Effect of semaglutide on weight loss and glycaemic control in patients with Prader-Willi Syndrome and type 2 diabetes.

Prader-Willi Syndrome (PWS) is the most common genetic cause of obesity, occurring in approximately 1 in 15,000 newborns. It results from the lack of expression of genes on the paternal allele of the chromosomal region 15q-11q13 (65-75% due to type 1 or type 2 deletion). Individuals with PWS experience associated symptoms such as hypotonia, hyperphagia, and early-onset obesity (before 5 years of age). Around 20% of adults with PWS also develop type 2 diabetes. Previous studies have shown the beneficial effects of GLP1-RA medications, such as exenatide and liraglutide, in treating type 2 diabetes in PWS. However, there is limited information available on the use of semaglutide in PWS. This study aimed to evaluate the effects of semaglutide on weight loss and glycaemic control in four patients with PWS and type 2 diabetes associated with obesity. The patients were started on weekly subcutaneous progressive doses of semaglutide.

The Effects of Preoperative Glycaemic Control (HbA1c) on Bariatric and Metabolic Surgery Outcomes: Data from a Tertiary-Referral Bariatric Centre in the UK.

BACKGROUND: Current recommendations advocate the achievement of an optimal glucose control (HbA1c < 69 mmol/mol) prior to elective surgery to reduce risks of peri- and post-operative complications, but the relevance for this glycaemic threshold prior to Bariatric Metabolic Surgery (BMS) following a specialist weight management programme remains unclear. METHODS: We undertook a retrospective cohort study of patients with type 2 diabetes mellitus (T2DM) who underwent BMS over a 6-year period (2016-2022) at a regional tertiary referral following completion of a specialist multidisciplinary weight management. Post-operative outcomes of interest included 30-day mortality, readmission rates, need for Intensive Care Unit (ICU) care and hospital length of stay (LOS) and were assessed according to HbA1c cut-off values of < 69 (N = 202) and > 69 mmol/mol (N = 67) as well as a continuous variable. RESULTS: A total of 269 patients with T2D were included in this study. Patients underwent primary Roux en-Y gastric bypass (RYGB, n = 136), Sleeve Gastrectomy (SG, n = 124), insertion of gastric band (n = 4) or one-anastomosis gastric bypass (OAGB, n = 4). No significant differences in the rates of complications were observed between the two groups of pre-operative HbA1c cut-off values. No HbA1c threshold was observed for glycaemic control that would affect the peri- and post-operative complications following BMS. CONCLUSIONS: We observed no associations between pre-operative HbA1C values and the risk of peri- and post-operative complications. In the context of a specialist multidisciplinary weight management programme, optimising pre-operative HbA1C to a recommended target value prior to BMS may not translate into reduced risks of peri- and post-operative complications.

HCC is associated with diabetes and longitudinal blood glucose control in a national cohort with cirrhosis.

BACKGROUND: Diabetes is associated with HCC; however, the impact of longitudinal blood glucose (BG) control on HCC risk in cirrhosis is not well known. We investigated this knowledge gap in a cohort of United States Veterans with cirrhosis from 2015 to 2021. METHODS: We used repeated hemoglobin A1c measurements to categorize follow-up time according to BG control (defined as hemoglobin A1c < 7%) state over time: uncontrolled, nonsustained control (≤2 y), or sustained control (>2 y). We performed a sensitivity analysis using hemoglobin A1c < 8% to define BG control. We used Fine and Gray Cox proportional hazards regression with death and transplant as competing events to compare rates of incident HCC. RESULTS: Our study included 81,907 individuals, 56.2% of whom had diabetes at baseline. There were 8,002 incident HCCs. The rate of HCC was 18% higher in diabetes (95% CI: 13% - 24%), and the relative increase in the rate of HCC varied by etiology of cirrhosis from nonsignificant (HCV) to an increase of 120% (HBV). Uncontrolled and nonsustained BG control was associated with 1.80 (95% CI: 1.70-1.91) and 2.34 (95% CI: 2.21-2.48) times the rate of HCC compared to sustained BG control, respectively. Using Hgb A1c < 8% to define BG control, HCC rates in uncontrolled and nonsustained BG control were 2.43 (2.28-2.58) and 2.23 (2.11-2.36) times that observed in sustained BG control. CONCLUSIONS: Associations between diabetes and HCC in cirrhosis vary according to the longitudinal BG control state. Inadequate BG control is consistently associated with a higher risk of HCC, and long-term BG control should be considered in comprehensive cirrhosis care.

Glycemic control and macular edema in patients undergoing cataract surgery.

AIMS: Cataract, the most common cause of blindness, has higher prevalence among patients with diabetes mellitus. About 20% of cataract surgeries are performed on patients with diabetes. One of the complications of cataract surgery is pseudophakic cystoid macular edema (CME). This study examined whether patients' glycemic control (as indicated by HbA1c level before cataract surgery) is associated with CME incidence within one year post-surgery. METHODS: We conducted a retrospective cohort study of 1285 diabetes patients over age 18 who underwent cataract surgery between January 2015 and January 2020. Data were obtained from medical records reporting glycated hemoglobin (HbA1c) level prior to surgery and post-operative CME with intraocular anti-vascular endothelial growth factor injections. RESULTS: The patients with CME complications were younger, with longer duration diabetes, and higher percentages of type 1 diabetes and diabetic retinopathy. The main variables influencing risk of post-operative CME were found to be diabetic retinopathy and HbA1c level. Multivariate analysis revealed that HbA1c is an independent risk for post-operative CME with a relative risk of 2.01 when HBa1c is above 7 c (95% CI, 1.10-3.67). CONCLUSION: The study demonstrates that pre-cataract surgery diabetes control, measured by HbA1c level, is an independent risk factor for developing post-surgery CME.

Effects of Intensive Blood Glucose Control on Surgical Site Infection for Liver Transplant Recipients: A Randomized Controlled Trial.

BACKGROUND: The evidence supporting intensive blood glucose control to prevent surgical site infections (SSIs) among liver transplant recipients is insufficient. We aimed to assess the effects of postoperative intensive blood glucose control (IBGC) against standard blood glucose control (SBGC) on the incidence of SSIs among adult liver transplant recipients. METHODS: We performed a randomized controlled trial (ClinicalTrials.gov identifier NCT03474666). The IBGC target was 80 to 130 mg/dL, and the SBGC target was below 180 mg/dL. Analyses were made on an intention-to-treat basis. RESULTS: Of the 41 recipients enrolled onto the trial, 20 were randomly allocated to the IBGC group and 21 to the SBGC group. There were no significant differences in SSIs among recipients allocated to either group (relative risk [RR], 0.78; 95% confidence interval [CI], 0.21-2.88; P = .69). Mean (SD) blood glucose levels were significantly lower in the IBGC group in the 24-hour period after surgery (145.0 [20.7] mg/dL and 230.2 [51.6] mg/dL; P = .001). While there were fewer episodes of hypoglycemia in the IBGC group, this was not statistically significant. There were no episodes of severe hypoglycemia in either group. Hyperglycemia and severe hyperglycemia were significantly more frequent in the SBGC group (RR, 0.70; 95% CI, 0.52-0.93; P = .001 and RR, 0.07; 95% CI, 0.01-0.48; P = .001, respectively). Length of hospital stay was significantly shorter for recipients in the IBGC group (13.1 [5.5] days vs 19.3 [12.1] days; P = .04). CONCLUSIONS: Although this small trial did not find intensive control reduced SSI, it was associated with lower blood glucose levels, fewer episodes of hyperglycemia and severe hyperglycemia, and shorter length of hospital stay.

Conventional Glycaemic Control May Not Be Beneficial in Diabetic Patients Following Cardiac Surgery.

INTRODUCTION: Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and emerging literature suggests that flexible glycaemic control in diabetic patients may be preferable. This study aims to assess the relationship between maximal postoperative in-hospital blood glucose levels (BSL) and the morbidity and mortality outcomes of diabetic and non-diabetic cardiac surgery patients. METHODS: A retrospective cohort analysis of all patients undergoing cardiac surgery at a tertiary single centre institution from 2015 to 2019 was undertaken. Early management and outcomes of hyperglycaemia following cardiac surgery were assessed via multivariable regression modelling. Follow-up was assessed to 1 year postoperatively. RESULTS: Consecutive non-diabetic patients (n=1,050) and diabetic patients (n=689) post cardiac surgery were included. Diabetics with peak BSL ≤13.9 mmol/L did not have an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L was associated with overall wound complications (5.7% vs 8.8%, OR 1.64 [1.00-2.69], p=0.049) and postoperative pneumonia (2.7% vs 7.3%, OR 2.35 [1.26-4.38], p=0.007). Diabetic patients with postoperative peak BSL >13.9 mmol/L were at an increased risk of overall wound complication (7.4% vs 14.8%, OR 2.47 [1.46-4.16], p<0.001), graft harvest site infection (3.7% vs 11.8%, OR 3.75 [1.92-7.30], p<0.001), and wound-related readmission (3.1% vs 8.8%, OR 3.11 [1.49-6.47], p=0.002) when compared to diabetics with peak BSL ≤13.9 mmol/L. CONCLUSION: In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L is associated with morbidity. In diabetic patients, hyperglycaemia with peak BSL ≤13.9 mmol/L was not associated with an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. Further investigation of flexible glycaemic targets (target BSL ≤13.9 mmol/L) in diabetic patients is warranted.

Real-world effectiveness of liraglutide versus dulaglutide in Japanese patients with type 2 diabetes: a retrospective study.

Real-world data comparing the effectiveness of various glucagon-like peptide 1 receptor agonists (GLP-1 RAs) in type 2 diabetes mellitus (T2DM) are limited. We investigated the clinical effectiveness of liraglutide and dulaglutide in Japanese T2DM in a real-world setting. This retrospective study included 179 patients with T2DM who were treated with GLP-1 RA for at least 12 months (liraglutide, n = 97; dulaglutide, n = 82). We used stabilized propensity score-based inverse probability of treatment weighting (IPTW) to reduce selection bias and confounding by observed covariates. Changes in glycated hemoglobin (HbA1c) at the end of the 12-month treatment were evaluated. After adjustment by stabilized propensity score-based IPTW, no significant differences were observed in patient characteristics between the liraglutide and dulaglutide groups. HbA1c was significantly lower at 12 months in both groups (liraglutide, 8.9 to 7.4%; dulaglutide, 8.7 to 7.5%). Multivariate linear regression analysis showed no differences in the extent of changes in HbA1c at 12 months between the two agents. High baseline HbA1c, the addition of GLP-1 RA treatment modality, and in-hospital initiation of GLP-1 RA treatment were identified as significant contributing factors to HbA1c reduction. The effects of liraglutide and dulaglutide on lowering HbA1c levels at 12 months were comparable in a real-world setting.

Effects of consumption of coconut oil or coconut on glycemic control and insulin sensitivity: A systematic review and meta-analysis of interventional trials.

BACKGROUND AND AIMS: The often purported claim that coconut fat is beneficial for cardiovascular health and was disputed in several recent meta-analyses. However, the evidence on the effects of coconut fat intake on glycemic control remains equivocal. We conducted a systematic review and meta-analysis in accordance with the PRISMA guidelines to determine the effects of dietary coconut fats on markers of acute and long-term glycemic control. METHODS AND RESULTS: PubMed, Scopus, ProQuest, and Web-of-Science databases were searched and the records were screened by three independent reviewers to identify interventional studies examining acute and long-term (i.e., >10 days) effects of coconut fat on glycemic control. DerSimonian-Laird random-effects meta-analyses were performed using the meta-package in R (4.0.2). Seven interventional studies on acute effects and 11 interventional studies on long-term effects of coconut fat were included. Meals with coconut fat acutely increased the incremental area under the curve (AUC) of glucose (p = 0.046) and decreased the incremental AUC of insulin (p = 0.037) vs. control meals. Long-term coconut fat intake increased HOMA-IR (p = 0.049), but did not significantly affect fasting glucose, insulin, or HOMA-ß vs. control meals. CONCLUSIONS: Coconut fat in meals seems to be associated with a diminished postprandial insulin response, resulting in a subtle increase in the postprandial glycemic response. Long-term intake of coconut fat seems to increase insulin resistance, yet does not seem to be beneficial for long-term glycemic control. Thus, our results disprove the popular claim that coconut fat improves glycemic control. REGISTRATION: PROSPERO registry (CRD42020183450).

Glycemic control and associated factors in patients with type 1 diabetes mellitus in primary care in Southeastern Brazil

Abstract Diabetes is a self-managed condition with knowledge, attitudes and practices that can influence the overall treatment and outcomes delay the complications of diabetes. However, the few reported studies published point out that: low education level, poor adherence to pharmacotherapy and diet recommendations, infrequent monitoring of blood glucose, and insulin dosage regimen are associated with higher hemoglobin levels. This study aimed to assess the knowledge, adherence medication, and complexity of pharmacotherapy in T1DM patients in Brazil. A cross-sectional study was conducted involving 156 T1DM patients who were attending in primary care. Logistic regression analyses were conducted to assess the variables associated with glycemic control. The overall assessments of T1DM patients for the glycemic control were bad (121, 77.6%). However, T1DM patients with high MedTake Test (OR=2.4, CI=1.1-5.7) and Morisky-Green Test (OR= 2.5, CI=1.1-6.1), and in the use of dosage insulin (>40 units, OR=0.3, CI=0.1-0.7) and postprandial glucose (100-125mg/dl, OR=3.8, CI=1.1-14.6) had better glycemic control compared to uncontrolled patients. Glycemic control in Brazilians adults with T1DM is low. We suggested the screening patients with low MedTake and Morisky-Green Tests, increasing patient knowledge as part of a complex intervention that may lead to substantially improved treatment outcomes in primary care

Lesiones cutáneas asociadas al uso de bombas de insulina y sistemas de monitoreo: un problema desafiante / Insulin pumps and glucose monitors related cutaneous lesions: a challenging problem

Los cuidados actuales de la diabetes incluyen altos niveles de tecnología y los pacientes utilizan diferentes dispositivos que pueden ayudar en su control metabólico, pero pueden impactar negativamente en su piel. Sensores de glucosa como el Freestyle, Dexcom, el Enlite de Medtronic y los sistemas de infusión continua de insulina contienen diferentes productos químicos que están en contacto directo con la piel del paciente y pueden causar una dermatitis irritativa o de contacto alérgica. Las lesiones incluyen eczema, prurito, heridas, cicatrices y cambios en la pigmentación de la piel. Los productos químicos involucrados que pueden ocasionarlas son el isobornil acrilato, N, N- dimetilacrilamida, etil cianoacrilato y colophonium, forzando a los pacientes a cambiar los sitios de infusión, el set de infusión o el sensor mismo más pronto de lo esperado, para reducir el nivel de daño en la piel. Existe gran número de productos que permiten proteger la piel y reducir el contacto de la piel con la cánula de la bomba o el sensor. Para reducir o prevenir el daño existen productos como cremas o spray y parches de hidrocoloide que actúan como barrera y existen técnicas para aplicar y retirar cuidadosamente los parches y adhesivos de los dispositivos. Una vez que las lesiones se han producido, el tratamiento incluye pomadas y a veces corticoides tópicos y/o antibióticos. Para prevenir o reducir el daño de la piel asociado al sensor y uso de la bomba de insulina, la industria que los produce debería incluir la información en relación a los productos químicos incluidos en cada dispositivo.

Diabetes care nowadays includes a high level of technology and patients use different devices which can help them in their glycemic control, but can have a negative impact on their skin. Glucose sensors such as Freestyle, Dexcom, Medtronic Enlite and also continuous subcutaneous insulin infusion systems contain different chemical products which are in direct contact with the patient's skin and can cause irritative or allergic contact dermatitis. Lesions include eczema, pruritus, wounds, scars and changes in skin pigmentation. The chemical products which can induce them are isobornyl acrylate, N, N- dimethylacrylamide, ethyl cyanoacrylate and colophonium, forcing patients to change the infusion site, set or the sensor itself, earlier than expected, in order to reduce the level of skin damage. There are a number of products which can protect the skin and reduce it's contact with the pump cannula or the sensor. To reduce or prevent damage, we have products such as barrier cream or spray films and hydrocolloid blister plasters and actions such as careful application and removal of device's patches and adhesives. Once lesions are established, treatment includes ointments and sometimes topical steroids and/ or antibiotics. In order to prevent or reduce skin damage related to sensor and insulin pump use, the manufacturers should include the information related to the chemicals included in each device.

Oral GLP-1 analogue: perspectives and impact on atherosclerosis in type 2 diabetic patients.

Cardiovascular events related to atherosclerosis are responsible for high morbidity and mortality among patients with type 2 diabetes. Improvement in care, especially in early stages, is crucial. Oral semaglutide, a glucagon-like peptide 1 analogue, controls blood glucose and results in significant body weight loss in patients with type 2 diabetes. Beyond these well-known effects, an interesting aspect of this drug is its antiatherogenic activity, which should be further explored in clinical practice. This paper reviews the evidence related to oral semaglutide decreasing cardiovascular risk in patients with type 2 diabetes, focusing on the drug's antiatherosclerotic properties. The glucagon-like peptide 1 analogue restores endothelial dysfunction, induces vasodilatation, and reduces plasma lipids. Oral semaglutide showed cardiovascular safety profile, with significant reduced risk of death from cardiovascular events. Based on current data, clinicians should consider oral semaglutide for type 2 diabetes management.

Efficacy and safety of once-weekly dulaglutide in adult Chinese patients with type 2 diabetes and lower baseline body mass index.

Highlights In Chinese patients with type 2 diabetes (T2D) and body mass index (BMI) <25 kg/m2 , dulaglutide demonstrated great improvements in glycemic control with mild body weight reduction and low hypoglycemia risk. The results indicate that dulaglutide is effective and safe in patients with T2D and lower BMI; therefore, BMI should not be a consideration when dulaglutide is prescribed to Chinese patients with T2D.

Comparative effectiveness of dulaglutide versus liraglutide in Asian type 2 diabetes patients: a multi-institutional cohort study and meta-analysis.

BACKGROUND: Head-to-head comparison of clinical effectiveness between dulaglutide and liraglutide in Asia is limited. This study was aimed to assess the real-world comparative effectiveness of dulaglutide versus liraglutide. METHODS: We conducted a retrospective cohort study by utilizing multi-institutional electronic medical records to identify real-world type 2 diabetes patients treated with dulaglutide or liraglutide during 2016-2018 in Taiwan and followed up until 2019. Effectiveness outcomes were assessed at every 3 months in the 1-year follow-up. Propensity score techniques were applied to enhance between-group comparability. Significant differences in changes of effectiveness outcomes between treatment groups during the follow-up were examined and further analyzed using mixed-model repeated-measures approaches. RESULTS: A total of 1512 subjects receiving dulaglutide and 1513 subjects receiving liraglutide were identified. At 12 months, significant HbA1c changes from baseline were found in both treatments (dulaglutide: - 1.06%, p < 0.001; liraglutide: - 0.83%, p < 0.001), with a significant between-group difference (- 0.23%, 95% confidence interval - 0.38 to - 0.08%, p < 0.01). Both treatments yielded significant declines in weight, alanine aminotransferase level, and estimated glomerular filtration rate from baseline (dulaglutide: - 1.14 kg, - 3.08 U/L and - 2.08 mL/min/1.73 m2, p < 0.01; liraglutide: - 1.64 kg, - 3.65 U/L and - 2.33 mL/min/1.73 m2, p < 0.001), whereas only dulaglutide yielded a significant systolic blood pressure reduction (- 2.47 mmHg, p < 0.001). Between-group differences in changes of weight, blood pressure, and liver and renal functions at 12 months were not statistically significant. CONCLUSIONS: In real-world T2D patients, dulaglutide versus liraglutide was associated with better glycemic control and comparable effects on changes of weight, blood pressure, and liver and renal functions.

Omega-3 polyunsaturated fatty acid supplementation versus placebo on vascular health, glycaemic control, and metabolic parameters in people with type 1 diabetes: a randomised controlled preliminary trial.

BACKGROUND: The role of omega-3 polyunsaturated fatty acids (n-3PUFA), and the potential impact of n-3PUFA supplementation, in the treatment and management of type 1 diabetes (T1D) remains unclear and controversial. Therefore, this study aimed to examine the efficacy of daily high-dose-bolus n-3PUFA supplementation on vascular health, glycaemic control, and metabolic parameters in subjects with T1D. METHODS: Twenty-seven adults with T1D were recruited to a 6-month randomised, double-blind, placebo-controlled trial. Subjects received either 3.3 g/day of encapsulated n-3PUFA or encapsulated 3.0 g/day corn oil placebo (PLA) for 6-months, with follow-up at 9-months after 3-month washout. Erythrocyte fatty acid composition was determined via gas chromatography. Endpoints included inflammation-associated endothelial biomarkers (vascular cell adhesion molecule-1 [VCAM-1], intercellular adhesion molecule-1 [ICAM-1], E-selectin, P-selectin, pentraxin-3, vascular endothelial growth factor [VEGF]), and their mediator tumor necrosis factor alpha [TNFα] analysed via immunoassay, vascular structure (carotid intima-media thickness [CIMT]) and function (brachial artery flow mediated dilation [FMD]) determined via ultrasound technique, blood pressure, glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG), and postprandial metabolism. RESULTS: Twenty subjects completed the trial in full. In the n-3PUFA group, the mean ± SD baseline n-3PUFA index of 4.93 ± 0.94% increased to 7.67 ± 1.86% (P < 0.001) after 3-months, and 8.29 ± 1.45% (P < 0.001) after 6-months. Total exposure to n-3PUFA over the 6-months (area under the curve) was 14.27 ± 3.05% per month under n-3PUFA, and 9.11 ± 2.74% per month under PLA (P < 0.001). VCAM-1, ICAM-1, E-selectin, P-selectin, pentraxin-3, VEGF, TNFα, CIMT, FMD, blood pressure, HbA1c, FPG, and postprandial metabolism did not differ between or within groups after treatment (P > 0.05). CONCLUSIONS: This study indicates that daily high-dose-bolus of n-3PUFA supplementation for 6-months does not improve vascular health, glucose homeostasis, or metabolic parameters in subjects with T1D. The findings from this preliminary RCT do not support the use of therapeutic n-3PUFA supplementation in the treatment and management of T1D and its associated complications. Trial Registration ISRCTN, ISRCTN40811115. Registered 27 June 2017, http://www.isrctn.com/ISRCTN40811115 .

Clinical efficacy and predictors of response to dulaglutide in type-2 diabetes.

Aim of this retrospective multicenter observational study was to evaluate the efficacy and safety of the glucagon-like peptide-1 receptor agonist (GLP-1 RA) dulaglutide in a type-2 diabetic real-world population and to determine the factors predicting the response in terms of glycated haemoglobin (HbA1c) and other relevant clinical outcomes. Data for efficacy outcomes, adverse events and drug discontinuation were collected from records of patients with type-2 diabetes treated with once-a-week 1.5 mg of dulaglutide for 12 months in routine clinical practice. Initial analysis included 782 patients and 626 had complete follow-up at 6- and 12-months. There was a significant reduction of HbA1c at 6 months (-1 ± 0.8 %, p < 0.0001), which remained stable at 12-months follow-up (-1 ± 0.9 %, p < 0.0001). The percentage of subjects with HbA1c≤7.0 % increased significantly from 7.2 % at baseline to 52.7 % at 6 months to 55.8 % at 12 months. Predictors of the achievement of HbA1c≤7.0 % were low baseline HbA1c and short duration of diabetes. The reduction of HbA1c was associated with reductions of BMI, waist circumference, fasting plasma glucose and blood pressures. Neither sex nor age had significant effects on any clinical or laboratory outcome. The effects of dulaglutide on HbA1c, BMI and SBP tended to be greater in patients who shifted from dipeptidyl peptidase-IV inhibitors (-0.8 ± 0.8 %) than other GLP-1 RA, even if an improvement of HbA1c reduction (-0.5 %) was also seen in those shifting from other GLP-1 RA. This study confirms that addition of dulaglutide 1.5 mg once a week in real word settings has beneficial effects on both clinical and laboratory outcomes in patients with uncontrolled type-2 diabetes. Dulaglutide has a greater effect on HbA1c in patients with higher baseline values and helps achieve a target HbA1c≤7.0 %, more consistently in patients with lower baseline HbA1c and shorter diabetes duration.

Association between intensive glycemic control and mortality in elderly diabetic patients in the primary care: A retrospective cohort study.

OBJECTIVE: To examine the association between the most recent HbA1c values and the mortality of elderly Type 2 Diabetic (T2DM) patients managed in the public primary care setting and to explore the associating risk factors. DESIGN: Retrospective cohort study. SUBJECTS: All T2DM patients aged 65 or above, who attended a public primary care clinic for regular follow up from 01/01/2012 to 31/12/2012 were included. Their follow up status till 31/12/2017 was reviewed. Those who were deceased on or before 31/12/2017 were matched randomly with controls that were alive in the same cohort for comparison. MAIN OUTCOME MEASURES: Patients' demographics, smoking status, duration of T2DM, biochemical parameters including the most recent HbA1c, lipid profile, renal function test, drug profile, co-morbidities and all-cause mortality were retrieved from Hospital Authority's CDARS and CMS systems. RESULTS: Both high (>8.0%) and low (<6.5%) HbA1c values were associated with increased odd ratio of all-cause mortality among T2DM elderly patients treated in the primary care. There was a 3-fold increase in odd ratio when the HbA1c reading was very low (<6.0%). Associated risk factors for all-cause mortality in elderly T2DM patients included smoker status, lower BMIs, and higher LDL levels and use of sulphonylureas. CONCLUSIONS: Glycemic target for elderly T2DM patients should be approached cautiously. Over-aggressive treatment may lead to increased mortality among elderly T2DM patients.

Poor glycemic control is associated with significant increase in major limb amputation and adverse events in the 30-day postoperative period after infrainguinal bypass.

OBJECTIVE: Understanding modifiable risk factors to improve surgical outcomes is increasingly important in value-based health care. There is an established association between peripheral artery disease (PAD), diabetes, and limb loss, but less is known about expected outcomes after revascularization relative to the degree of glycemic control. The purpose of this study was to determine the association between hemoglobin A1c (HbA1c) management in diabetics and surgical outcomes after open infrainguinal bypass. METHODS: The Vascular Quality Initiative infrainguinal bypass module was used to identify adult patients (≥18 years) with a history of diabetes who underwent bypass for PAD between 2011 and 2018. Exclusion criteria included missing or illogical HbA1c values and if the indication for the limb treated was not PAD. Patients were categorized by preoperative HbA1c levels as low severity/controlled (<7.0%), high severity (7.0%-10.0%), and very high severity (>10.0%). Primary outcomes were 30-day incidence of major adverse cardiac events (MACEs), major adverse limb events (MALEs), ipsilateral amputation, and 1-year all-cause mortality. Thirty-day outcomes were calculated using multivariable regression to compute odds ratios; hazard ratios were calculated for all-cause mortality. All analyses were adjusted for demographics, comorbidities, and clinical characteristics. RESULTS: The final sample included 30,813 operations (27,988 unique patients): 17,517 (57%) nondiabetic patients, 5194 patients with low-severity/controlled diabetes, and 8102 (26%) patients with poorly controlled diabetes, including 5531 (70%) treated with insulin. There were 6439 (21%) patients with high-severity HbA1c values and 1663 (5%) patients with very-high-severity HbA1c values. Those with a very high HbA1c level were more likely to be nonwhite, insulin dependent, and active smokers. Compared with nondiabetics, patients with very-high-severity HbA1c had an 81% increase in MACEs and 31% increase in MALEs, whereas patients with high-severity HbA1c only had a 49% increase in MACEs and a 12% increase in MALEs. Each one-step increase in severity category (eg, low to high to very high) was associated with an average 29% increase in the odds of MACEs and an 8% increase in the odds of MALEs. CONCLUSIONS: Uncontrolled diabetes with an HbA1c value >10.0% was associated with significantly worse 30-day surgical outcomes. Patients with incrementally better glycemic control (HbA1c level of 7.0%-10.0%) did not suffer the same rate of complications, suggesting that preoperative attempts at improving diabetes management even slightly could lead to improved surgical outcomes in open infrainguinal bypass patients.

Valoración de la glucemia sérica como marcador pronóstico en el paciente séptico crítico / Assessment of serum glycemia as a prognostic marker in critically septic patient

La glucemia es factor de riesgo de infección, sin embargo, no existen evidencias suficientes que permitan utilizarla como marcador pronóstico de mortalidad en el paciente séptico crítico. Se realizó un estudio longitudinal y prospectivo, para evaluar la utilidad de la glucemia como factor pronóstico de mortalidad en pacientes sépticos críticos. Se incluyeron 206 pacientes que ingresaron de forma consecutiva en la Terapia Intensiva (piso 8) del Hospital "Hermanos Ameijeiras". La gravedad se evaluó a través de la escala Simplified Acute Physiology Score (SAPS-3). Se midió el valor diario de glucemia en ayunas durante los primeros 6 días de estadía, el valor más alto de los 3 primeros días y la diferencia de valores entre el tercer y el primer día. Se aplicó el coeficiente de correlación de Spearman para variables cuantitativas. Se estudió el valor independiente de la variable mediante varios modelos de regresión logística. Se consideró una significación estadística de p<0,05. Se encontró asociación entre el SAPS-3 y la glucemia del primer día (p=0,01). Los valores de glucemia entre vivos y fallecidos no mostraron diferencias significativas. El valor más alto de glucemia de los 3 primeros días para sobrevivientes fue de 8,41 (±3,25) mmol/L, y 8,72 (±3,04) mmol/L para los fallecidos. No hubo diferencias entre la resta de los valores de glucemia entre el tercer y el primer día entre vivos (-0,17±3,9 mmol/L) y fallecidos (0,07±2,8 mmol/L) (p=0,66). No se demostró utilidad de la glucemia como marcador pronóstico en relación con la mortalidad en pacientes con sepsis, aunque la glucemia del primer día se asoció con la gravedad(AU)

Glycemia is a infection risk factor, however, there are not enough evidences allowing its use as a prognostic marker of mortality in critical septic patients. Study includes 206 patients admitted in a consecutive way in Intensive Therapy Care (eight floor) of the "Hermanos Ameijeiras" Clinical Surgical Hospital. Severity was assessed according to the Simplified Acute Physiology Score scale (SAPS-3). The fasting daily value of glycemia was measured for the first 6 days of stay, the higher value during the 3 first days and the values difference between the third and the first day. The Spearmen's correlation coefficient was applied for quantitative variables. The independent value of the variable was studied using several logistic regression forms. A statistic significance of p<0,05 was considered. There was association between SAPS-3 and the first day glycemia (p=0,01). Glycemia among the living and death persons haven't significant differences. The higher value of glycemia of the first three days for survivors was of 8,41 (±3,25) mmol/L and 8,72 (±3,04) mmol/L for deceased. There weren't differences between the glycemia subtraction between the third and the first day among the leaving persons(-0,17 ±3,9 mmol/L) and those deceased (0,07±2,8 mmol/L) (p=0,66). It was impossible to demonstrate the usefulness of glycemia as a prognostic marker in relation to mortality in patients presenting with sepsis although glycemia of first day was associated with severity(AU)