Screening for Glucose Perturbations and Risk Factor Management in Dysglycemic Patients With Coronary Artery Disease-A Persistent Challenge in Need of Substantial Improvement: A Report From ESC EORP EUROASPIRE V.

OBJECTIVE: Dysglycemia, in this survey defined as impaired glucose tolerance (IGT) or type 2 diabetes, is common in patients with coronary artery disease (CAD) and associated with an unfavorable prognosis. This European survey investigated dysglycemia screening and risk factor management of patients with CAD in relation to standards of European guidelines for cardiovascular subjects. RESEARCH DESIGN AND METHODS: The European Society of Cardiology's European Observational Research Programme (ESC EORP) European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V (2016-2017) included 8,261 CAD patients, aged 18-80 years, from 27 countries. If the glycemic state was unknown, patients underwent an oral glucose tolerance test (OGTT) and measurement of glycated hemoglobin A1c. Lifestyle, risk factors, and pharmacological management were investigated. RESULTS: A total of 2,452 patients (29.7%) had known diabetes. OGTT was performed in 4,440 patients with unknown glycemic state, of whom 41.1% were dysglycemic. Without the OGTT, 30% of patients with type 2 diabetes and 70% of those with IGT would not have been detected. The presence of dysglycemia almost doubled from that self-reported to the true proportion after screening. Only approximately one-third of all coronary patients had completely normal glucose metabolism. Of patients with known diabetes, 31% had been advised to attend a diabetes clinic, and only 24% attended. Only 58% of dysglycemic patients were prescribed all cardioprotective drugs, and use of sodium-glucose cotransporter 2 inhibitors (3%) or glucagon-like peptide 1 receptor agonists (1%) was small. CONCLUSIONS: Urgent action is required for both screening and management of patients with CAD and dysglycemia, in the expectation of a substantial reduction in risk of further cardiovascular events and in complications of diabetes, as well as longer life expectancy.

Assessment of the Dynamic Insulin Secretion and Sensitivity Test (DISST) Pre and Post Gastric bypass Surgery.

OBJECTIVE: To compare the dynamic insulin secretion and sensitivity test (DISST) with the euglycaemic clamp in individuals undergoing open Roux-en-Y gastric bypass (RYGB) surgery prior-to and one month after surgery. METHODS: Insulin sensitivity in individuals with obesity undergoing RYGB was studied with DISST and a euglycaemic hyperinsulinaemic clamp. RESULTS: Eleven participants, including nine females, mean(SD) age 51.2 (12.1) yrs, with a preoperative BMI of 48.7(9.5)kg/m2 were studied. Weight reduced from a mean (SD) of 133.8 (29.8) kg to 123.8 (28.9) kg post-surgery (p<0.001). The mean (SD) insulin sensitivity index (ISI-DISST) was 3.07×10-4 (2.18) L.pmol-1.min-1 preoperatively and 2.36 ×10-4 (0.78)L.pmol-1.min-1 postoperatively (p=0.37). The mean(SD) clamp ISI was 2.14 ×10-2 (1.80) mg.L.kg-1.min-1.pmol-1 and 2.00×10-2.(0.76) mg.L.kg-1.min-1.pmol-1 postoperatively (p=0.86). Correlation between ISI-DISST and ISI-Clamp preoperatively was r=0.81(95%CI 0.37-0.95) and post-operatively r=0.47(95%CI 0-0.88). Bland-Altman analysis demonstrates systematic bias between the two tests, where DISST underestimated insulin sensitivity compared with the clamp by 0.96×10-2.mg.L.kg-1.min-1.pmol-1 (95%CI -2.24 to 0.32). CONCLUSIONS: There was a strong correlation between DISST and the clamp preoperatively and DISST can be used to estimate insulin sensitivity in individuals with morbid obesity. After RYGB surgery, DISST had a weaker correlation with the clamp suggesting the fundamental physiological determinants of insulin sensitivity being measured by each method change in different ways with changes in glucose homeostasis following RYGB surgery.

Glucose Variability Based on Continuous Glucose Monitoring Assessment Is Associated with Postoperative Complications after Cardiovascular Surgery.

PURPOSE: This purpose of this prospective study was to use a continuous glucose monitoring (CGM) system to evaluate the suitability of our institution's glucose management protocol after cardiovascular surgery and to clarify the impact of glycemic variability on postoperative complications. METHODS: In all, 76 patients who underwent elective cardiovascular surgery and were monitored perioperatively using a CGM system were evaluated. Postoperative glucose management consisted of continuous intravenous insulin infusion (CIII) in the intensive care unit, and subcutaneous insulin injections (SQII) after oral food intake started. CIII and subcutaneous injections were initiated when blood glucose level exceeded 150 mg/dL. CGM data were used to analyze perioperative glycemic variability and association with postoperative complications. RESULTS: Target glucose levels (71-180 mg/dL) were achieved during 97.1 ± 5.5% and 86.4 ± 19.0% of the continuous insulin infusion and subcutaneous injection periods, respectively. Major postoperative complications were surgical site infections, found in 6.6% of total patients, and atrial fibrillation, found in 44% of patients with off-pump coronary artery bypass grafting. High glycemic variability during SQII was associated with increased risk for both complications. CONCLUSION: Data analysis revealed that our glucose management protocol during CIII was adequate. However, the management protocol during SQII required improvement.

Cardiovascular Risk Assessment: A Systematic Review of Guidelines.

BACKGROUND: Many guidelines exist for screening and risk assessment for the primary prevention of cardiovascular disease in apparently healthy persons. PURPOSE: To systematically review current primary prevention guidelines on adult cardiovascular risk assessment and highlight the similarities and differences to aid clinician decision making. DATA SOURCES: Publications in MEDLINE and CINAHL between 3 May 2009 and 30 June 2016 were identified. On 30 June 2016, the Guidelines International Network International Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and Web sites of organizations responsible for guideline development were searched. STUDY SELECTION: 2 reviewers screened titles and abstracts to identify guidelines from Western countries containing recommendations for cardiovascular risk assessment for healthy adults. DATA EXTRACTION: 2 reviewers independently assessed rigor of guideline development using the Appraisal of Guidelines for Research and Evaluation II instrument, and 1 extracted the recommendations. DATA SYNTHESIS: Of the 21 guidelines, 17 showed considerable rigor of development. These recommendations address assessment of total cardiovascular risk (5 guidelines), dysglycemia (7 guidelines), dyslipidemia (2 guidelines), and hypertension (3 guidelines). All but 1 recommendation advocates for screening, and most include prediction models integrating several relatively simple risk factors for either deciding on further screening or guiding subsequent management. No consensus on the strategy for screening, recommended target population, screening tests, or treatment thresholds exists. LIMITATION: Only guidelines developed by Western national or international medical organizations were included. CONCLUSION: Considerable discrepancies in cardiovascular screening guidelines still exist, with no consensus on optimum screening strategies or treatment threshold. PRIMARY FUNDING SOURCE: Barts Charity.

Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement.

DESCRIPTION: Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for diabetes in asymptomatic adults. METHODS: The USPSTF reviewed the evidence on screening for impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes in asymptomatic, nonpregnant adults who are at average or high risk for diabetes and its complications. POPULATION: This recommendation applies to adults aged 40 to 70 years seen in primary care settings who do not have symptoms of diabetes and are overweight or obese. RECOMMENDATION: The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (B recommendation).

Using Continuous Glucose Monitoring Data and Detrended Fluctuation Analysis to Determine Patient Condition: A Review.

Patients admitted to critical care often experience dysglycemia and high levels of insulin resistance, various intensive insulin therapy protocols and methods have attempted to safely normalize blood glucose (BG) levels. Continuous glucose monitoring (CGM) devices allow glycemic dynamics to be captured much more frequently (every 2-5 minutes) than traditional measures of blood glucose and have begun to be used in critical care patients and neonates to help monitor dysglycemia. In an attempt to obtain a better insight relating biomedical signals and patient status, some researchers have turned toward advanced time series analysis methods. In particular, Detrended Fluctuation Analysis (DFA) has been a topic of many recent studies in to glycemic dynamics. DFA investigates the "complexity" of a signal, how one point in time changes relative to its neighboring points, and DFA has been applied to signals like the inter-beat-interval of human heartbeat to differentiate healthy and pathological conditions. Analyzing the glucose metabolic system with such signal processing tools as DFA has been enabled by the emergence of high quality CGM devices. However, there are several inconsistencies within the published work applying DFA to CGM signals. Therefore, this article presents a review and a "how-to" tutorial of DFA, and in particular its application to CGM signals to ensure the methods used to determine complexity are used correctly and so that any relationship between complexity and patient outcome is robust.

Three-year effects on dietary quality of health education: a randomized controlled trial of people with screen-detected dysglycaemia (The ADDITION study, Denmark).

BACKGROUND: Healthy diet is a core component in prevention and self-management of type 2 diabetes and cardiovascular disease. The long-term efficacy was assessed of a theory-based health education programme 'Ready to Act' on dietary quality in people with screen-detected dysglycaemia. METHODS: Five hundred and nine adults with prediabetes (impaired glucose tolerance, impaired fasting glycaemia) or type 2 diabetes were recruited through screening for type 2 diabetes [the ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care) study, DK] and then randomly assigned to health education or to a control group (I = 322; C = 187). The intervention group was offered a 12-week programme in health-related action competence including 2 one-to-one and 8 group sessions (18 h). Dietary quality was measured by the Dietary Quality Score_revised (0-8 points) at baseline and at one- and 3-year follow-up. Changes were analysed by multilevel analyses. RESULTS: The analysis included data from 444 participants (87%). At the 3-year follow-up, the intervention group had significantly increased dietary quality compared with the control group (net change: 0.39 Dietary Quality Score_revised points, P = 0.04). The intake of unsaturated fats used on bread and for cooking increased in the intervention group compared with the control group at the 3-year follow-up (net change: 31 g/week; P = 0.02). A non-significant tendency toward an increased intake of vegetables in the intervention group compared with the control group was seen (net change: 111 g/week; P = 0.16). No changes were seen in fish intake. CONCLUSIONS: Health education aiming at action competence improved the long-term dietary quality in a population with dysglycaemia, especially according to the intake of unsaturated fat. The ADDITION trial was registered at ClinicalTrials.gov ID no NCT00237549.

Let's prevent diabetes: study protocol for a cluster randomised controlled trial of an educational intervention in a multi-ethnic UK population with screen detected impaired glucose regulation.

BACKGROUND: The prevention of type 2 diabetes is a globally recognised health care priority, but there is a lack of rigorous research investigating optimal methods of translating diabetes prevention programmes, based on the promotion of a healthy lifestyle, into routine primary care. The aim of the study is to establish whether a pragmatic structured education programme targeting lifestyle and behaviour change in conjunction with motivational maintenance via the telephone can reduce the incidence of type 2 diabetes in people with impaired glucose regulation (a composite of impaired glucose tolerance and/or impaired fasting glucose) identified through a validated risk score screening programme in primary care. DESIGN: Cluster randomised controlled trial undertaken at the level of primary care practices. Follow-up will be conducted at 12, 24 and 36 months. The primary outcome is the incidence of type 2 diabetes. Secondary outcomes include changes in HbA1c, blood glucose levels, cardiovascular risk, the presence of the Metabolic Syndrome and the cost-effectiveness of the intervention. METHODS: The study consists of screening and intervention phases within 44 general practices coordinated from a single academic research centre. Those at high risk of impaired glucose regulation or type 2 diabetes are identified using a risk score and invited for screening using a 75 g-oral glucose tolerance test. Those with screen detected impaired glucose regulation will be invited to take part in the trial. Practices will be randomised to standard care or the intensive arm. Participants from intensive arm practices will receive a structured education programme with motivational maintenance via the telephone and annual refresher sessions. The study will run from 2009-2014. DISCUSSION: This study will provide new evidence surrounding the long-term effectiveness of a diabetes prevention programme conducted within routine primary care in the United Kingdom. TRIAL REGISTRATION: Clinicaltrials.gov NCT00677937.

Evaluation of different methods for assessment of insulin sensitivity in Gottingen minipigs: introduction of a new, simpler method.

The use of animal models in diabetes research requires reliable tests for evaluation of insulin sensitivity and beta-cell function. Minipigs are being increasingly used in metabolic research, and the aim of this study was to compare different tests and indexes for evaluation of insulin sensitivity and beta-cell function in Göttingen minipigs. Hyperinsulinemic, isoglycemic clamp, intravenous (IVGTT) and oral glucose tolerance tests (OGTT), and a modified insulin tolerance test were performed in minipigs fed either low- or high-energy diet. Furthermore, the reproducibility of IVGTT-derived parameters was assessed. Previously described insulin sensitivity indexes [steady-state glucose infusion rate/glucose concentration/insulin concentration from clamp (M/G/I); oral glucose insulin sensitivity (OGIS) and ISI(comp) from OGTT; S(I) from minimal model analysis of IVGTT; and quantitative insulin sensitivity check index from fasting values] were calculated together with an insulin sensitivity index from the modified insulin tolerance test (ISI(ITT)) and a new simple index (S2) derived from the first 30 min of the IVGTT. beta-Cell function was assessed from the IVGTT and the OGTT. Reproducibility of the IVGTT-derived parameters was calculated as median intraindividual coefficient of variation (CV%).M/G/I correlated significantly only with S2 (P < 0.05, r = 0.54). S2 furthermore correlated with S(I) (P < 0.001, r = 0.81), ISI(ITT) (P < 0.001, r = 0.57), and the two indexes from OGTT, ISI(comp) (P < 0.001, r = 0.78) and OGIS (p < 0.05, r = 0.48). No correlation was found between beta-cell function indexes from OGTT and IVGTT. The median CV% of the new S2 index was 13. In conclusion, the new simple index of insulin sensitivity, S2, was revealed to be useful for evaluation of insulin sensitivity in pigs.

Assessment of mental deterioration with the Cognitive Abilities Screening Instrument (CASI) and glucose hypometabolism in Alzheimer's disease: the Osaki-Tajiri Project.

The Cognitive Abilities Screening Instrument (CASI) is a screening test for dementia consisting of 9 domains. We investigated the relationships between CASI domain scores and cerebral glucose metabolism (CMRglc) as shown by positron emission tomography. Fifteen patients with very mild Alzheimer's disease (AD) and 15 with mild AD were studied using the [(18)F]fluoro-deoxyglucose method. The 9 CASI domains were classified into four clusters (recent memory, frontal cortex cluster, posterior cortex cluster, and orientation). Using the region of interest method, the recent memory cluster was correlated with the bilateral hippocampal CMRglc, the frontal cortex cluster was correlated with the bilateral anterior and right inferior frontal CMRglc, the posterior cortex cluster was correlated with the bilateral temporo-parieto-occipital and occipital CMRglc, and the orientation cluster was correlated with the left anterior frontal CMRglc (Spearman's correlations). The use of statistical parametric mapping showed that most CASI domains were correlated with CMRglc of the left frontal lobe, the temporal lobe, and the angular gyrus. These findings show that the mental dysfunction assessed using CASI in AD patients has a neurobiological basis.