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BACKGROUND: Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients. METHODS: The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed. RESULTS: Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients' race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies. CONCLUSIONS: Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.
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Diabetes Mellitus Tipo 2 , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiología , HumanosRESUMEN
This article offers a systematic literature review (SLR) on the use of the MiniMed 780G automated insulin delivery system (MM780G) in people with type 1 diabetes (PwT1D) during Ramadan intermittent fasting. It also presents consensus recommendations on the use of MM780G during the Ramadan period. The SLR was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. The recommendations resulted from a consensus-forming process involving a panel of experts. The process considered evidence found in the SLR as well as the expert opinions. In total, six studies were included in the SLR. The evidence and expert opinions led to recommendations related to (a) pre-Ramadan counseling of MM780G users who plan to fast; (b) suggested MM780G settings, meal announcement strategy, and safety aspects during Ramadan (including a contingency plan); and (c) post-Ramadan transition into and out of Eid-al-Fitr festivities. The SLR findings showed that the MM780G maintains glycemic control at target in PwT1D during Ramadan (meeting continuous glucose monitoring-based clinical targets proposed by the International Consensus on Time-in-Range) while ensuring low rates of hypoglycemia and diabetic ketoacidosis. Automated insulin delivery also helps PwT1D fast more days of Ramadan compared with users of other less advanced modalities of treatment. Pre-Ramadan guidance on specific aspects of the MM780G along with the International Diabetes Federation and Diabetes and Ramadan International Alliance counseling guidelines is recommended. There is still a challenge with post-Iftar hyperglycemia, which could potentially be mitigated by following the recommendations outlined in this article.
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Background: Diabetic foot ulcers (DFUs) are debilitating to the patient and costly for the healthcare system. We set up the Diabetic Rapid Evaluation and lower limb Amputation Management (DREAM) clinic with the aim of providing early directed specialist care to patients with DFUs. With early management, we hope to treat DFUs in its early stages, reducing the need for and associated morbidity of major and minor lower limb amputations. Objectives: We evaluated the outcomes of the fast-access DREAM clinic with multi-disciplinary evaluation for patients with DFUs. Outcomes include time from the point of referral to DREAM clinic evaluation, amputation rates and wound healing rates. Design: Patients presenting with DFU to the DREAM clinic were enrolled. A podiatrist made the first assessment, followed by immediate specialist consultation with Endocrinologists, Vascular surgeons or Orthopaedic surgeons as required. Methods: Data on baseline demographics and DFU characteristics were collected. Outcomes evaluated were wound healing at 12 weeks, wound salvage rates, time to DREAM clinic access and time to specialist referral. Results: Sixty-eight patients were enrolled, with 57.3% males, and mean age of 63 ± 13.0 years. Majority of ulcers were classified as neuropathic (41.3%) and located at the digits (40%). At 12-weeks follow-up, 1 had undergone major amputation, 9 minor amputations and 4 surgical debridements. The median time to DREAM clinic evaluation from first presentation was 3 days (IQR 7). Eleven (16.2%) required >1 specialist consult. Twenty (29.4%) were hospitalised for treatment. Twelve underwent revascularisation within 4 days (IQR 3.5). Twenty-four patients (35.3%) continued podiatry follow-up, having 28 DFUs in which 20 (71.4%) healed within 12 weeks. Conclusion: The fast-access multidisciplinary DREAM clinic shows promising outcomes with lower major amputation rates and exemplary DFU healing outcomes.
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BACKGROUND: With the rising prevalence of diabetes, machine learning (ML) models have been increasingly used for prediction of diabetes and its complications, due to their ability to handle large complex data sets. This study aims to evaluate the quality and performance of ML models developed to predict microvascular and macrovascular diabetes complications in an adult Type 2 diabetes population. METHODS: A systematic review was conducted in MEDLINE®, Embase®, the Cochrane® Library, Web of Science®, and DBLP Computer Science Bibliography databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Studies that developed or validated ML prediction models for microvascular or macrovascular complications in people with Type 2 diabetes were included. Prediction performance was evaluated using area under the receiver operating characteristic curve (AUC). An AUC >0.75 indicates clearly useful discrimination performance, while a positive mean relative AUC difference indicates better comparative model performance. RESULTS: Of 13 606 articles screened, 32 studies comprising 87 ML models were included. Neural networks (n = 15) were the most frequently utilized. Age, duration of diabetes, and body mass index were common predictors in ML models. Across predicted outcomes, 36% of the models demonstrated clearly useful discrimination. Most ML models reported positive mean relative AUC compared with non-ML methods, with random forest showing the best overall performance for microvascular and macrovascular outcomes. Majority (n = 31) of studies had high risk of bias. CONCLUSIONS: Random forest was found to have the overall best prediction performance. Current ML prediction models remain largely exploratory, and external validation studies are required before their clinical implementation. PROTOCOL REGISTRATION: Open Science Framework (registration number: 10.17605/OSF.IO/UP49X).
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Diabetes Mellitus Tipo 2 , Adulto , Humanos , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Aprendizaje Automático , Redes Neurales de la Computación , Curva ROCRESUMEN
Ramadan fasting, a month-long annual practice for Muslims, can be challenging for those who have diabetes mellitus with or without associated complications or pre-existing comorbidities, as well as healthcare providers involved in their care. Inadequate preparation for this fasting period can result in increased complications. We reviewed the current practice of Muslims with diabetes mellitus in Singapore who intend to fast during Ramadan, with particular attention on locally available evidence. Adequate preparation for Ramadan fasting, including pre-Ramadan assessment, optimisation of glycaemic control, structured Ramadan-focused diabetes education, medication adjustment, glucose monitoring and test fasting, can lead to benefits in terms of improvements in metabolic control and reduced risk of fasting-related complications in people with diabetes mellitus. While there are ongoing efforts to reduce risk during this period, larger-scale national programmes are needed to avert complications and assess the long-term effects of Ramadan fasting in the local population.
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Diabetes Mellitus Tipo 2 , Humanos , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Islamismo , Singapur , Automonitorización de la Glucosa Sanguínea , Ayuno , GlucemiaRESUMEN
Background: Fasting during Ramadan is mandatory for all adult healthy Muslims. International studies found that most Muslims with diabetes mellitus fast during Ramadan. The main risk factors are hypoglycemia, Hyperglycemia, diabetic ketoacidosis, and dehydration during fasting. Therefore, stratification of the risks for severe acute diabetes complications needs to be considered for each individual and strategies personalized to advert these complications. The advent of new diabetes medications which are effective yet with a better safety profile and monitoring of blood glucose levels during the day are important to reduce the risk of untoward effects of hypoglycemia and hyperglycemia during Ramadan fasting. Here we review the safety and effectiveness of the newer diabetes medications for Ramadan fasting and whether it is safe to perform fasting after bariatric surgery. Methods: An extensive literature search using PubMed and Google Scholar was done using different search terms. The eligible studies were 48 randomized controlled trials, prospective observational studies, and reviews from January 2008 to June 2022 which were conducted in individuals living with diabetes. Results and Conclusions: The newer diabetes medications such as GLP-1 agonists, DPP-4 inhibitors, SGLT-2 inhibitors, and new Insulin therapy are thought to be safe and effective during fasting of Ramadan. These medications are associated with a reduction in HbA1c, body weight, systolic blood pressure and risk of hypoglycemia during Ramadan fasting. However, further studies with larger sample size are needed to confirm the efficacy and safety of these newer medications during Ramadan fasting. Individuals with Bariatric surgery should seek advice and approval to fast from the bariatric dietician, physician, and surgeon before the beginning of the month of Ramadan.
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Concurrent exercise and intermittent fasting regimens for long periods have been shown to enhance cardiometabolic health in healthy individuals. As exercise and fasting confer health benefits independently, we propose that Muslims who are fasting, especially those experiencing health and clinical challenges, continually engage in physical activity during the Ramadan month. In this opinion piece, we recommend walking football (WF) as the exercise of choice among Muslims who are fasting. WF can be played by any individual regardless of the level of fitness, skills, and age. WF has been shown to elicit cardiovascular and metabolic stress responses, which are suitable for populations with low fitness levels. Most importantly, WF has the inherent characteristics of being a fun team activity requiring social interactions among participants and, hence, likely to encourage long-term consistent and sustainable participation.
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OBJECTIVE: With rising health care costs and finite health care resources, understanding the population needs of different type 2 diabetes mellitus (T2DM) patient subgroups is important. Sparse data exist for the application of population segmentation on health care needs among Asian T2DM patients. We aimed to segment T2DM patients into distinct classes and evaluate their differential health care use, diabetes-related complications, and mortality patterns. RESEARCH DESIGN AND METHODS: Latent class analysis was conducted on a retrospective cohort of 71,125 T2DM patients. Latent class indicators included patient's age, ethnicity, comorbidities, and duration of T2DM. Outcomes evaluated included health care use, diabetes-related complications, and 4-year all-cause mortality. The relationship between class membership and outcomes was evaluated with the appropriate regression models. RESULTS: Five classes of T2DM patients were identified. The prevalence of depression was high among patients in class 3 (younger females with short-to-moderate T2DM duration and high psychiatric and neurological disease burden) and class 5 (older patients with moderate-to-long T2DM duration and high disease burden with end-organ complications). They were the highest tertiary health care users. Class 5 patients had the highest risk of myocardial infarction (hazard ratio [HR] 12.05, 95% CI 10.82-13.42]), end-stage renal disease requiring dialysis initiation (HR 25.81, 95% CI 21.75-30.63), stroke (HR 19.37, 95% CI 16.92-22.17), lower-extremity amputation (HR 12.94, 95% CI 10.90-15.36), and mortality (HR 3.47, 95% CI 3.17-3.80). CONCLUSIONS: T2DM patients can be segmented into classes with differential health care use and outcomes. Depression screening should be considered for the two identified classes of patients.
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Complicaciones de la Diabetes/mortalidad , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/mortalidad , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Costo de Enfermedad , Atención a la Salud/estadística & datos numéricos , Complicaciones de la Diabetes/complicaciones , Complicaciones de la Diabetes/epidemiología , Complicaciones de la Diabetes/terapia , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/terapia , Progresión de la Enfermedad , Femenino , Recursos en Salud/estadística & datos numéricos , Humanos , Análisis de Clases Latentes , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Estudios Retrospectivos , Singapur/epidemiología , Factores Socioeconómicos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/mortalidadRESUMEN
INTRODUCTION: This study aimed to explore the level of knowledge of Muslim patients with diabetes mellitus (DM) regarding DM and the self-management of DM when fasting during Ramadan. METHODS: Muslim patients with DM attending the Diabetes Centre of Singapore General Hospital, Singapore, were surveyed on their knowledge of DM and self-management of DM when fasting during Ramadan. Data on patient demographics, DM history and management of DM during the previous Ramadan was also collected. RESULTS: A total of 92 patients (34 male, 58 female) were surveyed. The mean age of the patients was 53.4 ± 13.3 years. The patients were either Malay (91.3%) or Indian (8.7%), and most (66.3%) had at least a secondary school education. Most (89.1%) had Type 2 DM. The mean duration of DM was 8.7 ± 5.1 years and mean pre-Ramadan haemoglobin A1c was 8.4% ± 1.8%. DM treatment consisted of insulin therapy (37.0%), oral glucose-lowering drugs (35.9%) and combined therapy (22.8%). The mean DM knowledge score was 58.8% for general knowledge and 75.9% for fasting knowledge. During the previous Ramadan, although 71.4% of the patients consulted their physicians, 37.3% did not monitor their blood glucose levels and 47.0% had hypoglycaemic episodes. Among those who had hypoglycaemia, 10.8% continued to fast. CONCLUSION: Unsafe self-management practices were observed among DM patients who fasted during Ramadan. Efforts should be made to bridge the gap between knowledge of DM and self-management of DM.
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Diabetes Mellitus Tipo 1/psicología , Diabetes Mellitus Tipo 2/psicología , Ayuno/psicología , Conocimientos, Actitudes y Práctica en Salud , Islamismo/psicología , Adulto , Anciano , Anciano de 80 o más Años , Glucemia , Estudios Transversales , Complicaciones de la Diabetes , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , Femenino , Hospitales Generales , Humanos , Hipoglucemia/complicaciones , Insulina/uso terapéutico , Masculino , Persona de Mediana Edad , Automanejo , Singapur/epidemiología , Encuestas y Cuestionarios , Adulto JovenRESUMEN
UNLABELLED: Type II amiodarone-induced thyrotoxicosis (AIT) is an uncommon cause of thyroid storm. Due to the rarity of the condition, little is known about the role of plasma exchange in the treatment of severe AIT. A 56-year-old male presented with thyroid storm 2months following cessation of amiodarone. Despite conventional treatment, his condition deteriorated. He underwent two cycles of plasma exchange, which successfully controlled the severe hyperthyroidism. The thyroid hormone levels continued to fall up to 10h following plasma exchange. He subsequently underwent emergency total thyroidectomy and the histology of thyroid gland confirmed type II AIT. Management of thyroid storm secondary to type II AIT can be challenging as patients may not respond to conventional treatments, and thyroid storm may be more harmful in AIT patients owing to the underlying cardiac disease. If used appropriately, plasma exchange can effectively reduce circulating hormones, to allow stabilisation of patients in preparation for emergency thyroidectomy. LEARNING POINTS: Type II AIT is an uncommon cause of thyroid storm and may not respond well to conventional thyroid storm treatment.Prompt diagnosis and therapy are important, as patients may deteriorate rapidly.Plasma exchange can be used as an effective bridging therapy to emergency thyroidectomy.This case shows that in type II AIT, each cycle of plasma exchange can potentially lower free triiodothyronine levels for 10h.Important factors to consider when planning plasma exchange as a treatment for thyroid storm include timing of each session, type of exchange fluid to be used and timing of surgery.
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INTRODUCTION: Millions of Muslim patients with diabetes mellitus (DM) fast during Ramadan. However, little is known about the metabolic impact of Ramadan fasting. We aimed to study the changes in body composition and metabolic profile in this group of patients. MATERIALS AND METHODS: We studied 29 Southeast Asian Muslim patients with type 2 diabetes; all underwent pre-Ramadan education. Study variables were weight change, body composition (using multifrequency bioimpedance method, InBody S20®, Biospace, South Korea), blood pressure (BP), glycated haemoglobin (HbA1c), fasting lipid profile, and caloric intake assessment using FoodWorks® nutrient analysis software. RESULTS: Twenty-three subjects fasted ≥15 days; mean ± SD: 57 ± 11 years; 52% were males. HbA1c improved significantly (8.6 ± 2.4% pre-Ramadan vs 8.0 ± 2.3% end-Ramadan, P = 0.017). Despite similar body weight, there was reduction in body fat mass (BFM) (30.9 ± 11 kg vs 29.2 ± 12.2 kg, P = 0.013). Multivariate analysis suggested that the reduction in HbA1c was attributed by reduction in BFM (ß = -0.196, P = 0.034). There was no change in visceral adiposity (visceral fat area (VFA)) but stratification by gender showed a reduction amongst females (137.6 ± 24.5 cm2 to 132.5 ± 25.7 cm2, P = 0.017). These changes occurred despite similar total caloric intake (1473.9 ± 565.4 kcal vs 1473.1 ± 460.4 kcal, P = 0.995), and proportion of carbohydrate (55.4 ± 6.3% vs 53.3 ± 7.5%, P = 0.25) and protein intake (17.6 ± 4.1% vs 17.3 ± 5.4%, P = 0.792), before and during Ramadan respectively, but with increased proportion of fat intake (11.9 ± 2.4% vs 13 ± 11.7%, P = 0.04). Seven out of 23 patients had medications adjusted to avert symptomatic hypoglycaemia but none of the patients developed severe hypoglycaemia. CONCLUSION: Ramadan fasting can be practiced safely with prior patient education and medication adjustment. It also confers modest benefits on metabolic profile and body composition, especially among females.