External validation of two diabetes risk scores in a young UK South Asian population

Aims

To externally validate the Leicester Practice Risk Score (LPRS) and the Leicester Risk Assessment score (LRAS) in a young South Asian population.

Methods

South Asian participants aged 25–39 years inclusive from a population based screening study were included. The risk scores were calculated and compared to the diagnosis of type 2 diabetes mellitus (T2DM) or T2DM and Impaired Glucose Regulation (IGR, including IFG and IGT) using either an oral glucose tolerance test (OGTT) or a HbA1c (≤48 mmol/mol/6.5% and ≤42 mmol/mol/6.0% respectively). Measures of discrimination and calibration were calculated.

Results

Of the 331 participants 8 (2.4%) had undiagnosed T2DM and 30 (9.1%) had IGR using an OGTT, 11 (3.4%) and 39 (12.1%) were found using HbA1c. Using the LPRS to detect T2DM on an OGTT gives an area under the ROC curve of 0.91 (95% CI 0.86, 0.97), including those with IGR gives an ROC of 0.72 (0.62–0.81), these values are 0.93 (0.88, 0.98) and 0.68 (0.60, 0.77) when using an HbA1c to define outcome. Acceptable levels of calibration were seen. Similar results are found for the LRAS.

Conclusions

These scores can be used to identify those with undiagnosed T2DM and/or IGR in a young South Asian population. This is the first study to externally validate scores developed for prevalent undiagnosed disease in this age group using both OGTT and HbA1c.     

Evaluation of the relationship between weight change and glycemic control after initiation of antidiabetic therapy in patients with type 2 diabetes using electronic medical record data

Aims

This study evaluates the relationship between HbA1c and weight change outcomes by anti-diabetic weight-effect properties in patients newly treated for type 2 diabetes; a relationship not previously characterized.

Methods

Electronic medical records of patients with type 2 diabetes newly prescribed anti-diabetic monotherapy were assessed to identify HbA1c goal attainment [(<53 mmol/mol)] and weight change at 1-year. Anti-diabetics were categorized by weight-effect properties: weight-gain (sulfonylureas, thiazolidinediones) and weight-loss/neutral (metformin, DPP-4 inhibitors, GLP-1 agonists). Logistic regression analyses identified likelihood of attaining HbA1c goal or ≥3% weight loss by anti-diabetic category controlling for baseline characteristics. MANOVA was used to identify correlation between changes in weight and HbA1c.

Results

The study included 28,290 patients. Mean age ± sd was 61 years ± 11.8. Baseline HbA1c was 7.4% ± 1.6 (57 mmol/mol ± 17); 67.3% were prescribed a weight-loss/neutral anti-diabetic. At 1-year, more patients in the weight-loss/neutral anti-diabetic category lost weight (≥3%) than in the weight-gain anti-diabetic category (40.4% vs. 24.2%, p < 0.001) or had an HbA1c < 7.0% (<53 mmol/mol) (71.1% vs. 63.8%, p < 0.001). Those prescribed a weight-gain anti-diabetic were 53% less likely to lose weight and 29% less likely to be at HbA1c goal than those prescribed a weight-loss/neutral anti-diabetic (p < 0.001). Weight loss and HbA1c outcomes were significantly correlated (p < 0.001).

Conclusions

Weight loss of ≥3% was associated with better glycemic control in patients newly treated for type 2 diabetes. Anti-diabetics associated with weight-loss/neutrality were associated with greater weight loss and HbA1c goal attainment and may facilitate efforts to co-manage weight and glycemia in the ambulatory-care setting.     

Variations in erythrocyte antioxidant levels and lipid peroxidation status and in serum lipid profile parameters in relation to blood haemoglobin A1c values in individuals with type 2 diabetes mellitus

Aims

The present study aimed to evaluate the antioxidant and lipid peroxidation status in erythrocytes and serum lipid profile parameters, in relation to haemoglobin A1c (HbA1c) concentrations, in patients with type 2 diabetes mellitus and in normal healthy individuals.

Methods

Sixty test individuals with diabetes and 15 control individuals were categorized as: Group I, control (non-diabetes); Group II, individuals with diabetes with HbA1c levels ≤7.0% (53 mmol/mol); Group III, individuals with diabetes with HbA1c levels between 7.1 and 8.0% (54 and 64 mmol/mol); Group IV, individuals with diabetes with HbA1c levels between 8.1 and 9.0% (65 and 75 mmol/mol); Group V, individuals with diabetes with HbA1c levels >9.0% (75 mmol/mol). Blood samples were collected to measure: blood glucose and HbA1c levels; haemolysate levels of enzymatic antioxidants and non-enzymatic antioxidants and malondialdehyde (MDA); and serum total cholesterol, triglyceride and high-density lipoprotein (HDL)-cholesterol levels. Correlations between blood HbA1c values and all parameters were sought.

Results

Significantly lower mean activities/levels of antioxidant parameters and significantly higher mean levels of MDA were noted in haemolysate samples from patients with diabetes than in those from control individuals. Significantly higher mean serum concentrations of total cholesterol and triglycerides and significantly lower mean concentrations of HDL-cholesterol were noted in patients with diabetes than in control individuals. Further, moderate to strong correlations were observed between values of antioxidants, MDA and lipid profile parameters and blood concentrations of HbA1c.

Conclusion

These results suggest that HbA1c values may be potentially useful not only to indicate long-term glycemic control to indicate onset of complications at a clinically detectable level and molecular level.     

Hemoglobin A1C in non-diabetic patients: An independent predictor of coronary artery disease and its severity

Aims

To determine the association between glycated hemoglobin (HbA1c) and angiographically proven coronary artery disease (CAD) and its severity in nondiabetic individuals.

Methods

We enrolled 299 consecutive individuals undergoing coronary angiography for suspected ischemia. Patients were included if they had no history of prior revascularization or diabetes mellitus and had fasting blood glucose < 126 mg/dl (7.0 mmol/l) and HbA1c < 6.5% (47 mmol/mol). The severity of the CAD was also evaluated using the Gensini score. Serum HbA1c (NGSP certified Method), highly sensitive C-reactive protein (hsCRP), lipid profile, insulin and APO lipoprotein A1 and B100 levels were measured.

Results

Mean age was 58.8 ± 10.4 year; 60.9% men. One hundred forty seven patients had significant CAD (≥50% stenosis in any major vessel). With increasing HbA1c levels, there was a significant increase in the prevalence of CAD and number of vessels involved. In multivariate analysis, HbA1c emerged as an independent predictor of significant CAD (OR: 2.8, 95% CI: 1.3–6.2, p = 0.009). Adjusted ORs for the occurrence of CAD were highest in subjects with both hsCRP and HbA1c in the upper 2 quartiles (OR: 4.183; 95% CI: 1.883–9.290, p < 0.0001). There was a significant association between Gensini score and increasing HbA1c tertiles (p = 0.038). The ideal cut-off value of HbA1c for prediction of the occurrence of CAD was 5.6% 38 mmol/mol) (sensitivity: 60.5%, specificity: 52%).

Conclusions

In non-diabetic subjects, HbA1c could be utilized for risk stratification of CAD and its severity, independent of traditional cardiovascular risk factors, insulin resistance and inflammatory markers.     

Evaluation of performance of A1c and FPG tests for screening newly diagnosed diabetes defined by an OGTT among tuberculosis patients—A study from India

Aim

The methods used for diagnosis of diabetes have limitations particularly in situations associated with stress hyperglycemia. Aim of this study was to evaluate the performance of A₁c and fasting plasma glucose (FPG) tests for screening newly diagnosed diabetes (NDD) defined by OGTT among tuberculosis (TB) cases in India.

Methods

A total of 983 subjects aged ≥18 years with TB were selected from 7 TB units – 4 urban, 2 rural and 1 semi-urban areas of Tamil Nadu, India, during August 2010–March 2011. Screening for diabetes was carried out by 2-h 75 g OGTT. Classification of glucose intolerance status was based on WHO criteria. HbA₁c was measured by high performance liquid chromatography using Bio-Rad turbo machine. HbA₁c ≥ 47.5 mmol/mol was used for diagnosis of diabetes. FPG was estimated by glucose-oxidase method. Known cases of subjects with diabetes were excluded and final analysis was done using data of 779 individuals. The performance of A₁c and FPG tests was evaluated against the results of OGTT using receiver operating characteristic curve analysis.

Results

Prevalence of NDD was 10.8%. The areas under the curve (AUC) were 0.754 [95% confidence interval (CI) 0.68–0.83] (p < 0.001) for A₁c and 0.662 (95% CI 0.58–0.74) for FPG (p < 0.001) in NDD subjects. The HbA₁c cut-off point of ≥47.5 mmol/mol gave a sensitivity of 59.1% and specificity of 91.7%, and the respective values were 34.8% and 97.5% for FPG in subjects with NDD.

Conclusion

HbA₁c performed better than FPG as a screening tool for newly diagnosed diabetes among subjects with TB.     

Impact of introducing HbA1c into the diagnostic criteria on prevalence and cardiovascular risk profiles of individuals with newly diagnosed diabetes in Japan: the Toranomon Hospital Health Management Center Study 2 (TOPICS 2)

Objective

To evaluate the impact of HbA1c for diagnosis of diabetes and investigate whether cardiovascular risks profiles differ among individuals with diabetes diagnosed by HbA1c or fasting plasma glucose (FPG).

Methods

This cross-sectional study involved 26,884 participants (30.6% women; aged 20-91 years) without known diabetes. Subjects were categorized into 4 groups according to the presence or absence of FPG ≥7.0 mmol/L and/or HbA1c ≥6.5%, which were American Diabetes Association criteria. Oral glucose tolerance test data were not available.

Results

Prevalence of undiagnosed diabetes was 3.6%. Of those individuals, 47.5% fulfilled both two criteria and 26.0% fulfilled only HbA1c criterion. Individuals with diabetes according to FPG ≥7.0 mmol/L alone were characterized as having poorly controlled hypertension while those with HbA1c ≥6.5% alone were characterized as older, female, and having lower blood pressure and γ-glutamyltransferase values. Persons with newly diagnosed diabetes by HbA1c had low HDL cholesterol and high LDL or non-HDL cholesterol levels.

Conclusions

Introducing HbA1c into the diagnosis allowed detection of many previously undiagnosed cases of diabetes in Japanese individuals. Those diagnosed by FPG were characterized by hypertension and those diagnosed by HbA1c had unfavorable lipid profiles, reflecting an atherosclerotic trait.     

Effect of glycemic control on intact parathyroid hormone level in end stage renal disease patients on maintenance hemodialysis

Aims

We evaluated the relationship between iPTH levels and glycemic control in patients with diabetes and end stage renal disease (ESRD) on maintenance hemodialysis (MHD).

Methods

The study included 98 subjects with ESRD and type 2 diabetes aged 30–75 years who were on MHD. These were divided into two groups – patients with HbA1c >7.0 (53 mmol/mol) (poor glycemic control group) and patients with HbA1c <7.0 (53 mmol/mol) (good glycemic control group). All patients had been on regular bicarbonate haemodialysis for more than 6 months using polysulfone membrane dialyzer; 4 h per episode 3 times/week, with a dialysis fluid of 3.0 mEq/L of calcium concentration. 1-α-(OH)D3 and calcium carbonate were used routinely in all patients. The contribution of each relevant biological parameter to serum iPTH level was assessed using multiple regression test.

Results

Poor glycemic control was associated with reduced serum iPTH level and good glycemic control with higher serum iPTH. The serum HbA1c level was significantly correlated with the serum iPTH level (p = 0.0003).

Conclusions

Glycemic control is a significant determinant of iPTH level in diabetic ESRD patients on MHD.     

Screening for gestational diabetes mellitus and its prevalence in Bangladesh

Background

The prevalence of gestational diabetes mellitus (GDM) has important health complications for both mother and child and is increasing all over the world. Although prevalence estimates for GDM are not new in developed and many developing countries, data are lacking for many low-income countries like Bangladesh.

Objective

To evaluate the prevalence of GDM in Bangladesh.

Research design and methods

This cross-sectional study included 3447 women who consecutively visited the antenatal clinics with an average gestation age of 26 weeks. GDM was defined according to WHO criteria (fasting plasma glucose [FPG] ≥7.0 mmol/L or 2-h ≥7.8 mmol/L) and the new ADA criteria (FPG ≥5.3 mmol/L or 2-h ≥8.6 mmol/L OGTT). We also calculated overt diabetes as FPG ≥7.0 mmol/L.

Results

Prevalence of GDM was 9.7% according to the WHO criteria and 12.9% according to the ADA criteria in this study population. Prevalence of overt diabetes was 1.8%. Women with GDM were older, higher educated, had higher household income, higher parity, parental history of diabetes, and more hypertensive, compared with non-GDM women.

Conclusion

This study demonstrates a high prevalence of GDM in Bangladesh. These estimates for GDM may help to formulate new policies to prevent and manage diabetes.     

The 5-time point oral glucose tolerance test as a predictor of new-onset diabetes after kidney transplantation

Aims

To evaluate the predictive power of the 5-time point oral glucose tolerance test (OGTT) for new-onset diabetes after kidney transplantation (NODAT).

Methods

We performed a retrospective study of 145 patients without diabetes who received kidney transplantations at our hospital. The 5-time point OGTT was performed before transplantation. The area under a receiver-operating characteristic curve (aROC) was used for evaluating the predictive power of 5-time point OGTT values.

Results

Seventeen patients developed NODAT within 1 year after transplantation. All postload plasma glucose (PPG) levels were higher in patients who developed NODAT than in those who did not; fasting plasma glucose levels were not different. The aROC for the area under the glucose concentration-time curve was significantly greater than that for fasting plasma glucose. Univariate and multivariate analyses showed that each PPG level was an independent risk factor for NODAT. Furthermore, patients with normal glucose tolerance (NGT) or impaired glucose tolerance (IGT) could be stratified with a 1-h plasma glucose (1h-PG) cut-off point of 8.4 mmol/L. The incidences of NODAT were 23.5%, 16.7%, 9.1%, and 0% for patients with IGT + 1h-PG ≥8.4 mmol/L,IGT + 1h-PG <8.4 mmol/L, NGT + 1h-PG ≥ 8.4 mmol/L, and NGT + 1h-PG < 8.4 mmol/L, respectively.

Conclusions

The area under the glucose concentration-time curve and each PPG concentration during the 5-time point OGTT are strong predictors of NODAT. A 1h-PG cut-off point of 8.4 mmol/L plus NGT/IGT can be used to identify patients at intermediate and high risk of developing NODAT.     

Ethnic disparities in the association of impaired fasting glucose with the 10-year cumulative incidence of type 2 diabetes

Aims

Evidence of ethnic disparities in the conversion of prediabetes to type 2 diabetes is scarce. We studied the association of impaired fasting glucose (IFG) and fasting plasma glucose (FPG) with the 10-year cumulative incidence of type 2 diabetes in three ethnic groups.

Methods

We analyzed data for 90 South-Asian Surinamese, 190 African-Surinamese, and 176 ethnic Dutch that were collected in the periods 2001–2003 and 2011–2012. We excluded those with type 2 diabetes or missing FPG data. We defined baseline IFG as FPG of 5.7–6.9 mmol/L. We defined type 2 diabetes at follow-up as FPG ≥ 7.0 mmol/L, HbA1c ≥ 48 mmol/mol (6.5%), or self-reported type 2 diabetes.

Results

10-Year cumulative incidences of type 2 diabetes were: South-Asian Surinamese, 18.9%; African-Surinamese, 13.7%; ethnic Dutch, 4.5% (p < 0.05). The adjusted association of baseline IFG and FPG with the 10-year cumulative incidence of type 2 diabetes was stronger for South-Asian Surinamese than for African-Surinamese and ethnic Dutch. The IFG (compared to normoglycaemia) ORs were 11.1 [3.0–40.8] for South-Asian Surinamese, 5.1 [2.0–13.3] for African-Surinamese, and 2.2 [0.5–10.1] for ethnic Dutch.

Conclusions

The 10-year cumulative incidence of type 2 diabetes was higher and associations with baseline IFG and FPG were stronger among South-Asian Surinamese and African-Surinamese than among ethnic Dutch. Our findings confirm the high risk of type 2 diabetes in South-Asians and suggest more rapid conversion in populations of South-Asian origin and (to a lesser extent) African origin than European origin.     

Reasons for non-intensification of treatment in people with type 2 diabetes receiving oral monotherapy: Outcomes from the prospective DIAttitude study

Objectives

To describe the management of glucose-lowering agents in people with type 2 diabetes initially on oral monotherapy, cared for by French general practitioners, and to identify reasons underlying treatment non-intensification.

Methods

People with type 2 diabetes on oral monotherapy were recruited by general practitioners and followed-up over 12 months. Patient characteristics, HbA1c, and glucose-lowering treatments were recorded electronically. Management objectives and reasons for treatment non-intensification were solicited from the general practitioners.

Results

A total of 1212 patients were enrolled by 198 general practitioners; 937 patients (mean age 68 years) were treated with oral monotherapy, and 916 patients had at least two successive HbA1c values recorded. Of these, 390 patients (43%) had HbA1c ≥ 6.5% on both occasions, and 164/390 (42%) had their treatment intensified. The 226 patients whose treatment was not intensified were older (69 ± 11 years vs. 66 ± 12 years, P = 0.02) and had better glycaemic control at study inclusion (6.9% ± 0.6 vs. 7.3% ± 0.8, P < 0.0001) than treatment intensified patients. Among uncontrolled patients, there were no differences in general practitioner treatment objectives at inclusion for treatment intensified and non-intensified patients; the main reason given by general practitioners for non-intensification was that the patient had an adequate HbA1c (66%). HbA1c did exceed the 6.5% target, but was less than 7.0% in 69% of cases.

Conclusions

General practitioners showed a patient-centred approach to treatment, but clinical inertia was apparent for 31% of the uncontrolled patients.     

Increase in physical activity is associated with lower HbA1c levels in children and adolescents with type 1 diabetes: Results from a cross-sectional study based on the Swedish pediatric diabetes quality registry (SWEDIABKIDS)

Aims

To evaluate the associations between physical activity (PA) and metabolic control, measured by glycated hemoglobin (HbA1c), in a large group of children and adolescents with type 1 diabetes.

Methods

Cross-sectional analysis of data from 4655 patients, comparing HbA1c values with levels of physical activity. The data for the children and adolescents were obtained from the Swedish pediatric diabetes quality registry, SWEDIABKIDS. The patients were 7–18 years of age, had type 1 diabetes and were not in remission. Patients were grouped into five groups by frequency of PA.

Results

Mean HbA1c level was higher in the least physically active groups (PA0: 8.8% ± 1.5 (72 ± 16 mmol/mol)) than in the most physically active groups (PA4: 7.7% ± 1.0 (60 ± 11 mmol/mol)) (p < 0.001). An inverse dose–response association was found between PA and HbA1c (β: −0.30, 95% CI: −0.34 to −0.26, p < 0.001). This association was found in both sexes and all age groups, apart from girls aged 7–10 years. Multiple regression analysis revealed that the relationship remained significant (β: −0.21, 95% CI: −0.25 to −0.18, p < 0.001) when adjusted for possible confounding factors.

Conclusions

Physical activity seems to influence HbA1c levels in children and adolescents with type 1 diabetes. In clinical practice these patients should be recommended daily physical activity as a part of their treatment.     

The utility of urinary myo-inositol as a marker of glucose intolerance

Objective

The most common screening tests for glucose intolerance are fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Because it reflects the current status of hyperglycemia, urinary myo-inositol (UMI) may be useful. We evaluated UMI as a screening tool for glucose intolerance.

Design and methods

A cross-sectional, community-based population study of 1057 Japanese residents. 173 with an FPG level between 5.5 and 6.9 mmol/L and an HbA1c under 6.5% had an oral glucose tolerance test. We measured UMI level before (fasting UMI) and 2 h after (2 h-UMI) glucose ingestion. Δ-UMI was defined as the difference between fasting UMI and 2 h-UMI.

Results

Δ-UMI, 2 h-UMI and HbA1c levels significantly increased as glucose intolerance worsened. Δ-UMI level was significantly positively correlated with 2 h-UMI level (r = 0.896, p < 0.001). Using cutoff levels from receiver operating characteristic (ROC) analyses, the sensitivity of Δ-UMI (82.1%) and 2 h-UMI (79.3%) were higher than that of HbA1c (48.3%). The area under the ROC curve values for Δ-UMI (0.903) and 2 h-UMI (0.891) were higher than that for HbA1c (0.785).

Conclusions

2 h-UMI is useful as a non-invasive screening of glucose intolerance.     

A cost-effectiveness analysis of a telephone-linked care intervention for individuals with Type 2 diabetes

Aim

To assess the cost-effectiveness of an automated telephone-linked care intervention, Australian TLC Diabetes, delivered over 6 months to patients with established Type 2 diabetes mellitus and high glycated haemoglobin level, compared to usual care.

Methods

A Markov model was designed to synthesize data from a randomized controlled trial of TLC Diabetes (n = 120) and other published evidence. The 5-year model consisted of three health states related to glycaemic control: ‘sub-optimal’ HbA_1c ≥58 mmol/mol (7.5%); ‘average’ ≥48–57 mmol/mol (6.5–7.4%) and ‘optimal’ <48 mmol/mol (6.5%) and a fourth state ‘all-cause death’. Key outcomes of the model include discounted health system costs and quality-adjusted life years (QALYS) using SF-6D utility weights. Univariate and probabilistic sensitivity analyses were undertaken.

Results

Annual medication costs for the intervention group were lower than usual care [Intervention: £1076 (95%CI: £947, £1206) versus usual care £1271 (95%CI: £1115, £1428) p = 0.052]. The estimated mean cost for intervention group participants over five years, including the intervention cost, was £17,152 versus £17,835 for the usual care group. The corresponding mean QALYs were 3.381 (SD 0.40) for the intervention group and 3.377 (SD 0.41) for the usual care group. Results were sensitive to the model duration, utility values and medication costs.

Conclusion

The Australian TLC Diabetes intervention was a low-cost investment for individuals with established diabetes and may result in medication cost-savings to the health system. Although QALYs were similar between groups, other benefits arising from the intervention should also be considered when determining the overall value of this strategy.     

Effect of gender on treatment outcomes in type 2 diabetes mellitus

Aim

To evaluate the effect of gender on clinical outcomes in people with type 2 diabetes mellitus (T2DM) receiving antidiabetes therapy.

Methods

This is a pooled analysis from nine similarly designed phase 3 and 4 randomized, controlled studies evaluating insulin glargine and an active comparator (NPH insulin, insulin lispro, premixed insulin, oral antidiabetes drugs, dietary intervention) in adults with T2DM. Impact of gender on outcomes including HbA1c, fasting plasma glucose (FPG), weight-adjusted insulin dose, and hypoglycemia incidence was evaluated after 24 weeks of treatment.

Results

Overall, 1651 male and 1287 female individuals were included; 49.8% and 50.2% were treated with insulin glargine or comparators, respectively. Females receiving insulin glargine were less likely than males to achieve a glycemic target of HbA1c ≤ 7.0% (53 mmol/mol) (54.3% vs 60.8%, respectively, p = 0.0162); there was no difference between females and males receiving comparators (52.7% vs 51.3%, respectively, p = 0.4625). Females had significantly greater reductions in FPG (3.1 mg/dL, p = 0.0458), required significantly higher insulin doses (0.03 IU/kg, p = 0.0071), and had significantly higher annual rates of symptomatic (p < 0.0001), glucose-confirmed (<50 and <70 mg/dL) symptomatic (p = 0.0005 and p < 0.0001), and severe hypoglycemia (p = 0.0020) than males.

Conclusions

Females in this analysis had smaller reductions in HbA1c and were less likely to reach glycemic goals despite higher insulin doses and more hypoglycemic events than males. Differences in gender responses to therapy should be considered when individualizing treatment for people with T2DM.     

Interventions to maintain cardiac risk control after discharge from a cardiovascular risk reduction clinic: A randomized controlled trial

Aims

To evaluate the efficacy of two maintenance strategies compared to usual care after discharge from a pharmacist-led cardiovascular risk reduction clinic (CRRC).

Methods

Open-label, randomized-controlled trial of 200 consecutive CRRC patients that met clinic discharge criteria (HbA1c ≤7% (53 mmol/mol); blood pressure ≤140/80 mmHg for those with diabetes and ≤140/90 mmHg for those without diabetes; and an LDL-cholesterol ≤2.59 mmol/l). Participants were randomized to either [1] quarterly group medical visits or [2] quarterly CRRC individual clinic visits, or [3] a usual care control arm with the standard primary care alone first in a 1:1:1 ratio, followed by a 2:2:1 ratio after first 100 patients. Primary outcome measures were time to failure for guideline recommended goals of HbA1c and blood pressure over 12-months.

Results

Of the 200 participants randomized, 89% had diabetes and were similar in other cardiovascular risk factors. After 1-year, the HbA1c failure rate was 0.36 [95% CI, 0.28–0.47] per quarter for the group medical visit arm, 0.24 [95% CI, 0.18–0.33] per quarter for the quarterly CRRC individual arm and, 0.82 [95% CI, 0.69–0.96] per quarter for the usual care control arm, p < 0.001. The rate of failure for blood pressure was 0.31 [95% CI, 0.23–0.41] per quarter for the group medical visit arm, 0.22 [95% CI, 0.16–0.30] per quarter for the CRRC individual arm and, 0.53 [95% CI, 0.40–0.71] per quarter the control arm, p < 0.001.

Conclusion

After discharge from a CRRC program, both individual and group interventions are more effective in maintaining glycemia and blood pressure control for patients with diabetes than usual care after 1-year of follow-up.     

Residual dysglycemia when at target HbA1c of 7% (53 mmol/mol) in persons with type 2 diabetes

Aims

To understand the composition of the residual dysglycemia when HbA_1c is between 6.5% (48 mmol/mol) and 7% (53 mmol/mol), representing the definition of diabetes and the recommended treatment goal, respectively.

Methods

One hundred persons with type 2 diabetes and a HbA_1c < 7% (53 mmol/mol), treated with diet alone and/or oral hypoglycemic agents underwent continuous glucose monitoring (CGM) and were further divided into two subgroups 1 (n = 50) and 2 (n = 50) according to whether the HbA_1c was <6.5% (48 mmol/mol) or 6.5–6.9% (48–52 mmol/mol), respectively. A similar analysis was performed in those on diet alone: subgroups A (n = 34, HbA_1c < 6.5%, 48 mmol/mol) and B (n = 10, HbA_1c 6.5–6.9%, 48–52 mmol/mol). The residual dysglycemia determined from the CGM was assessed using glucose exposures defined as areas under curves (AUCs) and mean glucose values.

Results

Averaged 2-h postprandial glucose value (averaged PPG, mmol/L, mean ± SD) and postprandial glucose exposure (AUCpp, mean ± SD, mmol·L⁻¹·h) were significantly higher in subgroup 2 (mean HbA_1c = 6.7%, 50 mmol/mol) than in subgroup 1 (mean HbA_1c = 6.0%, 42 mmol/mol): averaged PPG = 8.1 ± 1.3 versus 7.3 ± 1.3 mmol/L (p < 0.002); AUCpp = 23.5 ± 8.6 versus 16.2 ± 8.6 (p < 0.0001). The percentages of persons with averaged PPG ≥ 7.8 mmol/L were 52% and 24% (p < 0.01) in subgroups 2 and 1, respectively. Similar results were observed in those (subgroups A and B) who were on diet alone.

Conclusions

The residual dysglycemia in type 2 diabetes with HbA_1c between 6.5 and 6.9% (48–52 mmol/mol) inclusive is mainly due to remnant abnormal postprandial glucose excursions. Consequently, HbA_1c < 6.5% (48 mmol/mol) is an achievable goal with therapeutic measures aimed at reducing postmeal glucose when the HbA_1c is at 7% (53 mmol/mol).     

Cyst carcinoembryonic antigen in differentiating pancreatic cysts: A meta-analysis

Background

Using carcinoembryonic antigen in discriminating between benign and malignant disease remains controversial.

Aims

We aim to evaluate the diagnostic accuracy of cyst fluid carcinoembryonic antigen in predicting malignant pancreatic cystic lesions.

Methods

We performed a literature search of MEDLINE and EMBASE. We included studies that compared the diagnostic accuracy of carcinoembryonic antigen with histology. Pooled estimates of diagnostic precision were calculated using random-effects models.

Results

Eight studies (504 patients) were included. The carcinoembryonic antigen cutoff level for determining a malignant cyst ranged from 109.9 to 6000 ng/mL. Pooled estimates of carcinoembryonic antigen in malignant cysts prediction were poor: pooled sensitivity of 63%, pooled specificity of 63%. The positive likelihood ratio was 1.89 and the negative likelihood ratio was 0.62. The diagnostic odds ratio was 3.84. The area under the summary receiver–operating characteristic curve was 0.70. In subgroup analysis of patients with mucinous cysts (mucinous cystic neoplasm and intraductal papillary mucinous neoplasm; 5 studies, 227 patients), pooled sensitivity was 65%, pooled specificity 66% and diagnostic odds ratio 4.74 respectively.

Conclusion

This meta-analysis suggests that the accuracy of carcinoembryonic antigen in differentiating “between benign and malignant” pancreatic cysts was poor. The decision to perform surgical resection for pancreatic cystic lesions should not be based solely on carcinoembryonic antigen level.