groups. In the BUAL group, women underwent BUAL before placental delivery; in the control group, women had cesarean delivery without BUAL. The primary outcome was the estimated blood loss during cesarean.Results: Intraoperative blood loss during cesarean was significantly lower in the BUAL group than in the control group (523.4 ± 41.0 vs 619.6 ± 36.1 mL; P=0.003). Blood loss in the first 6 hours after cesarean was also significantly lower in the BUAL group than in the control group (246.1 ± 21.4 vs 326.1 ± 18.5 mL; P=0.006). There was no difference in operative time between the two groups (52.1 ± 6.1 vs 52.2 ± 6.8, P=0.880).Conclusion: BUAL during cesarean was found to be an effective method for decreasing blood loss during and after cesarean delivery among women at risk of uterine atony and subsequent PPH. CLINICALTRIALS.GOV: NCT03591679. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the traction placed on a transcervical Foley catheter balloon inserted for the induction of mid-trimester missed abortion results in faster time of abortion.Study design: It was randomized clinical trial conducted at Assiut Woman's Health Hospital, Egypt, from September 2016 to August 2017 on women with missed abortion in the mid-trimester. Participants were randomly assigned to transcervical Foley catheter balloon insertion with or without traction. The primary outcome of this study was insertion to abortion time. The secondary outcomes included insertion to catheter expulsion time, vaginal bleeding, and pain associated with insertion. The outcome variables were analyzed using Mann-Whitney U and chi-square tests. A logistic regression model was utilized to examine the association between patient's characteristics and the failure of Foley catheter balloon expulsion within 24 hours.Results: Two hundred women were recruited (100 women in each group). The insertion to abortion time was significantly shorter in group I (traction group) than group II (no traction group) (16.49 ± 2.59 versus 18.24 ± 3.30 hours; p = .000). Insertion to balloon expulsion time in group I was also significantly short (7.92 ± 0.86 versus 9.12 ± 1.19 hours; p = .000). However, a significantly higher rate of vaginal bleeding and a higher degree of pain were reported by the women in group I (p = .008, p = .000; respectively). The nulliparity, longer interpregnancy interval (>22 months), smaller gestational age (<14 weeks) and lower Bishop Score before insertion (<2) were significantly associated with a higher likelihood of Foley catheter balloon expulsion failure within 24 hours.Conclusion: The small time advantage of traction does not compensate for the downsides of traction, mainly pain, analgesic use, and vaginal bleeding. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of aspirin on fetal weight in fetuses with idiopathic asymmetrical intrauterine growth restriction (IUGR) complicated by abnormal umbilical artery Doppler indices.Materials and Methods: The study was a randomized controlled trial conducted at Woman's Health Hospital, Assiut, Egypt, between June 2016 and the January 2017 included 60 pregnant women (28-30 weeks) with idiopathic asymmetrical IUGR associated with abnormal umbilical artery Doppler indices. Women were randomly assigned to group I (aspirin 75 mg) daily for four weeks or group II (no intervention). The primary outcome was the fetal weight after four weeks. Secondary outcomes included Doppler blood flow changes in the umbilical artery plus delivery and neonatal outcomes.Results: The estimated fetal weight and umbilical artery blood flow increased significantly in aspirin group (p = .00) when compared with no intervention group. As regard neonatal outcomes; aspirin group showed better results and encouraging outcomes (p < .05).Conclusions: Aspirin improves fetal weight and umbilical artery blood flow in idiopathic asymmetrical IUGR fetuses complicated by abnormal umbilical artery Doppler blood flow. [ABSTRACT FROM AUTHOR]

Objective: The current study compares the efficacy of the classic approach and the uterine sounding sparing approach (a new approach) for copper intrauterine device (Cu-IUD) insertion. Study design: A randomized clinical trial. Setting: Woman's Health Hospital, Assiut, Egypt. Materials and methods: The current study was an open parallel randomized clinical study conducted in Assiut Woman's Health Hospital, Egypt included women requesting Copper IUD insertion. Enrolled women were randomized into 2 groups; group I included women subjected to classic approach for Cu-IUD insertion and group II included women had Cu-IUD insertion using the uterine sound-sparing approach (USSA). This approach utilized transvaginal ultrasound (TV/US) for assessment of the uterine cavity length and position before IUD insertion without using uterine sounding. The primary outcome was the successful Cu-IUD insertion. Results: 46 women were analyzed in group I and 46 in group II. The pain during IUD insertion and 5 min post-insertion was significantly lower in group II than group I (p < .001). The Cu-IUD inserted easier in group I than group II (p < .001). Moreover; significant shorter duration of insertion was reported in group II (p = .002). More satisfied women were found in group II (p = .0001). At the 4 weeks follow-up; TV/US showed that all IUDs were in place in all women. Conclusions: Cu-IUD can be inserted successfully without using uterine sound provided using TV/US prior to insertion. This method associated with less pain, greater women satisfaction during insertion with shorter duration. [ABSTRACT FROM AUTHOR]

Background and Objectives: To determine how frequently diabetic diets are recommended to individuals with diabetes in South Asia, whether they are followed, and if they are associated with healthier dietary choices and clinical benefits.Methods and Study Design: Data are from the Centre for cArdiometabolic Risk Reduction in South-Asia Cohort Study. Participants with self-reported physician-diagnosed diabetes (n=1849) were divided into four groups based on whether they reported being prescribed and/or were following a diabetic diet. Linear regression was used to estimate associations between these groups and outcomes.Results: 53% of participants with self-reported diabetes reported not being prescribed or following a diabetic diet. Among those prescribed and following a diet, mean whole grain consumption was 1.18 times/day and refined grain consumption was 0.75 times/day compared to 0.88 times/day and 1.74 times/day, respectively, among those neither prescribed nor following a diet (both p<0.0001). Following a diet despite not being prescribed a diet was not associated with glycemic control, blood pressure, or body mass index, but was associated with a -8.54 mg/dL (95% confidence interval: -15.5, -1.58) lower low-density lipoprotein cholesterol compared to not following and not being prescribed a diet after adjustment for confounders.Conclusion: Though participants who were prescribed diabetic diets and followed them exhibited healthier dietary choices, the majority of participants with diabetes in urban South Asia was neither prescribed nor followed such diets. Moreover, there was no statistically significant clinical benefit, thus indicating that current dietary modifications may not be large enough or consistent enough to produce meaningful changes in health outcomes in this population. [ABSTRACT FROM AUTHOR]

Objective: The study aims to assess the efficacy of single versus double-daily oral iron dose on prevention of iron deficiency anemia in women with twin gestations.Materials and Methods: A randomized controlled trial (NCT02858505) conducted at Woman's Health Hospital, Assiut, Egypt, between August 2015 and June 2016 included 120 non-anemic pregnant women with twin gestations in the first trimester. Women were randomly assigned to either group I (27 mg elemental iron) or group II (54 mg elemental iron) daily starting from 12 weeks of pregnancy till 36 weeks. The primary outcomes included the mean level of hemoglobin, hematocrit and serum ferritin at 36 weeks' gestation.Results: Both iron doses maintained the mean hemoglobin and hematocrit within the normal level from 12 weeks to 36 weeks (p = 0.378 and p = 0.244, respectively). However, the mean serum ferritin level was higher in group II than group I (p = 0.000) at 36 weeks' gestation. Moreover, women in group II reported more side effects than group I at 36 weeks' gestation.Conclusions: Doubling the prophylactic iron dose is comparable to single dose in the prevention of iron deficiency anemia among women with twin gestations with more side effects. [ABSTRACT FROM AUTHOR]

National surveillance data show a sustained decline in the incidence rate of diagnosed diabetes, which has been heralded as a success in the battle against diabetes in the U.S. In this Perspective, we take a closer look at these data and provide additional insights to help interpret these trends. We examine multiple sources of data on the prevalence and incidence of diabetes in the U.S. as well as data on trends in diabetes risk factors to provide context for these national surveillance findings. Although some of the incidence decline may represent real progress against diabetes, it is likely that there are also nonbiological factors at play, especially changes in diagnostic criteria for diabetes. We present and discuss data that suggest improved detection and changes in screening and diagnostic practices may have resulted in the depletion of the "susceptible population." Providing this context for the recent declines in new diabetes diagnoses observed in national data is critical to help avoid misinterpretation. We argue that it is premature to declare victory against the epidemic of diabetes in the U.S. and discuss how we might better focus current public health efforts, including a specific emphasis to address prediabetes. [ABSTRACT FROM AUTHOR]

Recent USPSTF and ADA guidelines expanded criteria of whom to test to identify prediabetes and diabetes. We described which Americans are eligible and report receiving glucose testing by USPSTF 2015 and 2021 as well as ADA 2003 and 2022 recommendations, and performance of each guideline. We analyzed cross-sectional data from 6,007 non-pregnant U.S. adults without diagnosed diabetes in the 2013–2018 National Health and Nutrition Examination Surveys. We reported proportions of adults who met each guideline's criteria for glucose testing and reported receiving glucose testing in the past three years, overall and by key population subgroups,. Defining prediabetes (FPG 100–125 mg/dL and/or HbA1c 5.7–6.4 %) or previously undiagnosed diabetes (FPG ≥ 126 mg/dL and/or HbA1c ≥ 6.5 %), we assessed sensitivity and specificity. During 2013–2018, 76.7 million, 90.4 million, 157.7 million, and 169.5 million US adults met eligibility for glucose testing by USPSTF 2015, 2021, and ADA 2003 and 2022 guidelines, respectively. On average, 52 % of adults reported receiving glucose testing within the past 3 years. Likelihood of receiving glucose testing was lower among younger adults, men, Hispanic adults, those with less than high school completion, those living in poverty, and those without health insurance or a usual place of care than their respective counterparts. ADA recommendations were most sensitive (range: 91.0 % to 100.0 %) and least specific (range: 18.3 % to 35.3 %); USPSTF recommendations exhibited lower sensitivity (51.9 % to 66.6 %), but higher specificity (56.6 % to 74.5 %). An additional 12–14 million US adults are eligible for diabetes screening. USPSTF 2021 criteria provide balanced sensitivity and specificity while ADA 2022 criteria maximize sensitivity. Glucose testing does not align with guidelines and disparities remain. [ABSTRACT FROM AUTHOR]

Introduction: There is a dearth of data on common multimorbidity clusters and the healthcare costs for individuals with mental health disorders. This study aimed to identify clinically meaningful physical-mental multimorbidity clusters, frequently occurring clusters of conditions, and healthcare utilization patterns and expenditure among patients attending a psychiatric outpatient clinic. Materials and Methods: Data were collected in the psychiatric outpatient department among patients aged 18 years and above in February-July 2019 (n = 500); follow-up data on non-communicable disease incidence were collected after 18 months. For analysis, morbidity clusters were defined using two approaches: 1) agglomerative hierarchical clustering method to identify clusters of diseases; and 2) non-hierarchical cluster k mean analysis to identify clusters of patients. Self-reported healthcare costs in these clusters were also calculated. Result: Two disease clusters were identified: using the 1st approach were; 1) hypertension, diabetes, and mood disorder; 2) Neurotic, stress-related, and somatoform disorders, and acid peptic disease. Three clusters of patients identified using the 2nd approach were identified: 1) those with mood disorders and cardiometabolic, musculoskeletal, and thyroid diseases; 2) those with neurotic, substance use, and organic mental disorders, cancer, and epilepsy; and 3) those with Schizophrenia. Patients in Cluster 1 were taking more than six medicines and had more hospital visits. Within 18 months, 41 participants developed either one or two chronic conditions, most commonly diabetes, hypertension, or thyroid disease. Conclusion: Cardiometabolic diseases are most commonly clustered with mood disorders. There is a need for blood pressure and sugar measurement in psychiatric clinics and mood disorder screening in cardiac, endocrinology, and primary care clinics. [ABSTRACT FROM AUTHOR]

Background: Community consultation (CC) is required for research in emergency settings using an exception from informed consent (EFIC) in the United States, but uncertainty persists regarding best CC practices. There is ongoing debate about whom to include in CC, specifically, whether to prioritize geographically defined communities or individuals with connections to the condition. Understanding the impact of personal disease experience on views of EFIC research is important for designing CC and interpreting its results.Methods: This study was a secondary analysis of surveys administered to 2612 participants at 12 sites in CC events conducted for ProTECT III: Progesterone for Traumatic Brain Injury, a Phase III, randomized trial conducted using EFIC. Key survey domains included personal traumatic brain injury (TBI) experience, demographic information, and acceptance of both hypothetical personal enrollment under EFIC and the use of EFIC in general in ProTECT III. Descriptive statistics and multivariable regression models were used to explore relationships between key domains.Results: TBI patients, those with family members/loved ones with TBI, and those who knew someone else with TBI were slightly more accepting of hypothetical personal enrollment under EFIC (adjusted odds ratio [OR] 1.14 [0.78–1.67], 1.54 [1.17–2.02], and 1.51 [1.19–1.92], respectively) and use of EFIC in general (adjusted OR 1.17 [0.83–1.64], 1.39 [1.08–1.77], and 1.06 [0.86–1.31], respectively) than those without this. In a subgroup analysis based on race, white participants with any disease experience had higher levels of acceptance of EFIC, as expected. However, there was numerically lower acceptance of personal and general EFIC enrollment among black participants with closer TBI connections.Conclusions: Personal TBI experience was associated with increased acceptance of EFIC research for that condition, except among black participants. Heterogeneity of the effect of personal disease experience on EFIC views further supports inclusion of individuals with relevant disease experience in CC and highlights the importance of engaging minority participants. [ABSTRACT FROM PUBLISHER]

Objective: To test the effect of aspirin and omega 3 on fetal weight as well as feto-maternal blood flow in asymmetrical intrauterine growth restriction (IUGR).Study Design: This study is a clinically registered (NCT02696577), open, parallel, randomized controlled trial, conducted at Assiut Woman's Health Hospital, Egypt including 80 pregnant women (28-30 weeks) with IUGR. They were randomized either to group I: aspirin or group II: aspirin plus omega 3. The primary outcome was the fetal weight after 6 weeks of treatment. Secondary outcomes included Doppler blood flow changes in both uterine and umbilical arteries, birth weight, time and method of delivery and admission to NICU. The outcome variables were analyzed using paired and unpaired t-test.Results: The estimated fetal weight increased significant in group II more than group I (p=0.00). The uterine and umbilical arteries blood flow increased significantly in group II (p<0.05). The birth weight in group II was higher than that observed in group I (p<0.05).Conclusion: The using of aspirin with omega 3 is more effective than using aspirin only in increasing fetal weight and improving utero-placental blood flow in IUGR. [ABSTRACT FROM AUTHOR]

We examined factors responsible for variation in cardiovascular disease (CVD) mortality across US counties in 2009-2013. We linked county-level census, survey, administrative, and vital statistics data to examine 4 sets of features: demographic factors, social and economic factors, health-care utilization and features of the environment, and population health indicators. County-level associations of these features (standardized to a mean of 0 with a standard deviation of 1) with cardiovascular deaths per 100,000 person-years among adults aged 45-74 years was modeled using 2-level hierarchical linear regression with random intercept for state. The percentage of CVD mortality variation (intercounty disparity) modeled by each set of features was quantified. Demographic composition accounted for 36% of county CVD mortality variation, and another 32% was explained after inclusion of economic/social conditions. Health-care utilization, features of the environment, and health indicators explained an additional 6% of CVD mortality variation. The largest contributors to CVD mortality levels were median income (-23.61 deaths/100,000 person-years, 95% CI: -26.95, -20.26) and percentage without a high school education (20.71 deaths/100,000 person-years, 95% CI: 16.48, 24.94). In comparison, the largest health-related contributors were health-care utilization (19.35 deaths/100,000 person-years, 95% CI: 16.36, 22.34) and CVD risk factors (4.80 deaths/100,000 person-years, 95% CI: 2.14, 7.46). Improving healthcare access and decreasing the prevalence of traditional CVD risk factors may reduce county CVD mortality levels, but improving socioeconomic circumstances of disadvantaged counties will be required in order to reduce CVD mortality disparities across counties. [ABSTRACT FROM AUTHOR]

Background: Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia.Objective: To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes.Design: Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328).Setting: Diabetes clinics in India and Pakistan.Patients: 1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level ≥8% plus systolic blood pressure [BP] ≥140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level ≥130 mg/dL).Intervention: Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records.Measurements: Proportions achieving HbA1c level less than 7% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes).Results: Baseline characteristics were similar between groups. Median diabetes duration was 7.0 years; 6.8% and 39.4% of participants had preexisting cardiovascular and microvascular disease, respectively; mean HbA1c level was 9.9%; mean BP was 143.3/81.7 mm Hg; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2% vs. 8.1%; relative risk, 2.24 [95% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (-0.50% [CI, -0.69% to -0.32%]), systolic BP (-4.04 mm Hg [CI, -5.85 to -2.22 mm Hg]), diastolic BP (-2.03 mm Hg [CI, -3.00 to -1.05 mm Hg]), and LDLc level (-7.86 mg/dL [CI, -10.90 to -4.81 mg/dL]) and reported higher HRQL and treatment satisfaction.Limitation: Findings were confined to urban specialist diabetes clinics.Conclusion: Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics.Primary Funding Source: National Heart, Lung, and Blood Institute and UnitedHealth Group. [ABSTRACT FROM AUTHOR]

Mohammed Ali and Venkat Narayan describe the challenge of implementing evidence-based interventions for prevention for the large number of people at increased risk of type 2 diabetes. [ABSTRACT FROM AUTHOR]

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA 1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA 1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes. [ABSTRACT FROM AUTHOR]

Purpose: Intra-articular steroid injection is commonly given for the non-operative management of foot and ankle arthritis; however, there is little evidence in the literature about the effectiveness of these injections. The aim of our study was to assess the effectiveness of injections given for the treatment of foot and ankle arthritis. Methods: We retrospectively reviewed the prospectively collected data of 64 foot and ankle injections done over a period of 12 months. 0.5% Chirocaine and 40 mg of Kenalog was used for the injection. A visual analogue score was used to determine the efficacy of the injection. Results: The mean follow up was 12 months. 84% (54/64) patients had significant pain relief following the foot and ankle injection. 16% (10/64) went on to have further procedures at six months. There were 6 patients with ankle arthritis in whom the injection effect did not last more than six months. Two had arthroscopic debridement, two had fusion and of the remaining two patients, one was not fit for surgery and the last one declined surgical intervention. Additionally at six months there were two patients with midfoot OA and two with hindfoot OA, who required further procedures. Patients with no remaining symptoms were either discharged or given an open appointment. Conclusions: Our study has shown that patients receiving an intra-articular steroid injection for forefoot conditions have positive outcomes following the injection for six months. Whereas 22% of patients having an intra-articular steroid injection for the ankle, hindfoot and midfoot arthritis have failed to maintain the symptom relief at six months and required further intervention.. This information is useful when obtaining an informed consent from the patient receiving an intra-articular injection for foot and ankle conditions. [ABSTRACT FROM AUTHOR]

Background: Diabetes is an important contributor to global morbidity and mortality. The contributions of population aging and macroeconomic changes to the growth in diabetes prevalence over the past 20 years are unclear. Methods: We used cross-sectional data on age- and sex-specific counts of people with diabetes by country, national population estimates, and country-specific macroeconomic variables for the years 1990, 2000, and 2008. Decomposition analysis was performed to quantify the contribution of population aging to the change in global diabetes prevalence between 1990 and 2008. Next, age-standardization was used to estimate the contribution of age composition to differences in diabetes prevalence between high-income (HIC) and low-to-middle-income countries (LMICs). Finally, we used non-parametric correlation and multivariate first-difference regression estimates to examine the relationship between macroeconomic changes and the change in diabetes prevalence between 1990 and 2008. Results: Globally, diabetes prevalence grew by two percentage points between 1990 (7.4 %) and 2008 (9.4 %). Population aging was responsible for 19 % of the growth, with 81 % attributable to increases in the age-specific prevalences. In both LMICs and HICs, about half the growth in age-specific prevalences was from increasing levels of diabetes between ages 45-65 (51 % in HICs and 46 % in LMICs). After age-standardization, the difference in the prevalence of diabetes between LMICs and HICs was larger (1.9 % point difference in 1990; 1.5 % point difference in 2008). We found no evidence that macroeconomic changes were associated with the growth in diabetes prevalence. Conclusions: Population aging explains a minority of the recent growth in global diabetes prevalence. The increase in global diabetes between 1990 and 2008 was primarily due to an increase in the prevalence of diabetes at ages 45-65. We do not find evidence that basic indicators of economic growth, development, globalization, or urbanization were related to rising levels of diabetes between 1990 and 2008. [ABSTRACT FROM AUTHOR]

The article discusses the conference related to noncommunicable diseases (NCD), which was held in September 2014. It mentions the initiatives taken by the global health industry to narrow down the gap between research work concerning communicable and non-communicable diseases. It reflects on the funding source for clinical research and public health research, and encourages exchange of health innovation between the U.S. health industry and the global health industry. [ABSTRACT FROM AUTHOR]

Introduction: This study compares the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a low-dose combined oral contraceptive (COC) in reducing adenomyosis-related pain and bleeding.Materials and Methods: A randomized clinical trial included 62 participants complaining of pain and bleeding that was associated with adenomyosis. Participants were randomly assigned to either LNG-IUS or COC treatment. The outcomes included the improvement of pain using a visual analogue scale, menstrual blood loss using a menstrual diary and estimated uterine volume by ultrasound for 6 months of treatment. We also compared uterine arteries and intramyometrial Doppler indices before and 6 months after treatment with both LNG-IUS and COCs.Results: Both treatments significantly reduced pain after 6 months of use; however, the reduction was greater in the LNG-IUS group (from 6.23±0.67 to 1.68±1.25) compared with the COCs group (from 6.55±0.68 to 3.90±0.54). Both treatment arms significantly decreased the number of bleeding days, uterine volume and Doppler blood flow in the uterus from before to after treatment. These effects were more significant in the LNG-IUS arm compared with the COC arm.Conclusion: Both LNG-IUS and COCs decreased the pain and menstrual bleeding that is associated with adenomyosis. However, LNG-IUS is more effective than the COCs in reducing pain and menstrual blood loss. This effect may be secondary to the decrease in uterine volume and the increase in blood flow resistance. [ABSTRACT FROM AUTHOR]

Noncommunicable diseases are the leading health concerns of the modern era, accounting for two-thirds of global deaths, half of all disability, and rapidly growing costs. To provide a contemporary overview of the burdens caused by noncommunicable diseases, we compiled mortality data reported by authorities in forty-nine countries for atherosclerotic cardiovascular diseases; diabetes; chronic respiratory diseases; and lung, colon, breast, cervical, liver, and stomach cancers. From 1980 to 2012, on average across all countries, mortality for cardiovascular disease, stomach cancer, and cervical cancer declined, while mortality for diabetes, liver cancer, and female chronic respiratory disease and lung cancer increased. In contrast to the relatively steep cardiovascular and cancer mortality declines observed in high-income countries, mortality for cardiovascular disease and chronic respiratory disease was flat in most low- and middle-income countries, which also experienced increasing breast and colon cancer mortality. These divergent mortality patterns likely reflect differences in timing and magnitude of risk exposures, health care, and policies to counteract the diseases. Improving both the coverage and the accuracy of mortality documentation in populous low- and middle-income countries is a priority, as is the need to rigorously evaluate societal-level interventions. Furthermore, given the complex, chronic, and progressive nature of noncommunicable diseases, policies and programs to prevent and control them need to be multifaceted and long-term, as returns on investment accrue with time. [ABSTRACT FROM AUTHOR]

Aim To investigate insulin sensitivity and insulin secretion patterns among Asian Indian youth without and with type 2 diabetes (T2DM-y defined as onset of diabetes at or below 25years) with normal and high visceral fat (VF) levels. Methods We recruited 74 T2DM-y individuals, within 18 months of diagnosis and compared them to 77 age-matched controls with normal glucose tolerance (NGT). Using L4/L5 abdominal CT images, VF levels were categorized as normal or high according to their median values. Oral glucose tolerance tests (glucose and insulin measures) were used to derive Matsuda index, insulin resistance (HOMA-IR) and oral disposition index (DIo). Relationships between measures of insulin sensitivity and secretion and T2DM-y by VF level were assessed using standardized multinomial regression models. Results Participants were categorized into four groups: NGT-normal VF; NGT-high VF; T2DM-normal VF, and T2DM-high VF. Among NGTs, those with high VF had significantly lower insulin sensitivity (0.013 vs.0.019 pM −1 ) and Matsuda index (10.2 vs.13.8), than normal VF. When compared, T2DM-high VF had lowest insulin sensitivity (0.009 vs.0.019, 0.013, 0.012 pM-1; p < 0.001), Matsuda index (6.4 vs. 13.8, 10.2, 8.6; p < 0.001), OGIS 120 (305 vs. 396, 382, 316; p < 0.001) and DIo (0.48 vs. 3.75, 3.20, 0.55 mmol/L; p < 0.001). At every category of 2 h PG values, NGT-high VF had lower DIo than NGT-normal VF participants. In standardized multinomial models, that included DIo and Matsuda index adjusted for age, gender, BMI, and leptin, DIo (Odds ratio: 0.001; 95%Confidence interval: 0.000–0.020), matsuda index (0.26; 0.07–0.93), age (2.92; 1.18–7.19) and leptin (3.17; 1.12–8.99) were associated with high VF among T2DM. Conclusion Lower DIo and Matsuda index, younger age and higher leptin were independently associated with high visceral fat among T2DM participants. Also, lower DIo was seen with increasing 2 h PG values even among normal glucose tolerant individuals. [ABSTRACT FROM AUTHOR]

Background: Screening guidelines are used to help identify prediabetes and diabetes before implementing evidence-based prevention and treatment interventions. We examined screening practices benchmarking against two US guidelines, and the capacity of each guideline to identify dysglycemia. Methods: Using 2007–2012 National Health and Nutrition Examination Surveys, we analyzed nationally-representative, cross-sectional data from 5,813 fasting non-pregnant adults aged ≥20 years without self-reported diabetes. We examined proportions of adults eligible for diagnostic glucose testing and those who self-reported receiving testing in the past three years, as recommended by the American Diabetes Association (ADA) and the US Preventive Services Task Force (USPSTF-2008) guidelines. For each screening guideline, we also assessed sensitivity, specificity, and positive (PPV) and negative predictive values in identifying dysglycemia (defined as fasting plasma glucose ≥100 mg/dl or hemoglobin A1c ≥5.7%). Results: In 2007–2012, 73.0% and 23.7% of US adults without diagnosed diabetes met ADA and USPSTF-2008 criteria for screening, respectively; and 91.5% had at least one major risk factor for diabetes. Of those ADA- or USPSTF-eligible adults, about 51% reported being tested within the past three years. Eligible individuals not tested were more likely to be lower educated, poorer, uninsured, or have no usual place of care compared to tested eligible adults. Among adults with ≥1 major risk factor, 45.7% reported being tested, and dysglycemia yields (i.e., PPV) ranged from 45.8% (high-risk ethnicity) to 72.6% (self-reported prediabetes). ADA criteria and having any risk factor were more sensitive than the USPSTF-2008 guideline (88.8–97.7% vs. 31.0%) but less specific (13.5–39.7% vs. 82.1%) in recommending glucose testing, resulting in lower PPVs (47.7–54.4% vs. 58.4%). Conclusion: Diverging recommendations and variable performance of different guidelines may be impeding national diabetes prevention and treatment efforts. Efforts to align screening recommendations may result in earlier identification of adults at high risk for prediabetes and diabetes. [ABSTRACT FROM AUTHOR]

Achieving social and economic growth requires collaboration, especially in global health. If universities are to improve health globally, they will need to train students and to support faculty who can effectively collaborate with those from other disciplines and cultures. [ABSTRACT FROM AUTHOR]

Background: A "cascade-of-care" concept helped to address im plementation gaps in HIV care. Objective: To develop a similar cascade for U.S. diabetes care to visualize gaps in awareness of diagnosis, engagement, and treatment. Design: Nationally representative cross-sectional surveys. Setting: 20 07 to 2012 NHANES (National Health and Nutrition Examination Surveys). Participants: Nonpregnant civilians aged 18 years or older. Measurements: Standardized data collection and laboratory procedures. Diabetes care was benchmarked against recent diabetes and cardiovascular risk reduction guidelines. Results: In 2012, an estimated 28.4 million (1 1 .8% ) U.S. adults had diabetes, of whom 20.5 million (7 2 .2% ) were aware of their diagnosis. Among diagnosed adults, 9 5 .3% had a usual care provider and 91 .7% made 2 or more visits in the past year. In contrast, among undiagnosed adults, 84 .5% had a usual care provider and 66 .5% reported 2 or more visits in the past year. Am ong diagnosed adults, 63 .7% , 6 5 .5% , 5 6 .6% , and 80 .6% met individualized hemoglobin A1c, blood pressure (BP < 1 4 0 /8 0 mmHg), lipid (lowdensity lipoprotein [LDL] cholesterol < 2 .6 m m o l/L [< 1 0 0 mg/dL]), and nonsmoking goals, respectively; 26 .7% met combined ABC (hemoglobin A1c, BP, and LDL cholesterol) targets, and 21.3% met combined ABC targets and did no t smoke. Among undiagnosed adults, 7 7 .0% , 5 7 .9% , 3 6 .0% , and 77 .9% met hemoglobin A1c, BP, lipid, and nonsmoking goals, respectively; 22 .1% met combined ABC targets; and 18.8% met combined ABC targets and were nonsmokers. Limitation: Institutionalized and noncivilian persons are not surveyed in NHANES. Conclusion: Three of 10 adults with diabetes remain undiagnosed, which may be related to less access to care. Compared with diagnosed adults, undiagnosed adults have less elevated hemoglobin A1c levels, less lipid treatment and worse control, and similarly poor BP and combined ABC control regardless o f smoking status. A d dressing these care gaps in both groups would prevent long-term complications. [ABSTRACT FROM AUTHOR]

Globally, the HIV epidemic is evolving. Life expectancy for HIV-infected individuals has been extended because of more effective and more widely available antiretroviral therapy. As a result, chronic noncommunicable diseases (NCDs) have become important comorbid conditions. In particular, HIV-infected persons are increasingly at risk of developing metabolic (diabetes, dyslipidemias), body composition (lipodystrophy, overweight/obesity) and bone mineral density abnormalities. We have summarized the published epidemiological and clinical literature regarding these HIV-NCD comorbidities in low- and middle-income countries (LMICs). We found important gaps in knowledge. Specifically, there are few studies that use standardized methods and metrics; consequently, prevalence or incidence data are not comparable. There are very little or no data regarding the effectiveness or cost-effectiveness of clinical monitoring or therapeutic interventions for metabolic disorders in HIV-infected individuals. Also, although NCDs continue to grow in the HIV-negative population of most LMICs, there are few data comparing the incidence of NCD comorbidities between HIV-infected and HIV-negative populations. To address these gaps, we describe potential research and capacity development priorities for the future. [ABSTRACT FROM AUTHOR]

Background: Low fruit and vegetable (FV) intake is a leading risk factor for chronic disease globally, but much of the world’s population does not consume the recommended servings of FV daily. It remains unknown whether global supply of FV is sufficient to meet current and growing population needs. We sought to determine whether supply of FV is sufficient to meet current and growing population needs, globally and in individual countries. Methods and Findings: We used global data on agricultural production and population size to compare supply of FV in 2009 with population need, globally and in individual countries. We found that the global supply of FV falls, on average, 22% short of population need according to nutrition recommendations (supply:need ratio: 0.78 [Range: 0.05–2.01]). This ratio varies widely by country income level, with a median supply:need ratio of 0.42 and 1.02 in low-income and high-income countries, respectively. A sensitivity analysis accounting for need-side food wastage showed similar insufficiency, to a slightly greater extent (global supply:need ratio: 0.66, varying from 0.37 [low-income countries] to 0.77 [high-income countries]). Using agricultural production and population projections, we also estimated supply and need for FV for 2025 and 2050. Assuming medium fertility and projected growth in agricultural production, the global supply:need ratio for FV increases slightly to 0.81 by 2025 and to 0.88 by 2050, with similar patterns seen across country income levels. In a sensitivity analysis assuming no change from current levels of FV production, the global supply:need ratio for FV decreases to 0.66 by 2025 and to 0.57 by 2050. Conclusion: The global nutrition and agricultural communities need to find innovative ways to increase FV production and consumption to meet population health needs, particularly in low-income countries. [ABSTRACT FROM AUTHOR]

Google Scholar Crossref Search ADS PubMed WorldCat 11 Enas EA, Mohan V, Deepa M, Farooq S, Pazhoor S, Chennikkara H. The metabolic syndrome and dyslipidemia among Asian Indians: a population with high rates of diabetes and premature coronary artery disease. Tablet-based questionnaires facilitate the easier acquisition of data (eliminates the transfer of data from paper forms to electronic databases), execution of skip patterns and application of instant data-checking rules. [Extracted from the article]

The article discusses a study which examined whether goals were achieved in U.S. diabetes care from 1999 to 201. The researchers analyzed data for adults with self-reported diabetes from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System. It was found that tobacco use remained high and almost half of U.S. diabetics failed to meet the recommended goals for diabetes care.

The B-Lynch brace suture technique is a life-saving procedure. It is a simple and safe alternative to hysterectomy. Thus, it preserves fertility with less surgical morbidity. In this case series, we evaluated the use of a novel modification of the B-Lynch brace suture to minimise its potential reported complications. Five women with intractable primary atonic postpartum haemorrhage were reported. They were initially managed with bilateral uterine artery ligation. The procedure was resorted to women who did not respond to ligation. The procedure is efficient. Women were followed up for up to 24 months to report any complications. [ABSTRACT FROM AUTHOR]

The article offers information on a report which examines the glycemic control levels achieved among adults in the U.S. diagnosed with diabetes by socioeconomic, clinical, and demographic, health-care access-related characteristics. The data from National Health and Nutrition Examination Surveys (NHANES) in 2007-2010 was analyzed to determine the characteristics and proportions of adults with self-reported diagnosed diabetes. It shows that the adults presented poor glycemic control.

Nationally representative estimates indicate that 18.8 million adults in the United States have received a diagnosis with diabetes mellitus. When glycemic control is not optimized, diabetes imposes additional burdensome care requirements, health-care costs, and high risk of disabling complications, and this has been especially evident in socioeconomically disadvantaged and minority populations. For example, higher levels of glycated hemoglobin (A1c) have been associated with increased risk of diabetic retinopathy, increased risk of chronic kidney disease, and increased risk of cardiovascular disease. Reducing A1c levels through combined clinical and effective self-management has demonstrated reduced risk for microvascular complications. Although the most appropriate target A1c levels to achieve optimal health impact might vary among persons, the majority of adults with diabetes will benefit from reduction of A1c levels to <=7%; targets for patients with a history of severe hypoglycemia, or with limited life expectancy, or with advanced complications, or with certain comorbid conditions might be higher. Nevertheless, an A1c level of 9% constitutes a clearly modifiable, high level of risk that few, if any, persons with diabetes should be exposed to. Accordingly, the Healthy People 2020 objectives include a 10% reduction in the proportion of the diabetes population that has poor glycemic control (A1c >9%) as a target. [ABSTRACT FROM AUTHOR]

Background: Cardio-metabolic diseases (CMDs) are a growing public health problem, but data on incidence, trends, and costs in developing countries is scarce. Comprehensive and standardised surveillance for noncommunicable diseases was recommended at the United Nations High-level meeting in 2011. Aims: To develop a model surveillance system for CMDs and risk factors that could be adopted for continued assessment of burdens from multiple perspectives in South-Asian countries. Methods: Design: Hybrid model with two cross-sectional serial surveys three years apart to monitor trend, with a three-year prospective follow-up of the first cohort. Sites: Three urban settings (Chennai and New Delhi in India; Karachi in Pakistan), 4000 participants in each site stratified by gender and age. Sampling methodology: Multi-stage cluster random sampling; followed by within-household participant selection through a combination of Health Information National Trends Study (HINTS) and Kish methods. Culturally-appropriate and methodologically-relevant data collection instruments were developed to gather information on CMDs and their risk factors; quality of life, health-care utilisation and costs, along with objective measures of anthropometric, clinical and biochemical parameters. The cohort follow-up is designed as a pilot study to understand the feasibility of estimating incidence of risk factors, disease events, morbidity, and mortality. Results: The overall participant response rate in the first cross-sectional survey was 94.1% (Chennai 92.4%, n = 4943; Delhi 95.7%, n = 4425; Karachi 94.3%, n = 4016). 51.8% of the participants were females, 61.6% < 45 years, 27.5% 45-60 years and 10.9% >60 years. Discussion: This surveillance model will generate data on prevalence and trends; help study the complex life-course patterns of CMDs, and provide a platform for developing and testing interventions and tools for prevention and control of CMDs in South-Asia. It will also help understanding the challenges and opportunities in establishing a surveillance system across countries. [ABSTRACT FROM AUTHOR]