Unveiling the Spectrum of Glucose Variability: A Novel Perspective on FreeStyle Libre Monitoring Data.

INTRODUCTION: Since the introduction of insulin therapy, it has become apparent that type 1 diabetes (T1D) is accompanied by long-term microvascular and macrovascular complications. In the context of the many benefits of continuous glucose monitoring (CGM), there remain opportunities to study the large amount of data now available in order to maximise its potential in the endeavour to reduce the occurrence of diabetes tissue complications in the longer term. METHODS: Continuous glucose monitoring values were downloaded for 89 type 1 diabetes mellitus (T1D) individuals for up to 18 months from 2021 to 2023. Data for patient demographics was also taken from the patient record which included Sex, Date of Birth, and Date of Diagnosis. The recorded laboratory glycated haemoglobin (HbA1c) test results were also recorded. The glucose management index (GMI) was calculated from average glucose readings for 18 months using the formula GMI (%) = (0.82 - (Average glucose/100)). This was then adjusted to give GMI (mmol/mol) = 10.929 * (GMI (%) - 2.15). Average Glucose Fluctuation (AGF) was calculated by adding up the total absolute change value between all recorded results over 18 months and dividing by the number of results minus one. The % Above Critical Threshold (ACT) was calculated by summing the total number of occurrences for each result value. A cumulative 95% limit was then applied to identify the glucose value that only 5% of results exceeded in the overall population. Using this value, we estimated the percentage of total tests that were above the Critical Threshold (ACT). RESULTS: The mean age of the participants was 42.6 years, and the mean duration of T1D was 18.4 years. A total of 3.22 million readings were analysed, yielding an average blood glucose level of 10.3 mmol/l and a GMI of 57.2 mmol/mol. There was a strong correlation between GMI and measured HbA1c (r2 = 0.82). However, there were patients who had an above-critical threshold (ACT) of 4-10% at a GMI of 60 mmol/mol or less. The percentage average value at the time of day (%AVTD) was applied to all blood glucose readings at each 15-min interval throughout the day, averaged over 18 months. The %AVTD of GMI (overall average 57.2 mmol/mol) increased after midday, dipped at 18:00, and peaked at 22:00. The %AVTD of AGF (overall average 0.60 mmol/l) showed higher change rates after 09:00 declining at the end of the day. The %AVTD of ACT peaked at 22:00, with those having the highest %ACT showing an additional peak at 15:00. CONCLUSIONS: We have shown here that the percentage glucose results above 18 mmol/l (top 5% of distribution) increased exponentially above 54 mmol/mol HbA1c. The %AVTD is introduced as a useful measure. Our data indicate that over the 24-h period, improvement in metabolic control could be focussed on the afternoon and evening, when there are higher-than-average levels of GMI, a higher-than-average degree of glucose change, and higher-than-average risks of being above the critical threshold. In conclusion, a measure of glycaemic variation based on the amplitude of glucose change to a population mean could be used to provide valuable clinical insights into glucose change over a 24-h period.

Effect of time restricted eating versus current practice in dietetics on glycaemic control and cardio-metabolic outcomes in individuals at risk of developing type 2 diabetes: Protocol for a multi-centre, parallel group, non-inferiority, randomised controlled trial.

BACKGROUND: Time restricted eating (TRE) is a dietary strategy that may improve metabolic health. However, no studies have compared TRE with current practice (CP) in dietetics. HYPOTHESIS: TRE will not be inferior to CP to improve glycaemic control in individuals at risk of type 2 diabetes (T2D). METHODS: This parallel group, randomised, non-inferiority, controlled trial randomised 247 participants by site and glycated haemoglobin (HbA1c) into TRE or CP (1:1) for 12 months. Participants were aged 35-70 years, with a body mass index (BMI) >25 but <45 kg/m2, and score ≥15 on the Australian type 2 diabetes risk (AUSDRISK) assessment, without a diagnosis of T2D. Study visits were balanced between groups and all participants received five consultations at 0, 0.5, 1, 2 and 3 months. TRE followed a self-selected 9 h eating window (≥0600 and ≤1900), whereas CP followed Australian dietary guidelines. OUTCOMES: The primary endpoint is the estimate of group mean difference (TRE vs CP) of HbA1c at 4 months in a covariate linear regression adjusting for stratification factors and sex. Secondary efficacy outcomes at 4 and 12 months are changes in fasting glucose, fasting insulin, HOMA-IR and nocturnal glucose by continuous glucose monitor incremental area under the curve and change in HbA1c at 12 months. Other endpoints are exploratory and will not be adjusted for multiplicity. CONCLUSIONS: We will determine whether TRE is an alternate strategy to current practice in dietetics to improve glucose control. TRIAL REGISTRATION: NCT04762251; 21 Feb 2021.

Impact of haemoglobin variants on the diagnostic sensitivity of glycated haemoglobin (HbA1c) assay methodologies in sub-Saharan Africa: a laboratory-based method validation study.

Introduction: the utility of glycated haemoglobin (HbA1c) for the diagnosis and monitoring of diabetes in sub-Saharan Africa is uncertain due to limited data on the performance of the available HbA1c assay methods in this population, which has a high prevalence of haemoglobin variants. We aimed to compare the diagnostic accuracy of the major HbA1c methodologies (Boronate Affinity, Capillary Electrophoresis, High Performance Liquid Chromatography, Immunoassay) in an African population, and assess the impact of the common haemoglobin variant HbAS (sickle cell trait). Methods: whole blood samples were obtained from 182 individuals living with type 2 diabetes in Uganda. HbA1c values for each method were compared to average glucose measured over 14 days by continuous glucose monitoring (CGM). To determine concordance, the three HbA1c assay methods were compared to the capillary electrophoresis method. Results: there was a strong correlation between CGM average glucose levels and all four HbA1c methodologies (r=0.81-0.89) which did not differ in those with and without HbAS (present in 37/182 participants). The presence of HbAS did not alter the relationship between HbA1c and CGM glucose for any assay (p for interaction >0.2 for all methods). Diagnostic accuracy for CGM average glucose thresholds of 7 and 10mmol/L was similar across methods (area under the receiver operating characteristic curve 0.80-0.84 and 0.76-0.84 respectively). The maximum bias between the HbA1c assay methodologies was 2 mmol/mol (2.07%). Conclusion: all major HbA1c technologies offer accurate and comparable HbA1c measurement even in this population with high prevalence of haemoglobin variants.

Retrospective Observational Study on Assessing Sitagliptin and Dapagliflozin as a Fixed-Dose Combination in the Indian Population With Type 2 Diabetes Mellitus: The SIDAXA Study.

Introduction Type 2 diabetes mellitus (T2DM), a prevalent chronic metabolic disorder, necessitates multifaceted treatment approaches. Emerging studies highlight the cardiovascular advantages of sodium-glucose transport protein 2 (SGLT2) and dipeptidyl peptidase 4 (DPP-4) inhibitors in T2DM. This investigation delves into the synergistic effects of the fixed-dose combination (FDC) of sitagliptin and dapagliflozin, offering insights into its safety and efficacy for the Indian population. Methods This real-world, retrospective, observational study spanned 328 cases across 111 Indian centres, evaluating the safety, efficacy, and clinical utilization of the sitagliptin and dapagliflozin FDC in T2DM patients after obtaining ethical approval. Assessments at baseline, week four, and week 12 encompassed hemoglobin A1C (HbA1C), fasting plasma glucose (FPG), postprandial blood glucose (PPBG), low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight change. The statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 29.0.1.0(171) (IBM Corp., Armonk, NY, USA) with a significance level p<0.05. Results Study participants [mean age: 51.14±5.55 years, 77.74% (n=255) males, 22.26% (n=73) females] exhibited prevalent risk factors like sedentary lifestyle (n=167, 50.91%) and smoking (n=147, 44.82%). Comorbidities included hypertension (n=235, 71.65%) and dyslipidaemia (n=139, 42.38%). Metformin (n=282, 85.98%) and sulfonylurea (n=134, 40.85%) were commonly prescribed concomitant oral antidiabetic agents (OADs). FDC administration significantly reduced HbA1c by 1.05 ± 0.83% (p < 0.0001) at week 12. FPG and PPBG showed significant reductions of 22.98 ± 22.23 mg/dL (p < 0.0001), 165.50 ± 37.02 mg/dL and 40.94 ± 36.04 mg/dL (p < 0.0001) at four weeks respectively. By week 12, significant reductions were noted in SBP (14.61±13.98mmHg reduction, p-value <0.0001), DBP (7.80±8.45mmHg reduction, p-value <0.0001), and LDL-C levels (18.14±23.95 mg/dL reduction, p-value <0.0001). In patients with established cardiovascular disease, there was reduction in HbA1c levels by 1.02 ± 0.63% after 12 weeks, with FPG decreasing by 54.52 ± 32.67 mg/dL and PPBG decreasing by 88.73 ± 44.90 mg/dL. Treatment-emergent adverse events included headache, changes in micturition, genital mycotic infection, and nausea and diarrhoea which were mild, transient, and necessitated no treatment discontinuation. Conclusion The FDC of sitagliptin and dapagliflozin significantly improved glycaemic control and lipid profiles in T2DM patients, particularly those with coronary artery disease. It demonstrated a favourable safety profile in the Indian population, signifying its potential as an effective and well-tolerated therapeutic option in patients with established cardiovascular disease.

Lower achievement of guideline recommended care in Canadian adults with early-onset diabetes: A population-based cohort study.

AIMS: Adults with early-onset diabetes (age < 40 years) have an increased risk of complications, and it is unclear whether they are receiving guideline recommended care. We compared the frequency and results of haemoglobin A1c (HbA1c) testing in adults with early-onset and usual-onset diabetes and assessed factors related to guideline concordance. METHODS: Population-level databases from Alberta, Canada (∼4.5 million) were used to identify adults with incident diabetes. The cohort was stratified by age at diagnosis (< 40 vs. ≥ 40 years) and then followed for 365 days for HbA1c testing. Adjusted multivariable analyses were used to identify clinical and sociodemographic factors associated with guideline concordance. RESULTS: Among 23,643 adults with incident diabetes (mean age 54.1 ± 15.4 years; 42.1 % female), 18.9 % had early-onset diabetes. Early-onset diabetes was associated with lower frequency of testing (adjusted odds ratio (aOR), 0.80; 95 % CI 0.70-0.90) and above target glycaemic levels compared to usual-onset diabetes (aOR, 1.45; 95 % CI 1.29-1.64). Factors associated with guideline concordant frequency of HbA1c testing were rural residence and insulin use. CONCLUSIONS: In our universal care setting with premium-free health care, early-onset diabetes was associated with lower rates of HbA1c testing and sub-optimal glycaemic control compared to those with usual-onset diabetes.

Inflammatory and endothelial host responses in community-acquired pneumonia: exploring the relationships with HbA1c, admission plasma glucose, and glycaemic gap-a cross-sectional study.

Introduction: Diabetes is associated with dysregulated immune function and impaired cytokine release, while transient acute hyperglycaemia has been shown to enhance inflammatory cytokine release in preclinical studies. Although diabetes and acute hyperglycaemia are common among patients with community-acquired pneumonia (CAP), the impact of chronic, acute, and acute-on-chronic hyperglycaemia on the host response within this population remains poorly understood. This study investigated whether chronic, acute, and acute-on- chronic hyperglycaemia are associated with distinct mediators of inflammatory, endothelial, and angiogenic host response pathways in patients with CAP. Methods: In a cross-sectional study of 555 patients with CAP, HbA1c, admission plasma (p)-glucose, and the glycaemic gap (admission p-glucose minus HbA1c- derived average p-glucose) were employed as measures of chronic, acute, and acute-on-chronic hyperglycaemia, respectively. Linear regression was used to model the associations between the hyperglycaemia measures and 47 proteins involved in inflammation, endothelial activation, and angiogenesis measured at admission. The models were adjusted for age, sex, CAP severity, pathogen, immunosuppression, comorbidity, and body mass index. Adjustments for multiple testing were performed with a false discovery rate threshold of less than 0.05. Results: The analyses showed that HbA1c levels were positively associated with IL-8, IL-15, IL-17A/F, IL-1RA, sFlt-1, and VEGF-C. Admission plasma glucose was also positively associated with these proteins and GM-CSF. The glycaemic gap was positively associated with IL-8, IL-15, IL-17A/F, IL-2, and VEGF-C. Conclusion: In conclusion, chronic, acute, and acute-on-chronic hyperglycaemia were positively associated with similar host response mediators. Furthermore, acute and acute-on-chronic hyperglycaemia had unique associations with the inflammatory pathways involving GM-CSF and IL-2, respectively.

Insights into the Feasibility and Acceptability of a Mobile Insulin Titration Application in Clinical Practice and Its Effects on Diabetes Outcomes.

Introduction: Insulin therapy is most effective if patients learn how to properly adjust insulin to achieve glycaemic targets. There is a need for methods and tools that can assist these processes in clinical practice. The purpose of this feasibility study was to evaluate an approach to support insulin dose adjustment in individual patients using a mobile titration application (app). Methods: A cohort of adults (N=36) with type 2 diabetes with suboptimal glycaemia who were starting basal insulin self-titration were trained by a diabetes care and education specialist to use a mobile titration app to guide adjusting insulin doses. Glycaemia, diabetes distress and patient and provider satisfaction were assessed during the first 3 months after initiating basal insulin titration using the mobile app. Results: Mean haemoglobin type A1c (HbA1c) was significantly reduced by an average of 2.1 ± 2.2% from baseline to 3 months (p<0.001). Diabetes distress significantly decreased from baseline to follow-up with scores going down (or improving) across all scales. Both patients and providers reported high levels of satisfaction and positive experiences. Conclusion: The model offers a promising solution to streamline insulin dosage adjustments to achieve specific clinical and self-management goals with high expectations for long-term benefits and warrants further investigation.

A matched cohort study evaluating the risks of infections in people with type 1 diabetes and their associations with glycated haemoglobin.

AIMS: People with type 1 diabetes (T1D) have raised infection rates compared to those without, but how these risks vary by age, sex and ethnicity, or by glycated haemoglobin (HbA1c), remain uncertain. METHODS: 33,829 patients with T1D in Clinical Practice Research Datalink on 01/01/2015 were age-sex-ethnicity matched to two non-diabetes patients. Infections were collated from primary care and linked hospitalisation records during 2015-2019, and incidence rate ratios (IRRs) were estimated versus non-diabetes. For 26,096 people with T1D, with ≥3 HbA1c measurements in 2012-2014, mean and coefficient of variation were estimated, and compared across percentiles. RESULTS: People with T1D had increased risk for infections presenting in primary care (IRR = 1.81, 95%CI 1.77-1.85) and hospitalisations (IRR = 3.37, 3.21-3.53) compared to non-diabetes, slightly attenuated after further adjustment. Younger ages and non-White ethnicities had greater relative risks, potentially explained by higher HbA1c mean and variability amongst people with T1D within these sub-groups. Both mean HbA1c and greater variability were strongly associated with infection risks, but the greatest associations were at the highest mean levels (hospitalisations IRR = 4.09, 3.64-4.59) for >97 versus ≤53 mmol/mol. CONCLUSIONS: Infections are a significant health burden in T1D. Improved glycaemic control may reduce infection risks, while prompter infection treatments may reduce hospital admissions.

Effectiveness of Bariatric Surgery in the Management of Type 2 Diabetes Mellitus: A Case Report and Literature Review.

Type 2 diabetes (T2DM) and obesity represent major global health burdens and economic costs to healthcare systems. T2DM management is challenging due to multiple comorbidities and limited drug efficacy. Bariatric surgery has emerged as an effective treatment approach. A 65-year-old man with refractory obesity (BMI > 35 kg/m2) and poorly controlled T2DM underwent gastric bypass surgery in 2018. Prior to surgery, medication noncompliance and dietary measures failed to achieve adequate glycemic control or weight loss. Postoperatively, the patient lost 20 kg and achieved improved T2DM control (HbA1C reduction), allowing complete cessation of diabetic medications. The patient's case demonstrates bariatric surgery's potential to significantly alter the clinical course of obesity and T2DM versus standard care. National guidelines outline eligibility criteria for bariatric referral; however, utilization rates remain low (<1%) despite over two million eligible individuals in the United Kingdom. Improved access could reduce disease burden and healthcare costs from diabetes complications over the long term. This case report provides a real-world example supporting bariatric surgery as an effective intervention for appropriately selected patients with obesity and uncontrolled T2DM, with the potential to improve clinical outcomes and lower costs associated with diabetes management.

Glucose indices as inflammatory markers in children with acute surgical abdomen: a cross-sectional study.

BACKGROUND: Glycaemic dysregulation potentiates the pro-inflammatory response and increases oxidative injury; therefore, preoperative hyperglycaemia is linked to increased mortalities. In addition, inflammation is accompanied by higher glycated haemoglobin (HbA1c) levels, and the relationship between this and random blood sugar (RBS) could be non-linear. METHODS: This is a cross-sectional study. Non-diabetic paediatric patients with acute surgical abdomen, presenting to the emergency surgical services were enrolled, over a period of 6 months. They were all screened for their random blood sugar and HbA1c levels. RESULTS: Fifty-three cases were studied. The prevalence of glycaemic dysregulation in the enrolled children was high. Abnormal HbA1c was observed in 66% of the study group. Stress hyperglycaemia was observed in 60% of the enrolled children. There was a significant correlation (r = 0.770, p-value: < 0.001) between RBS and the total leucocytic count (TLC). The TLC cutoff value for predicting stress hyperglycaemia was 13,595 cells/mm3. The cutoff value of RBS for predicting leukocytosis was 111.5 mg/dl. Median RBS level was significantly higher in complicated appendicitis (169.5 mg/dl), compared to uncomplicated appendicitis (118.0 mg/dl). CONCLUSION: HbA1c and RBS could be used as inflammatory markers for surgical acute abdomen and its degree of severity, respectively. HbA1c rises in a considerable number of cases with surgical acute abdomen, irrespective of the disease stage. However, as the disease progresses, the random blood sugar rises due to stress hyperglycaemia, thus becoming a surrogate inflammatory marker.

What is already known on this topic? Preoperative stress hyperglycaemia is common in children, and it is linked to adverse postoperative outcomes. HbA1c could be a marker for inflammation and oxidative stress.What does this study add? HbA1c could be an inflammatory marker for surgical acute abdomen, irrespective of the disease stage, as it had a high prevalence in the enrolled children with an acute surgical abdomen. However, as the disease progresses, the random blood sugar rises due to stress hyperglycaemia, thus becoming a surrogate inflammatory marker, as there is a significant correlation between it and the TLC.How might this study affect research, practice, or policy? The novelty in this study centers around the role of glucose metabolism, as evaluated by random blood sugar and HBA1c, in the diagnostic evaluation and prognostication of inflammation, represented by the surgical acute abdomen. This may invite further research into understanding the underlining mechanisms. The outcome of the clinical management of conditions involving inflammation can be improved by using the proposed biomarkers, as peri/preoperative hyperglycaemia could lead to morbidity and mortality, consequently, as proven, the reliability of those biomarkers facilitates risk assessment and stratification. As both tests are cost-effective and universally available, they can be readily implemented in practice guidelines and departmental policies.

Correlation between Red Cell Distribution Width and Glycaemic Control among Adults with Type II Diabetes Mellitus at Aminu Kano Teaching Hospital, North-Western Nigeria.

BACKGROUND: Red Blood Cell Distribution Width (RDW) measures the degree of variation in red blood cell size and it is a good predictor of complications in many conditions such as diabetes mellitus (DM). This study aimed to determine the relationship between RDW and glycaemic control in patients with type II DM. MATERIALS AND METHODS: It was a cross-sectional comparative study where patients with type II DM and apparently healthy non-DM volunteers were recruited. Blood samples were collected and analysed for RDW, Fasting Plasma Glucose (FPG) level and Glycated Haemoglobin (HbA1c). Data were analyzed using Statacorp version 13. RESULTS: A total of 180 participants were enrolled (90 cases, 90 controls). The mean (±SD) ages of cases and controls were 42 (± 11.94) and 34 (± 9.5) years, respectively. Females constituted the majority (49/90; 54.4%) in both groups. The cases had higher RDW than the controls (15.5 ± 1.0% versus 14.3 ± 1.7 %, p=0.630). The correlation between RDW and HbA1c revealed a weak statistically significant relationship (r=0.096, p=0.03) while a weak negative relationship was observed between the RDW and FPG (r = -0.006, p=0.956) which was not statistically significant. However, a negative finding showed a positive correlation between RDW and MCH (p-value = 0.003) and MCHC (p-value = 0.0002). CONCLUSION: Red cell distribution width has a direct relationship with HbA1c in patients with DM. Therefore, we recommend that clinicians pay attention to this detail while evaluating patients with DM.

CONTEXTE: La largeur de distribution des globules rouges (LDG) mesure le degré de variation de la taille des globules rouges et constitue un bon prédicteur des complications dans de nombreuses affections telles que le diabète sucré (DS). Cette étude visait à déterminer la relation entre la largeur de distribution des globules rouges et le contrôle de la glycémie chez les patients atteints de diabète de type II. MATÉRIELS ET MÉTHODES: Il s'agit d'une étude comparative transversale dans laquelle ont été recrutés des patients atteints de diabète de type II et des volontaires non diabétiques apparemment en bonne santé. Des échantillons de sang ont été prélevés et analysés pour déterminer le temps de travail quotidien, le taux de glucose plasmatique à jeun et l'hémoglobine glyquée (HbA1c). Les données ont été analysées à l'aide de la version 13 de Statacorp. RÉSULTATS: Au total, 180 participants ont été recrutés (90 cas, 90 témoins). Les âges moyens (±SD) des cas et des témoins étaient respectivement de 42 (± 11,94) et 34 (± 9,5) ans. Les femmes constituaient la majorité (49/90;54,4%) dans les deux groupes. Les cas avaient un TDR plus élevé que les témoins (15,5 ± 1,0 % contre 14,3 ± 1,7 %, p=0,630). La corrélation entre le TDR et l'HbA1c a révélé une faible relation statistiquement significative (r=0,096, p=0,03), tandis qu'une faible relation négative a été observée entre le TDR et la glycémie (r= -0,006, p=0,956), qui n'était pas statistiquement significative. Cependant, une corrélation positive a été observée entre le RDW et la MCH (valeur p=0,003) et la MCHC (valeur p=0,0002). CONCLUSION: La largeur de distribution des globules rouges a une relation directe avec l'HbA1c chez les patients atteints de diabète. Par conséquent, nous recommandons aux cliniciens de prêter attention à ce détail lors de l'évaluation des patients atteints de diabète. Mots clés: Largeur de distribution des globules rouges (RDW), Hémoglobine glyquée (HbA1c), Diabète sucré (DM).

A Review on Glycemic Control in Type 2 Diabetes Mellitus by Arm Ergometer Exercise.

It has been suggested that regular physical activity has become a part of rehabilitation in controlling blood glucose levels in type 2 diabetes mellitus patients. In type 2 diabetes mellitus the cells become resistant to insulin, which leads to elevated blood glucose over time and leads to prediabetes and type 2 diabetes mellitus (T2DM). The typical adult's blood contains about 5-10 grams of glucose when their blood glucose content is 100 milligrams per decilitre. About half a billion individuals are at risk for diabetes worldwide. Physical exercise has been proved to be better therapy for controlling blood glucose in persons at risk for diabetes, preventing further body complications. Three significant interests in exercising to delay the onset of T2DM. First, increased blood flow into the muscle is triggered by skeletal muscle activity, which promotes glucose absorption from the bloodstream. Second, it reduces abdominal adipose tissue, a well-known risk of metabolic disease. Third, physical exercise with moderate intensity has been proven to boost glucose uptake by 40 percent. Globally and in developing nations like India, the burden of diabetes is expanding, attributable to a rise in overweight/obesity and sedentary lifestyles. It is difficult to provide healthcare for diseases like diabetes since it requires a consistent commitment to the prescribed course of treatment. Based on the correlation between fasting plasma glucose (FPG) or hemoglobin A1c (HbA1c) and retinopathy, cut-off values for glucose and HbA1c are estimated.

Glycaemic control and factors affecting it in type 1 diabetes in children: experience from a tertiary care centre in India.

INTRODUCTION: Optimal glycaemic control is essential for the prevention of future micro- and macrovascular complications in type 1 diabetes (T1D). The type of insulin, the type of insulin delivery device, the caregiver's knowledge, the patient's age, duration of diabetes, and self-monitoring of blood glucose affect glycaemic control in type 1 diabetes. In the present study, we analysed glycaemic control and factors affecting it at a tertiary care centre in northern India. MATERIAL AND METHODS: A retrospective review of records of patients registered between 2015 and 2018 was done. The data on demographic and disease-related factors were collected from the records. The different groups were compared with the t-test, one-way ANOVA, or Kruskal-Wallis test. RESULTS: The mean age at the time of evaluation was 10.43 ±4.04 years (2-21 years), and the mean disease duration was 46.61 ±28.49 months (16-141 months). Most of the patients were prepubertal and using a basal-bolus regimen. The mean glycated haemoglobin (HbA1c ) was 7.96 ±1.46%, but only 24% had HbA1c below the International Society of Paediatric and Adolescent Diabetes (ISPAD) recommended desirable level of below 7%. Forty-six patients suffered one or more micro-macrovascular complications, and dyslipidaemia was the most common complication. Children with a longer duration of disease (8.39 ±1.42% vs. 7.59 ±1.65%), an episode of DKA (diabetes ketoacidosis) within a year of evaluation (9.19 ±2.54% vs. 7.93 ±1.39%), lower maternal (8.22 ±1.37% vs. 7.56 ±1.45%) and paternal education (8.26 ±1.67% vs. 7.78 ±1.30%), and hyperthyroid state (9.43 ±2.28% vs. 7.91 ±1.45%) had higher HbA1c. CONCLUSIONS: Better diabetes education focusing on parents with lower education strata and children with longer disease duration and poor compliance can help improve glycaemic control in developing countries like India.

Revised Glycemic Index for Diagnosing and Monitoring of Diabetes Mellitus in South Indian Population.

AIM: To find the optimal threshold of fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) for diagnosis of diabetes mellitus (DM) and to evaluate the association with diabetic retinopathy (DR) in the South Indian population. SETTINGS AND DESIGN: A retrospective population-based study. METHODS AND MATERIALS: A total of 909 newly detected type 2 DM patients were selected from our two previously conducted studies, which include an urban and a rural population of South India. All underwent estimation of fasting, postprandial plasma glucose (PPG), and other biochemical tests. A comprehensive and detailed ophthalmic examination was carried out. The fundi of patients were photographed using 45°, four-field stereoscopic photography. Based on receiver operating characteristic (ROC) curves, sensitivity and specificity were derived. RESULTS:  The optimal cut-off values determined by maximizing the sensitivity and specificity of FPG and HbA1c using the Youden index were ≥ 6.17 mmol/L and ≥ 6.3%, respectively. By distributing the cut-off points into deciles and comparing them to the WHO criteria, we found that our HbA1c level of 6.60% was more than the WHO threshold (6.5%), with higher sensitivity (81.6%) and lower specificity (48.3%). The FPG level of 6.80 mmol/L was lower to the WHO criteria (7 mmol/L) with increased sensitivity (77.0%) and lower specificity (45.7%). Prevalence of DR by HbA1c levels between 6.5% and 6.9% was 15.3%. The prevalence of DR was more in the FPG category between 6.4 and 6.9 mmol/L and ≥ 7.5 mmol/L. CONCLUSION: Our population-based data indicate that for the South Indian population HbA1c value of ≥63 % and FPG value of ≥6.17 mmol/L may be optimal for diagnosing DM with a high level of accuracy and will be useful for the identification of mild and moderate DR.

Concurrent Presentation of Diabetic Nephropathy and Type 1 Diabetes Mellitus in a Pediatric Patient.

Diabetic nephropathy (DN) is the most consequential and longstanding microvascular complication of type 1 diabetes mellitus (T1DM) and the most common cause for renal replacement therapy throughout the world. The most important risk factor for DN includes poor glycemic control. We present a rare case where biopsy-proven grade 3 DN had a concurrent presentation at the time of diagnosis of T1DM in a 12-year-old female child. This earlier than expected DN noted in this patient raises the question regarding the need for earlier surveillance for DN in children.

The use of glycated haemoglobin (HbA1C) in determining glycemic control (and relevance of BMI) in diabetic patients in Ahmadu Bello University Teaching Hospital Zaria, Nigeria.

This study was carried out to specifically investigate the local HbA1C level and determine extent of (if any) variation from the WHO (World Health Organization) recommended threshold for the diagnosis of diabetes and prediabetes using blood glucose as a benchmark. In addition, we also looked to see what role BMI (Body Mass Index) plays among subjects used for the study. 152 subjects were used for the study: 101 diabetic subjects and 51 non-diabetic control subjects. 5 mL of blood sample was collected from each of the subjects after about 8-10 h of overnight fasting. 3-4 mL of the sample was centrifuged and the serum analysed for glucose. The remaining 1-2 ml was transferred into EDTA bottles and analysed immediately for glycated haemoglobin (HbA1C). The BMI (kg/m2) was calculated by dividing the weight in kilograms (kg) by the square of the height in metres (m2). For the BMI, no significant difference was observed between the diabetic subjects (mean = 25.75 kg/m2) and the non-diabetic control subjects (mean = 25.09 kg/m2). Thirty-seven (37) of the diabetic subjects and twenty-three (23) of the non-diabetic subjects had HbA1C levels (mean = 6.96% and 6.29% respectively) that would imply either prediabetes or diabetes but were actually normal going by their fasting blood glucose (FBG) levels. A new chart for the interconversions between FBG and HbA1c and for predicting their expected values from each other was realized, drawn up and recommended for consideration in the management of diabetic patients along with the WHO recommended chart. There are a lot of normal individuals with HbA1c level that does not conform to (or that are simply higher than) what is regarded as the threshold for the onset of diabetes or prediabetes. Generally, the local (Nigerian) glycated haemoglobin (HbA1c) level can therefore be said to be distinctly higher for a given blood glucose range and should be taken as such in the management of diabetes in this environment. Being overweight or obese is not prerequisite to the development of diabetes or abnormal glycated haemoglobin level.

A comparison of the performance of voltammetric aptasensors for glycated haemoglobin on different carbon nanomaterials-modified screen printed electrodes.

The integration of carbon nanomaterials into electrochemical aptasensors has gained significant interest in the recent years because of their high electrical conductivity, mechanical strength, and large surface area. However, no comparative study has been reported so far between different carbon nanomaterials for aptasensing applications. Here, we report, a comparative investigation of six carbon electrode materials (carbon, graphene (G), graphene oxide (GO), multi-wall carbon nanotube (MWCNT), single walled carbon nanotube (SWCNT) and carbon nanofiber (CNF)) on the performance of glycated haemoglobin (HbA1c) aptasensor prepared by physical adsorption. The aptamers were non-covalently immobilized on the six nanomaterial electrodes via π-π stacking interactions between the DNA nucleobases and the surface of the carbon material which creates a barrier to the electron transfer. However, upon binding of the target protein to the aptamer, the aptamer dissociates from the surface leading to enhancement of the electron transfer which represent the basis of the detection. The aptamer adsorption, sensors responses and selectivity of the different nanomaterials were compared showing better performance of the SWCNT-based sensor. The voltammetric SWCNT aptasensors showed high sensitivity and selectivity with detection limits of 0.13 pg/mL and 0.03 pg/mL for total haemoglobin (tHb) and HbA1c, respectively. The aptasensor showed selectivity against other proteins in the blood including cystic fibrosis transmembrane conductance regulator (CFTR), survival motor neuron (SMN), dedicator of cytokinesis 8 (DOCK8), signal transducer and activator of transcription 3 (STAT3). This SWCNT aptasensor was superior to the reported detection assays for HbA1c in terms of sensitivity, selectivity and cost. Moreover, our results demonstrate that the choice of the carbon nanomaterial can have a profound impact on the biosensing performance.

Impact of Bariatric Surgical Intervention on Peripheral Blood Neutrophil (PBN) Function in Obesity.

AIM: The aim of this study was to investigate the impact of weight loss following gastric band surgery on multiple measures of peripheral blood neutrophil (PBN) function. MATERIAL AND METHODS: Twenty-three obese patients undergoing gastric band surgery were recruited to a longitudinal intervention study, alongside non-obese, healthy gender- and age-matched controls. Eighteen pairs of patients and controls completed all stages of the study. PBNs were isolated by density centrifugation and a comprehensive analysis of PBN function was undertaken at various stages of the patients' bariatric surgical care pathway. RESULTS: Obese patients exhibited exaggerated PBN activity in response to various stimuli, characterised by higher reactive oxygen species (ROS) generation (n = 18, p < 0.001) and release of pro-inflammatory cytokines (n = 10, p < 0.05) and lower PBN extracellular trap (NET) formation (n = 18, p < 0.01). PBN chemotactic accuracy was also impaired prior to surgery (n = 18, p < 0.01). Weight loss was associated with normalised NET production and lower ROS production and cytokine release relative to healthy controls. However, chemotactic accuracy remained impaired in patients. CONCLUSIONS: Weight loss following gastric band surgery was associated with a decrease in the pro-inflammatory activities of peripheral blood neutrophils (PBNs). A hyper-inflammatory PBN phenotype, involving excess ROS and cytokine release, reduced NET formation and chemotaxis, may lead to a reduced ability to eliminate infection, alongside inflammation-mediated tissue damage in obese individuals.

Evaluation of random plasma glucose for assessment of glycaemic control in type 2 diabetes mellitus.

OBJECTIVE: To evaluate the accuracy of random plasma glucose in outpatients with type 2 diabetes mellitus for assessing glycaemic control. METHODS: This comparative, cross-sectional study was conducted at the chemical pathology department of PNS Shifa Hospital, Karachi, from August 2015 to March 2016, and comprised data of subjects with type 2 diabetes mellitus who reported for evaluation of glycaemic control in non-fasting state. All blood samples were analysed for random plasma glucose and glycated haemoglobin. Random plasma glucose was compared as an index test with glycated haemoglobin considering it as reference standard at a value of less than 7% for good glycaemic control. SPSS 20 was used for data analysis. RESULTS: Of the 222 subjects, 93(42%) had good glycaemic control. Random plasma glucose showed strong positive correlation with glycated haemoglobin (p=0.000).Area under curve for random plasma glucose as determined by plotting receiver operating characteristic curve against glycated haemoglobin value of 7% was 0.89 (95% confidence interval: 0.849-0.930). Random plasma glucose at cut-off value of 150 mg/dl was most efficient for ruling out poor glycaemic control among patients with type 2 diabetes mellitus with 90.7% sensitivity and69.9% specificity and Youden's index of 0.606. CONCLUSIONS: Random plasma glucose may be used to reflect glycaemic control in adults with type 2 diabetes mellitus in areas where glycated haemoglobin is not feasible.

An Audit of Clinical Practice in a Single Centre in Kuwait: Management of Children on Continuous Subcutaneous Insulin Infusion and Cardiovascular Risk Factors Screening.

OBJECTIVES: To audit the current clinical practice of continuous subcutaneous insulin infusion (CSII) for the treatment of type 1 diabetes mellitus (T1D) in children and adolescents attending a single centre in Kuwait. METHODS: A one year retrospective audit was performed in children and adolescents with T1D on CSII, who attended the paediatric diabetes clinic, Dasman Diabetes Institute during 2012. The primary outcome measure was glycaemic control as evidenced by glycated haemoglobin (HbA1c) level and the secondary outcome measures were the frequency of monitoring of the risk for microvascular complications and occurrence of acute complications and adverse events. RESULTS: 58 children and adolescents (mean age ± SD: 12.6 ± 4.1 years) were included. Mean HbA1c at baseline was 8.8% (72.7 mmol/mol) and 8.9% (73.8 mmol/mol) at the end of a 12 months observation period. Children with poor control (HbA1c >9.5% (80 mmol/mol) had a significant 1.4% reduction in HbA1c compared with the overall reduction of 0.1% (p=0.7). Rate of screening for cardiovascular risk factors and for long term complications were well documented. However, there was underreporting of acute complications such as severe hypoglycaemia and diabetic ketoacidosis. Only 1.7% of patients discontinued the pump. CONCLUSION: There was no significant change in HbA1c values at the end of 12 months follow up. However, HbA1c values in poorly controlled children improved. CSII requires care by skilled health professionals as well as education and selection of motivated parents and children.