BMJ Open Diabetes Research & Care最新文献

Introduction: Ringer's lactate (RL), a balanced crystalloid by regenerating bicarbonate ion, may lead to early diabetic ketoacidosis (DKA) resolution and reduced hyperchloremia as compared with 0.9% saline (NS).

Research design and methods: This was a double-blind randomized controlled trial conducted in the pediatric emergency and intensive care units of a teaching hospital. Children with type 1 diabetes mellitus (T1DM) aged 9 months to 12 years who presented in DKA were included. Participants were randomized to receive either NS or RL as initial fluid (used for both resuscitation and replacement). The primary outcome was time to resolution of DKA. Secondary outcomes included change in serum chloride and bicarbonate from baseline, total fluid received and incidence of acute kidney injury.

Results: The study was conducted between December 2020 and December 2021, and 67 children were recruited (34 in the NS group and 33 in the RL group). The mean time to DKA resolution was shorter in the RL group compared with the NS group (12.9±7.9 vs 16.8±9 hours). The mean difference and HR for time to DKA resolution in the RL group compared with the NS group were 3.85 hours (95% CI 0.3 to 8) and 1.39 hours (95% CI 1.25 to 1.56), respectively. The rise in chloride from baseline was higher in the NS group as compared with the RL group at 4 and 8 hours (8.7±5.6 vs 3.9±5.1 mmol/L) and (10.8±7.7 vs 4.4±8.3 mmol/L), respectively. On the contrary, the rise in bicarbonate from baseline to 12 hours was significantly higher in the RL group as compared with the NS group (14.7±1.6 vs 12.9±3.1).

Conclusions: The time to resolution of DKA was shorter in RL group as compared with the NS group. Regeneration of bicarbonate from lactate ion in the RL forms a strong physiological basis for this outcome as compared with hyperchloremia induced by NS. This makes RL a favorable option in children with DKA.

Introduction: Recent post hoc analyses indicate that patients with normal or low body mass index (BMI) benefit from sodium-glucose cotransporter-2 (SGLT2) inhibitor use. We aimed to evaluate the effects of SGLT2 inhibitors on renal and patient outcomes in patients with diabetes and normal or low BMI.

Research design and methods: This single-center retrospective cohort study included 5,842 adult patients with type 2 diabetes and BMI<23 kg/m² from 2016 to 2020. Patients were divided into control and SGLT2 inhibitor groups and matched using propensity scores. The primary outcome was the annual change in the estimated glomerular filtration rate (eGFR). Secondary outcomes included change in BMI, a composite renal outcome (eGFR decline of ≥40% from baseline or end-stage kidney disease), all-cause mortality, and cardiovascular disease (CVD).

Results: Overall, 648 patients were selected for propensity score matching, of whom 216 (33.3%) were receiving SGLT2 inhibitors. The mean age and eGFR were 61.6 years and 84.7 mL/min/1.73 m², respectively. The median urine albumin-to-creatinine ratio was 11.6 mg/gCr. The control group showed relatively unchanged eGFR over time, whereas the SGLT2 inhibitor group showed an increase in eGFR over time (0.0 vs +0.3 mL/min/1.73 m²/year, p=0.0398). SGLT2 inhibitor use was associated with a lower risk of mortality (HR 0.171, 95% CI 0.041 to 0.718, p=0.0159) and composite renal outcome (HR 0.223, 95% CI 0.052 to 0.952; p=0.0426), but not with the risk of CVD.

Conclusions: SGLT2 inhibitor use may reduce the risk of eGFR decline and all-cause mortality even in low-risk patients with diabetes and normal or low BMI.

Introduction: Several factors influence individuals' confidence to perform diabetes-related self-care activities, including perceived patient-provider communication, diabetes duration and age at diagnosis. It has been well-documented that patient-provider communication is essential when managing chronic diseases such as diabetes; however, the impact of this communication with diabetes duration and age at diabetes diagnosis on confidence in performing self-care behaviors is obscure.

Research design and methods: We utilized data from the 2021 Household Component of the Medical Expenditure Survey among participants 18 years or older who had completed the Diabetes Care Survey. Ordinal logistic regression models were utilized to assess the association between confidence in performing diabetes self-care (outcome) and perceived communication with healthcare providers (exposure). Age at diabetes diagnosis and diabetes duration were secondary exposures of interest.

Results: 1231 participants were included in the analyses. In primary analyses, we observed that greater perceived healthcare provider communication resulted in greater confidence in diabetes self-care (OR (95% CI) 1.14 (1.08, 1.21)). Results also showed that patients who were diagnosed at older ages have less confidence in managing their diabetes than patients diagnosed at younger ages (OR (95% CI) 0.93 (0.88, 0.99)); correspondingly, longer diabetes duration was associated with greater confidence in diabetes self-care (OR (95% CI) 1.09 (1.01, 1.17)).

Conclusions: Confidence in self-care is greatly influenced by perceptions of patient-provider communication, age at diagnosis and diabetes duration. Specifically, having healthcare providers clearly explain things to patients is vital to increasing diabetes self-care. Because self-care is important when managing chronic diseases such as diabetes, future studies should tailor interventions for optimal outcomes.

Introduction: Roux-en-Y gastric bypass (RYGB) increases the risk of postprandial hypoglycemia, whereas pregnancy decreases insulin sensitivity, which could be expected to counteract hypoglycemia. We examined if RYGB performed prior to pregnancy altered the postprandial glucose metabolism and enteropancreatic hormone responses to a mixed meal test (MMT).

Research design and methods: Twenty-three women with RYGB and 23 women matched on prepregnancy body mass index and parity underwent a 4-hour MMT in the first and third trimester of pregnancy with measurement of circulating levels of glucose, insulin, C-peptide, glucose-dependent insulin peptide (GIP), glucagon-like peptide 1 (GLP-1), glucagon, free fatty acids, and lactate. Biochemical hypoglycemia was defined as plasma glucose <3.5 mmol/L.

Results: Women with RYGB had earlier and higher peak glucose, lower nadir glucose levels, and a higher frequency of biochemical hypoglycemia compared with women without RYGB in both the first and third trimester. The lower glucose levels were preceded by markedly elevated total GLP-1 and insulin levels in women with RYGB, whereas total GIP levels were unaltered. The glucagon levels were lower in women with RYGB. In the first trimester MMT, peak and area under the curve of total plasma GLP-1 and serum insulin levels were negatively associated with nadir plasma glucose, while the early postmeal response of plasma glucagon was positively associated with nadir plasma glucose in the third trimester.

Conclusions: These results provide novel insights into the combined effects of RYGB and pregnancy on postmeal glucose metabolism and enteropancreatic hormone responses during pregnancy, and how these changes associate with an increased risk of postprandial hypoglycemia.

Trial registration number: NCT03713060.

Objective: There is a need for comparable worldwide data on the impact of diabetes on mortality. This study assessed diabetes and all-cause mortality among middle-aged and older adults in five countries.

Research design and methods: We analyzed adults aged 51 years or older followed between 2010 and 2020 from population-based cohorts from China, England, Mexico, rural South Africa, and the USA. The cohorts are part of an international network of longitudinal aging studies with similar sampling designs, eligibility, and assessment methods. Diabetes was defined by self-report or an elevated diabetes blood-based biomarker meeting the clinical criteria for diabetes. All-cause mortality was assessed through linkages or informant interviews. We used Poisson regression models to estimate mortality rate ratios and mortality rate differences, comparing people with diabetes to those without diabetes. Models were adjusted for age, gender, education, smoking status, body mass index, economic status, and, in South Africa, HIV status.

Results: We included 29 397 individuals, of whom 4916 (16.7%) died during the study period. The median follow-up time ranged from 4.6 years in South Africa to 8.3 years in China. The adjusted all-cause mortality rate ratios for people with diabetes versus those without diabetes ranged from 1.53 (95% CI: 1.39 to 1.68) in the USA to 2.02 (95% CI: 1.34 to 3.06) in Mexico. The adjusted mortality rate differences (per 1000 person-years) for people with diabetes vers those without diabetes ranged from 11.9 (95% CI: 4.8 to 18.9) in England to 24.6 (95% CI: 12.2 to 37.0) in South Africa.

Conclusions: Diabetes was associated with increased all-cause mortality in population-based cohorts in China, England, Mexico, rural South Africa, and the USA. Limitations included differences in diabetes biomarkers and selection criteria across cohorts. The results highlight the urgent need to implement clinical and public health interventions worldwide to reduce excess diabetes mortality.

Introduction: In type 2 diabetes (T2D), beta cell failure is often associated with islet inflammation driven by the innate immune response, with macrophages playing a significant role. However, the composition and phenotype of lymphoid immune cells in the islets of individuals with T2D have not been extensively studied. This study aims to characterize and compare the presence, phenotype, and frequency of islet-associated lymphocytes-specifically T, B, and natural killer (NK) cells-in patients with T2D and non-diabetic organ donors.

Research design and methods: Multicolor flow cytometry was employed to detect NK, B, and T cells in dissociated pancreatic islets from 13 T2D and 44 non-diabetic donors. The frequencies and phenotypes of T cell subsets were determined using markers for memory differentiation status and tissue-resident T cells. The frequencies of alpha and beta cells were assessed by flow cytometry, and the insulin secretion level was measured by ELISA.

Results: In both T2D and non-diabetic islets, CD3(+) T cells were the predominant lymphocytes, mainly central and effector memory phenotypes, with a bias toward CD8(+) T cells expressing canonical residency markers (CD69 and CD103). The frequencies of CD19(+) B cells and CD3(-) CD16(+) CD56(+) NK cells were low in both groups. The proportions of these immune and beta cells were similar between T2D and non-diabetic donors. However, T2D donors had a higher proportion of glucagon-producing alpha cells and significantly reduced glucose-stimulated insulin secretion compared with non-diabetic individuals.

Conclusions: In T2D islets, resident CD8(+) T cells with a central memory phenotype dominate the lymphoid immune cell population, similar to non-diabetic donors. These findings provide the first insights into the memory T cell composition in human pancreatic islets in T2D, suggesting that the diabetic condition does not significantly alter the lymphoid landscape of pancreatic islets.

Introduction: Women with type 2 diabetes are at risk of commencing pregnancy while using medications that are either not recommended for pregnancy or with known teratogenicity, which may contribute to adverse pregnancy outcomes. In this study, we aimed to characterize pregnancy-related risk factors and medication exposures among women with type 2 diabetes.

Research design and methods: Individual health characteristics, sociodemographic information, and prescription data were extracted from the primary care records of women aged 18-45 years with type 2 diabetes in participating general practices in the UK. Prescribed medications were categorized according to suitability for pregnancy: recommended, not recommended, or not recommended but used if clinically indicated. Logistic regression was used to estimate associations between individual characteristics and medications not recommended for pregnancy.

Results: Data on 725 women were extracted. Prescribed medications suggested the presence of numerous comorbidities, with diabetes medications (65%, n=471) and statins (20%, n=145) most frequently prescribed. 37% (n=268) of women took ≥3 medications, and a third (n=269) took medications not recommended for pregnancy. Among those not prescribed contraception (89%, n=646), no one met all clinically recommended pre-pregnancy criteria. In multivariable logistic regression analysis, polypharmacy (OR 3.49 95% CI 2.88 to 4.30) and age (OR 1.04 95% CI 1.00 to 1.09) were associated with use of medications not recommended for pregnancy.

Conclusions: Women with type 2 diabetes have suboptimal contraceptive provision despite multiple exposures to medications not recommended for pregnancy. Regular assessment of contraceptive use, reproductive intentions, and medication review is urgently needed in primary care settings to minimize pregnancy-related risks.

Introduction: The integration of continuous glucose monitoring (CGM) into clinical practice has rapidly emerged in the last decade, changing the evaluation of long-term glucose regulation in patients with diabetes. When using CGM-derived metrics to evaluate long-term glucose regulation, it is essential to determine the minimal observation period necessary for a reliable estimate. The approach of this study was to calculate mean absolute errors (MAEs) for varying window lengths, with the goal of demonstrating how the CGM observation period influences the accuracy of the estimation of 90-day glycemic control.

Research design and methods: CGM data were collected from the DIABASE cohort (ZGT hospital, The Netherlands). Trailing aggregates (TAs) were calculated for four CGM-derived metrics: time in range (TIR), time below range (TBR), glucose management indicator (GMI) and glycemic variability (GV). Arbitrary MAEs for each patient were compared between the TAs of window lengths from 1 to 89 days and a reference TA of 90 days, which is assumed to reflect long-term glycemic regulation.

Results: Using 14 days of CGM data resulted in 65% of subjects having their TIR estimation being below a MAE threshold of 5%. In order to have 90% of the subjects below a TIR MAE threshold of 5%, the observation period needs to be 29 days.

Conclusions: Although there is currently no consensus on what is an acceptable MAE, this study provides insight into how MAEs of CGM-derived metrics change according to the used observation period within a population and may thus be helpful for clinical decision-making.

Introduction: Type 1 diabetes is burdensome, requiring complex daily management and making people more prone to emotional distress. To better detect diabetes-related distress (DD) and identify at-risk patients, we aimed to provide an in-depth characterization of DD in people with type 1 diabetes.

Research design and methods: We included adults with type 1 diabetes from the Suivi en France des personnes avec un Diabète de Type 1 cohort who filled in the Problem Areas in Diabetes questionnaire (PAID ≥40 indicates high DD). Age and sex-adjusted multivariable logistic regression models analyzed individual characteristics, clinical indicators, diabetes-related complications and psychological factors. We further analyzed DD according to six data-driven subdimensions: emotional distress, fear of complications, social distress, eating distress, management distress, and diabetes burnout.

Results: In total, 1220 participants (50.6% female, age 42 years (SD 13.9), diabetes duration 24.7 years (13.6)) had a total mean PAID score of 39.6 (21.7) and 592 (48.5%) reported high DD. Leading subdimensions of DD included fear of complications (50.1 (24.4)) and diabetes burnout (45.9 (24.5)). Females, younger age, social vulnerability, smoking, and the presence of retinopathy were positively associated with high DD (p<0.05). We observed similar DD levels across HbA1c levels and treatment modalities, including automated insulin delivery and continuous glucose monitoring use. Several psychological factors, such as anxiety/depression, poor sleep quality, and treatment burden, were strongly associated with DD (p<0.001).

Conclusions: We provide a holistic clinical phenotyping approach that enables the identification of determinants and prevalence of DD, overall and according to key DD subdimensions, in a large and diverse population. Our results underscore the importance of developing DD-targeted prevention and intervention strategies focused specifically on high-risk groups and the most impactful distress subdimensions to reduce the impact of type 1 diabetes burden.

Trial registration number: NCT04657783.