In latent autoimmune diabetes in adults, mortality was similar to T2DM but retinopathy was higher at 5.9 y.

SOURCE CITATION: Wei Y, Herzog K, Ahlqvist E, et al. All-cause mortality and cardiovascular and microvascular diseases in latent autoimmune diabetes in adults. Diabetes Care. 2023;46:1857-1865. 37635682.

In type 2 diabetes, the effectiveness and side effects of GLP-1 RAs vary.

SOURCE CITATION: Yao H, Zhang A, Li D, et al. Comparative effectiveness of GLP-1 receptor agonists on glycaemic control, body weight, and lipid profile for type 2 diabetes: systematic review and network meta-analysis. BMJ. 2024;384:e076410. 38286487.

'Werner Syndrome foot'-A case series of four Irish Traveller siblings with Werner Syndrome, diabetes mellitus and complex foot disease.

AIMSWERNER SYNDROME IS A RARE PREMATURE AGEING AUTOSOMAL RECESSIVE DISORDER CAUSED BY PATHOGENIC VARIANTS IN THE WRN GENE. PEOPLE WITH WERNER SYNDROME MAY DEVELOP DIABETES MELLITUS. CHRONIC FOOT ULCERATION IS SEEN, WITH SOME CHARACTERISTICS OVERLAPPING WITH DIABETIC FOOT DISEASE. HOWEVER, THE CLINICAL COURSE OF THE ULCERATION IS ATYPICAL OF DIABETIC FOOT DISEASE. WE PRESENT FOUR SIBLINGS FROM AN IRISH TRAVELLER FAMILY WITH WERNER SYNDROME TO HIGHLIGHT THE COMPLEXITY OF THIS CONDITION. THE IRISH TRAVELLER POPULATION ARE AN INDIGENOUS, ENDOGAMOUS POPULATION IN WHICH CONSANGUINITY IS COMMON. AS A RESULT, RARE AUTOSOMAL RECESSIVE DISORDERS ARE PREVALENT AMONG THIS POPULATION: . METHODS: We describe our experience managing the complex foot disease seen in all four siblings. Foot complications present in the siblings include painful peripheral neuropathy, chronic foor ulceration, underlying osteomyelitis and acral melanoma. RESULTS: The cases are described individually, with a particular focus on the complex foot disease associated with the condition. CONCLUSIONS: Although the siblings attend a diabetic foot clinic, we suggest that the combination of clinical features seen in these cases is unique to Werner syndrome and warrants the title 'Werner Syndrome' (rather than 'Diabetic') foot.

In type 1 diabetes, weekly basal insulin Fc was noninferior to daily insulin degludec for HbA1c at 26 wk.

SOURCE CITATION: Kazda CM, Bue-Valleskey JM, Chien J, et al. Novel once-weekly basal insulin Fc achieved similar glycemic control with a safety profile comparable to insulin degludec in patients with type 1 diabetes. Diabetes Care. 2023;46:1052-1059. 36920867.

In type 2 diabetes, weekly basal insulin Fc was noninferior to daily insulin degludec for HbA1c at 26 wk.

SOURCE CITATION: Bue-Valleskey JM, Kazda CM, Ma C, et al. Once-weekly basal insulin Fc demonstrated similar glycemic control to once-daily insulin degludec in insulin-naive patients with type 2 diabetes: a phase 2 randomized control trial. Diabetes Care. 2023;46:1060-1067. 36944059.

In T1DM, open-source automated insulin delivery increased glucose time in target vs. sensor-augmented pumps.

SOURCE CITATION: Burnside MJ, Lewis DM, Crocket HR, et al. Open-source automated insulin delivery in type 1 diabetes. N Engl J Med. 2022;387:869-81. 36069869.

Implementing an integrated diabetic foot care programme in Ireland: podiatrists' experience.

BACKGROUND: International evidence suggests that an integrated multidisciplinary approach to diabetic foot management is necessary to prevent ulceration and progression to amputation. Many health systems have introduced policies or models of care supporting the introduction of this evidence into practice, but little is known about the experiences of those involved in implementation. This study addresses this gap by examining the experiences of podiatrists providing integrated diabetic foot care. METHODS: Between October 2017 and April 2018, an online survey comprising closed and open-ended questions on podiatrists' demographics, clinical activity, links with other services, continuous professional development activities and experiences of implementing the Model of Care was administered to podiatrists (n = 73) working for Ireland's Health Service Executive in the community and hospital setting. Data were analysed using descriptive statistics and qualitative content analysis. RESULTS: The response rate was 68% (n = 50), with 46% (n = 23), 38% (n = 19) and 16% (n = 8) working across hospital, community and both settings, respectively. Most reported treating high-risk patients (66%), those with active foot disease (61%) and educating people about the risk of diabetes to the lower limb (80%). Reported challenges towards integrated diabetic foot care include a perceived lack of awareness of the role of podiatry amongst other healthcare professionals, poor integration between hospital and community podiatry services, especially where new services had been developed, and insufficient number of podiatrists to meet service demands. CONCLUSION: Previous evidence has shown that there is often a gap between what is set out by a policy and what it looks like when delivered to service users. Results from the current study support this, highlighting that while most podiatrists work in line with national recommendations, there are specific gaps and challenges that need to be addressed to ensure successful policy implementation.

Estimating the cost of type 1 diabetes in Ireland.

BACKGROUND: Type 1 diabetes is a chronic disease, which given its existing and projected prevalence, is likely to pose a significant economic burden, both in terms of directs costs to the healthcare system and indirect costs to society. We aimed to estimate the economic burden of type 1 diabetes in Ireland, which at present, is unknown. METHODS: A cost of illness study was undertaken to estimate the cost of type 1 diabetes in Ireland for 2018. Data for prevalence, morbidity, mortality, healthcare resource use, absenteeism, and unit costs were obtained from national, and where necessary, international sources. Direct healthcare costs were estimated for primary care, outpatient, emergency and inpatient care, for associated complications, structured education programmes, insulin and related care. Additionally, indirect costs from lost earnings due to premature death and employee absenteeism were estimated. RESULTS: Type 1 diabetes was estimated to cost €129 million in Ireland in 2018, with direct healthcare costs accounting for €81.5 million or 63% and indirect costs for €47.5 million or 37% of the total. On average, this amounted to €3994 per patient in direct healthcare costs and €2326 per patient in indirect costs. CONCLUSION: Type 1 diabetes is a leading public health problem. Our study is the first to assess the economic burden of type 1 diabetes in Ireland, and our results should be informative to policymakers tasked with prioritising healthcare and research funding resource allocation.

International comparison of glycaemic control in people with type 1 diabetes: an update and extension.

AIMS: To update and extend a previous cross-sectional international comparison of glycaemic control in people with type 1 diabetes. METHODS: Data were obtained for 520,392 children and adults with type 1 diabetes from 17 population and five clinic-based data sources in countries or regions between 2016 and 2020. Median HbA1c (IQR) and proportions of individuals with HbA1c < 58 mmol/mol (<7.5%), 58-74 mmol/mol (7.5-8.9%) and ≥75 mmol/mol (≥9.0%) were compared between populations for individuals aged <15, 15-24 and ≥25 years. Logistic regression was used to estimate the odds ratio (OR) of HbA1c < 58 mmol/mol (<7.5%) relative to ≥58 mmol/mol (≥7.5%), stratified and adjusted for sex, age and data source. Where possible, changes in the proportion of individuals in each HbA1c category compared to previous estimates were calculated. RESULTS: Median HbA1c varied from 55 to 79 mmol/mol (7.2 to 9.4%) across data sources and age groups so a pooled estimate was deemed inappropriate. OR (95% CI) for HbA1c < 58 mmol/mol (<7.5%) were 0.91 (0.90-0.92) for women compared to men, 1.68 (1.65-1.71) for people aged <15 years and 0.81 (0.79-0.82) aged15-24 years compared to those aged ≥25 years. Differences between populations persisted after adjusting for sex, age and data source. In general, compared to our previous analysis, the proportion of people with an HbA1c  < 58 mmol/l (<7.5%) increased and proportions of people with HbA1c ≥ 75 mmol/mol (≥9.0%) decreased. CONCLUSIONS: Glycaemic control of type 1 diabetes continues to vary substantially between age groups and data sources. While some improvement over time has been observed, glycaemic control remains sub-optimal for most people with Type 1 diabetes.

In T2DM, weekly insulin icodec did not differ from daily glargine for reducing HbA1c or significant/severe hypoglycemia.

SOURCE CITATION: Rosenstock J, Bajaj HS, Janez A, et al. Once-weekly insulin for type 2 diabetes without previous insulin treatment. N Engl J Med. 2020:383:2107-16. 32960514.

In men who are overweight or obese, adding testosterone therapy reduced glucose intolerance/T2DM.

SOURCE CITATION: Wittert G, Bracken K, Robledo KP, et al. Testosterone treatment to prevent or revert type 2 diabetes in men enrolled in a lifestyle programme (T4DM): a randomised, double-blind, placebo-controlled, 2-year, phase 3b trial. Lancet Diabetes Endocrinol. 2021;9:32-45. 33338415.

A simulation study of the economic and health impact of a diabetes prevention programme in Ireland.

AIMS: Type 2 diabetes is a major public health issue that has a large effect on society including its health and social services. The aims of this paper are to generate a projection of the number of cases and explore the potential impact of a preventive intervention targeted at people with pre-diabetes on disease prevalence, complications, mortality and cost. METHODS: A Markov simulation model of diabetes and pre-diabetes in Ireland, for the period 1991 to 2036, was generated based on international epidemiological data. The simulation was calibrated with the available Irish data on the prevalence of pre-diabetes, diabetes and diabetic complications. The economic and health impact of a hypothetical nationwide preventive intervention programme, which reduces the incidence by a factor consistent with the international literature, was estimated under three scenarios of alternative effectiveness and uptake. RESULTS: The estimated number of people over 40 years of age with type 2 diabetes in Ireland is projected to increase from 216,000 in 2020 to 414,000 in 2036. A prevention programme, based on the NHS Diabetes Prevention Programme, is estimated to result in a reduction of between 2000 (0.5%) and 19,000 (4.6%) in the number of prevalent cases of diabetes in 2036 resulting in substantial health and quality of life benefits. CONCLUSIONS: A wide range of initiatives with uncertain outcomes will be required to reduce the impact of obesity and type 2 diabetes. A diabetes prevention programme seems likely to be worth pursuing as one element of this set of initiatives.

Diabetes distress instruments in adults with Type 1 diabetes: A systematic review using the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist.

AIMS: To identify all extant instruments used to measure diabetes distress in adults with Type 1 diabetes and to evaluate the evidence for the measurement properties of these instruments. METHODS: Medline, Embase, CINAHL plus and PsycINFO were systematically searched from inception up until 12 March 2020 for all publications which evaluated the psychometric properties of diabetes distress measurement instruments. The quality of the methodology and the measurement properties in the identified studies were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. RESULTS: Seven out of the 7656 articles retrieved in the search were included in the final review. Four diabetes distress measurement instruments were identified, none of which displayed evidence for all measurement properties specified in the COSMIN guidelines. The Problem Areas in Diabetes-11 (PAID-11) demonstrated the best psychometric properties, displaying strong evidence for structural validity, internal consistency, hypothesis testing, responsiveness and criterion validity. The Problem Areas in Diabetes scale (PAID) was the most frequently investigated instrument, demonstrating good relevance and hypothesis testing across four studies; however, concerns remain over its factor structure. CONCLUSION: The PAID-11 appears to be the most psychometrically sound instrument for measuring diabetes distress in adults with Type 1 diabetes, displaying strong evidence for a range of measurement properties. However, as only one study evaluated this instrument and its content validity has yet to be assessed, further validation is warranted. Additional qualitative work is needed to assess the content validity of these instruments among individuals with Type 1 diabetes.

SGLT2 inhibitors increase risk for diabetic ketoacidosis in type 2 diabetes.

SOURCE CITATION: Liu J, Li L, Li S, et al. Sodium-glucose co-transporter-2 inhibitors and the risk of diabetic ketoacidosis in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes Obes Metab. 2020;22:1619-27. 32364674.

Which diagnostic tests in everyday clinical practice are (not) useful in the management of diabetic foot disease?

This commentary reviews the use of a small number of tests used in the routine management of foot disease in diabetes. The aim is to consider some of the evidence underlying the use of these tests and the difficulties that can be encountered in interpretation. All tests have their limitations and it is important for these to be understood by the clinicians who request them. There are few test results which are categorically diagnostic in the field of the diabetic foot and the majority merely provide supporting evidence for a diagnosis that is either less or more strongly suspected on other grounds.

In-hospital metabolic regulation in patients with a diabetic foot ulcer: is it worthwhile?

It is well established that hyperglycaemia is associated with many negative cardiovascular and immunological effects. Because of the high prevalence of underlying vascular disease along with associated infection, patients with diabetic foot ulcers are especially vulnerable to these adverse consequences. While studies consistently demonstrate worse outcomes in the setting of hyperglycaemia during hospitalization, multiple trials examining the effects of intensive glycaemic control reveal mixed results. In particular, effects on mortality are varied, and although there may be some benefit in the setting of infection, hypoglycaemia is a concern when glucose levels are treated down to the normoglycaemic range. Therefore, although metabolic regulation is worthwhile theoretically, the optimal intensity of control is unclear. There is a need for future research to clarify the benefits and risks associated with strict metabolic control in patients with diabetic foot ulceration. In the interim recommendations from international guidelines should be followed; these advise pre-meal glucose targets of <7.8 mmol/L and random targets of <10.0 mmol/L in general medical and surgical settings.

Barriers and facilitators associated with attendance at hospital diabetes clinics among young adults (15-30 years) with type 1 diabetes mellitus: a systematic review.

Regular clinic attendance is recommended to facilitate self-management of diabetes. Poor attendance is common among young adults with type 1 diabetes mellitus (DM). This systematic review aimed to produce a narrative synthesis of the evidence regarding factors which promote or impede regular attendance at adult diabetes clinics among young adults (15-30 years) with type 1 DM. Studies reporting facilitators and barriers to clinic attendance were identified by searching four electronic databases, checking reference lists, and contacting diabetes research networks. A total of 12 studies (8 quantitative and 4 qualitative) met the inclusion criteria. Young adult's experiences transitioning from paediatric to adult diabetes care can influence attendance at the adult clinic positively if there is a comprehensive transition programme in place, or negatively if the two clinics do not communicate and provide adequate support. Post-transition, relationship development and perceptions of the value of attending the clinic are important for regular attendance. Controlled research is required to better understand decisions to attend or not attend outpatient services among people with chronic conditions. Service delivery must be sensitive to the developmental characteristics of young adults and tailored support may be required by young adults at greatest risk of non-attendance.