Diabetic Medicine最新文献

Aims

The Adolescent Mirror is a dialogue tool designed to support communication in type 1 diabetes care. This study reports on its development and evaluation in separate clinical consultations with adolescents and with parents.

Methods

A qualitative approach was used to adapt The Family Mirror for adolescents. In the development phase, data from three prior studies were analyzed to identify themes relevant to adolescents' experiences with diabetes, which informed the creation of new quotations. In the test phase, the tool was tested in an outpatient clinic with 18 children and adolescents, 21 parents and three diabetes nurses. Children and adolescents participated in peer group sessions, while their parents joined parallel sessions, both facilitated by nurses with researcher support. In the evaluation phase, focus group discussions were conducted to gather participant feedback. Sessions were audio recorded, transcribed and analyzed using an inductive thematic approach, as described by Braun and Clarke.

Results

The Adolescent Mirror comprised 66 quotation cards: 37 shared between adolescents and parents, 16 specific to adolescents and 13 specific to parents. The tool successfully facilitated discussions on diabetes-related topics such as emotional impact, independence and daily challenges. Adolescents engaged in meaningful conversations with peers, and parents gained insight into each other's experiences. The fact that the tool was based on quotes from other adolescents with diabetes was highlighted as an advantage.

Conclusions

The Adolescent Mirror appears to be a feasible tool for supporting conversations about the psychosocial aspects of living with diabetes. It may help adolescents feel acknowledged and understood, while also providing a way of facilitating dialogue among parents of adolescents with diabetes.

Aims

The Real-world Evidence for Decisions in Diabetes (REDDIE) project aims to better understand how to use real-world data (RWD) to advance research related to diabetes. To achieve this aim, four national registries (National Diabetes Audit (NDA (England)), Diabetes Patienten Verlaufsdokumentation (DPV (Germany)), Swedish National Registries (NDR), Danish National Registries (DNR)) are contributing data to the REDDIE project. This publication aims to describe the four registries and compare their unique strengths and limitations.

Methods

Data regarding the four registries were extracted from their inception until 2024. Data regarding demographics, prescriptions, outcomes, lifestyle and diabetes-specific variables (usage of continuous glucose monitors) were summarised.

Results

A core set of variables was identified across all four registries in the REDDIE project. Demographic information, diabetes-related medication, measures of glycaemic control and lifestyle factors are measured in all four registries. The DNR, NDA and NDR also contain wider prescription data, diagnosis data (cardiovascular disease, retinopathy) and mortality data. The DPV registry does not contain these data but contains detailed data on continuous glucose monitor and insulin pump usage. Differences in the methodologies employed and data fields collected were identified, including in data collection techniques, linkage processes, follow-up protocols and the range of variables recorded. Even with this diversity in data collection, there remains a significant opportunity to perform collaborative analysis between the registries. By combining RWD collected in different populations and health care systems with diverse demographics, the transferability of evidence will increase, enabling research studies to be more representative and inclusive of diverse populations.

Conclusion

The four registries that make up the REDDIE project contain many commonly collected variables. However, each registry presents specific strengths and limitations. By including all four databases, the REDDIE project benefits from the complementary strengths of each database.

Aims

Diabetes is characterized by clinical heterogeneity. This study aimed to identify different clinical phenotypes of real-world people with diabetes and to assess their associations with major adverse cardiovascular events (MACEs).

Methods

From a prospective Polish registry of people with diabetes, hierarchical cluster analysis was performed based on 19 variables, including co-morbidities and cardiovascular (CV) risk factors. The primary outcome was the risk of MACEs (CV death, acute coronary syndrome and myocardial revascularizations, ischaemic stroke, new onset heart failure, and hospitalization for CV reasons). Secondary exploratory outcomes were each MACE component and all-cause death.

Results

On 2109 participants (median age 60 years, interquartile range [IQR] 45–69, 51.3% men) included, three different phenotypes were identified: (i) cluster 1 (27.8%) – young with type 1 diabetes; (ii) cluster 2 (42.0%) – elderly with type 2 diabetes and high complexity; (iii) cluster 3 (30.2%) – middle-aged with type 2 diabetes and cardiometabolic risk factors.

Compared to cluster 1, the risk of primary outcome was higher for clusters 2 and 3 (adjusted hazard ratio [aHR] 2.93, 95% CI 1.60–5.36, and aHR 1.85 95% CI 1.07–3.20, respectively). Using cluster 3 as the reference, cluster 1 was associated with a lower risk (aHR 0.54, 95% CI 0.31–0.94), and cluster 2 with a higher risk (aHR 1.58, 95% CI 1.08–2.33).

Conclusions

People with diabetes aggregate into different clinical phenotypes, each with different risks of MACEs. Integrated approaches tailored to these diverse clinical profiles are needed to improve outcomes in this heterogeneous and multifaceted disease.

Aims

Effective diabetes self-management increasingly depends on the interplay between health literacy, numeracy and digital health literacy, given the growing integration of advanced digital tools into diabetes care routines. Little is known about the current state of these skills among people with insulin-treated diabetes. Therefore, this study aims to assess (digital) health literacy and numeracy in people with diabetes on intensive insulin therapy and to explore their associations with glycaemic control, health behaviours, clinical outcomes and patient-reported outcomes.

Methods

The Exploring Diabetes Health Literacy and Numeracy across Europe (EDUCATE) study is a multicentre cross-sectional study aiming to recruit 209 adults with type 1, type 2, or pancreatogenic diabetes on intensive insulin therapy in four European outpatient clinics. Participants will be asked to complete questionnaires, record their dietary patterns, and wear both a physical activity tracker and a blinded continuous glucose monitor for two weeks. The primary outcome is health literacy, assessed using the validated Health Literacy questionnaire. Secondary outcomes include numeracy, digital health literacy, glycaemic outcomes, health behaviour (e.g., diet and physical activity), and patient-reported-outcomes (e.g., quality-of-life and diabetes distress).

Results

Findings will be diseminated through peer-reviewed scientific journals, and academic conferences or media outlets to inform the wider public.

Conclusion

EDUCATE will assess digital health literacy and numeracy in people with diabetes on intensive insulin regimens across four European countries. A deeper understanding of the current landscape of health literacy and its association with glycaemic outcomes may support the development of targeted interventions. These interventions are aimed at empowering people with diabetes and reducing socio-economic and cultural health disparities.

Aims

Diabetic neuropathic pain (DNP) is a debilitating complication of diabetes mellitus that significantly impairs patients' quality of life. In this study, we aimed to investigate whether much higher plasma advanced glycation end products (AGEs) concentrations discriminate between diabetes-affected individuals with pain and those without pain.

Methods

We administered exogenous AGEs intravenously to C57BL/6J wild-type mice and assessed nociceptive behaviours, as well as anxiety- and depression-like behaviours. To explore the further mechanism, we knocked out the protein tyrosine phosphatase 1B (PTP1B) in the spinal dorsal horn by injecting the AAV viral construct encoding short-hairpin RNA (shRNA). Electrophysiological recordings were used to assay the N-methyl-D-aspartate receptor (NMDAR) function.

Results

Our results demonstrated that elevated plasma AGEs levels led to significant hyperalgesia, which was alleviated by the specific knockout of PTP1B in the spinal dorsal horn. However, this knockout did not ameliorate AGEs-induced anxiety- and depression-like behaviours. Electrophysiological recordings revealed that AGEs enhanced NMDAR-mediated excitatory postsynaptic currents (eEPSCs) in spinal cord slices, an effect attenuated by PTP1B inhibition. Biochemical analyses showed that AGEs decreased phosphorylation at the Tyr529 site of Src kinase and increased phosphorylation at the Tyr1472 site of the NMDAR subunit 2B (GluN2B); these changes were reversed by PTP1B knockdown.

Conclusion

These findings suggest that elevated plasma AGEs contribute to hyperalgesia through a PTP1B-dependent mechanism involving Src/NMDAR signalling in the spinal dorsal horn. Targeting the AGEs-PTP1B-NMDAR pathway may offer new therapeutic strategies for managing DNP.

Aims

Sulphonylurea agents are typically used to treat HNF4A-MODY based on the pharmacogenetic aetiology of the condition, although limited evidence exists in the literature for this practice. The aims of this study were to determine the efficacy of sulphonylurea drugs during follow-up, to explore the role of adjunctive therapies in this cohort and to describe micro- and macrovascular complications over longitudinal follow-up.

Methods

Forty-two individuals with an HNF4A mutation were phenotyped in detail, including an oral glucose tolerance test to establish insulin secretory capacity. Subsequent markers, including oral hypoglycaemic usage, end-organ complications, weight, cardiovascular co-morbidity and biochemistry including HbA_1c and urinary albumin, were recorded at clinical follow-up.

Results

Significant HbA_1c reduction (p = 0.045) was observed in 51.6% of people with an HNF4A gene mutation on sulphonylurea monotherapy, and glycaemic control persisted after 6 years (IQR: 3.5–11) of follow-up. Adjunct agents including insulin are used in 48.4% of the cohort. These individuals have higher BMI (p = 0.037), longer duration of diabetes (p = 0.03) and reduced insulin secretory capacity (AUC C-peptide p = 0.01). Retinopathy was observed in 24.4%, nephropathy in 12.9% and coronary heart disease in 22.6% of the cohort.

Conclusion

Individuals with an HNF4A mutation and normal BMI are likely to respond to sulphonylurea therapy. Avoidance of weight gain is associated with ongoing responsiveness to monotherapy. Adjunct therapies including GLP1RA and SGLT2i may play a role in further glycaemic management in addition to renal protective and cardioprotective effects.

Aims

Safe management of people with Type 1 diabetes and Eating Disorders study (STEADY), a complex psychological intervention, defined by the Medical Research Council as involving multiple interacting components and individualised delivery, is a treatment designed for people with Type 1 diabetes and mild-to-moderate disordered eating (T1DE) which integrates cognitive behavioural therapy (CBT) with diabetes education. STEADY was previously tested in a feasibility randomised controlled trial (RCT), and the purpose of this work was to maximise trial learning to support future scaling up of STEADY in a multi-site RCT.

Methods

This study addressed three research questions: (1) Which STEADY toolkit tools were used in the intervention, and at which point? (2) To what extent was treatment delivered as intended, reflecting the minimum competency (≥3) on the Cognitive Therapy Rating Scale (Revised; CTS-R)? (3) How long did it take to deliver the STEADY intervention?

Results

A range of STEADY tools were used during the trial; the five most frequent tools were CBT formulation (72 uses), behavioural experiments (47 uses), thought records (43 uses), goal setting (40 uses) and understanding emotions and ‘riding the wave’ (40 uses). The CTS-R mean score was 3.81 ± 0.74, indicating competent adherence to CBT. Mean time to completion was 153.3 days (SD = 73).

Conclusions

When scaling up for a multi-site RCT, some participants may need greater flexibility regarding timing to access all STEADY sessions. STEADY can be personalised through its toolkit-based approach, and therapists should be mindful and trained in the range of tools available.

Aims

Diabetic sensorimotor polyneuropathy (DSPN) is the most common chronic complication of diabetes. Heterogeneity in outcome measures across DSPN trials may have hindered the development of novel therapies. No core outcome set (COS) exists to standardise DSPN trial outcomes. This systematic review aims to identify and synthesise outcomes reported in DSPN interventional trials.

Methods

The protocol was pre-registered on PROSPERO (CRD42023408403) and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Prospective DSPN interventional trials since 2018 were searched with a predefined strategy, and primary and secondary verbatim outcomes were extracted, merged and organised using a taxonomy recommended by Core Outcome Measures in Effectiveness Trials (COMET). Outcome measuring tools were summarised descriptively.

Results

Of the 4851 abstracts screened, 184 were eligible (protocols, n = 24; ongoing trials, n = 48 completed trials without published results, n = 11; published trials with results, n = 101). Pain was the most common primary (n = 127) and secondary (n = 64) unique outcome. By taxonomy, nervous system outcomes were the most common primary (n = 174) and secondary (n = 89) measure. The most common measuring tools were the visual analogue scale (n = 37), numerical rating scale (n = 37) and nerve conduction study (n = 34). Over 30 distinct measuring tools were utilised to measure nervous system outcomes.

Conclusions

Despite consistent outcome reporting, variability in measuring tools highlights the need for a COS with standardised tools. Patient-reported outcomes were more common than assessor-reported outcomes; however, using both may reduce response variability and bias. These findings will inform a future Delphi process to develop a COS for DSPN.

Aim

To explore the experiences of patients, families and clinicians managing steroid-induced hyperglycaemia (SIH) out of the hospital and identify areas for improved care.

Methods

We searched hospital records to identify patients requiring input from the diabetes inpatient team between February 2022 and March 2023 due to steroid usage. Clinicians, patients and their family members were interviewed remotely about their experiences of care and views on how to improve it. Patient characteristics were extracted from hospital records and descriptively summarised. Interview data were subjected to framework analysis.

Results

We interviewed 23 patients (60% male, aged 40–88 years). The median (IQR) glucocorticoid daily dose (prednisolone-equivalent) was 40 mg (20–60). Fifteen (65%) patients were followed up after discharge by the diabetes specialist team, the remainder being referred to primary care. Nine family members and five diabetes care clinicians were also interviewed.

SIH impacts negatively on patients' and families' physical and social well-being and increases clinical workload. Participants reported feeling anxious and uncertain when self managing SIH out of hospital, particularly those with multimorbidity and no prior history of diabetes. Regular post-discharge clinical follow-up builds patients' confidence and satisfaction, but there was limited post-discharge follow-up care, and conflicting advice was provided on SIH management from different care teams. Better discharge care planning, communication, family support and provision of SIH self management resources could improve care and experiences.

Conclusion

Our findings emphasise having robust, individualised, post-discharge care planning; better communication across care pathways; and provision of skills and resources to all partners in healthcare.