OBJECTIVE Newborns delivered by women with gestational diabetes mellitus (GDM) have accelerated intrauterine growth earlier than the current recommended screening period. We aimed to determine whether universal GDM screening using a single oral glucose intolerance test (OGTT) at 18–20 weeks’ gestation improves pregnancy outcomes compared with standard screening at 24–28 weeks’ gestation. RESEARCH DESIGN AND METHODS We conducted a dual-center, parallel, randomized controlled trial with a planned interim analysis in singleton pregnant women to compare the effect of midpregnancy screening for GDM at 18–20 weeks’ gestation and standard screening at 24–28 weeks’ gestation. GDM was universally screened and diagnosed using 75-g OGTTs and the International Association of the Diabetes and Pregnancy Study Groups criteria. The primary outcome was a composite measure of primary cesarean delivery, birth weight >90th percentile, neonatal hypoglycemia, cord serum C-peptide >90th percentile, gestational hypertension, preeclampsia, and birth trauma. RESULTS The trial was stopped early for futility after the interim analysis. Of the 967 women included in the intention-to-treat analysis, the primary outcome was not significantly different between the two groups. Neonatal hypoglycemia was significantly lower and neonatal adiposity in women with GDM was higher in the midpregnancy screening group compared with the standard screening group. Adverse event rates were similar between the two groups. CONCLUSIONS Advancing universal GDM screening to midpregnancy at 18–20 weeks’ gestation may not improve pregnancy outcomes, except for a reduction in neonatal hypoglycemia. Newborns of women diagnosed with GDM through midpregnancy screening had higher neonatal adiposity.
{"title":"The Effect of Midpregnancy Screening for Gestational Diabetes Mellitus on Pregnancy Outcomes: The TESGO Randomized Controlled Trial","authors":"Chun-Heng Kuo, Ming-Wei Lin, Szu-Chieh Chen, I-Weng Yen, Kang-Chih Fan, Chih-Yao Hsu, Chien-Nan Lee, Chin-Hao Chang, Yu-Han Chang, Yi-Yun Tai, Chin-Ho Cheng, Kuan-Ying Huang, Wen-Wei Hsu, Jessica Kang, Jin-Chung Shih, Ming-Hua Ho, Tzu-Yi Chen, Shin-Yu Lin, Hung-Yuan Li","doi":"10.2337/dc25-0084","DOIUrl":"https://doi.org/10.2337/dc25-0084","url":null,"abstract":"OBJECTIVE Newborns delivered by women with gestational diabetes mellitus (GDM) have accelerated intrauterine growth earlier than the current recommended screening period. We aimed to determine whether universal GDM screening using a single oral glucose intolerance test (OGTT) at 18–20 weeks’ gestation improves pregnancy outcomes compared with standard screening at 24–28 weeks’ gestation. RESEARCH DESIGN AND METHODS We conducted a dual-center, parallel, randomized controlled trial with a planned interim analysis in singleton pregnant women to compare the effect of midpregnancy screening for GDM at 18–20 weeks’ gestation and standard screening at 24–28 weeks’ gestation. GDM was universally screened and diagnosed using 75-g OGTTs and the International Association of the Diabetes and Pregnancy Study Groups criteria. The primary outcome was a composite measure of primary cesarean delivery, birth weight >90th percentile, neonatal hypoglycemia, cord serum C-peptide >90th percentile, gestational hypertension, preeclampsia, and birth trauma. RESULTS The trial was stopped early for futility after the interim analysis. Of the 967 women included in the intention-to-treat analysis, the primary outcome was not significantly different between the two groups. Neonatal hypoglycemia was significantly lower and neonatal adiposity in women with GDM was higher in the midpregnancy screening group compared with the standard screening group. Adverse event rates were similar between the two groups. CONCLUSIONS Advancing universal GDM screening to midpregnancy at 18–20 weeks’ gestation may not improve pregnancy outcomes, except for a reduction in neonatal hypoglycemia. Newborns of women diagnosed with GDM through midpregnancy screening had higher neonatal adiposity.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"99 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145127770","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rajiv Agarwal, Jennifer B. Green, Hiddo J.L. Heerspink, Johannes F.E. Mann, Janet B. McGill, Amy K. Mottl, Masaomi Nangaku, Julio Rosenstock, Muthiah Vaduganathan, Meike Brinker, Charlie Scott, Li Li, Na Li, Katja Rohwedder, Peter Rossing
OBJECTIVE The CONFIDENCE trial demonstrated additive benefits of simultaneous initiation of finerenone, a nonsteroidal mineralocorticoid receptor antagonist, and a sodium–glucose cotransporter 2 (SGLT2) inhibitor compared with monotherapy in reducing the urinary albumin-to-creatinine ratio (UACR). This prespecified analysis evaluated whether safety and efficacy of combination therapy varies by baseline glucagon-like peptide 1 receptor agonist (GLP-1 RA) use. RESEARCH DESIGN AND METHODS Adults with chronic kidney disease (UACR ≥100 to <5,000 mg/g; estimated glomerular filtration rate [eGFR] 30–90 mL/min/1.73 m2) and type 2 diabetes (glycated hemoglobin <11% [97 mmol/mol]) were randomized (1:1:1) to once-daily finerenone, empagliflozin, or finerenone plus empagliflozin. RESULTS Among 800 participants, 182 (23%) used a GLP-1 RA at baseline. At day 180, UACR change from baseline in participants using a GLP-1 RA was −51% (95% CI −59 to −40%) with combination therapy, −34% (−48 to −18%) with finerenone, and −36% (−48 to −21%) with empagliflozin. Corresponding results in those not using a GLP-1 RA at baseline were −56% (−62 to −50%), −37% (−45 to −28%), and −33% (−41 to −23%), respectively. Hyperkalemia incidence rates with combination therapy were 9.0% and 9.5% among individuals with and without baseline GLP-1 RA use. eGFR changes were consistent among individuals with and without baseline GLP-1 RA use. Acute kidney injury was uncommon. Decreases in systolic blood pressure were observed and were more pronounced with combination therapy. CONCLUSIONS In CONFIDENCE, simultaneous initiation with finerenone and an SGLT2 inhibitor was effective and well tolerated compared with monotherapy, irrespective of background use of a GLP-1 RA.
{"title":"Impact of Baseline GLP-1 Receptor Agonist Use on Albuminuria Reduction and Safety With Simultaneous Initiation of Finerenone and Empagliflozin in Type 2 Diabetes and Chronic Kidney Disease (CONFIDENCE Trial)","authors":"Rajiv Agarwal, Jennifer B. Green, Hiddo J.L. Heerspink, Johannes F.E. Mann, Janet B. McGill, Amy K. Mottl, Masaomi Nangaku, Julio Rosenstock, Muthiah Vaduganathan, Meike Brinker, Charlie Scott, Li Li, Na Li, Katja Rohwedder, Peter Rossing","doi":"10.2337/dc25-1673","DOIUrl":"https://doi.org/10.2337/dc25-1673","url":null,"abstract":"OBJECTIVE The CONFIDENCE trial demonstrated additive benefits of simultaneous initiation of finerenone, a nonsteroidal mineralocorticoid receptor antagonist, and a sodium–glucose cotransporter 2 (SGLT2) inhibitor compared with monotherapy in reducing the urinary albumin-to-creatinine ratio (UACR). This prespecified analysis evaluated whether safety and efficacy of combination therapy varies by baseline glucagon-like peptide 1 receptor agonist (GLP-1 RA) use. RESEARCH DESIGN AND METHODS Adults with chronic kidney disease (UACR ≥100 to &lt;5,000 mg/g; estimated glomerular filtration rate [eGFR] 30–90 mL/min/1.73 m2) and type 2 diabetes (glycated hemoglobin &lt;11% [97 mmol/mol]) were randomized (1:1:1) to once-daily finerenone, empagliflozin, or finerenone plus empagliflozin. RESULTS Among 800 participants, 182 (23%) used a GLP-1 RA at baseline. At day 180, UACR change from baseline in participants using a GLP-1 RA was −51% (95% CI −59 to −40%) with combination therapy, −34% (−48 to −18%) with finerenone, and −36% (−48 to −21%) with empagliflozin. Corresponding results in those not using a GLP-1 RA at baseline were −56% (−62 to −50%), −37% (−45 to −28%), and −33% (−41 to −23%), respectively. Hyperkalemia incidence rates with combination therapy were 9.0% and 9.5% among individuals with and without baseline GLP-1 RA use. eGFR changes were consistent among individuals with and without baseline GLP-1 RA use. Acute kidney injury was uncommon. Decreases in systolic blood pressure were observed and were more pronounced with combination therapy. CONCLUSIONS In CONFIDENCE, simultaneous initiation with finerenone and an SGLT2 inhibitor was effective and well tolerated compared with monotherapy, irrespective of background use of a GLP-1 RA.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"73 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145084281","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ben Nash, Loren Sher, Steven James, Ziad Nehme, Jason Talevski, Zoe Schofield, David O’Neal, Leonid Churilov, Glen Noonan, Renza Scibilia, Rodney Kwok, Elif I. Ekinci
OBJECTIVE New approaches to diabetes care are needed to better identify and manage diabetes emergencies outside of hospitals. RESEARCH DESIGN AND METHODS A descriptive analysis of routinely collected data was conducted using data from the Victorian Virtual Emergency Department (VVED) Diabetes, a telehealth service that provides emergency care, including ketone testing by ambulance personnel, for patients across Victoria, Australia, experiencing non–life-threatening diabetes-related emergencies. RESULTS Between July and December 2024, VVED Diabetes managed 868 diabetes-related emergencies, with 82.5% treated in the community, avoiding a physical emergency department visit. Referrals came from various sources, including Ambulance Victoria (26%), aged care facilities (29%), and self-registrations (20%). Hyperglycemia accounted for 46% of presentations. No clinical adverse events were reported, and patients gave positive feedback in a postdischarge survey. CONCLUSIONS VVED Diabetes delivers safe, timely, and high-quality treatment for individuals with diabetes who are acutely unwell, while ensuring the efficient use of limited hospital resources.
{"title":"Reimagining Acute Diabetes Care: Insights From the Victorian Virtual Emergency Department","authors":"Ben Nash, Loren Sher, Steven James, Ziad Nehme, Jason Talevski, Zoe Schofield, David O’Neal, Leonid Churilov, Glen Noonan, Renza Scibilia, Rodney Kwok, Elif I. Ekinci","doi":"10.2337/dc25-0852","DOIUrl":"https://doi.org/10.2337/dc25-0852","url":null,"abstract":"OBJECTIVE New approaches to diabetes care are needed to better identify and manage diabetes emergencies outside of hospitals. RESEARCH DESIGN AND METHODS A descriptive analysis of routinely collected data was conducted using data from the Victorian Virtual Emergency Department (VVED) Diabetes, a telehealth service that provides emergency care, including ketone testing by ambulance personnel, for patients across Victoria, Australia, experiencing non–life-threatening diabetes-related emergencies. RESULTS Between July and December 2024, VVED Diabetes managed 868 diabetes-related emergencies, with 82.5% treated in the community, avoiding a physical emergency department visit. Referrals came from various sources, including Ambulance Victoria (26%), aged care facilities (29%), and self-registrations (20%). Hyperglycemia accounted for 46% of presentations. No clinical adverse events were reported, and patients gave positive feedback in a postdischarge survey. CONCLUSIONS VVED Diabetes delivers safe, timely, and high-quality treatment for individuals with diabetes who are acutely unwell, while ensuring the efficient use of limited hospital resources.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"38 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145017245","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anika Bilal, Fanchao Yi, Keri Whitaker, Zahra A. Khan, Richard E. Pratley, Anna Casu
OBJECTIVE Although continuous glucose monitoring (CGM) reduces hypoglycemia and may improve impaired awareness of hypoglycemia (IAH), its effectiveness in older adults at high risk remains unknown. RESEARCH DESIGN AND METHODS This post hoc analysis of the WISDM study focuses on CGM use over 52 weeks. IAH was assessed using the Clarke original score (Clarke-full) and its subscales, Hypoglycemia Awareness Factor (HAF) and Severe Hypoglycemia Experienced Factors (SHEF), at baseline, 26 weeks, and 52 weeks. RESULTS After 26 (n = 184) and 52 weeks (n = 94) of CGM use, Clarke-SHEF decreased significantly (P = 0.02 and P < 0.0001, respectively), whereas Clarke-full and Clarke-HAF remained unchanged. After 52 weeks, Clarke-full but not Clarke-HAF improved in the IAH subgroup, highlighting the importance of selecting the appropriate scoring method for IAH. CONCLUSIONS In older adults with type 1 diabetes, CGM improves hypoglycemia; however, its role in improving IAH is variable, depending on the scoring method. This study highlights the limitations of the Clarke score.
{"title":"Effects of Continuous Glucose Monitoring on Impaired Awareness of Hypoglycemia in Older Adults With Type 1 Diabetes: A Post Hoc Analysis of the WISDM Study","authors":"Anika Bilal, Fanchao Yi, Keri Whitaker, Zahra A. Khan, Richard E. Pratley, Anna Casu","doi":"10.2337/dc25-0971","DOIUrl":"https://doi.org/10.2337/dc25-0971","url":null,"abstract":"OBJECTIVE Although continuous glucose monitoring (CGM) reduces hypoglycemia and may improve impaired awareness of hypoglycemia (IAH), its effectiveness in older adults at high risk remains unknown. RESEARCH DESIGN AND METHODS This post hoc analysis of the WISDM study focuses on CGM use over 52 weeks. IAH was assessed using the Clarke original score (Clarke-full) and its subscales, Hypoglycemia Awareness Factor (HAF) and Severe Hypoglycemia Experienced Factors (SHEF), at baseline, 26 weeks, and 52 weeks. RESULTS After 26 (n = 184) and 52 weeks (n = 94) of CGM use, Clarke-SHEF decreased significantly (P = 0.02 and P &lt; 0.0001, respectively), whereas Clarke-full and Clarke-HAF remained unchanged. After 52 weeks, Clarke-full but not Clarke-HAF improved in the IAH subgroup, highlighting the importance of selecting the appropriate scoring method for IAH. CONCLUSIONS In older adults with type 1 diabetes, CGM improves hypoglycemia; however, its role in improving IAH is variable, depending on the scoring method. This study highlights the limitations of the Clarke score.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"4 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144987414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hannah G. Gordon, Alexis Shub, Susan P. Walker, Richard J. Hiscock, Jessica Atkinson, Stephen Tong, Roxanne M. Hastie, Anthea C. Lindquist, Natasha L. Pritchard
OBJECTIVE To determine the relationships between diabetes in pregnancy, birth weight, and stillbirth risk, using population-based data. RESEARCH DESIGN AND METHODS All singleton births in Victoria, Australia, between 2009 and 2020 were linked with perinatal and diabetes data. For each diabetes subgroup (type 1, type 2, and gestational diabetes [diet-controlled, insulin-controlled]), we assessed the proportion of infants with a birth weight in <10th or >97th centile, the probability of stillbirth by birth weight centile, and stillbirth rate per 1,000 pregnancies across gestational age. RESULTS Our study cohort of 860,042 included 100,856 pregnancies (11.7%) complicated by diabetes in pregnancy. Compared with no diabetes, women with diabetes in pregnancy gave birth earlier (median gestation 38.7 weeks vs. 39.4) and had more iatrogenic births (65% vs. 44%). Gestational diabetes was associated with a lower overall risk of stillbirth compared with no diabetes (diet-controlled: relative risk [RR] 0.75 [95% CI 0.64–0.89]; insulin-controlled: RR 0.37 [95% CI 0.25–0.50]). Compared with no diabetes, preexisting diabetes was associated with an increased risk of stillbirth (RR 2.68 [95% CI 2.01–3.56]), with this trend persisting across all gestational ages and birth weights. This was particularly observed among infants in the >97th centile (type 1 diabetes: RR 3.96 [95% CI 1.23–12.76]; type 2 diabetes: RR 4.02 [95% CI 1.71–9.47]). CONCLUSIONS In our cohort, gestational diabetes was associated with a lower stillbirth risk compared with no diabetes, which potentially can be explained by increased monitoring and earlier iatrogenic delivery. Preexisting diabetes was associated with a higher overall risk of stillbirth, with macrosomic fetuses in the >97th centile representing a particularly high-risk group requiring close monitoring.
目的利用基于人群的数据，确定妊娠期糖尿病、出生体重和死产风险之间的关系。研究设计和方法澳大利亚维多利亚州2009年至2020年间的所有单胎分娩与围产期和糖尿病数据相关。对于每一个糖尿病亚组（1型、2型和妊娠期糖尿病[饮食控制、胰岛素控制]），我们评估了出生体重低于1 / 3的婴儿比例。第十或&；gt；第97百分位，按出生体重百分位计算的死产概率，以及整个妊娠期每1000例妊娠的死产率。结果：860,042例研究队列包括100,856例妊娠合并糖尿病（11.7%）。与未患糖尿病的妇女相比，妊娠期患有糖尿病的妇女分娩更早（中位妊娠期38.7周对39.4周），医源性分娩更多（65%对44%）。与无糖尿病患者相比，妊娠期糖尿病患者死产的总体风险较低（饮食控制：相对风险[RR] 0.75 [95% CI 0.64-0.89]；胰岛素控制：RR 0.37 [95% CI 0.25-0.50]）。与未患糖尿病的孕妇相比，先前存在的糖尿病与死产风险增加相关（RR 2.68 [95% CI 2.01-3.56]），这种趋势在所有胎龄和出生体重中持续存在。这在婴儿中尤为明显。第97百分位（1型糖尿病：RR 3.96 [95% CI 1.23-12.76]； 2型糖尿病：RR 4.02 [95% CI 1.71-9.47]）。结论：在我们的队列中，与无糖尿病患者相比，妊娠期糖尿病与较低的死产风险相关，这可能是由于监测的增加和早期医源性分娩所致。先前存在的糖尿病与死产的总体风险较高有关，与巨大胎儿有关；第97百分位代表需要密切监测的特别高危人群。
{"title":"Maternal Diabetes, Fetal Growth and Stillbirth Risk: A Population-Wide Retrospective Cohort Study From Victoria, Australia","authors":"Hannah G. Gordon, Alexis Shub, Susan P. Walker, Richard J. Hiscock, Jessica Atkinson, Stephen Tong, Roxanne M. Hastie, Anthea C. Lindquist, Natasha L. Pritchard","doi":"10.2337/dc25-0833","DOIUrl":"https://doi.org/10.2337/dc25-0833","url":null,"abstract":"OBJECTIVE To determine the relationships between diabetes in pregnancy, birth weight, and stillbirth risk, using population-based data. RESEARCH DESIGN AND METHODS All singleton births in Victoria, Australia, between 2009 and 2020 were linked with perinatal and diabetes data. For each diabetes subgroup (type 1, type 2, and gestational diabetes [diet-controlled, insulin-controlled]), we assessed the proportion of infants with a birth weight in &lt;10th or &gt;97th centile, the probability of stillbirth by birth weight centile, and stillbirth rate per 1,000 pregnancies across gestational age. RESULTS Our study cohort of 860,042 included 100,856 pregnancies (11.7%) complicated by diabetes in pregnancy. Compared with no diabetes, women with diabetes in pregnancy gave birth earlier (median gestation 38.7 weeks vs. 39.4) and had more iatrogenic births (65% vs. 44%). Gestational diabetes was associated with a lower overall risk of stillbirth compared with no diabetes (diet-controlled: relative risk [RR] 0.75 [95% CI 0.64–0.89]; insulin-controlled: RR 0.37 [95% CI 0.25–0.50]). Compared with no diabetes, preexisting diabetes was associated with an increased risk of stillbirth (RR 2.68 [95% CI 2.01–3.56]), with this trend persisting across all gestational ages and birth weights. This was particularly observed among infants in the &gt;97th centile (type 1 diabetes: RR 3.96 [95% CI 1.23–12.76]; type 2 diabetes: RR 4.02 [95% CI 1.71–9.47]). CONCLUSIONS In our cohort, gestational diabetes was associated with a lower stillbirth risk compared with no diabetes, which potentially can be explained by increased monitoring and earlier iatrogenic delivery. Preexisting diabetes was associated with a higher overall risk of stillbirth, with macrosomic fetuses in the &gt;97th centile representing a particularly high-risk group requiring close monitoring.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"14 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144987389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jennifer R. Snaith, Phoom Narongkiatikhun, Petter Bjornstad, Jerry R. Greenfield, Kalie L. Tommerdahl
In type 1 diabetes, a condition that necessitates lifelong exogenous insulin replacement, there is heavy reliance on technology-assisted insulin delivery and glucose monitoring. Yet, people living with type 1 diabetes still face dysglycemia, weight gain, vascular complications, ketoacidosis and severe hypoglycemia, and psychological distress. Cardiovascular and kidney disease remain the leading causes of morbidity and mortality, yet traditional risk factors (smoking, hypertension, hyperlipidemia, obesity, hyperglycemia) incompletely explain this excess burden. Emerging evidence highlights the role of insulin resistance, inflammation, and endothelial dysfunction exacerbated by current subcutaneous insulin therapies in type 1 diabetes, independent of overweight/obesity status. This has fueled interest in addressing metabolic challenges in type 1 diabetes through novel insulin analogs, adjunctive noninsulin therapies, and integrated technologies. Our review explores the potential synergy between technologies and adjunctive therapeutics to address unique physiologic drivers of metabolic dysfunction in type 1 diabetes. Innovations such as multihormonal systems, dynamic glucose and ketone monitoring, and automated insulin titration hold promise. However, leveraging emerging insights from nutrient-stimulated hormone-based therapies and other drug classes such as insulin-sensitizing agents and sodium–glucose cotransporter 2 inhibitors could pave the way for designing combination type 1 diabetes–specific therapies. Large, placebo-controlled trials are needed to progress the field toward use of combination therapies that reduce metabolic and vascular complications and ease patient burden in type 1 diabetes.
{"title":"Advancing Type 1 Diabetes Management: Integrating Novel Therapies, Technologies, and Adjunctive Approaches","authors":"Jennifer R. Snaith, Phoom Narongkiatikhun, Petter Bjornstad, Jerry R. Greenfield, Kalie L. Tommerdahl","doi":"10.2337/dci25-0015","DOIUrl":"https://doi.org/10.2337/dci25-0015","url":null,"abstract":"In type 1 diabetes, a condition that necessitates lifelong exogenous insulin replacement, there is heavy reliance on technology-assisted insulin delivery and glucose monitoring. Yet, people living with type 1 diabetes still face dysglycemia, weight gain, vascular complications, ketoacidosis and severe hypoglycemia, and psychological distress. Cardiovascular and kidney disease remain the leading causes of morbidity and mortality, yet traditional risk factors (smoking, hypertension, hyperlipidemia, obesity, hyperglycemia) incompletely explain this excess burden. Emerging evidence highlights the role of insulin resistance, inflammation, and endothelial dysfunction exacerbated by current subcutaneous insulin therapies in type 1 diabetes, independent of overweight/obesity status. This has fueled interest in addressing metabolic challenges in type 1 diabetes through novel insulin analogs, adjunctive noninsulin therapies, and integrated technologies. Our review explores the potential synergy between technologies and adjunctive therapeutics to address unique physiologic drivers of metabolic dysfunction in type 1 diabetes. Innovations such as multihormonal systems, dynamic glucose and ketone monitoring, and automated insulin titration hold promise. However, leveraging emerging insights from nutrient-stimulated hormone-based therapies and other drug classes such as insulin-sensitizing agents and sodium–glucose cotransporter 2 inhibitors could pave the way for designing combination type 1 diabetes–specific therapies. Large, placebo-controlled trials are needed to progress the field toward use of combination therapies that reduce metabolic and vascular complications and ease patient burden in type 1 diabetes.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"8 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144919053","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Philip M. Clarke, Xinyang Hua, Ruth L. Coleman, John Chalmers, Mark Woodward, Jennifer B. Green, Darren K. McGuire, Lee-Ling Lim, Amanda I. Adler, Rury R. Holman
OBJECTIVE To examine differences in case-fatality incidence among individuals with type 2 diabetes after major coronary or cerebrovascular events by geographic region and country income level. RESEARCH DESIGN AND METHODS We studied ADVANCE, TECOS, and EXSCEL participants who experienced within-trial major coronary (fatal or nonfatal myocardial infarction or sudden cardiac death) or cerebrovascular (fatal or nonfatal stroke) events. Case fatality was defined as death at the time or within 30 days of an event. We compared geographic regions with the reference category (Western Europe, North America, or Australia and New Zealand) and compared medium- and low-income countries, based on gross national income per capita by the World Bank, with the reference category (high). Unadjusted and adjusted analyses were performed for each trial using logistic regression for individual participant data, and the results were meta-analyzed. Adjustments were made for previous cardiovascular events and risk factors. RESULTS There were 2,574 major coronary and 1,247 cerebrovascular events among the 40,563 study participants. Postcoronary case-fatality adjusted odds ratios (95% CIs), compared with the reference group, were 3.31 (2.32–4.72), 2.78 (2.11–3.66), and 2.84 (1.71–4.73) for Asia, Central and Eastern Europe, and South America and Africa, respectively. The odds ratio for low- and middle-income versus high-income countries was 3.07 (2.41–3.92). Case fatality after a major cerebrovascular event did not differ by geographic region or income group. CONCLUSIONS Postcoronary case fatality was substantially higher in Asia, Central and Eastern Europe, and South America and Africa compared with Western countries and higher in low- and middle-income countries compared with high-income countries.
{"title":"International Variation in Case Fatality After Major Coronary or Cerebrovascular Events in Individuals With Type 2 Diabetes: Evidence From ADVANCE, TECOS, and EXSCEL","authors":"Philip M. Clarke, Xinyang Hua, Ruth L. Coleman, John Chalmers, Mark Woodward, Jennifer B. Green, Darren K. McGuire, Lee-Ling Lim, Amanda I. Adler, Rury R. Holman","doi":"10.2337/dc25-0541","DOIUrl":"https://doi.org/10.2337/dc25-0541","url":null,"abstract":"OBJECTIVE To examine differences in case-fatality incidence among individuals with type 2 diabetes after major coronary or cerebrovascular events by geographic region and country income level. RESEARCH DESIGN AND METHODS We studied ADVANCE, TECOS, and EXSCEL participants who experienced within-trial major coronary (fatal or nonfatal myocardial infarction or sudden cardiac death) or cerebrovascular (fatal or nonfatal stroke) events. Case fatality was defined as death at the time or within 30 days of an event. We compared geographic regions with the reference category (Western Europe, North America, or Australia and New Zealand) and compared medium- and low-income countries, based on gross national income per capita by the World Bank, with the reference category (high). Unadjusted and adjusted analyses were performed for each trial using logistic regression for individual participant data, and the results were meta-analyzed. Adjustments were made for previous cardiovascular events and risk factors. RESULTS There were 2,574 major coronary and 1,247 cerebrovascular events among the 40,563 study participants. Postcoronary case-fatality adjusted odds ratios (95% CIs), compared with the reference group, were 3.31 (2.32–4.72), 2.78 (2.11–3.66), and 2.84 (1.71–4.73) for Asia, Central and Eastern Europe, and South America and Africa, respectively. The odds ratio for low- and middle-income versus high-income countries was 3.07 (2.41–3.92). Case fatality after a major cerebrovascular event did not differ by geographic region or income group. CONCLUSIONS Postcoronary case fatality was substantially higher in Asia, Central and Eastern Europe, and South America and Africa compared with Western countries and higher in low- and middle-income countries compared with high-income countries.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"10 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144919054","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Edyta Schaefer, Janett Barbaresko, Michael Roden, Oliver Kuss, Sabrina Schlesinger
OBJECTIVE To investigate the association between adherence to a plant-based dietary index (PDI), healthy PDI, and unhealthy PDI with all-cause mortality in people with type 2 diabetes and to assess whether associations varied by diabetes subgroups. RESEARCH DESIGN AND METHODS We included 4,829 UK Biobank participants with type 2 diabetes and at least two 24-h dietary recalls. We generated overall, healthy, and unhealthy scores. Multivariable Cox regression estimated hazard ratios (HRs) and 95% CIs for all-cause mortality, comparing the highest tertile (T3) with the lowest T1 of adherence to PDI, a healthy PDI, and an unhealthy PDI. Interactions between PDI adherence and diabetes subgroups (HbA1c, waist circumference, age at diagnosis, diabetes duration) were assessed by two-dimensional B-splines and by including product terms into the model. RESULTS During a mean follow-up of 11.3 years, 679 deaths occurred. Individuals with the highest PDI adherence, compared with those with lowest, were at lower risk of all-cause mortality (T3 vs. T1: HR 0.79 [95% CI 0.63; 0.99]), and a similar direction was observed for those with a healthy PDI (0.82 [0.67; 1.02]) but the 95% CI included the null value. Unhealthy PDI was associated with increased mortality risk (1.24 [1.00; 1.54]). The associations of PDI, healthy PDI, and unhealthy PDI with all-cause mortality risk were more pronounced for those with poorer glycemic control, higher waist circumference, diagnosis earlier in life, and longer diabetes duration. CONCLUSIONS Higher PDI adherence was associated with decreased mortality risk and higher unhealthy PDI adherence with an increased mortality risk. There was an indication for differences in these association depending on diabetes subgroups.
目的研究坚持植物性饮食指数（PDI）、健康PDI和不健康PDI与2型糖尿病患者全因死亡率之间的关系，并评估这种关系是否因糖尿病亚组而异。研究设计和方法我们纳入了4829名英国生物银行参与者，他们患有2型糖尿病，并且至少有两次24小时饮食回顾。我们生成了总体、健康和不健康的分数。多变量Cox回归估计了全因死亡率的风险比（hr）和95% ci，比较了坚持PDI、健康PDI和不健康PDI的最高终点（T3）和最低终点（T1）。PDI依从性与糖尿病亚组（HbA1c、腰围、诊断时年龄、糖尿病持续时间）之间的相互作用通过二维b样条和将产品项纳入模型来评估。结果：在平均11.3年的随访期间，发生679例死亡。与PDI依从性最低的个体相比，PDI依从性最高的个体全因死亡风险较低（T3 vs. T1: HR 0.79 [95% CI 0.63; 0.99]）， PDI健康的个体也有类似的趋势（0.82[0.67;1.02]），但95% CI包括零值。不健康的PDI与死亡风险增加相关（1.24[1.00;1.54]）。PDI、健康PDI和不健康PDI与全因死亡风险的关联在血糖控制较差、腰围较高、生命早期诊断和糖尿病病程较长的患者中更为明显。结论：较高的PDI依从性与死亡风险降低有关，而较高的不健康PDI依从性与死亡风险增加有关。有迹象表明，根据糖尿病亚组，这些关联存在差异。
{"title":"Plant-Based Dietary Patterns Associated With Reduced Risk of All-Cause Mortality in Diabetes Subgroups: A Prospective Cohort Study From the UK Biobank","authors":"Edyta Schaefer, Janett Barbaresko, Michael Roden, Oliver Kuss, Sabrina Schlesinger","doi":"10.2337/dc25-0344","DOIUrl":"https://doi.org/10.2337/dc25-0344","url":null,"abstract":"OBJECTIVE To investigate the association between adherence to a plant-based dietary index (PDI), healthy PDI, and unhealthy PDI with all-cause mortality in people with type 2 diabetes and to assess whether associations varied by diabetes subgroups. RESEARCH DESIGN AND METHODS We included 4,829 UK Biobank participants with type 2 diabetes and at least two 24-h dietary recalls. We generated overall, healthy, and unhealthy scores. Multivariable Cox regression estimated hazard ratios (HRs) and 95% CIs for all-cause mortality, comparing the highest tertile (T3) with the lowest T1 of adherence to PDI, a healthy PDI, and an unhealthy PDI. Interactions between PDI adherence and diabetes subgroups (HbA1c, waist circumference, age at diagnosis, diabetes duration) were assessed by two-dimensional B-splines and by including product terms into the model. RESULTS During a mean follow-up of 11.3 years, 679 deaths occurred. Individuals with the highest PDI adherence, compared with those with lowest, were at lower risk of all-cause mortality (T3 vs. T1: HR 0.79 [95% CI 0.63; 0.99]), and a similar direction was observed for those with a healthy PDI (0.82 [0.67; 1.02]) but the 95% CI included the null value. Unhealthy PDI was associated with increased mortality risk (1.24 [1.00; 1.54]). The associations of PDI, healthy PDI, and unhealthy PDI with all-cause mortality risk were more pronounced for those with poorer glycemic control, higher waist circumference, diagnosis earlier in life, and longer diabetes duration. CONCLUSIONS Higher PDI adherence was associated with decreased mortality risk and higher unhealthy PDI adherence with an increased mortality risk. There was an indication for differences in these association depending on diabetes subgroups.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"11 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144915481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Janni E. Larsson, Lonny Stokholm, Toke Bek, Nis Andersen, Jens Andresen, Javad Hajari, Steffen Heegaard, Kurt Højlund, Ryo Kawasaki, Sören Möller, Frederik N. Pedersen, Katja C. Schielke, Anne Thykjær Petersen, Jakob Grauslund, Elisabeth R. Mathiesen, Caroline S. Laugesen
OBJECTIVE To evaluate the risk of treatment of sight-threatening diabetic retinopathy (DR) defined as panretinal photocoagulation for proliferative DR or anti–vascular endothelial growth factor injections for diabetic macular edema (DME) during and after pregnancy compared with nonpregnant control participants. RESEARCH DESIGN AND METHODS This was a matched cohort study of women with type 1 diabetes who gave birth in 2013–2022 and who had DR levels recorded in the national Danish Registry of Diabetic Retinopathy during and after pregnancy. Control participants consisted of nonpregnant women with type 1 diabetes, individually matched by baseline DR level. Data were collected from relevant national registers from 36 months before pregnancy until 36 months after. RESULTS We included 1,041 pregnant women and 1,041 matched control participants. At baseline, the median duration (interquartile range [IQR]) of diabetes was 13 (6, 19) and 10 (5, 17) years for cases and control participants. Median baseline HbA1c (IQR) was 57 (50, 67) compared with 64 (55, 79) mmol/mol (7.4% vs. 8%), and DR was present in 42.7% of both groups. During and after pregnancy, treatment of proliferative DR with panretinal photocoagulation occurred to a similar extent in both groups (pregnant women vs. control participants: during treatment: 1.2% vs. 1.1%, respectively, OR 1.18 [95% CI 0.53, 2.66]); and after treatment: 2.7% vs. 2.9%, respectively, OR 0.93 [95% CI 0.55, 1.57]). Treatment of DME was rare in both groups. Progression to proliferative DR was not higher in the pregnant group (adjusted hazard ratio 0.64 [95% CI 0.32, 1.31]). CONCLUSIONS In this nationwide register study of women with type 1 diabetes, pregnant women and retinopathy-matched, nonpregnant control participants had a similar risk of developing sight-threatening DR requiring treatment during and within 36 months after pregnancy.
目的：与未怀孕的对照组相比，评估妊娠期间和妊娠后治疗威胁视力的糖尿病视网膜病变（DR）的风险，DR定义为增殖性DR的全视网膜光凝治疗或抗血管内皮生长因子注射治疗糖尿病黄斑水肿（DME）。研究设计和方法这是一项匹配队列研究，研究对象为2013-2022年分娩的1型糖尿病女性，她们在怀孕期间和怀孕后的糖尿病视网膜病变国家登记处记录了DR水平。对照组由未怀孕的1型糖尿病妇女组成，分别与基线DR水平相匹配。从怀孕前36个月到怀孕后36个月的相关国家登记处收集数据。结果我们纳入了1041名孕妇和1041名匹配的对照受试者。在基线时，糖尿病患者和对照组的中位病程（四分位数范围[IQR]）分别为13年（6,19年）和10年（5,17年）。中位基线HbA1c （IQR）为57 (50,67)mmol/mol, 64 (55,79) mmol/mol(7.4%对8%)，两组均有42.7%的患者出现DR。在怀孕期间和怀孕后，两组用全视网膜光凝治疗增散性DR的发生率相似（孕妇与对照组：治疗期间分别为1.2%对1.1%，OR为1.18 [95% CI 0.53, 2.66]）；治疗后：2.7% vs. 2.9%, OR 0.93 [95% CI 0.55, 1.57])。两组均未见DME治疗。妊娠组向增殖性DR的进展并不高（校正风险比0.64 [95% CI 0.32, 1.31]）。结论：在这项全国范围内登记的1型糖尿病女性、孕妇和视网膜病变匹配的非怀孕对照参与者在怀孕期间和怀孕后36个月内发生视力威胁DR需要治疗的风险相似。
{"title":"Sight-Threatening Diabetic Retinopathy During and After Pregnancy—A Nationwide Matched-Cohort Study","authors":"Janni E. Larsson, Lonny Stokholm, Toke Bek, Nis Andersen, Jens Andresen, Javad Hajari, Steffen Heegaard, Kurt Højlund, Ryo Kawasaki, Sören Möller, Frederik N. Pedersen, Katja C. Schielke, Anne Thykjær Petersen, Jakob Grauslund, Elisabeth R. Mathiesen, Caroline S. Laugesen","doi":"10.2337/dc25-0758","DOIUrl":"https://doi.org/10.2337/dc25-0758","url":null,"abstract":"OBJECTIVE To evaluate the risk of treatment of sight-threatening diabetic retinopathy (DR) defined as panretinal photocoagulation for proliferative DR or anti–vascular endothelial growth factor injections for diabetic macular edema (DME) during and after pregnancy compared with nonpregnant control participants. RESEARCH DESIGN AND METHODS This was a matched cohort study of women with type 1 diabetes who gave birth in 2013–2022 and who had DR levels recorded in the national Danish Registry of Diabetic Retinopathy during and after pregnancy. Control participants consisted of nonpregnant women with type 1 diabetes, individually matched by baseline DR level. Data were collected from relevant national registers from 36 months before pregnancy until 36 months after. RESULTS We included 1,041 pregnant women and 1,041 matched control participants. At baseline, the median duration (interquartile range [IQR]) of diabetes was 13 (6, 19) and 10 (5, 17) years for cases and control participants. Median baseline HbA1c (IQR) was 57 (50, 67) compared with 64 (55, 79) mmol/mol (7.4% vs. 8%), and DR was present in 42.7% of both groups. During and after pregnancy, treatment of proliferative DR with panretinal photocoagulation occurred to a similar extent in both groups (pregnant women vs. control participants: during treatment: 1.2% vs. 1.1%, respectively, OR 1.18 [95% CI 0.53, 2.66]); and after treatment: 2.7% vs. 2.9%, respectively, OR 0.93 [95% CI 0.55, 1.57]). Treatment of DME was rare in both groups. Progression to proliferative DR was not higher in the pregnant group (adjusted hazard ratio 0.64 [95% CI 0.32, 1.31]). CONCLUSIONS In this nationwide register study of women with type 1 diabetes, pregnant women and retinopathy-matched, nonpregnant control participants had a similar risk of developing sight-threatening DR requiring treatment during and within 36 months after pregnancy.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"19 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144906061","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
OBJECTIVE The predictive power of urinary titin for incident sarcopenia was studied in Japanese individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS Baseline urinary titin levels were measured, and sarcopenia was evaluated annually using the Asian Working Group for Sarcopenia (AWGS) 2019 criteria. Kaplan-Meier curves, Cox models, and time-dependent receiver operating characteristic analyses were used to assess incident sarcopenia. RESULTS Among 444 participants (median follow-up, 1,078 days), 41 developed sarcopenia. The high titin tertile was associated with an elevated sarcopenia risk (log-rank P = 0.04). Cox models associated titin with sarcopenia (adjusted hazard ratio per SD 1.37, 95% CI 1.05–1.77, P = 0.019) and low muscle strength. Risk estimates were consistent across subgroups, including those aged ≥70 years, men, individuals with BMI <25 kg/m2, HbA1c ≥7%, and estimated glomerular filtration rate ≥60 mL/min/1.73 m2 (P for interaction > 0.05). CONCLUSIONS Elevated urinary titin levels predict sarcopenia and low muscle strength in individuals with type 2 diabetes, supporting its use as a noninvasive biomarker.
目的研究尿titin对日本2型糖尿病患者肌肉减少症的预测能力。研究设计和方法测量基线尿titin水平，并使用亚洲肌肉减少症工作组（AWGS） 2019标准每年评估肌肉减少症。Kaplan-Meier曲线、Cox模型和随时间变化的受试者工作特征分析用于评估肌肉减少症。结果：在444名参与者中（中位随访1078天），41人发生了肌肉减少症。高titin水平与肌少症风险升高相关（log-rank P = 0.04）。Cox模型将titin与肌肉减少症（校正风险比/ SD 1.37, 95% CI 1.05-1.77, P = 0.019）和低肌力相关。风险估计在亚组中是一致的，包括年龄≥70岁的人、男性、BMI和lt；25 kg/m2, HbA1c≥7%，估计肾小球滤过率≥60 mL/min/1.73 m2（相互作用P < 0.05）。结论尿titin水平升高可预测2型糖尿病患者的肌肉减少症和低肌力，支持其作为无创生物标志物的应用。
{"title":"Prediction of Sarcopenia Onset in Type 2 Diabetes Using Urinary Titin Levels: A Japanese Prospective Cohort Study","authors":"Hayato Tanabe, Yoshinori Takiguchi, Rie Tsutsumi, Kaori Shiroma, Mizusa Hyodo, Yuna Izumi-Mishima, Kazuhiro Nomura, Masafumi Matsuo, Hiroshi Sakaue, Michio Shimabukuro","doi":"10.2337/dc25-1067","DOIUrl":"https://doi.org/10.2337/dc25-1067","url":null,"abstract":"OBJECTIVE The predictive power of urinary titin for incident sarcopenia was studied in Japanese individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS Baseline urinary titin levels were measured, and sarcopenia was evaluated annually using the Asian Working Group for Sarcopenia (AWGS) 2019 criteria. Kaplan-Meier curves, Cox models, and time-dependent receiver operating characteristic analyses were used to assess incident sarcopenia. RESULTS Among 444 participants (median follow-up, 1,078 days), 41 developed sarcopenia. The high titin tertile was associated with an elevated sarcopenia risk (log-rank P = 0.04). Cox models associated titin with sarcopenia (adjusted hazard ratio per SD 1.37, 95% CI 1.05–1.77, P = 0.019) and low muscle strength. Risk estimates were consistent across subgroups, including those aged ≥70 years, men, individuals with BMI &lt;25 kg/m2, HbA1c ≥7%, and estimated glomerular filtration rate ≥60 mL/min/1.73 m2 (P for interaction &gt; 0.05). CONCLUSIONS Elevated urinary titin levels predict sarcopenia and low muscle strength in individuals with type 2 diabetes, supporting its use as a noninvasive biomarker.","PeriodicalId":11140,"journal":{"name":"Diabetes Care","volume":"12 1","pages":""},"PeriodicalIF":16.2,"publicationDate":"2025-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144898086","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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