Pharmacologic interventions for painful diabetic neuropathy: An umbrella systematic review and comparative effectiveness network meta-analysis.

BACKGROUND: Multiple treatments for painful diabetic peripheral neuropathy are available. PURPOSE: To evaluate the comparative effectiveness of oral and topical analgesics for diabetic neuropathy. DATA SOURCES: Multiple electronic databases between January 2007 and April 2014, without language restriction. STUDY SELECTION: Parallel or crossover randomized, controlled trials that evaluated pharmacologic treatments for adults with painful diabetic peripheral neuropathy. DATA EXTRACTION: Duplicate extraction of study data and assessment of risk of bias. DATA SYNTHESIS: 65 randomized, controlled trials involving 12 632 patients evaluated 27 pharmacologic interventions. Approximately one half of these studies had high or unclear risk of bias. Nine head-to-head trials showed greater pain reduction associated with serotonin-norepinephrine reuptake inhibitors (SNRIs) than anticonvulsants (standardized mean difference [SMD], -0.34 [95% credible interval {CrI}, -0.63 to -0.05]) and with tricyclic antidepressants (TCAs) than topical capsaicin 0.075%. Network meta-analysis showed that SNRIs (SMD, -1.36 [CrI, -1.77 to -0.95]), topical capsaicin (SMD, -0.91 [CrI, -1.18 to -0.08]), TCAs (SMD, -0.78 [CrI, -1.24 to -0.33]), and anticonvulsants (SMD, -0.67 [CrI, -0.97 to -0.37]) were better than placebo for short-term pain control. Specifically, carbamazepine (SMD, -1.57 [CrI, -2.83 to -0.31]), venlafaxine (SMD, -1.53 [CrI, -2.41 to -0.65]), duloxetine (SMD, -1.33 [CrI, -1.82 to -0.86]), and amitriptyline (SMD, -0.72 [CrI, -1.35 to -0.08]) were more effective than placebo. Adverse effects included somnolence and dizziness with TCAs, SNRIs, and anticonvulsants; xerostomia with TCAs; and peripheral edema and burning sensation with pregabalin and capsaicin. LIMITATION: Confidence in findings was limited because most evidence came from indirect comparisons of trials with short (≤3 months) follow-up and unclear or high risk of bias. CONCLUSION: Several medications may be effective for short-term management of painful diabetic neuropathy, although their comparative effectiveness is unclear. PRIMARY FUNDING SOURCE: Mayo Foundation for Medical Education and Research.

Systematic reviews to ascertain the safety of diabetes medications.

Clinicians and patients with type 2 diabetes enjoy an expanding list of medications to improve glycemic control. With this expansion has come a flurry of concerns about the safety of these antihyperglycemic agents, concerns that affect judgments about the risk/benefit balance of therapy. Some of these safety signals have been identified through the synthesis of existing research evidence. Thus, it has become important for clinicians and clinical policymakers to understand the strengths and limitations of systematic reviews and meta-analyses in determining the safety of diabetes medications. In this paper, we highlight key safety concerns with diabetes medications and discuss the role evidence synthesis plays in each, with special attention to its strengths and limitations.

Inpatient glycemic management in noncritically ill patients: Updated guidelines.

Hyperglycemia is common in hospitalized patients and is traditionally managed with scheduled and correctional doses of insulin. The authors present an overview of the latest (2022) guidelines from the Endocrine Society on inpatient hyperglycemia management in noncritically ill patients, which includes a role for newer diabetes technologies and nontraditional insulin and noninsulin therapies.

Perioperative management of diabetes in patients undergoing bariatric and metabolic surgery: a narrative review and the Cleveland Clinic practical recommendations.

Bariatric and metabolic surgery is an effective treatment for patients with severe obesity and obesity-related diseases. In patients with type 2 diabetes, it provides marked improvement in glycemic control and even remission of diabetes. In patients with type 1 diabetes, bariatric surgery may offer improvement in insulin sensitivity and other cardiometabolic risk factors, as well as amelioration of the mechanical complications of obesity. Because of these positive outcomes, there are increasing numbers of patients with diabetes who undergo bariatric surgical procedures each year. Prior to surgery, efforts should be made to optimize glycemic control. However, there is no need to delay or withhold bariatric surgery until a specific glycosylated hemoglobin target is reached. Instead, treatment should focus on avoidance of early postoperative hyperglycemia. In general, oral glucose-lowering medications and noninsulin injectables are not favored to control hyperglycemia in the inpatient setting. Hyperglycemia in the hospital is managed with insulin, aiming for perioperative blood glucose concentrations between 80 and 180 mg/dL. Following surgery, substantial changes of the antidiabetic medication regimens are common. Patients should have a clear understanding of the modifications made to their treatment and should be followed closely thereafter. In this review article, we describe practical recommendations for the perioperative management of diabetes in patients with type 2 or type 1 diabetes undergoing bariatric surgery. Specific recommendations are delineated based on the different treatments that are currently available for glycemic control, including oral glucose-lowering medications, noninsulin injectables, and a variety of insulin regimens.

Rapid onset type-1 diabetes and diabetic ketoacidosis secondary to nivolumab immunotherapy: a review of existing literature.

Nivolumab is a programmed cell death receptor (PD-1) inhibitor that is increasingly used for various malignancies, both as a first line agent and as salvage therapy. Being a PD-1/PD-1 ligand checkpoint inhibitor, it is known to cause autoimmune inflammation of various organs and has been associated with thyroiditis, insulitis, colitis, hepatitis and encephalitis to name a few. There are increasing reports of nivolumab leading to acute onset fulminant type 1 diabetes and diabetic ketoacidosis (DKA). We present a case of a 68-year-old man who developed DKA after 2 doses of nivolumab for metastatic melanoma. He was found to have type 1 diabetes, but no diabetes related antibodies were positive. He recovered from diabetes and continues to use insulin 1 year after his diagnosis. This case and associated review illustrates the importance of educating and monitoring patients who start nivolumab therapy regarding this potentially life threatening complication.

Hemodynamic Patterns Identified by Impedance Cardiography Predict Mortality in the General Population: The PREVENCION Study.

Background Blood pressure is determined by the interactions between the heart and arterial properties, and subjects with identical blood pressure may have substantially different hemodynamic determinants. Whether arterial hemodynamic indices quantified by impedance cardiography ( ICG ), a simple operator-independent office procedure, independently predict all-cause mortality in adults from the general population, and specifically among those who do not meet criteria for American College of Cardiology/American Heart Association stage 2 hypertension, is currently unknown. Methods and Results We studied 1639 adults aged 18 to 80 years from the general population. We used ICG to measure hemodynamic parameters and metrics of cardiac function. We assessed the relationship between hemodynamic parameters measured at baseline and all-cause mortality over a mean follow-up of 10.9 years. Several ICG parameters predicted death. The strongest predictors were total arterial compliance index (standardized hazard ratio=0.38; 95% confidence interval=0.31-0.46; P<0.0001) and indices of cardiac contractility: velocity index (standardized hazard ratio=0.45; 95% confidence interval=0.37-0.55; P<0.0001) and acceleration index (standardized hazard ratio=0.44; 95% confidence interval=0.35-0.55; P<0.0001). These remained independently predictive of death after adjustment for multiple confounders, as well as systolic and diastolic blood pressure. Among subjects without stage 2 hypertension (n=1563), indices of cardiac contractility were independently predictive of death and identified a subpopulation (25% of non-stage-2 hypertensives) that demonstrated a high 10-year mortality risk, equivalent to that of stage 2 hypertensives. Conclusions Hemodynamic patterns identified by ICG independently predict mortality in the general population. The predictive value of ICG applies even in the absence of American College of Cardiology/American Heart Association stage 2 hypertension and identifies higher-risk individuals who are in earlier stages of the hypertension continuum.

Prevalence of the metabolic syndrome in Peruvian Andean hispanics: the PREVENCION study.

Data regarding the prevalence of metabolic syndrome (MTS) in Andean populations are limited. We evaluated the prevalence of MTS according to American Heart Association/National Heart, Lung and Blood Institute criteria among 1878 subjects in the PREVENCION study in Peru. In women, the most common component was low HDL cholesterol (60.9%) followed by abdominal obesity (36.9%). In men, the most common component was elevated triglycerides (52.0%) followed by low HDL cholesterol (32.5%), whereas the prevalence of abdominal obesity was 14%. Abnormal fasting glucose was the least common component in men (5.4%) and women (5.0%). The prevalence of MTS was significantly higher in women compared to men (23.2% versus 14.3%) and increased steeply with age, particularly in women (p<0.0001). Using body mass index (BMI>or=30kg/m2) instead of waist circumference as a component of the MTS lead to equivalent prevalence estimates of MTS in men but significantly underestimated the prevalence in women. The MTS is highly prevalent among Peruvian Andeans, particularly in older women. The pattern of MTS components in this Andean population is characterized by a high prevalence of dyslipidemia and a relatively low prevalence of elevated fasting glucose. Further studies are required to characterize genetic and environmental determinants of these patterns.

BE SMART: strategies for foot care and prevention of foot complications in patients with diabetes.

BACKGROUND: Diabetic foot ulcers and lower extremity amputations are common complications of diabetes mellitus that are associated with substantial morbidity, loss of quality of life, disability, and a high social and economic burden. The implementation of strategies to prevent these complications is a key aspect of diabetes care. OBJECTIVES: The objective of this article is to provide an overview of the available evidence on preventive diabetic foot care. STUDY DESIGN: Literature review. METHODS: Narrative review based on a thorough search of previous relevant studies, systematic reviews, and clinical guidelines on diabetic foot care published in English. RESULTS: We describe diabetic foot care strategies that can be categorized within defined domains for the purpose of helping clinicians to remember them. We use the mnemonic "BE SMART" (Be aware of the risk factors, Educate patients and health providers, Structured clinical assessment, Metabolic evaluation and management, Assessment of Risk, and Team care) to organize these domains. CONCLUSION: Diabetic foot ulcers and lower extremity amputations are potentially preventable complications. Clinicians taking care of patients with diabetes should know, understand, and remember the multiple aspects of diabetic foot care. CLINICAL RELEVANCE: This review can be used as a reference source for those interested in the care of diabetic foot. It highlights the importance of risk factor recognition, education, a structured clinical and metabolic evaluation, and also the importance of assigning patients a risk category that can help guiding multidisciplinary management efforts.

Prospective risk factors for increased central augmentation index in men and women.

BACKGROUND: Arterial wave reflections are important determinants of central pressure pulsatility and left ventricular afterload. The augmentation index (AIx) is the most widely used surrogate of arterial wave reflections. Despite multiple cross-sectional studies assessing the correlates of AIx, little prospective data exist regarding changes in AIx over time. We aimed to assess the predictors of changes in AIx over time in adults from the general population. METHODS: We performed radial arterial tonometry assessments a median of 3.18 ± 0.4 years apart on 143 nondiabetic adult participants in the population-based PREVENCION study. Central AIx was obtained using the generalized transfer function of the Sphygmocor device. RESULTS: Predictors of the change in AIx over time were investigated. Among men (n = 67), the change in AIx was predicted by abdominal obesity (standardized ß for waist circumference = 0.34; P = 0.002), impaired fasting glucose (standardized ß = 0.24; P = 0.009), and the change in heart rate (standardized ß = -0.78; P < 0.001). Among women (n = 76), the change in AIx was predicted by non-high-density lipoprotein cholesterol (standardized ß = 0.33; P = 0.001), C-reactive protein levels (standardized ß = 0.24; P = 0.02), change in mean arterial pressure (standardized ß = 0.33; P = 0.001), and change in heart rate (standardized ß = -0.52; P < 0.001). CONCLUSIONS: Metabolic and inflammatory factors predicted changes in AIx over time, with important sex differences. Metabolic factors, such as abdominal obesity and impaired fasting glucose, predicted changes in AIx in men, whereas C-reactive protein and non-high-density lipoprotein cholesterol levels predicted changes in women. Our findings highlight the impact of sex on arterial properties and may guide the design of interventions to favorably impact changes in late systolic pressure augmentation.

[Shared decision making and minimal disruptive medicine in the management of chronic diseases]. / Toma de decisiones compartidas y medicina mínimamente impertinente en el manejo de las enfermedades crónicas.

Chronic diseases are the leading cause of morbidity and mortality worldwide. These conditions require considerable time investment and resources from the health system in Peru, as well as from patients and their families. Paradoxically, the developed medical strategies for managing these conditions generate a constant and increasing burden for the patient and their environment, which affects quality of life and therapeutic results. In this article, the role of shared decision making and minimal disruptive medicine will be described as strategies to address these problems.

A systematic review of shared decision making interventions in chronic conditions: a review protocol.

BACKGROUND: Chronic conditions are a major source of morbidity, mortality and cost worldwide. Shared decision making is one way to improve care for patients with chronic conditions. Although it has been widely studied, the effect of shared decision making in the context of chronic conditions is unknown. METHODS/DESIGN: We will perform a systematic review with the objective of determining the effectiveness of shared decision making interventions for persons diagnosed with chronic conditions. We will search the following databases for relevant articles: PubMed, Scopus, Ovid MEDLINE, Ovid EMBASE, Ovid EBM Reviews CENTRAL, CINAHL, and Ovid PsycInfo. We will also search clinical trial registries and contact experts in the field to identify additional studies. We will include randomized controlled trials studying shared decision making interventions in patients with chronic conditions who are facing an actual decision. Shared decision making interventions will be defined as any intervention aiming to facilitate or improve patient and/or clinician engagement in a decision making process. We will describe all studies and assess their quality. After adjusting for missing data, we will analyze the effect of shared decision making interventions on outcomes in chronic conditions overall and stratified by condition. We will evaluate outcomes according to an importance ranking informed by a variety of stakeholders. We will perform several exploratory analyses including the effect of author contact on the estimates of effect. DISCUSSION: We anticipate that this systematic review may have some limitations such as heterogeneity and imprecision; however, the results will contribute to improving the quality of care for individuals with chronic conditions and facilitate a process that allows decision making that is most consistent with their own values and preferences. TRIAL REGISTRATION: PROSPERO Registration Number: CRD42013005784.

Metabolic syndrome in andean populations.

The metabolic syndrome, a cluster of metabolic abnormalities, has been linked to both cardiovascular disease and type 2 diabetes mellitus risk. Several studies have shown that ethnicity is an important determinant for risk of developing the metabolic syndrome; therefore, further understanding of the prevalence and presentation of the metabolic syndrome in various ethnic groups is needed. Latin American communities, and particularly Andean countries, are largely understudied in relation to the metabolic syndrome and until recently, the prevalence of this metabolic disturbance in Andean Hispanics was unknown. Nonetheless, recent (and ongoing) population studies are providing important data regarding the prevalence and patterns of the metabolic syndrome in various Andean countries. This review aims to summarize and interpret the information provided by these studies in an effort to better characterize the metabolic syndrome in Andean Hispanics.

Optimal definitions for abdominal obesity and the metabolic syndrome in Andean Hispanics: the PREVENCION study.

OBJECTIVE: We aimed to establish optimal definitions for abdominal obesity and metabolic syndrome (MetS) among Andean adults. RESEARCH DESIGN AND METHODS: Among 1,448 Andean adults, we assessed the relationship between waist circumference and subclinical vascular disease assessed by carotid intima-media thickness (cIMT) and manifest cardiovascular disease (M-CVD). RESULTS: Optimal waist circumference cutoffs to classify individuals with abnormal cIMT or M-CVD were >97 and >87 cm in men and women, respectively. With these cutoffs, there was substantial disagreement between the original American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI) and the recently updated MetS definition, particularly among men (kappa = 0.85). Subjects with MetS identified by the updated definition but not meeting the original AHA/NHLBI MetS criteria demonstrated significantly increased cIMT (P < 0.001) compared with subjects who did not meet the MetS criteria by either definition. CONCLUSIONS: Our findings support the use of ethnic-specific waist circumference cutoffs and the updated MetS definition in Andean adults.

Toma de decisiones compartidas y medicina mínimamente impertinente en el manejo de las enfermedades crónicas / Shared decision making and minimal disruptive medicine in the management of chronic diseases

Las enfermedades crónicas son la causa más importante de morbilidad y mortalidad a nivel mundial. Estas condiciones requieren considerable inversión de tiempo y recursos por parte del sistema de salud en el Perú, así como de los pacientes y sus familiares. Paradójicamente, las estrategias médicas desarrolladas para el manejo de estas condiciones generan una carga constante y creciente para el paciente y su entorno, que repercute en la calidad de vida del paciente y en los resultados terapéuticos. En este artículo describimos el rol de la toma de decisiones compartidas y de la medicina mínimamente impertinente como estrategias para abordar estos problemas.

Chronic diseases are the leading cause of morbidity and mortality worldwide. These conditions require considerable time investment and resources from the health system in Peru, as well as from patients and their families. Paradoxically, the developed medical strategies for managing these conditions generate a constant and increasing burden for the patient and their environment, which affects quality of life and therapeutic results. In this article, the role of shared decision making and minimal disruptive medicine will be described as strategies to address these problems.

Prevalence of lifestyle-related cardiovascular risk factors in Peru: the PREVENCION study.

OBJECTIVES: To estimate the prevalence of lifestyle-related cardiovascular risk factors in the adult population of Arequipa, the second largest city in Peru. METHODS: The prevalence and patterns of smoking, alcohol drinking, lack of physical activity, high-fat diet, and low fruit and vegetable intake were evaluated among 1 878 subjects (867 men and 1 011 women) in a population-based study. RESULTS: The age-standardized prevalence of current smoking, former smoking, and never smoking were 21.6%, 14.3%, and 64.1%, respectively. The prevalence of current smoking was significantly higher in men than women (31.1% vs. 12.1%; P < 0.01). The prevalence of current alcohol use was 37.7% and significantly higher in men than women (55.5% vs. 19.7%; P < 0.01). Similarly, the prevalence of binge drinking was 21.2%, and the percentage of men who binge drink (36.1%) was significantly higher than for women (6.4%; P < 0.01). The vast majority of alcohol drinkers reported a pattern of alcohol consumption mainly on weekends and holidays rather than regular drinking with meals during the week. The proportion of insufficiently active people was 57.6% and was significantly higher in women than men (63.3% vs. 51.9%; P < 0.01). Overall, 42.0% of adults reported consuming high-fat diets, 34.5% reported low fruit intake, and 33.3% reported low vegetable intake. CONCLUSIONS: The high prevalence of lifestyle-related cardiovascular risk factors found in this Andean population is of concern. Preventive programs are urgently needed to deal with this growing problem.

Prevalence and patterns of hypertension in Peruvian Andean Hispanics: the PREVENCION study.

Cardiovascular disease is emerging as a leading cause of morbidity and mortality in Latin America. Population-based data regarding the prevalence of hypertension and hypertension subtypes in Andean Hispanic populations are scarce. The authors performed a population-based study that included 1878 Peruvian Andean adults to determine: (1) the prevalence, awareness, and control of hypertension and (2) the relative frequency of hypertension subtypes (systolic vs. diastolic). The prevalence of hypertension was 15.7% (95% confidence interval [CI], 14.0%-17.4%), did not differ by gender, and increased steeply with age, particularly in women. Awareness, treatment, and control rates were 47.9%, 39.5%, and 14%, respectively. Diastolic blood pressure increased until age 50 years and reached a plateau thereafter, whereas mean arterial pressure continued to increase with age even after age 50 years. Furthermore, in sharp contrast with the United States population, the predominant type of hypertension was systodiastolic (41.7%; 95% CI, 35.1%-48.5%). Isolated systolic hypertension accounted for only 29.3% of cases (95% CI, 23.9%-35.4%) and was responsible for a minority of cases in all age groups before age 70 years. Hypertension subtypes in this Andean population seem to differ significantly from those present in the United States population, with a much larger proportion of systodiastolic and diastolic hypertension even with advanced age. These differences result from interactions between hemodynamic and structural factors, and further studies aimed at characterizing their genetic and environmental determinants and implications in end-organ damage and prognosis in this population may contribute to understanding the pathophysiology of hypertension.