Effect of albiglutide on cardiovascular outcomes in older adults: A post hoc analysis of a randomized controlled trial.

AIM: To analyse the effects of albiglutide, a glucagon-like peptide 1 receptor agonist, on cardiovascular outcomes in older adults aged ≥65 years with type 2 diabetes and cardiovascular disease who participated in the Harmony Outcomes trial (NCT02465515). MATERIALS AND METHODS: We conducted a post hoc analysis of the primary endpoint of the Harmony Outcomes trial-time to first occurrence of a major adverse cardiovascular event-in subgroups of participants aged <65 and ≥65 years and <75 and ≥75 years at baseline. Hazard ratios and 95% confidence intervals (CIs) were generated using Cox proportional hazards regression. RESULTS: The analysis population included 9462 Harmony Outcomes participants, including 4748 patients ≥65 and 1140 patients ≥75 years at baseline. Hazard ratios for the prevention of major adverse cardiovascular events were 0.66 (95% CI, 0.53-0.82) in persons <65 and 0.86 (95% CI, 0.71-1.04) in those ≥65 years (age interaction p = .07), and 0.78 (95% CI, 0.67-0.91) in <75 and 0.70 (95% CI, 0.48-1.01) in ≥75 year age groups (interaction p = .6). When analysed as a continuous variable, age did not modify the effect of albiglutide on the primary endpoint. CONCLUSIONS: This post hoc analysis adds to the body of literature showing that glucagon-like peptide 1 receptor agonists added to standard type 2 diabetes therapy safely reduce the incidence of cardiovascular events in older adults with established cardiovascular disease. In this analysis, the risk-benefit profile was similar between younger and older age groups treated with albiglutide.

Emergency Department Management of Uncomplicated Hyperglycemia in Patients without History of Diabetes.

BACKGROUND: Hyperglycemia is a common finding in patients presenting to the emergency department (ED). Recommendations addressing uncomplicated hyperglycemia in the ED are limited, and the management of those without a prior diagnosis of diabetes presents a challenge. OBJECTIVE: This narrative review will discuss the ED evaluation and management of hyperglycemic adult patients without a history of diabetes who do not have evidence of a hyperglycemic crisis, such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. DISCUSSION: Many adults who present to the ED have risk factors for diabetes and meet American Diabetes Association (ADA) criteria for diabetes screening. A new diagnosis of type 2 diabetes can be established in the ED by the ADA criteria in patients with a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) and symptoms of hyperglycemia. The diagnosis should be considered in patients with an elevation in random blood glucose > 140 mg/dL (7.8 mmol/L). Treatment may begin in the ED and varies depending on the presenting severity of hyperglycemia. Treatment options include metformin, long-acting insulin, or deferring for close outpatient management. CONCLUSIONS: Emergency clinician knowledge of the evaluation and management of new-onset hyperglycemia and diabetes is important to prevent long-term complications.

An overview of GLP-1 agonists and recent cardiovascular outcomes trials.

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are emerging as an important therapy to consider for patients with type 2 diabetes (T2D) given this class of treatment's ability to reduce glycated haemoglobin and their associated weight loss and low risk for hypoglycaemia. Additionally, seven cardiovascular outcomes trials (CVOTs) have been performed in the past 4 years using lixisenatide, liraglutide, semaglutide, exenatide, albiglutide, dulaglutide and oral semaglutide. All have found non-inferiority for cardiovascular outcomes, with many finding superiority of these drugs. These findings have transformed our guidelines on pharmacological treatment of T2D. This review article will discuss GLP-1 RA therapy, review the seven CVOTs reported to date and discuss the implications on current guidelines and therapies going forward.

Cardiovascular safety and lower severe hypoglycaemia of insulin degludec versus insulin glargine U100 in patients with type 2 diabetes aged 65 years or older: Results from DEVOTE (DEVOTE 7).

AIMS: The aim of this study was to describe the risks of cardiovascular (CV) events and severe hypoglycaemia with insulin degludec (degludec) vs insulin glargine 100 units/mL (glargine U100) in patients with type 2 diabetes (T2D) aged 65 years or older. MATERIALS AND METHODS: A total of 7637 patients in the DEVOTE trial, a treat-to-target, randomized, double-blind trial evaluating the CV safety of degludec vs glargine U100, were divided into three age groups (50-64 years, n = 3682; 65-74 years, n = 3136; ≥75 years, n = 819). Outcomes by overall age group and randomized treatment differences were analysed for major adverse cardiovascular events (MACE), all-cause mortality, severe hypoglycaemia and serious adverse events (SAEs). RESULTS: Patients with increasing age had higher risks of CV death, all-cause mortality and SAEs, and there were non-significant trends towards higher risks of MACE and severe hypoglycaemia. Treatment effects on the risk of MACE, all-cause mortality, severe hypoglycaemia and SAEs were consistent across age groups, based on the non-significant interactions between treatment and age with regard to these outcomes. CONCLUSIONS: There were higher risks of CV death, all-cause mortality and SAEs, and trends towards higher risks of MACE and severe hypoglycaemia with increasing age after adjusting for baseline differences. The effects across age groups of degludec vs glargine U100 on MACE, all-cause mortality and severe hypoglycaemia were comparable, suggesting that the risk of MACE, as well as all-cause mortality, is similar and the risk of severe hypoglycaemia is lower with degludec regardless of age. Evidence is conclusive only until 74 years of age.

THE MANAGEMENT OF HYPERGLYCEMIA IN NONCRITICALLY ILL HOSPITALIZED PATIENTS TREATED WITH CONTINUOUS ENTERAL OR PARENTERAL NUTRITION.

OBJECTIVE: Hyperglycemia is a common problem in hospitalized patients receiving artificial nutrition, and this development of hyperglycemia during parenteral nutrition therapy (PNT) and enteral nutrition therapy (ENT) increases the risks of hospital-related complications and mortality. This review aims to discuss the pathogenesis of hyperglycemia from artificial nutrition in the hospital, summarize current evidence on the treatment of hyperglycemia with insulin in these patients, and review current guidelines. METHODS: A systematic literature review using PubMed and the Medical Subject Headings (MeSH) terms "hyperglycemia," "enteral nutrition," and "parenteral nutrition" were used to evaluate the current evidence available for treating noncritically ill patients with hyperglycemia who were receiving artificial nutrition. RESULTS: The literature review showed that few randomized control trials exist regarding treatment of hyperglycemia in this cohort of patients, and the multiple retrospective evaluations that have addressed this topic provided varied results. In general, intravenous (IV) continuous insulin infusion offers the best glycemic control; however, this route of insulin administration is often burdensome for floor patients and their care teams. Administration of scheduled subcutaneous (SQ) insulin in patients on ENT or PNT is a safe and effective way to manage hyperglycemia, however limited data exist on an appropriate insulin regimen. CONCLUSION: Further prospective, randomized control trials are necessary to determine the optimal treatment of hyperglycemia for patients receiving ENT or PNT. ABBREVIATIONS: BG = blood glucose; CG = conventional glycemic control; ENT = enteral nutrition therapy; GIP = glucose-dependent insulinotropic polypeptide; GLP-1 = glucagon-like peptide 1; IG = intensive glycemic control; IV = intravenous; NPH = neutral protamine Hagedorn; PNT = parenteral nutrition therapy; SQ = subcutaneous; T2DM = type 2 diabetes mellitus; TDD = total daily dose; TPN = total parenteral nutrition.

COMPARISON OF THE LONG-TERM EFFECTS OF LIRAGLUTIDE AND GLIMEPIRIDE MONOTHERAPY ON BONE MINERAL DENSITY IN PATIENTS WITH TYPE 2 DIABETES.

OBJECTIVE: Patients with type 2 diabetes have an increased risk of fragility fractures; the cause is unclear but is likely multifactorial. Some diabetes treatments induce bone loss, accentuating underlying skeletal fragility and increasing fracture risk. This subgroup analysis aimed to compare long-term effects of liraglutide and glimepiride on bone mineral density (BMD) in patients with type 2 diabetes. METHODS: LEAD-3, a 52-week, double-blind, active-control, phase III, multicenter trial, investigated the efficacy of liraglutide (1.2 and 1.8 mg/day) versus glimepiride monotherapy in type 2 diabetes. A 52-week, open-label extension followed, in which participants remained on randomized therapy. A subgroup of participants underwent BMD measurement by dual-energy X-ray absorptiometry at baseline, 52, and 104 weeks. The main outcome measure was change from baseline in total body BMD at 52 and 104 weeks, assessed by analysis of covariance. RESULTS: A total of 746 patients with type 2 diabetes aged 19 to 79 years were randomized into the main trial. Of these, 61 patients (20 assigned to liraglutide 1.8 mg/day, 23 to liraglutide 1.2 mg/day, 18 to glimepiride 8 mg/day) had BMD measurements. Baseline age, body mass index, diabetes duration, glycated hemoglobin, and total BMD were similar across treatment groups. There was no apparent difference in mean total BMD change from baseline in patients receiving liraglutide 1.8 or 1.2 mg/day or glimepiride 8 mg/day at 52 or 104 weeks. CONCLUSION: In this small subgroup analysis, liraglutide monotherapy did not negatively affect total BMD in a 2-year prospective study, suggesting it may not exacerbate the consequences of bone fragility.

Impact of GLP-1 Receptor Agonist Use in Patients With Steatotic Liver Disease and Type 2 Diabetes: A Retrospective Cohort Study.

Background: Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) help manage type 2 diabetes (T2DM) and may have efficacy in steatotic liver disease. Objective: To determine the prevalence and clinical impact of GLP-1 RA use in patients with T2DM and liver disease. Methods: This was a retrospective study of adult patients with T2DM and nonalcoholic fatty liver disease (NAFLD), nonalcoholic fatty liver (NAFL), or nonalcoholic steatohepatitis (NASH) between 1/1/21-12/31/21. Patients with hepatitis B or C, or on pioglitazone were excluded. Eligible patients treated with a GLP-1 RA were compared to controls. The primary outcome was change in Fibrosis-4 (FIB-4) score, with NAFLD Fibrosis Score (NFS) as a secondary outcome. Follow-up scores were calculated from labs within 3 to 15 months after baseline. Results: Of 242 eligible patients, 79 patients (32.6%) were treated with a GLP-1 RA. At baseline, FIB-4 score was lower and NFS was higher in the GLP-1 RA group vs controls (1.80 vs 2.33; P = .101, .36 vs -.47, P < .001; respectively). At follow up, FIB-4 score decreased to 1.77 in the GLP-1 RA group and increased to 2.71 in controls (P = .045). Follow up NFS was stable in the GLP-1 RA group and increased in the control group (.36 vs -.43; P = .308). Conclusion: Patients treated with GLP-1 RAs had less evidence of liver fibrosis progression compared to no treatment, although the differences were small. These results suggest that treatment with GLP-1 RAs may have clinical impact on slowing liver fibrosis, however results should be confirmed in a larger, more diverse sample.

Navigating the Debate on Managing Large (≥4 cm) Thyroid Nodules.

Purpose: Discordant practice guidelines for managing large thyroid nodules may result in unnecessary surgeries and costs. Recent data suggest similar false-negative rates in fine needle aspiration (FNA) biopsies between small (<4 cm) and large (≥4 cm) nodules, indicating that monitoring rather than surgery may be appropriate for large biopsy-negative nodules. We investigated the management of thyroid nodules ≥4 cm to determine the proportion of surgeries not necessary for diagnostic purposes and examined for potential predictors. Methods: This was a retrospective cohort study of patients who received a FNA of nodule(s) ≥4 cm between 11/1/2014 and 10/31/2019 at the University of Vermont Medical Center. A surgery was considered unnecessary if the FNA result was benign in the absence of any of the following: compressive symptoms, family history of thyroid cancer in a first degree relative, history of neck irradiation, toxic nodule or toxic multinodular goiter, or substernal extension. Data were analyzed with Wilcoxon rank sum tests, chi square, or Fisher's exact tests. Results: 177 patients had a ≥4 cm nodule during the timeframe and half (54.2%) had surgery. Patients who underwent surgery were significantly younger (51.5 years vs. 62 years; P < 0.001), more likely to report obstructive symptoms (34.4% vs. 12.1%; P < 0.001) and had a larger nodule size (5.0 cm vs. 4.7 cm; P=0.26). Forty-one patients with benign (Bethesda II) FNA results had surgery, all with negative surgical pathology. Thirteen percentage (23/177) of surgeries were potentially not necessary for diagnostic purposes. Conclusion: Approximately half of our patients with ≥4 cm nodules had surgery, with 13% having surgery not necessary for diagnostic purposes revealing opportunities for improving care and costs.

The Impact of a Nursing Strike on Glycemic Control in Hospitalized Patients with Diabetes.

Introduction Hyperglycemia and hypoglycemia have been found to increase morbidity and mortality among hospitalized patients with diabetes. In July of 2018, our academic medical center experienced a 48-hour nursing strike, during which time 600 replacement nurses were employed. This cohort study evaluated the impact of the nursing strike on glycemic control among hospitalized patients with diabetes. Methods Point-of-care fingerstick blood glucose (POC BG) values among hospitalized patients with diabetes were compared between the 48-hour nursing strike period and two 48-hour periods when the nursing strike did not occur. We evaluated the percentage of POC BG values that were hyperglycemic (POC BG 181-250 mg/dL), severely hyperglycemic (POC BG >250 mg/dL), and hypoglycemic (POC BG <70 mg/dL). Additionally, we assessed the proportion of patients who experienced one or more days of hypoglycemia, hyperglycemia, or severe hyperglycemia. Results We found a significant association between the distributions of POC BG test results during the nursing strike; test results more frequently showed hyperglycemia, severe hyperglycemia, or hypoglycemia during the nursing strike than during the control period (p=0.006). There was a significant difference in the days of hypoglycemia, with 7.7% of patients experiencing one or more days of hypoglycemia during the strike period compared with 1.4% of patients during the control period (p=0.03). Conclusion Nursing strikes have been employed as a last resort in contract negotiations with hospitals, but they have the potential to significantly affect patient care and safety. Further studies are needed to evaluate these impacts to prepare for future workforce disruptions.

Predictors and Consequences of Inappropriate Thyroid Ultrasound in Hypothyroidism.

Introduction In 2012, the American Board of Internal Medicine Foundation established the Choosing Wisely® initiative, partnering with specialist societies to promote evidence-based care. Under this program, the Endocrine Society recommends against ordering thyroid ultrasounds in individuals with subclinical or overt hypothyroidism and a normal neck exam. We sought to understand the prevalence, predictors, and consequences of thyroid ultrasound performed at our academic medical center that are not in compliance with this recommendation. Methods We conducted a retrospective cohort study of electronic health record data from January 1, 2016 to July 31, 2018. Data were extracted from records of all patients who underwent thyroid ultrasonography. Ultrasounds were considered inappropriate if they were ordered based on hypothyroidism, without other clear indications. Results A total of 2,021 patients underwent thyroid ultrasonography, of which 572 (28.3%) were diagnosed with hypothyroidism. Among the patients with hypothyroidism, 40 were identified as having received an inappropriate ultrasound (7.0%). Of those patients who received inappropriate ultrasounds, 42.5% had subsequent medical encounters, with a mean charge of $851 (standard deviation = $271) per patient. Using a multivariable model, the odds of receiving an inappropriate ultrasound were significantly higher for patients younger than 50 years of age (odds ratio: 2.37, 95% confidence interval: 1.01-5.58). Conclusion Seven percent of thyroid ultrasounds were inappropriately ordered in a cohort with hypothyroidism. Patients aged <50 years were at an increased risk of inappropriate ultrasound. Sequelae of inappropriate ultrasound included further medical encounters and financial burdens. Systems to reduce the inappropriate use of thyroid ultrasound may lessen the consequences of unnecessary medical imaging.

GLP-1 Analogs and DPP-4 Inhibitors in Type 2 Diabetes Therapy: Review of Head-to-Head Clinical Trials.

The incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are released from enteroendocrine cells in response to the presence of nutrients in the small intestines. These homones facilitate glucose regulation by stimulating insulin secretion in a glucose dependent manner while suppressing glucagon secretion. In patients with type 2 diabetes (T2DM), an impaired insulin response to GLP-1 and GIP contributes to hyperglycemia. Dipeptidyl peptidase-4 (DPP-4) inhibitors block the breakdown of GLP-1 and GIP to increase levels of the active hormones. In clinical trials, DPP-4 inhibitors have a modest impact on glycemic control. They are generally well-tolerated, weight neutral and do not increase the risk of hypoglycemia. GLP-1 receptor agonists (GLP-1 RA) are peptide derivatives of either exendin-4 or human GLP-1 designed to resist the activity of DPP-4 and therefore, have a prolonged half-life. In clinical trials, they have demonstrated superior efficacy to many oral antihyperglycemic drugs, improved weight loss and a low risk of hypoglycemia. However, GI adverse events, particularly nausea, vomiting, and diarrhea are seen. Both DPP-4 inhibitors and GLP-1 RAs have demonstrated safety in robust cardiovascular outcome trials, while several GLP-1 RAs have been shown to significantly reduce the risk of major adverse cardiovascular events in persons with T2DM with pre-existing cardiovascular disease (CVD). Several clinical trials have directly compared the efficacy and safety of DPP-4 inhibitors and GLP-1 RAs. These studies have generally demonstrated that the GLP-1 RA provided superior glycemic control and weight loss relative to the DPP-4 inhibitor. Both treatments were associated with a low and comparable incidence of hypoglycemia, but treatment with GLP-1 RAs were invariably associated with a higher incidence of GI adverse events. A few studies have evaluated switching patients from DPP-4 inhibitors to a GLP-1RA and, as expected, improved glycemic control and weight loss are seen following the switch. According to current clinical guidelines, GLP-1RA and DPP-4 inhibitors are both indicated for the glycemic management of patients with T2DM across the spectrum of disease. GLP-1RA may be preferred over DPP- 4 inhibitors for many patients because of the greater reductions in hemoglobin A1c and weight loss observed in the clinical trials. Among patients with preexisting CVD, GLP-1 receptor agonists with a proven cardiovascular benefit are indicated as add-on to metformin therapy.

Unique Multidisciplinary Training Practices in Cytopathology: Simulation Training in Ultrasound-Guided Fine Needle Aspiration of the Thyroid.

The training of ultrasound-guided fine needle aspiration in pathology residency and fellowship programs can be a challenging task with variable outcomes, particularly when there is a lack of a standardized approach. In 2014, the Department of Pathology and Laboratory Medicine in collaboration with the Endocrine Division of the Department of Medicine at the University of Vermont Medical Center implemented simulation training for the incoming cytopathology and endocrinology fellows prior to fellows interacting with patients at the clinic in order to provide a structured approach to learning the technical components of ultrasound-guided fine needle aspiration. In 2018, a second simulation session was added to focus on communication, providing fellows an opportunity to further develop the communication skills that enhance patient connection, empathy, and trust. The combined simulation experience has provided the fellows an ideal learning environment to enhance their understanding of the technical aspects of ultrasound-guided fine needle aspiration as well as the necessary components of communication prior to having to perform the procedure on actual patients. This results in a biopsy clinic that runs more efficiently with improved patient satisfaction and trainee confidence when addressing patient concerns. This collaborative training experience also addresses many of the important aspects surrounding the Accreditation Council for Graduate Medical Education competencies in patient safety, procedure, communication, professionalism, and team-based systems. We report the details of these simulation sessions, how they are structured, key stakeholders involved, and means for communicating feedback to our learners with an emphasis on the importance and value of utilizing standardized patients.

Metastatic Lung Cancer Presenting as Monocular Blindness and Panhypopituitarism Secondary to a Pituitary Metastasis.

BACKGROUND Sellar masses are most commonly pituitary adenomas, however, about 1% of surgical resected pituitary lesions are found to be metastatic disease. It is hard to distinguish pituitary adenomas from metastatic disease. The most common primary sources for pituitary metastases are breast and lung cancer. CASE REPORT In this paper, we report the case of a woman who presented with right-sided vision loss who was found to have a sellar mass and panhypopituitarism. Subsequent imaging showed a large mass in her left upper lung with additional lesions in the spleen and adrenal glands. Neurosurgery performed an urgent transsphenoidal resection, with pathology confirming lung adenocarcinoma. CONCLUSIONS This is an unusual presentation of metastatic lung cancer, with the patient's primary symptoms being related to her pituitary metastasis and panhypopituitarism. Pituitary metastases are most commonly asymptomatic, although they can present with visual disturbances, diabetes insipidus, or panhypopituitarism. Pituitary metastases should be on the differential for sellar masses, particularly with specific radiographic findings, visual disturbances, and/or the presence of diabetes insipidus.

A Retrospective Study of Early vs Delayed Home Dose Basal Insulin in the Acute Management of Diabetic Ketoacidosis.

BACKGROUND: Insulin via continuous intravenous infusion (ICII) is a standard of care for treating patients with diabetic ketoacidosis (DKA). Once DKA is resolved, ICII is transitioned to subcutaneous therapy. However, recent guidelines recommend continuation of home dose subcutaneous basal insulin (HDBI) in patients with DKA. The objective of this study was to evaluate outcomes in patients who received early vs delayed HDBI. METHODS: This is a retrospective cohort study of patients ≥16 years old admitted to the medical intensive care unit between 1 July 2012 and 30 June 2015 with a primary diagnosis of DKA who received ICII and HDBI. Patients were stratified into early or delayed groups if they received HDBI before or after resolution of DKA, respectively. The primary outcome was incidence of transitional failure, defined as resumption of ICII or recurrence of DKA after initial ICII discontinuation. RESULTS: A total of 106 admissions were included for analysis; 33 (31.1%) received early HDBI. The incidence of transitional failure was similar between the early and delayed groups (OR, 0.60; 95% CI, 0.26 to 1.44; P = 0.72). In the early group, ICII duration was shorter at 13.8 hours [interquartile range (IQR), 10.1 to 16.5] vs 17.1 hours (IQR, 12.6 to 21.1; P = 0.04), with a trend toward lower rates of hypoglycemia (OR, 0.41; 95% CI, 0.16 to 1.05; P = 0.058). CONCLUSION: There was no significant difference in incidence of transitional failure between early and delayed HDBI. Early HDBI was associated with a shorter duration of ICII and a trend toward less hypoglycemia. A prospective analysis is needed to confirm these findings.

Thyroid Storm and Complete Heart Block after Treatment with Radioactive Iodine.

Thyroid storm is a rare endocrine emergency characterized by dysfunction of multiple organ systems. Thyroid storm is more common in Graves' disease and can be precipitated by surgery, trauma, infection, metabolic abnormalities, iodine load, and parturition. We present a diagnostically challenging case of thyroid storm precipitated by radioiodine therapy and accompanied by bradycardia, a rare but life-threatening complication related to treatment for hyperthyroidism.

Nausea/vomiting · tachycardia · unintentional weight loss · Dx?

A 22-year-old woman presented to the emergency department (ED) with a 24-hour history of nausea, vomiting, diarrhea, generalized abdominal pain, and mild headache. She denied shortness of breath, chest pain, or anxiety, and didn't have a history of cardiac problems. The physical examination revealed tachycardia (heart rate, 135 beats/min) and a respiratory rate of 24 breaths per minute.

A False Positive I-131 Metastatic Survey Caused by Radioactive Iodine Uptake by a Benign Thymic Cyst.

Thyroid carcinoma is the most common endocrine malignancy in the United States with increasing incidence and diagnosis but stable mortality. Differentiated thyroid cancer rarely presents with distant metastases and is associated with a low risk of morbidity and mortality. Despite this, current protocols recommend remnant ablation with radioactive iodine and evaluation for local and distant metastasis in some patients with higher risk disease. There are several case reports of false positive results of metastatic surveys that are either normal physiologic variants or other pathological findings. Most false positive findings are associated with tissue that has physiologic increased uptake of I-131, such as breast tissue or lung tissue; pathological findings such as thymic cysts are also known to have increased uptake. Our case describes a rare finding of a thymic cyst found on a false positive I-131 metastatic survey. The patient was taken for surgical excision and the final pathology was a benign thymic cyst. Given that pulmonary metastases of differentiated thyroid cancer are rare, thymic cysts, though also rare, must be part of the differential diagnosis for false positive findings on an I-131 survey.

Screening and treatment by the primary care provider of common diabetes complications.

Diabetes is the leading cause of end-stage renal disease, blindness, and nontraumatic lower-limb amputation. The largest reductions in cardiovascular events are seen when multiple risk factors are addressed simultaneously. The benefit of aspirin as secondary prevention in patients with previous stroke or myocardial infarction has been well established. Regular, dilated eye examinations are effective in detecting sight-threatening diabetic retinopathy and have been shown to prevent blindness. The use of appropriate tools and clinical examination/inspection provides greater than 87% specificity in detecting diabetic peripheral neuropathy. Early treatment of risk factors, including hypertension, hyperglycemia, and dyslipidemia can delay or prevent diabetic nephropathy.