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To determine the effect of glucagon-like peptide 1 receptor agonists (GLP-1RAs) on albuminuria in adult patients with type 2 diabetes mellitus (T2DM).Medline Ovid, Scopus, Web of Science, EMCARE and CINAHL databases from database inception until 27 January 2022. Studies were eligible for inclusion if they were randomized controlled trials that involved treatment with a GLP-1RA in adult patients with T2DM and assessed the effect on albuminuria in each treatment arm. Data extraction was conducted independently by three individual reviewers. The PRISMA guidelines were followed regarding data extraction and quality assessment. Data were pooled using a random effects inverse variance model and all analysis was carried out with RevMan 5.4 software. The Jadad scoring tool was employed to assess the quality of evidence and risk of bias in the randomized controlled trials.The initial search revealed 2419 articles, of which 19 were included in this study. An additional three articles were identified from hand-searching references of included reviews. Therefore, in total, 22 articles comprising 39 714 patients were included. Meta-analysis suggested that use of GLP1-RAs was associated with a reduction in albuminuria in patients with T2DM (weighted mean difference -16.14%, 95% CI -18.42 to -13.86%; p .0001) compared with controls.This meta-analysis indicates that GLP-1RAs are associated with a significant reduction in albuminuria in adult patients with T2DM when compared with placebo.

Introduction. Infected diabetic foot is the leading cause of hospital admissions for people with diabetes mellitus. Diabetic foot osteomyelitis (DFO) causes high morbidity and significant mortality. Current diagnostic tests for DFO are either expensive, invasive, or of low diagnostic yield. Objective. The objective of the study was to determine whether serum levels of procalcitonin (PCT), an inflammatory marker, differ between DFO and diabetic foot ulcers without osteomyelitis (ie, cellulitis) as controls. The authors also aimed to assess the usefulness of PCT in diagnosing DFO. Methods. A case-control study was designed comparing DFO with diabetic foot cellulitis as the control. Patients were classified as having osteomyelitis and cellulitis based on the International Working Group on the Diabetic Foot diagnostic criteria. Serum inflammatory markers PCT, adiponectin, C-reactive protein-1, osteoprotegerin (OPG), osteopontin (OPN), and interleukin 6 (IL-6) were analyzed in patients with DFO and controls. Results. The median serum procalcitonin was significantly higher in the DFO group 108.5 pg/mL (range, 65.0–124.0 pg/mL) compared with 57.0 pg/mL (range, 37.2–77.0 pg/mL) controls (P = .02). Procalcitonin had a sensitivity of 79% compared with 50%, 63%, 66%, and 75% for adiponectin, OPG, OPN, and IL-6, respectively. Procalcitonin had a specificity of 70% compared with 50%, 71%, 70%, and 64%. Receiver operator characteristic curves showed a value of area under the curve of 0.73 and 0.77 for PCT and IL-6 compared with 0.4, 0.6, and 0.6 for adiponectin, OPG, and OPN, respectively. Conclusions. In this study, procalcitonin was a useful diagnostic test for DFOs and provided distinct diagnostic discrimination between DFO from cellulitis. It may serve as a useful marker for diagnosing DFO. Further studies in a larger population are needed to verify the findings.

Background and Aims: Nerve conduction study (NCS) measures how fast an electrical impulse moves through the nerve and is a standard technique for diagnosing and assessing neurological diseases. Despite diabetes and obesity being a common accompaniment of peripheral neuropathy, their effects on NCS patterns have not been elucidated conclusively. Our study aimed to assess several anthropometric and metabolic factors with NCS outcomes to address this gap. Research Design and Methods: This retrospective chart analysis study was conducted on subjects who underwent NCS between 1 January 2009 and 31 December 2019 at a regional hospital. Metabolic, anthropometric, demographical and NCS data were collected from patients’ health records. Results: In total, 120 subjects presenting with sensorimotor peripheral neuropathy symptoms were included in the study. Age, HbA1c, urea and ESR variables were significantly negatively associated with nerve conduction outcomes (Spearman’s correlation rho between −0.210 and −0.456, p &lt, 0.038). HbA1c and age consistently had the most substantial contribution to velocity and amplitude in all regression models (beta coefficients between −0.157 and 0.516, p &lt, 0.001). Urea also significantly account for a large amount of variance in amplitude and velocity in the lower limbs. Conclusion: This study suggests that the severity of sensorimotor neuropathy is influenced by glycaemic control, age and uraemia. The interpretation of NCS results must consider these factors suggesting that improved glycaemic and uraemic control may improve nerve conduction outcomes.

Background Diabetes foot ulcer (DFU) is a complication of diabetes mellitus. Accurate diagnosis of DFU severity through inflammatory markers will assist in reducing impact on quality of life. We aimed to ascertain the diagnostic test accuracy of commonly used inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and white cell count (WCC) for the diagnosis and differentiation between DFU grades based on the International Working Group on the Diabetic Foot classification system. Methods This systematic review explored studies that investigated one or more of the above-listed index tests aiding in diagnosing infected DFU. This review was registered on PROSPERO database (ID = CRD42021255618) and searched 5 databases including an assessment of the references of included studies. Records were manually screened as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 16 studies were included which were assessed for quality using QUADAS-2 tool and meta-analysed using Meta-Disc v1.4. Results CRP had the greatest area under the curve (AUC) of 0.893 for diagnosing grade 2 DFU. This returned a pooled sensitivity and specificity of 77.4% (95% CI: 72% to 82%) and 84.3% (95% CI: 79% to 89%) respectively. In terms of diagnosing grade 3 DFU, procalcitonin had the highest AUC value of 0.844 when compared with other markers. The pooled sensitivity of PCT was calculated as 85.5% (95% CI: 79% to 90%) and specificity as 68.9% (95% CI: 63% to 75%). Conclusion CRP and PCT are the best markers for diagnosing grade 2 and grade 3 DFU respectively. Other markers are also valuable when used in conjunction with clinical judgement. The findings accentuate the necessity of further research to establish standardised cut-off values for these inflammatory markers in diagnosing diabetic foot ulcers.

Osteoporosis results from dysregulated bone remodeling with increased osteoclast-mediated destruction of bones. We have recently shown in vitro the truncated tryptophanyl-tRNA synthetase (mini-TrpRS)-dependent action of interferon-gamma (IFN-γ) to promote myeloid lineage multinucleation, a fundamental step in the osteoclast formation. In particular, we found that IFN-γ readily induced monocyte aggregation leading to multinuclear giant cell formation that paralleled marked upregulation of mini-TrpRS. However, blockade of mini-TrpRS with its cognate amino acid and decoy substrate D-Tryptophan prevented mini-TrpRS signaling, and markedly reduced the aggregation of monocytes and multinucleation in the presence of IFN. The cell signaling mechanism executed by mini-TrpRS appears inevitably in any inflammatory environment that involves IFN-γ with outcomes depending on the cell type involved. Here, we elaborate on these findings and discuss the potential role of the IFN-γ/mini-TrpRS signaling axis in osteoporosis pathophysiology, which may eventually materialize in a novel therapeutic perspective for this disease.

Background: Mobile applications (apps) have proven to be useful in supporting diabetes self-care, but non-consideration of users’ needs and non-inclusion of educational features are reasons for low continual use. Well-designed mobile apps that meet the needs of diabetes patients and provide ongoing self-management education and support are required. It was hypothesized that apps designed with such features can improve a range of measures including clinical outcomes, knowledge of diabetes, medication adherence, perceived ability for self-management, and quality-of-life. This may eventually facilitate a more robust and cost-effective approach for improving skills and motivation for the management of diabetes. Methods: This project will be conducted in two phases. It will initially employ a mixed methods study design to investigate the self-management needs and perceptions of diabetes patients on the use of mobile apps to support diabetes self-management. Results of the mixed methods study will inform the content and design of an app which will be employed as an intervention tool in a 12-month parallel randomized controlled trial (RCT). The RCT will compare outcomes in relation to standard-of-care alone with standard-of-care plus a mobile phone diabetes app among 150 insulin-requiring types 1 and 2 diabetes patients. The primary outcome measures are clinical parameters such as hemoglobin A1c (HbA1c), lipids, urine albumin-to-creatinine ratio, blood pressure, frequency in events of emergency hyperglycemia and hypoglycemia. Secondary outcomes include knowledge of diabetes, medication intake and adherence, perception of self-care, and quality-of-life. Discussion: Results from this study will provide empirical evidence on the usefulness of a mobile app developed based on self-management needs analysis of diabetic patients. The long-term goal is to harness knowledge gained from this study to provide evidenced-based data, which promote the scale-up or adoption of mobile applications that provide regular, ongoing education and self-management support to people living with diabetes. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000065291, Registered on 17 January, 2018 (prospectively registered)., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://www.youtube.com/watch?v=tGt_fYIKA9I

The study aimed at determining prevalence and risk factors (RFs) of diabetic lower limb amputations (LLAs).Electronic databases including PubMed, Medline, Web of Science, and Cochrane Library were searched from January 2003 to April 2021.Sixteen full-text published studies were reviewed. The prevalence of LLAs stood as high as 66%, with a combined prevalence of 19% (95% CI 10-29) using the random-effects model. The most prominent RFs for LLA were duration of diabetes mellitus (DM), age, renal impairment, and ethnic minority. Amongst Australians, Indigenous background is strongly associated with increased risk of the diabetic foot (DF) LLA.LLAs are considerably prevalent amongst patients with the DF and occur at even higher rates in patients with multimorbidity.

Summary Whilst literature is expanding on pasireotide use in the management of Cushing’s disease (CD), there is still currently much unknown about long-term and low-dose pasireotide use in CD. We present a 60-year-old female with residual CD after transphenoidal surgery (TSS), being successfully managed with S.C. pasireotide for over 10 years. For 6 years, her S.C. pasireotide was inadvertently administered at 360 µg twice daily (BID), almost half the recommended dose of 600 µg BID. Despite the low-dose, her urinary free cortisol (UFC) normalised within 6 months and Cushingoid features resolved. She remained in biochemical and clinical remission on the same low-dose for 6 years, before a medication audit discovered her mistaken dose and directed her to take 600 µg BID. With the higher dose 600 µg BID for the next 5 years, her glycaemia worsened without any changes in her UFC and residual tumour volume. Our case showed the continuing effectiveness and safety of treatment with S.C. pasireotide for more than 10 years, and that a low-dose regimen may be considered an option for responders by its safety profile. Learning points: A lower dose of pasireotide may be effective in the initial treatment of CD than the recommended 600 µg BID dosage, though more studies are required to explore this. Low-dose pasireotide use has the benefit of minimising adverse effects. In the long-term, pasireotide has a sustained clinical and biochemical effect and is well tolerated.

Background Mobile health apps are commonly used to support diabetes self-management (DSM). However, there is limited research assessing whether such apps are able to meet the basic requirements of retaining and engaging users. Objective This study aimed to evaluate participants’ retention and engagement with My Care Hub, a mobile app for DSM. Methods The study employed an explanatory mixed methods design. Participants were people with type 1 or type 2 diabetes who used the health app intervention for 3 weeks. Retention was measured by completion of the postintervention survey. Engagement was measured using system log indices and interviews. Retention and system log indices were presented using descriptive statistics. Transcripts were analyzed using content analysis to develop themes interpreted according to the behavioral intervention technology theory. Results Of the 50 individuals enrolled, 42 (84%) adhered to the study protocol. System usage data showed multiple and frequent interactions with the app by most of the enrolled participants (42/50, 84%). Two-thirds of participants who inputted data during the first week returned to use the app after week 1 (36/42, 85%) and week 2 (30/42, 71%) of installation. Most daily used features were tracking of blood glucose (BG; 28/42, 68%) and accessing educational information (6/42, 13%). The interview results revealed the app’s potential as a behavior change intervention tool, particularly because it eased participants’ self-care efforts and improved their engagement with DSM activities such as BG monitoring, physical exercise, and healthy eating. Participants suggested additional functionalities such as extended access to historical analytic data, automated data transmission from the BG meter, and periodic update of meals and corresponding nutrients to further enhance engagement with the app. Conclusions The findings of this short-term intervention study suggested acceptable levels of participant retention and engagement with My Care Hub, indicating that it may be a promising tool for extending DSM support and education beyond the confines of a physical clinic.

Background: Diabetes mellitus causes a large majority of non-traumatic major and minor amputations globally. Patients with diabetes are clinically complex with a multifactorial association between diabetic foot ulcers (DFU) and subsequent lower extremity amputations (LEA). Few studies show the long-term outcomes within the cohort of DFU-associated LEA. Aim: To highlight the long-term outcomes of LEA as a result of DFU. Methods: PubMed/MEDLINE and Google Scholar were searched for key terms, "diabetes", "foot ulcers", "amputations" and "outcomes". Outcomes such as mortality, re-amputation, re-ulceration and functional impact were recorded. Peer-reviewed studies with adult patients who had DFU, subsequent amputation and follow up of at least 1 year were included. Non-English language articles or studies involving children were excluded. Results: A total of 22 publications with a total of 2334 patients were selected against the inclusion criteria for review. The weighted mean of re-amputation was 20.14%, 29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively with significantly higher rates associated with major amputation, re-amputation and ischemic cardiomyopathy. Conclusion: Previous LEA, level of the LEA and patient comorbidities were significant risk factors contributing to re-ulceration, re-amputation, mortality and depreciated functional status.

The aim of this study was to evaluate the preliminary efficacy and user acceptance of My Care Hub (MCH) mobile app&mdash, developed to provide evidenced-based support and education on diabetes self-management (DSM). Using a mixed-methods design, the efficacy and acceptability of MCH were measured among people with type 1 or type 2 diabetes after three weeks of intervention. The primary outcome measure was level of involvement with DSM, while the mediating factors were skills and self-efficacy for DSM. Telephone interviews were conducted to elucidate information on perceptions of the app&rsquo, s impact on participants&rsquo, DSM and interest in future use. Statistically significant improvements were observed between pre- and post-intervention measures: DSM activities (4.55 &plusmn, 1.14 vs. 5.35 &plusmn, 0.84, p = 0.001), skills (7.10 &plusmn, 1.99 vs. 7.90 &plusmn, 1.67, p = 0.04), and self-efficacy (7.33 &plusmn, 1.83 vs. 8.07 &plusmn, 1.54, p = 0.03). Multivariate analysis showed that self-efficacy had the strongest, though not significant influence on DSM. Interview findings revealed that the app reinforced knowledge and provided motivation to participate in DSM activities. The study suggested a positive impact of MCH on DSM and acceptability by patients. To confirm these promising results, further large scale and long-term studies are required.

There is limited literature on IHD in DFU patients. This review aimed to determine the prevalence of and risk factors of IHD in patients with DFUs.Seven electronic databases were searched from inception to April 2021.The prevalence of IHD in DFU patients ranged from 6.83% to 60.61% with a pooled mean of 25.85% (95% CI, 24.28%-27.32%). Several risk factors were identified including hypertension, male gender, smoking, and peripheral vascular disease.We identified multiple risk factors for IHD requiring early interventions to increase long-term quality of life for patients with DFUs.

Background:Both activation of monocytes and increased serum fatty acid binding protein-4 (FABP4) occur in diabetes and are associated with increased atherosclerosis. The oxidized lipid, 9-hydroxyoctadecadienoic acid (9-HODE) increases FABP4 in macrophages, and is a ligand for G protein-coupled receptor 132 (GPR132). We investigated the involvement of GPR132 in mediating the 9-, 13-HODE stimulation of FABP4 secretion, and whether GPR132 expression is increased in monocytes from patients with type 2 diabetes.Methods:The effects of siRNA silencing of GPR132 gene and of the PPAR-γ antagonist T0070907 were studied in THP-1 cells. Serum levels of FABP4 and other adipokines were measured in patients with diabetes, and monocyte subpopulations were analyzed using flow cytometry. GPR132 mRNA was quantified in isolated CD14+cells.Results:9-HODE and 13-HODE increased FABP4 expression in THP-1 monocytes and macrophages, and also increased GPR132 expression. Silencing of GPR132 did not influence the increase in FABP4 with 9-HODE, 13-HODE, or rosiglitazone (ROSI). By contrast, T0070907 inhibited the effect of all three ligands on FABP4 expression. Diabetic subjects had increased serum FABP4, and activated monocytes. They also expressed higher levels of GPR132 mRNA in CD14+cells.Conclusions:We conclude that GPR132 is an independent monocyte activation marker in diabetes, but does not contribute to PPAR-γ-mediated induction of FABP4 by HODEs.

Asia-Pacific countries are experiencing lifestyle-related non-communicable disease crises. Kimbe, one of Papua New Guinea’s provincial capitals is noted as the fastest growing city in the South Pacific subcontinent yet its impact on diabetes mellitus (DM) is not known. To determine pattern of newly diagnosed DM, we conducted a retrospective review of Kimbe General Hospital medical admissions from January 2009 to December 2012. 125 patients were diagnosed with diabetes with male: female ratio of 1.1: 1. Overall, number of patients diagnosed with DM at the hospital increased rapidly from 16 in 2009 to 49 in 2012; p

BACKGROUND Mobile health apps are commonly used to support diabetes self-management (DSM). However, there is limited research assessing whether such apps are able to meet the basic requirements of retaining and engaging users. OBJECTIVE This study aimed to evaluate participants’ retention and engagement with My Care Hub, a mobile app for DSM. METHODS The study employed an explanatory mixed methods design. Participants were people with type 1 or type 2 diabetes who used the health app intervention for 3 weeks. Retention was measured by completion of the postintervention survey. Engagement was measured using system log indices and interviews. Retention and system log indices were presented using descriptive statistics. Transcripts were analyzed using content analysis to develop themes interpreted according to the behavioral intervention technology theory. RESULTS Of the 50 individuals enrolled, 42 (84%) adhered to the study protocol. System usage data showed multiple and frequent interactions with the app by most of the enrolled participants (42/50, 84%). Two-thirds of participants who inputted data during the first week returned to use the app after week 1 (36/42, 85%) and week 2 (30/42, 71%) of installation. Most daily used features were tracking of blood glucose (BG; 28/42, 68%) and accessing educational information (6/42, 13%). The interview results revealed the app’s potential as a behavior change intervention tool, particularly because it eased participants’ self-care efforts and improved their engagement with DSM activities such as BG monitoring, physical exercise, and healthy eating. Participants suggested additional functionalities such as extended access to historical analytic data, automated data transmission from the BG meter, and periodic update of meals and corresponding nutrients to further enhance engagement with the app. CONCLUSIONS The findings of this short-term intervention study suggested acceptable levels of participant retention and engagement with My Care Hub, indicating that it may be a promising tool for extending DSM support and education beyond the confines of a physical clinic.

Aneurysms demonstrate vascular smooth muscle cells (VSMC) phenotypic modulation characterized by the prevailing of synthetic over contractile properties. We have shown previously the ability of interferon-gamma (IFN-γ) to switch VSMC from contractile to synthetic phenotype via upregulating the truncated form of tryptophanyl-tRNA synthetase (mini-TrpRS) in vitro. Here we discuss a possible role of the IFN-γ/mini-TrpRS signalling axis in the pathology of human abdominal aortic aneurysm (AAA).

Non-adherence to self-management poses a serious risk to diabetes complications. Digital behavioural change interventions have the potential to provide education and motivate users to regularly engage with self-management of diabetes. This paper describes the development of My Care Hub mobile phone application (app) aimed at supporting self-management in people with type 1 or type 2 diabetes. The development of My Care Hub involved a comprehensive process of healthy behavioural change identification, end users’ needs, expert consensus, data security and privacy considerations. The app translation was a highly iterative process accompanied by usability testing and design modification. The app development process included: (1) behaviour change strategy selection; (2) users’ involvement; (3) expert advisory involvement; (4) data security and privacy considerations; (5) design creation and output translation into a smartphone app and (6) two usability testings of the app prototype version. The app features include self-management activities documentation, analytics, personalized and generalized messages for diabetes self-management as well as carbohydrate components of common foods in Australia. Twelve respondents provided feedback on the usability of the app. Initially, a simplification of the documentation features of the app was identified as a need to improve usability. Overall, results indicated good user satisfaction rate.

Diabetic foot syndrome demonstrates wound chronicity due to impaired tissue perfusion in lower limbs. Previous studies showed interferon-gamma (IFN-γ), a central inflammatory mediator in diabetic foot syndrome, to induce the truncated form of tryptophanyl-tRNA synthetase (mini-TrpRS) that has strong angiostatic properties. Recently we reported that mini-TrpRS signalling could be blocked in the presence of IFN-γ with D-tryptophan in vitro. Here we discuss the IFN-γ/mini-TrpRS axis in the pathology of diabetic foot syndrome and emerging therapeutic options.

Aims To evaluate outcomes of diabetic inpatient hypoglycemia among Aboriginal and Torres Strait Islander (ATSI) compared with Australian Caucasian patients. Methods A retrospective audit of diabetic patients aged > 18 years admitted at a regional hospital general ward between April 1, 2015, and March 31, 2016, was analyzed. The database contains clinical information at the time of admission and initial discharge and readmission within 4 weeks thereafter. Results A total of 1618 (of 6027) patients were admitted with diabetes representing 23.7% of the total ward admissions, of which 484 (29.9%) had inpatient hypoglycemia. Of the 91 patients with available data analyzed, ATSI origin with inpatient hypoglycemia was associated with longer length of stay (LOS) (hazard ratio [HR], 2.1, 95% confidence interval [CI], 1.2-3.5), whereas severe hypoglycemia (≤ 2.2 mmol/L) in both ATSI and non-ATSI was significantly associated with longer LOS (HR, 2.3; 95% CI, 1.2-4.2). No significant differences in LOS were found for gender, age, and Carlson comorbidity index (CCI). The adjusted model for likelihood of readmission, gender, indigenous status, and CCI were not significant risk factors for readmission to the hospital. Readmitted patients were older (50-59 years vs Conclusion We reported high rate of inpatient hypoglycemia in our study population. Indigenous Australian diabetic patients with inpatient hypoglycemia had significantly longer LOS compared with non-Indigenous Caucasian counterparts. Further prospective studies on a larger population are needed to confirm our findings.

Background: The prevalence of diabetes in rural and remote North Queensland is twice that of the general Australian population. The vast geographical distances in North Queensland prevent patients from accessing specialist diabetes care in tertiary hospitals. Telehealth (TH) presents a unique opportunity to overcome this barrier. However, the ability of TH to improve glycaemic control and vascular risk factors (blood pressure, body mass index, lipid profile) in comparison to traditional face-to-face (FTF) care in this population remains unknown. Methods: This was a retrospective cohort study of all diabetes-related telehealth consultations conducted at the Townsville Hospital from January 2016 to March 2018. The primary outcome was the change in HbA1c post-FTF (face-to-face) care versus post-TH care. Secondary outcomes included change in blood pressure, body mass index and lipid profile. We conducted a preliminary economic analysis to determine patient cost-savings from the tele-diabetes model of care. Results: 330 patients were included in the study. The majority (71%) had a diagnosis of type 2 diabetes. The median baseline HbA1c was 9.1% (8.0-10.8). HbA1c improved from 9.1% (post-FTF) to 8.1% post-TH intervention (z = -9.184, p Conclusions: Telehealth consultations improved glycaemic control and lipid levels more effectively than traditional face-to-face care with significant cost savings for a rural and remote population in North Queensland, Australia. Disclosure N. Nangrani: None. U. Malabu: None. V. Vangaveti: None.

Sodium-glucose cotransporter type-2 inhibitors (SGLT2is) reduce glomerular hyperfiltration in diabetic people with early diabetic nephropathy. The objective of this report was to assess changes in glomerular filtration rate in healthy cats after treatment with a SGLT2i. Eight healthy research adult castrated male cats were used in a randomized, controlled, cross-over study design. We induced isolated renal tubular glucosuria by dosing cats with the SGLT2i dapagliflozin. The cats received by mouth 10 mg dapagliflozin or control every 24 h in each of the 4, 5-d trial periods that were separated by a 7-d washout period. We assessed glomerular filtration rate (iohexol clearance method), serum urea, creatinine, symmetric dimethylarginine, and 24-h sodium and chloride urinary excretion on the fifth day of each trial period. We analyzed the data with a mixed linear model that included the fixed effects of treatment (treated and control) and trial period, and the random effect of the cat. Compared with controls, cats treated with dapagliflozin had a significant increase in mean (±SE) glomerular filtration rate (3.1 ± 0.2 vs 2.5 ± 0.2 mL/kg/min; P = 0.01), whereas there were no significant differences in serum urea, creatinine and symmetric dimethylarginine, and 24-h urine sodium and chloride excretion. We propose that dapagliflozin-mediated delivery of sodium and glucose distal from the proximal convoluted tubule induced compensatory increased sodium absorption at the thick ascending loop of Henle that resulted in decreased sodium delivery to the distal tubule leading to tubuloglomerular feedback–mediated glomerular hyperfiltration. Future studies should determine if SGLT2is' renoprotective effect in people can be enhanced with the addition of a Na+-K+-Cl− diuretic and whether dapagliflozin will be useful in mitigating proteinuria and hypertension that follow glomerular hyperfiltration in diabetic companion animals in a similar mechanism as in people.

Objectives: To review the use of telehealth in subjects with diabetic foot ulcer; evaluating its clinical outcomes, diagnostic accuracy, cost-effectiveness and behavioural perceptions. Design: Systematic review. Setting: Selected studies were conducted in Australia, USA, the Netherlands, Denmark, Poland and UK. Participants: A total of 948 identified studies were evaluated against the inclusion criteria. Eleven eligible studies were included for review. Patients with diabetic foot ulcer had to have telehealth guided management. Main outcome measures: Telehealth systems were evaluated against at least one of the following: clinical implications on ulcer healing and disease prognosis; diagnostic accuracy; cost-effectiveness; behavioural perceptions among health professionals or patients. Result: Eleven eligible studies were included for review. Studies that evaluated telehealth against clinical outcomes were underpowered by study design, sample sizes and short duration follow-up. Telehealth systems demonstrated good intra- and inter-observer reproducibility, high diagnostic accuracy and agreement with live assessments. Authors rationalised the cost-effectiveness of their respective telehealth systems, but could not support this with long-term cost analysis. Both patient and health professionals responded positively towards telehealth in surveys and face-to-face interviews. Conclusion: Telehealth yields high diagnostic accuracy, reproducibility and positive behavioural perceptions. However, it is not clear if telehealth use in diabetic foot management has favourable clinical and economic outcomes. More long-term prospective controlled trials on larger populations are needed to further characterise our findings.

Objective Dipeptidyl peptidase-4 (DPP-4) inhibitors have a well-known effect on glycaemic control in patients with diabetes but little is known on their wound healing role in this group of population. This paper reviews the effects of DPP-4 inhibitors on wound healing of diabetic foot ulcers. Methods Published data on effects and mechanism of DDP-4 inhibitors on wound healing were derived from Medline, PubMed and Google Scholar search of English language literature from 1994 to 2014 using the key words such as “DPP-4 inhibitors”, “endothelial healing” “diabetes” and “chronic ulcers”. Results DPP-4 inhibitors show a potential benefit in processes of wound healing in diabetic chronic foot ulcers. The enzyme inhibitors promote recruitment of endothelial progenitor cells and allow the final scaffolding of wounds. Furthermore DPP-4 inhibitors augment angiogenesis and have widespread effects on optimising the immune response to persistent hypoxia in chronic diabetes wounds. Conclusion DPP-4 inhibitors show promise in the local wound healing of diabetic foot ulcers in addition to its already established glycaemic control. In the light of high rate of amputations due to non-healing ulcers with profound psychological and economical liability, more investigations on the usefulness of DPP-4 inhibitors in the high risk diabetes population are needed.

ObjectiveThe study aimed to identify the common gaps in skills and self-efficacy for diabetes self-management and explore other factors which serve as enablers of, and barriers to, achieving optimal diabetes self-management. The information gathered could provide health professionals with valuable insights to achieving better health outcomes with self-management education and support for diabetes patients.MethodsInternational online survey and telephone interviews were conducted on adults who have type 1 or type 2 diabetes. The survey inquired about their skills and self-efficacy in diabetes self-management, while the interviews assessed other enablers of, and barriers to, diabetes self-management. Surveys were analysed using descriptive and inferential statistics. Interviews were analysed using inductive thematic analysis.ResultsSurvey participants (N = 217) had type 1 diabetes (38.2%) or type 2 diabetes (61.8%), with a mean age of 44.56 SD 11.51 and were from 4 continents (Europe, Australia, Asia, America). Identified gaps in diabetes self-management skills included the ability to: recognize and manage the impact of stress on diabetes, exercise planning to avoid hypoglycemia and interpreting blood glucose pattern levels. Self-efficacy for healthy coping with stress and adjusting medications or food intake to reach ideal blood glucose levels were minimal. Sixteen participants were interviewed. Common enablers of diabetes self-management included: (i) the will to prevent the development of diabetes complications and (ii) the use of technological devices. Issues regarding: (i) frustration due to dynamic and chronic nature of diabetes (ii) financial constraints (iii) unrealistic expectations and (iv) work and environment-related factors limited patients' effective self-management of diabetes.ConclusionsEducational reinforcement using technological devices such as mobile application has been highlighted as an enabler of diabetes self-management and it could be employed as an intervention to alleviate identified gaps in diabetes self-management. Furthermore, improved approaches that address financial burden, work and environment-related factors as well as diabetes distress are essential for enhancing diabetes self-management.

Background: The outcomes of telehealth in the management of type 2 diabetes (T2DM) have not been evaluated since the publication of recent clinical trials. Objective: To conduct a systematic review and meta-analysis of recently published randomized controlled trials (RCTs) to assess the biochemical, clinical and psychosocial outcomes of telehealth in subjects with T2DM. Methods: Electronic databases, MEDLINE, CINAHL, INFORMIT, SCOPUS and the Cochrane Central Register of Controlled Trials and reference lists of existing systematic reviews were searched until August 2017 to identify relevant studies. Study search and selection were performed by two independent reviewers. 4791 articles were retrieved of which 11 RCTs (n=3772) were included. A meta-analysis with random effects model was applied to estimate the pooled results. Results: Telehealth was associated with a statistically significant and clinically relevant absolute decline in glycosylated haemoglobin (HbA1c) compared to usual care (mean difference -0.17%; 95% CI -0.25 to -0.09%; p Conclusion: Telehealth interventions were associated with improved glycaemic control (HbA1c) in T2DM diabetic patients. However, no clinically relevant impact was observed on lipid profile, blood pressure, body mass index and psychosocial well-being. Future studies should seek to evaluate the effect of intervention duration on HbA1c, psychosocial outcomes and the effectiveness of telehealth in rural and underserved populations. Disclosure N. Nangrani: None. U. Malabu: None. V. Vangaveti: None.

BackgroundThere is increased research interest in the use of mobile phone apps to support diabetes management. However, there are divergent views on what constitute the minimum standards for inclusion in the development of mobile phone apps. Mobile phone apps require an evidence-based approach to development which will consequently impact on their effectiveness. Therefore, comprehensive information on developmental considerations could help designers and researchers to develop innovative and effective patient-centered self-management mobile phone apps for diabetes patients. ObjectiveThis systematic review examined the developmental considerations adopted in trials that engaged mobile phone applications for diabetes self-management. MethodsA comprehensive search strategy was implemented across 5 electronic databases; Medline, Scopus, Social Science Citation Index, the Cochrane Central Register of Controlled Trials and Cumulative Index of Nursing and Allied Health Literature (CINALHL) and supplemented by reference list from identified studies. Study quality was evaluated using the Joanna Briggs Critical appraisal checklist for trials. Information on developmental factors (health behavioral theory, functionality, pilot testing, user and clinical expert involvements, data privacy and app security) were assessed across experimental studies using a template developed for the review. ResultsA total of 11 studies (10 randomized controlled trials and 1 quasi-experimental trial) that fitted the inclusion criteria were identified. All the included studies had the functionality of self-monitoring of blood glucose. However, only some of them included functions for data analytics (7/11, 63.6%), education (6/11, 54.5%) and reminder (6/11, 54.5%). There were 5/11(45.5%) studies with significantly improved glycosylated hemoglobin in the intervention groups where educational functionality was present in the apps used in the 5 trials. Only 1 (1/11, 9.1%) study considered health behavioral theory and user involvement, while 2 (2/11, 18.1%) other studies reported the involvement of clinical experts in the development of their apps. There were 4 (4/11, 36.4%) studies which referred to data security and privacy considerations during their app development while 7 (7/12, 63.6%) studies provided information on pilot testing of apps before use in the full trial. Overall, none of the studies provided information on all developmental factors assessed in the review. ConclusionsThere is a lack of elaborate and detailed information in the literature regarding the factors considered in the development of apps used as interventions for diabetes self-management. Documentation and inclusion of such vital information will foster a transparent and shared decision-making process that will ultimately lead to the development of practical and user-friendly self-management apps that can enhance the quality of life for diabetes patients.

BACKGROUND There is increased research interest in the use of mobile phone apps to support diabetes management. However, there are divergent views on what constitute the minimum standards for inclusion in the development of mobile phone apps. Mobile phone apps require an evidence-based approach to development which will consequently impact on their effectiveness. Therefore, comprehensive information on developmental considerations could help designers and researchers to develop innovative and effective patient-centered self-management mobile phone apps for diabetes patients. OBJECTIVE This systematic review examined the developmental considerations adopted in trials that engaged mobile phone applications for diabetes self-management. METHODS A comprehensive search strategy was implemented across 5 electronic databases; Medline, Scopus, Social Science Citation Index, the Cochrane Central Register of Controlled Trials and Cumulative Index of Nursing and Allied Health Literature (CINALHL) and supplemented by reference list from identified studies. Study quality was evaluated using the Joanna Briggs Critical appraisal checklist for trials. Information on developmental factors (health behavioral theory, functionality, pilot testing, user and clinical expert involvements, data privacy and app security) were assessed across experimental studies using a template developed for the review. RESULTS A total of 11 studies (10 randomized controlled trials and 1 quasi-experimental trial) that fitted the inclusion criteria were identified. All the included studies had the functionality of self-monitoring of blood glucose. However, only some of them included functions for data analytics (7/11, 63.6%), education (6/11, 54.5%) and reminder (6/11, 54.5%). There were 5/11(45.5%) studies with significantly improved glycosylated hemoglobin in the intervention groups where educational functionality was present in the apps used in the 5 trials. Only 1 (1/11, 9.1%) study considered health behavioral theory and user involvement, while 2 (2/11, 18.1%) other studies reported the involvement of clinical experts in the development of their apps. There were 4 (4/11, 36.4%) studies which referred to data security and privacy considerations during their app development while 7 (7/12, 63.6%) studies provided information on pilot testing of apps before use in the full trial. Overall, none of the studies provided information on all developmental factors assessed in the review. CONCLUSIONS There is a lack of elaborate and detailed information in the literature regarding the factors considered in the development of apps used as interventions for diabetes self-management. Documentation and inclusion of such vital information will foster a transparent and shared decision-making process that will ultimately lead to the development of practical and user-friendly self-management apps that can enhance the quality of life for diabetes patients.

BackgroundMobile phone applications (apps) offer motivation and support for self-management of diabetes mellitus (DM), but their use is limited by high attrition due to insufficient consideration of end-users perspectives and usability requirements. This study aimed to examine app usage and feature preferences among people with DM, and explore their recommendations for future inclusions to foster engagement with diabetes apps.MethodsThe study was conducted internationally on adults with type 1 or type 2 DM using online questionnaire (quantitative) to investigate usage and preferences for app features that support diabetes self-management and semi structured telephone interview (qualitative) to explore suggestions on fostering engagement and specific educational information for inclusion into diabetes apps. Survey and interview data were analysed using descriptive/ inferential statistics and inductive thematic analysis respectively.ResultsA total of 217 respondents with type 1 DM (38.25%) or type 2 DM (61.8%), from 4 continents (Australia, Europe, Asia and America) participated in the survey. About half of the respondents (48%) use apps, mainly with features for tracking blood glucose (56.6%), blood pressure (51.9%) and food calories (48.1%). Preferred features in future apps include nutrient values of foods (56.7%), blood glucose (54.8%), physical exercise tracker (47%), health data analytics (42.9%) and education on diabetes self-management (40.6%). Irrespective of the type of DM, participants proposed future apps that are user friendly, support healthy eating, provide actionable reminders and consolidate data across peripheral health devices. Participants with type 1 DM recommended customised features with news update on developments in the field of diabetes. Nominated specific educational topics included tips on problem solving, use of insulin pump therapy, signs of diabetes complication and transitioning from paediatric into adult care.ConclusionsThe study has highlighted patients' perspectives on essential components for inclusion in diabetes apps to promote engagement and foster better health outcomes.

[Extract] The observations by Bakhtiyari and Mansournia on our study [1] were received with great interest. We believe our study was consistent with a case-control format [2]. In particular, our target population was selected from subjects diagnosed with diabetic foot ulcer (DFU) at the local high-risk foot clinic, effectively fulfilling the criteria of control (DFU without amputations) and case (DFU with amputation), as previously described [3].

A hypoglycemia-induced fall is common in older persons with diabetes. The etiology of falls in this population is usually multifactorial, and includes microvascular and macrovascular complications and age-related comorbidities, with hypoglycemia being one of the major precipitating causes. In this review, we systematically searched the literature that was available up to March 31, 2014 from MEDLINE/PubMed, Embase, and Google Scholar using the following terms: hypoglycemia; insulin; diabetic complications; and falls in elderly. Hypoglycemia, defined as blood glucose, Video abstract

Objective: To look into the glucose tolerance test characteristics and determine complications in non-gestational diabetes pregnant subjects. Methods: From 2006 to 2009 all non-gestational diabetes mellitus (non-GDM) pregnant women who delivered macrosomia at the North Australia's Townsville Hospital were retrospectively reviewed by extracting data from clinical record. Glucose tolerance tests results were analysed in the light of an earlier diagnosis of non-GDM. Results: Ninety-one non-GDM mothers with macrosomia were studied and compared with 41 normoglycemic subjects without macrosomia. Of the subjects with non-GDM macrosomia, 45 (49.4%) had normal 50 g glucose challenge test (GCT) without further testing, another 8 (8.8%) had abnormal GCT but normal 75 g oral glucose tolerance test (OGTT). A total of 4 (4.4%) subjects had normal GCT and OGTT. Interestingly, 14 out of 16 (87.5%) subjects who were tested with OGTT owing to past history of macrosomia had normal results but delivered macrosomic babies. Only 12 subjects had both GCT and OGTT, the rest of the cohort had either of the two tests. Subjects with non-GDM macrosomia had higher frequency of neonatal hypoglycaemia 34% as compared to 10% in non-macrosomic babies (P=0.003). Other feto-maternal complications were similar in both groups. Conclusions: No significant pattern of glucose tolerance characteristics was identified in non-GDM mothers with macrosomic babies. In spite of being normoglycemic significant neonatal hypoglycaemia was recorded in non-GDM macrosomic babies. Further prospective studies on a larger population are needed to verify our findings.

Background: Hyponatremia is known to be common electrolyte disturbance in the hospitalized patients. Yet there is no record on its magnitude in tropical Asia Pacific Australia in spite of higher risk due to associated endemic tropical infectious diseases. Objective: The aim of the study was to determine prevalence of hyponatremia in acute medical admissions in Northern Australasia. Design, setting and participants: We studied 469 consecutive acute medical admissions to a hospital in Australia's Far North Queensland during the colder months of June and July 2012. Main outcome measures: Prevalence of hyponatremia and its relationship with gender, age, diagnosis and prognosis in acute medical admissions. Results: On admission, hyponatremia (plasma sodium < 136 mmol/l) was present in 39.4% of patients, with mild (130 - 135), moderate (126 - 129 mmol/l) and severe (< 126 mmol/l) hyponatremia being present in 25.2 %, 10.7% and 3.6% respectively. Overall, adding together admission hyponatremia with that developing during admission, 45.2% of patients were affected with 11.5% and 4.1% having moderate or severe hyponatremia. Hypokalemia and hyperkalemia were present in 17% and 18.1% respectively. Overall, 275/469 patients (58.6%) presented with an electrolyte abnormality. There were significant correlations of hyponatremia with age but with gender and in-hospital mortality. Prevalence of hyponatremia was high across all diagnostic categories. Conclusions: The prevalence of hyponatremia appears to be high in the tropical North Australian population, this being the highest prevalence reported amongst acute hospital admissions. The previously reported correlations with age and mortality do appear to hold good for this population with a high prevalence of electrolyte disorders. Our data being a pilot study further prospective analysis on a larger population in the area is needed to confirm our findings.

Objective.The aim of the study was to evaluate the prevalence of and risk factors for lower limb amputation in a specialist foot clinic-based setting.Methods.A retrospective quantitative study was conducted, using clinical and biochemical profiles of diabetic foot patients attending the High Risk Foot Clinic at The Townsville Hospital, Australia, between January 1, 2011, and December 31, 2013.Results.The total study sample included 129 subjects, comprising 81 males and 48 females with M : F ratio of 1.7 : 1. Twenty-three subjects were Indigenous Australians, representing 17.8% of the study population. The average age of the cohort was 63.4 years ± 14.1 years [CI 90.98–65.89]. Lower limb amputation was identified as a common and significant outcome (n=44), occurring in 34.1%, more commonly amongst the Indigenous Australians (56.5% versus 29.2%;p=0.94, OR 0.94). Risk factors most closely associated with amputation included diabetic retinopathy (p=0.00, OR 4.4), coronary artery bypass graft (CABG) surgery (p=0.01, OR 4.1), Charcot’s arthropathy (p=0.01, OR 2.9), and Indigenous ethnicity (p=0.01, OR 3.4). Although average serum creatinine, corrected calcium, and glycosylated haemoglobin A1c (Hba1c) levels were higher amongst amputees they were statistically insignificant.Conclusions.Lower limb amputation is a common outcome and linked to ethnicity and neurovascular diabetic complications amongst subjects with diabetic foot ulcer. Further research is needed to identify why risk of lower limb amputation seems to differ according to ethnicity.

End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis.The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis.A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed.We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49-1.88] p 0.001), history of foot ulceration (OR 81 [18.20-360.48] p 0.001), peripheral arterial disease (OR 31.29 [9.02-108.56] p 0.001), peripheral neuropathy (OR 31.29 [9.02-108.56] p 0.001), foot deformity (OR 23.62 [5.82-95.93] p 0.001), retinopathy (OR 6.08 [2.64-14.02] p 0.001), dyslipidemia (OR 4.6 [1.05-20.05] p= 0.049) and indigenous background (OR 3.39 [1.38-8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p 0.05).There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.

Background.Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood.Aim.Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature.Methods.Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words.Results.Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin.Conclusions.This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis.

Thyroid disturbances are common in women during the reproductive years of their lives. Autoimmunity and altered iodine status together account for a high proportion of the abnormalities. Autoimmune thyroid disease is present in around 4% of young females, and up to 15% are at risk because they are thyroid antibody-positive. There is a strong relationship between thyroid immunity on the one hand and infertility, miscarriage, and thyroid disturbances in pregnancy and postpartum on the other hand. Suboptimal iodine status affects a large proportion of the world's population, and pregnancy further depletes iodine stores. There is controversy surrounding the degree to which iodine should be supplemented and the duration of supplementation. Recent studies have helped to clarify the relationship between maternal thyroid status and neuropsychological development of the child. The role of other environmental factors including smoking and selenium status is also now recognised. Universal screening for thyroid hormone abnormalities is not routinely recommended at present. However, measurement of thyroid function and autoantibodies should certainly be considered in those who are at high risk of thyroid disease and in those whose pregnancy is otherwise high risk. The practicing clinician needs to be aware of the thyroid changes which accompany pregnancy.

Severe illness can lead to multiple transient endocrinopathies. In adult patients, neuroendocrine alterations include sick euthyroid syndrome, an increase in corticosteroid levels, increase in prolactin levels, decreased insulin growth factor 1 levels and hypogonadism. We report the case of a 24-year-old man with meningococcal sepsis with multiple end-organ complications who developed persistent non-autoimmune hypothyroidism, adrenal insufficiency and primary hypogonadism all requiring hormone replacement. While adrenal insufficiency as part of the Waterhouse-Friderichsen syndrome is well described, reports of primary hypothyroidism and persistent primary hypogonadism in severe illness are exceedingly rare. Multiple combined endocrinopathies as in this case have not been reported previously. This case highlights the necessity of screening for endocrine abnormalities in severe illness and the need for treatment if persistent. It also raises a novel concept of meningococcal sepsis causing multiple endocrinopathies possibly via disseminated intravascular coagulopathy-related ischaemic damage.

[Extract] The prevalence of obesity is increasing globally. This with the aging population structure accounts for the increased prevalence of chronic diseases associated with obesity. For example, the number of people with diabetes in the world is projected to reach 300 million before 2025. Through childhood, adolescence, and adult life, obesity prevalence increases with age. However, the elderly (aged 60 plus), have a lower prevalence and in the extreme elderly (aged 80 plus), it is only a third of that in middle life. Obesity in the elderly presents a distinct problem. As at younger ages, it is associated with chronic diseases, and with functional and cognitive decline. However, the prevalence of being underweight is also a high and is itself a marker for poor health and functional decline. The ideal body weight and composition for elderly populations has yet to be defined. Weight management should be a target for certain elderly individuals whose health is at risk. However, in the elderly is important to maintain an optimal body composition as well as weight. Elderly individuals with weight-related diseases such as type 2 diabetes represent an obvious target for weight management. It is, in practice, difficult to identify elderly patients who would benefit from weight management programmes. The various components of the metabolic syndrome (MS) become more common with aging. Drugs to decrease cardiovascular risk and to treat diabetes and the other chronic diseases of aging have improved in recent years. The elderly are frequently prescribed complex drug regimens with which they often comply poorly, derive little benefit, and experience a high risk of adverse reactions and drug interactions. Although it is clear that obesity should be treated in high-risk elderly patients, pharmacotherapy and surgery do not have an evidence base specific to the elderly. There is emerging evidence to guide us with dietary and exercise therapy (1, 2). This review attempts to define the situations in which management of obesity is indicated, and to summarise what is known, and what is emerging, about the various treatment options.

The aim of the study was to determine surgical indication and complication of subtotal thyroidectomy in patients being treated for Graves' disease at King Khalid University Hospital Riyadh Saudi Arabia in the period between January 1996 and December 2005. Twenty-five out of 194 adult patients with Graves' disease had thyroidectomy for hyperthyroidism during the 10-year period representing 13% comprising 11 males and 14 females. Mean age at presentation for all the patients was 28±12 years. Males had higher serum T4 77.7±20.7 than females 49.8±21.9 pmol L-1; p