Diabetes care最新文献

Objective: Diabetic foot ulcers (DFUs) often lead to amputations. Limb salvage aims to preserve the lower extremity, but the complexity of care and uncertainty of healing can delay patients' return to normal activities. This study aimed to understand military veterans' preferences regarding limb salvage for DFUs, using a discrete choice experiment (DCE).

Research design and methods: A DCE was conducted with 98 veterans with diabetes at the Baltimore Veterans Affairs Medical Center. Participants were presented with 10 choice sets involving different levels of postrecovery mobility, amputation levels, and future surgery risks. These attributes were developed through literature review and interviews. Data were analyzed using a multinomial logit model to estimate the utility of each attribute level and assess preference heterogeneity.

Results: The study population was older (mean age 69 years), Black (61%), and male (94%). Half (53%) had a prior foot complication. Postrecovery mobility was the most important attribute (relative importance 53%), followed by amputation level (30%) and future surgery risk (18%). Veterans valued mobility highly, with significant utility differences between walking unaided and needing a wheelchair or scooter. They were willing to accept higher amputation levels to improve mobility.

Conclusions: Postrecovery mobility is a critical factor for veterans with DFUs, outweighing concerns about amputation level and future surgical risks. It should be a focus of shared decision-making. The study is limited by its single-site setting and study population. Broader research is needed. Understanding patient preferences through DCE can inform more patient-centered approaches to DFU management, potentially improving outcomes and satisfaction.

Objective: To compare the efficacy of real-time continuous glucose monitoring (CGM; intervention) with capillary blood glucose (CBG) monitoring (control) alone to achieve greater percent glucose time in range (%TIR) among pregnant individuals diagnosed gestational diabetes mellitus (GDM).

Research design and methods: This was an open-label, single-center, randomized controlled trial of pregnant individuals with GDM and ≥20 weeks' gestation. Subjects were randomly assigned (2:1) to use real-time CGM plus adjunctive CBG versus CBG alone for glucose monitoring. The intervention group was instructed on the continuous use of the Dexcom G6 CGM system from enrollment to admission for delivery. The control group used CBG monitoring four times per day underwent blinded CGM approximately every 20 days throughout the study period. The primary outcome was the CGM %TIR defined as 60-140 mg/dL (3.3-7.8 mmol/L) from study enrollment until hospital admission for delivery.

Results: A total of 111 participants were enrolled between February 2021 and June 2023 (n = 74 in intervention group; n = 37 in control group) with no statistical differences in demographic characteristics between the groups. The CGM group had significantly higher %TIR ±SD (93 ± 6 min vs. 88 ± 14 min at 60-140 mg/dL; P = 0.027). Among key secondary CGM metric outcomes, the intervention group had significantly higher daytime TIR with lower 24-h and daytime mean glucose and percent time >140 mg/dL compared with the control group.

Conclusions: We demonstrated a significantly higher %TIR using real-time CGM compared with CBG glucose monitoring among pregnant people with GDM. Studies are needed to determine if achieving lower CGM glucose levels can improve perinatal and neonatal outcomes.

Objective: The impact of diabetes in pregnancy on offspring neurodevelopment is unclear. We investigate whether exposure to diabetes in utero is associated with developmental vulnerability or educational delay during primary school.

Research design and methods: We used population-level pregnancy and birth data from 2009 to 2021 from Victoria, Australia, linked with standardized national assessments. Adjusting for a range of maternal and childhood covariates, we investigated whether diabetes in pregnancy was associated with an altered risk of developmental vulnerability compared with no diabetes in the first year of full-time school (ages 4-6 years), defined as below the tenth centile in two or more domains in the Australian Early Development Census (AEDC), and altered educational outcomes in grade 3 (ages 7-8 years), defined as the adjusted mean difference in overall z score in the National Assessment Program - Literacy and Numeracy test (NAPLAN).

Results: Our study comprised 177,898 children who had linked birth and AEDC data, and 115,231 with linked birth and NAPLAN data, including, respectively, 16,363 (9.2%) and 7,532 (6.5%) exposed to diabetes in pregnancy. Following adjusted analysis, diabetes in pregnancy was not associated with an altered risk of overall developmental vulnerability compared with no diabetes (adjusted relative risk 1.02 [95% CI 0.98, 1.07]). Diabetes was associated with a marginally higher overall NAPLAN z score, but below the prespecified threshold for clinical significance (adjusted mean difference 0.04 [95% CI 0.01, 0.07]).

Conclusions: Diabetes in pregnancy was not associated with overall developmental vulnerability or a clinically meaningful difference in educational outcomes. This should provide reassurance for patients and their treating clinicians.

Objective: To develop a U.S.-based microsimulation model for assessing the cost-effectiveness of interventions to manage type 1 diabetes.

Research design and methods: We developed risk equations for 14 diabetes-related complications and mortality, 12 risk factor progression equations, and one equation for utilities associated with 14 complications using data from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) studies and the Epidemiology of Diabetes Complications (EDC) study. We integrated all equations into a simulation model. We conducted internal and external validation and demonstrated the utility of the model using a real-world example. Main model-generated outcomes included cumulative incidence of diabetes-related complications, life years, quality-adjusted life years, medical costs, and incremental cost-effectiveness ratios.

Results: The model generates long-term clinical and economic outcomes from changes in risk factors of type 1 diabetes complications. Internal validation comparing modeled outcomes to observed data used to develop the model yielded good prediction accuracy, with mean absolute percentage error across all complications of 9% and correlation of cumulative failure rates above 0.9. External validation results were mixed, with occurrence of slight under- or overprediction across complications and studies. We illustrated the model with a case study estimating the effects of expanding the use of an insulin pump with continuous glucose monitoring to all people with type 1 diabetes.

Conclusions: Our new comprehensive type 1 diabetes simulation model can generate valid and accurate results for assessing the long-term cost-effectiveness of interventions to manage type 1 diabetes in the U.S.

Objective: To determine whether a slower, flexible titration regimen of semaglutide would improve adherence and reduce gastrointestinal adverse events (GI-AEs) compared with the label-recommended regimen in patients with type 2 diabetes (T2D).

Research design and methods: A total of 104 patients with T2D were randomized to label-recommended titration (0.25 mg, 0.5 mg, 1 mg at 4-week intervals) or flexible titration (starting at 0.0675 mg [measured as five clicks made by the dose selector dial], with gradual increases by 0.0675 mg/week and delays for GI-AEs) for 26 weeks.

Results: While final doses were similar between groups, only 2% of patients in the flexible arm withdrew due to GI-AEs vs. 19% in the label arm (P = 0.005). The flexible arm reported less nausea (45.1% vs. 64.2%; P = 0.051) and asthenia (9.8% vs. 24.5%; P = 0.047), with fewer days experiencing nausea (2.88 vs. 6.3 days; P = 0.017). HbA1c and BMI changes were similar between groups.

Conclusions: Slower, flexible titration improved adherence and reduced adverse events without compromising efficacy.