Risk factors for foot ulcers—A cross sectional survey from a primary care setting in Brazil

AimsTo identify the prevalence of higher risk of foot ulceration and associated factors among patients with diabetes mellitus (DM) at primary health care services.MethodsIndividuals with DM, registered at primary health care services in a municipality in southern Brazil, were interviewed and underwent foot examinations. Their risk of ulceration was classified in accordance with the recommendations of the International Working Group on the Diabetic Foot. Poisson bivariate and multivariate analyses were performed and adjusted prevalence ratios (PR) and 95% confidence intervals (CI) were calculated.ResultsThe prevalence of higher risk of foot ulceration among the 337 interviewees was 27.9% (95% CI 23.1–32.9). The following factors were associated with this risk: having been diagnosed with DM for more than 10 years (Adjusted-PR 1.669; 95% CI 1.175–2.373; p = 0.004); having had previous diagnoses of acute myocardial infarction (Adjusted-PR 1.873; 95% CI 1.330–2.638; p < 0.001) and stroke (Adjusted-PR 1.684; 95% CI 1.089–2.604; p = 0.019); presenting interdigital mycosis (Adjusted-PR 1.539; 95% CI 1.030–2.300; p = 0.035) and calluses (Adjusted-PR 1.654; 95% CI 1.117–2.451; p = 0.012).ConclusionsThe prevalence of higher risk of ulceration was high, which reinforces the importance of continued education for health care professionals in order to prevent complications in the feet of these patients.     

The effectiveness of foot care education on people with type 2 diabetes in Tehran,Iran

AimThe aim of this study was to evaluate the impact of a simple educational program on the knowledge and practice of people with type 2 diabetes in relation to the foot at risk in Tehran, Iran.MethodsOne hundred and forty-eight people with type 2 diabetes underwent a structured interview using a 32-item designed questionnaire (DiFoKaPS-32) about their knowledge of foot care standards in diabetes and their personal foot care behaviours. Each participant in the study received a single 20 min education session individually. The mode of the intervention was face-to-face.ResultsThe applied educational intervention aimed at patients with type 2 diabetes has improved their knowledge and practice about diabetic foot care (P < 0.0001 and P = 0.011; Wilcoxon Signed Ranks test, respectively). Knowledge and practice scores were increased significantly after the education in the lean group (BMI ≤ 25) rather than the obese ones.ConclusionsIn conclusion the findings of our study have shown that a simple face-to-face education is an effective and applied method to improve the knowledge about foot care. It has also shown that it could increase the motivation and change the behaviour of people with type 2 diabetes regarding their feet. In addition, the obese patients referring to a diabetic clinic need much more attentions and tighter care programs.     

Impact of diabetes on hospital adverse cardiovascular outcomes in acute coronary syndrome patients: Data from the Saudi project of acute coronary events

BackgroundDiabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi Arabia.MethodsACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patients.ResultsOf the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2 ± 11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hypertension, hyperlipidemia) prevalences and were more likely to present with non–ST-elevation myocardial infarction (40.2% vs. 31.4%, p < 0.001), heart failure (25.4% vs. 13.9%, p < 0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardiogenic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI, 1.02–3.30, p = 0.042).ConclusionsA substantial proportion of Saudi patients presenting with ACS have DM and a significantly worse prognosis. These data highlight the importance of cardiovascular preventative interventions in the general population.     

Does good clinical practice at the primary care improve the outcome care for diabetic patients? Gender differences

BackgroundThe Middle East region is predicted to have one of the highest prevalence of diabetes mellitus (DM) in the world. This is the first study in the region to assess treatment outcome of DM according to gender.ObjectiveTo assess the quality and effectiveness of diabetes care provided to patients attending primary care settings according to gender in the State of Qatar.DesignIt is an observational cohort study.SettingThe survey was carried out in primary health care (PHC) centers in the State of Qatar.Subjects and methodsThe study was conducted from January 2010 to August 2010 among diabetic patients attending (PHC) centers. Of the 2334 registered with diagnosed diabetes, 1705 agreed and gave their consent to take part in this study, thus giving a response rate of 73.1%. Face to face interviews were conducted using a structured questionnaire including socio-demographic, clinical and satisfaction score of the patients.ResultsMajority of subjects were diagnosed with type 2 DM (84.9%). A significantly larger proportion of females with DM were divorced or widowed (9.1%) in comparison to males with DM (3.4%; p < 0.001). A significantly larger proportion of females were overweight (46.5%; p = 0.009) and obese (29.5%; p = 0.003) in comparison to males. Males reported significantly greater improvements in mean values of blood glucose (mmol/l) (?2.11 vs. ?0.66; p = 0.007), HbA1c (%) (?1.44 vs. ?0.25; p = 0.006), cholesterol (mmol/l) (?0.16 vs. 0.12; p = 0.053) and systolic blood pressure (mmHg) (?9.04 vs. ?6.62; p < 0.001) in comparison to females. While there was a remarkable increase in male patients with normal range of fasting blood glucose (FBG; 51.6%) as compared to the FBG measurement 1 year before (28.5%: p < 0.001) there was only a slight increase in females normal range FBG during this period from 28.0% to 30.4% (p = 0.357).ConclusionThe present study revealed that the current form of PHC centers afforded to diabetic patients provided significantly improved outcomes for males, but only minor improved outcomes for females. This study reinforces calls for a gender-specific approach to diabetes care.     

A study of diabetes complications in an endogamous population: An emerging public health burden

AimThe aims of this study were to determine the prevalence of diabetic complications namely neuropathy, nephropathy, and retinopathy among Qatari's DM patients; and to find associations between these complications and socio-demographic and clinical characteristics in a highly consanguineous population.DesignIt is an observational cohort study.SettingThe survey was carried out at the Hamad General Hospital and Primary Health Care (PHC) centers in the State of Qatar.SubjectsThe study was conducted from May 2011 to January 2013 among Qatari nationals above 20 years of age. Of the 2346 registered with diagnosed diabetes attending Hamad General Hospital and PHC centers, 1633 (69.3%) agreed and gave their consent to take part in this study.MethodsQuestionnaire included socio-demographic variables, body mass index (BMI), consanguinity, lifestyle habits, family history of diabetes, blood pressure and development of diabetes complications such as retinopathy, nephropathy, and neuropathy were collected at regular intervals throughout the follow-up. Univariate and multivariate statistical analysis were performed.ResultsOut of 1633 diabetic patients, 842 (51.6%) were males. The prevalence of diabetic nephropathy 12.4% and retinopathy was 12.5% followed by neuropathy 9.5% among diabetic population. The proportion of diabetic neuropathy and nephropathy were significantly higher among diabetic patients with age 60 years and above as compared to younger age groups (p = 0.010). Nephropathy was significantly higher among male diabetic (p = 0.014) and smokers (p < 0.001) while diabetic neuropathy was more common among diabetic hypertensive patients (p = 0.028). Multivariate logistic regression showed that Age (p = 0.025), being male (p = 0.045), and having high blood pressure (p = 0.006) were significant predictors of diabetic neuropathy. For diabetic retinopathy, family history of DM (p < 0.001), consanguinity (p = 0.010), having high blood pressure (p = 0.042) and physical activity (p < 0.001) were significant predictors of diabetic retinopathy. Meanwhile, for diabetic nephropathy, age (p < 0.001), smoking (p = 0.045), physical activity (p < 0.001) hypertension (p < 0.001) and gender (p = 0.012) were the significant predictors.ConclusionDiabetes exerts a significant burden in Qatar, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high morbidity and mortality and prevalence of complications observed. The significant interactions between diabetes and associated complications highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.     

Clinical significance of UbA52 level in the urine of patients with type 2 diabetes mellitus and diabetic kidney disease

BackgroundUbiquitin-52 amino acid fusion protein (UbA52) is an important factor in the pathogenesis of diabetic kidney disease (DKD) and has been suggested a potential marker in the disease. However, whether upregulation of UbA52 marks early kidney injury in T2DM mellitus (T2DM) patients remains unclear. In this study, we examine the diagnostic value of UbA52 as a biomarker in predicting early diabetic kidney disease (DKD) in T2DM patients.MethodsWe used two-step ELISA to test UbA52 level in urine of 3 defined patient groups. Samples from T2DM patients without albuminuria or diabetic retinopathy (DM-WNP; n = 30), T2DM patients with albuminuria and diabetic retinopathy, excluding other renal diseases clinically (DM-NP; n = 30) and healthy controls (n = 30) were analyzed. Spearman's correlation analysis and multiple linear regression model were used to analyze the correlation of urinary UbA52 level with laboratory results regarding kidney function. Receiver operating characteristic curve (ROC) was used to evaluate the diagnostic value of UbA52 in predicting T2DM and early DKD.ResultsUrinary UbA52 level in DM-NP group was 1.75 times and 2.71 times higher than in DN-WNP (p = 0.004) and normal control group (p < 0.001), respectively. The level of urinary UbA52 correlated significantly with serum creatinine (r = 0.468, p < 0.001), GFR (r = −0.300, p = 0.004) and proteinuria (r = 0.484, p < 0.001). Multiple linear regression analysis showed that proteinuria level was independently associated with urinary UbA52 level (β = 0.833, p < 0.001). The area under the ROC of urinary UbA52 in diagnosing T2DM and DKD was 0.751 and 0.755, respectively.ConclusionThe level of urinary UbA52 increased significantly in T2DM patients with DKD. The level of proteinuria is independently associated with urinary UbA52 level. Urinary UbA52 could serve as an early marker in the diagnosis of DKD.ClinicalTrials.gov Identifier: NCT02204280.     

Circulatory adipocytokines and lipid profile variations in type-2 diabetic subjects: Desirable side-effects of antidiabetic drugs

AimInspite of availability of a variety of drugs to treat type 2 diabetes, little is known about their effects on other systems. Normalization of glucose metabolism by these drugs may consequently affect the secretory function in adipocytes. Secretory adipocytokines like adiponectin and leptin are emerging as novel therapeutic targets for type 2 diabetes mellitus (T2DM). The present study was undertaken to analyze the effects of commonly used Oral Hypoglycemic Agents (OHAs) alone, or in combination with other drugs and/or insulin on circulatory adiponectin and leptin levels, lipid profile, and blood pressure in diabetic subjects.MethodsThe study was undertaken at IRSHA and Bharati Vidyapeeth Medical College and Hospital, MS, India. Clinically diagnosed T2DM subjects and age, gender matched healthy controls were recruited. Fasting blood was collected from each subject and the blood samples were analyzed for circulatory adipocytokines and lipid parameters using commercial kits.ResultsSerum adiponectin levels were significantly increased while leptin significantly decreased in diabetic men (p < 0.05) and women (p < 0.001) on OHA, as compared to healthy controls. Triglyceride levels significantly decreased (p < 0.05) in diabetic men, however, they remained unchanged in women despite same drug treatment. Serum HDL and LDL levels (p < 0.001) were significantly lower in diabetic women as compared to healthy women. Systolic (p < 0.05) and diastolic (p < 0.001) blood pressure was significantly high in diabetic men but remained unchanged in women.ConclusionsFrequently used OHAs significantly improve circulatory levels of adipocytokines. Selecting best treatment option for each patient is a key, and 2012 European Association for the Study of Diabetes (EASD) and ADA guidelines recommend diabetes treatment to be individualized depending on various socioeconomic and lifestyle factors. We recommend regular analysis of circulatory adipocytokines in T2DM patients to help clinicians select the best treatment option to normalize levels of these important therapeutic targets.     

Serum uric acid concentration is associated with worsening in severity of diabetic retinopathy among type 2 diabetic patients in Taiwan—A 3-year prospective study

AimsTo explore the role of serum uric acid (SUA) concentration in diabetic retinopathy (DR) for patients with type 2 diabetes mellitus (T2DM).MethodsA 3-year prospective study in 749 patients with T2DM and without proliferative diabetic retinopathy (PDR) was conducted at a medical center. Baseline SUA concentration and parameters of glycemic control, blood pressure, kidney disease, and lipid profiles were analyzed to determine their contribution to DR.ResultsFundus examination showed that 184 patients (24.6%) had non-proliferative retinopathy and 565 (75.4%) without DR at baseline. After 3 years, increase in the severity of DR was recognized in 103 patients (13.8%), including 81 patients with newly developed DR. Patients with increase in severity of DR positively associated with duration of DM (11.9 vs. 9.4 years, p = 0.001), HbA1c (7.6 vs. 7.2%, p = 0.001), albuminuria (45.5 vs. 31.0%, p = 0.006), and SUA (6.47 vs. 5.87 mg/dl, p < 0.001) than did those without change in DR stage. Cox regression showed that patients with SUA in the 3rd (5.9–6.9 mg/dl) and 4th (≥7.0 mg/dl) quartiles had hazard ratios for DR worsening of 2.57 and 3.66 (95% C.I. 1.30–5.08 and 1.92–7.00) when compared with patients with SUA in the 1st quartile (<4.9 mg/dl).ConclusionsSUA concentration is associated with the increase in severity of DR over a 3-year period in patients with T2DM. Further study is required to define the exact role of SUA in DR.     

Comparison of the glycemic control of the normo- and hypertensive Chinese patients with type 2 diabetes in a general outpatient clinic in Hong Kong

ObjectivesTo describe and compare glycemic control between normo- and hypertensive type 2 diabetic Chinese patients in outpatient setting.MethodsThis retrospective cross-sectional study was performed by retrieving the records of 548 Chinese type 2 diabetic patients. HbA1c ≦ 6.5% was regarded as glycemic good control. Linear and logistic regressions were used to compare mean HbA1c levels and the proportions with good glycemic control between hypertensive and normotensive patients while controlling for confounders.ResultsThe means HbA1c for all diabetic, hypertensive and normotensive patients were 7.70, 7.55 and 8.01, respectively. The normotensive group had a significant higher HbA1c (p = 0.004). Significantly higher HbA1c was associated with lower age (CI of β: ?0.024 to ?0.001, p = 0.039), female gender (CI of β: 0.039–0.552, p = 0.024) and medication use (CI of β: 0.577–1.250, p < 0.001).The proportions with good glycemic control for the all diabetic, hypertensive, normotensive subjects were 0.235, 0.249 and 0.207, respectively. No significant difference was shown for the two groups’proportions (p = 0.283). Lower proportions of good control were shown in females (CI of OR: 0.398–0.905, p = 0.015) and those on medication (CI of OR: 0.211–0.543, p < 0.001) by stepwise logistic regression.ConclusionThe hypertensive diabetic patients had better glycemic control than the normotensives.     

The role of vitamin D,obesity and physical exercise in regulation of glycemia in Type 2 Diabetes Mellitus patients

AimThe aims of this study were to determine the role of vitamin D, obesity and physical exercise in the regulation of glycemia in Type 2 Diabetes Mellitus patients in a highly consanguineous population.DesignCase and control study.SettingThe survey was carried out at the Hamad General Hospital and Primary Health Care (PHC) centers in the State of Qatar.SubjectsThe study was conducted from November 2012 to June 2014 among subjects above 30 years of age. Of the 2224 registered with diagnosed diabetes and free diseases attending Hamad General Hospital and PHC centers agreed and gave their consent to study.MethodsQuestionnaire included socio-demographic variables, body mass index (BMI), consanguinity, lifestyle habits, family history of diabetes, blood pressure and development of diabetes complications such as retinopathy, nephropathy, and neuropathy were collected at regular intervals throughout the follow-up. Univariate and multivariate statistical analysis were performed.ResultsThere were statistically significant difference between patients with diabetic and control in terms of ethnicity (p = 0.012), level of education (p = 0.002), occupation (p < 0.001), monthly income (p < 0.001), BMI(p = 0.024), sport activity (p = 0.018), cigarette smoking (p < 0.001), consanguinity (p = 0.029) and family history of Diabetes Mellitus (p < 0.001) and co-morbidity hypertension (p = 0.041). Further, the biochemistry values in the studied subjects with T2DM compared to healthy controls and the study revealed that serum Vitamin D, BMI, fasting glucose level, calcium, HbA1c, total cholesterol HDL, LDL, bilirubin, triglycerides, uric acid and blood pressure systolic and diastolic were higher in T2DM compared to their counterparts. Multivariate logistic regression showed that vitamin D deficiency ng/mL, Family History of T2DM, BMI (kg/m²) hypertension, consanguinity, income, mother occupation, ethnicity, educational level and Lack of physical exercise variables were significant predictors of diabetes. In the group of Diabetes Mellitus Type 2 patients, 39.3% as opposed to 51.2% in the control group had vitamin D deficiency, 25(OH) D3 levels ≤ 10 ng/ml (p < 0.001). In the group of Diabetes Mellitus Type 2 patients, 34.6% as opposed to 37.9% in the control group had vitamin D insufficiency, 25(OH)D3 levels <20 ng/ml (p < 0.001). In the group of Diabetes Mellitus Type 2 patients, 22.8% as opposed to 14.2% in the control group had vitamin D sufficiency, 25(OH)D3 levels >30 10 ng/ml (p < 0.001).ConclusionVitamin D, family history of diabetes, consanguinity marriages’ and hereditary gene-environment interactions and physical exercise may also contribute to the current diabetes epidemic in Qatari’s Arab populations.     

Morphofunctional characteristics of the foot in patients with diabetes mellitus and diabetic neuropathy

AimsTo determine the structural and biomechanical characteristics associated with the conditions diabetes mellitus and diabetic neuropathy.MethodsObservational study of 788 patients conducted between February 2007 and February 2009, which included subjects with and without diabetes mellitus who had no active ulcer at enrollment. Demographic variables and the general and specific history of diabetes mellitus were recorded. The patient's foot type according to the Foot Posture Index, joint mobility and deformity were recorded.ResultsNo associations were found between the different foot types (neutral, pronated and supinated) and the structural and demographic variables at a general level, except for the pronated foot that was associated with a higher body mass index, longer suffering from diabetes and the presence of neuropathy [p < 0.001, OR (95% CI): 6.017 (4.198–8.624); p < 0.001, OR (95% CI): 1.710 (1.266–2.309); p = 0.010, OR (95% CI): 0.759 (0.615–0.937), respectively].ConclusionsThe confluence of risk factors such as neuropathy, body mass index, duration of diabetes and limited joint mobility in patients with diabetes mellitus and pronated foot may be a high-risk anthropometric pattern for developing associated complications such as Charcot foot. A prospective analysis of these patients is required to define the risk for developing Charcot neuroarthropathy.     

The impact of intensified clinical care on glycaemic control in patients with type 2 diabetes at Khayelitsha Community Health Centre,South Africa: Quasi-experimental study

AimThe aim was to evaluate the effect on glycaemic control of more intensive care for patients with very uncontrolled type-2 diabetes (HbA1c > 10%) at Khayelitsha Community Health Centre, South Africa.MethodsA pragmatic, quasi-experimental study. Patients with HBA1c > 10% were consecutively selected into a 6-month programme of intensified care involving monthly visits to a doctor, diabetes group education, escalation of treatment, and more frequent HbA1c testing by either point-of-care (POC) or laboratory. Participants were their own controls in a retrospective analysis of usual care during the previous year.ResultsAt baseline 236 patients had a mean HbA1c of 12.1%. The mean difference in HbA1c in the intervention group was −1.1% (p < 0.001). The intervention group were exposed to group diabetes education (100% vs 0%), more visits (3.8 vs 3.2, p < 0.001), more HbA1c tests (2.2 vs 0.9, p < 0.001). There was no difference in increased dose of insulin between the groups or between POC and standard laboratory intervention sub-groups.ConclusionThe introduction of group diabetes education was the most likely explanation for improved glycaemic control in this poor, under-resourced, public sector, peri-urban setting. The study demonstrates a feasible approach to improving diabetes care in the South African context.     

Assessment of awareness of diabetic retinopathy and utilization of eye care services among Turkish diabetic patients

AimsRaising awareness of diabetic retinopathy (DR) was shown to be a key element for early diagnosis and treatment of this blinding disease. There is very limited data about the knowledge level, attitude, and behavior of diabetic patients regarding DR in Turkey. This study was planned to assess the awareness of DR and the utilization of eye care services among Turkish diabetic patients.MethodsDiabetic patients who were under the care of ophthalmologists, endocrinologists, and/or primary care physicians were administered a questionnaire in order to assess their awareness of diabetes and its ocular complications.ResultsA total of 437 patients (51.8% female and 48.2% male) with a mean age of 55.2 ± 11.9 were included in the study. Of the 437 patients, 31.8% had not been educated about diabetes, 88.1% were aware that diabetes can affect the eyes, and 39.8% thought that diabetics with good glycaemic control might suffer from DR. While 86.7% thought that early diagnosis was possible in DR, 77.3% previously had eye examinations, and 41.9% stated that annual eye examinations were necessary for diabetics. An educational level of middle school or higher, duration of DM longer than 5 years, previous DM education, and recruitment from the university (ophthalmology department and endocrinology department) were associated with better awareness of DR. The independent factors associated with visiting an ophthalmologist on a regular basis were DM education, DM duration, and site of recruitment.ConclusionAlthough most of the patients know that DM affects the eye, there is a lack of appropriate knowledge and behavior about the management of DR. The importance of better control of DM and regular eye examination in the prevention of DR should be emphasized.     

Association entre tissu adipeux epicardique et dysfonction systolique infraclinique détectée par strain longitudinal chez les diabétiques mal équilibrés

ObjectiveThe aim of this study is to assess the association between epicardial adipose tissue (EAT) and infraclinical myocardial dysfunction detected by strain imaging in diabetic patients (T2DM) with poor glycemic control.Methods22 patients with T2DM and 22 healthy control subjects of similar age and sex were prospectively recruited. Echocardiographic parameters were investigated.ResultsIn comparison to controls, diabetic patients had significantly higher body mass index (27.7 vs. 24.6; P < 0.01), waist perimeter (103 vs. 84; P < 0.001) and usCRP level (5.4 vs. 1.5; P < 0.01). On echocardiography; no differences were found in terms of ejection fraction or ventricular mass; however, patients with T2DM had significantly thicker EAT (8.7 ± 0.7 vs. 3.0 ± 1.0; P < 0.001) and altered systolic longitudinal strain (−18.8 ± 3.2 vs. 22.3 ± 1.6; P < 0.001). On multivariate analysis, EAT was identified as an independent contributor (β=0,46, P = 0.001) to systolic longitudinal strain.ConclusionIn patients with T2DM and poor glycemic control; EAT was associated with infraclinical systolic dysfunction evaluated by global longitudinal strain despite normal at rest ejection fraction and no coronary artery disease.     

Paraoxonase 1 gene (Gln192–Arg) polymorphism and the risk of coronary artery disease in type 2 diabetes mellitus

BackgroundParaoxonase 1 (PON1) is reported to have antioxidant and cardioprotective properties. Recently, an association of glutamine (Gln) or type A/arginine (Arg) or type B polymorphism at position 192 of PON1 gene has been suggested with coronary artery disease (CAD) among patients with diabetes mellitus (DM). However, conflicting results have also been reported.ObjectivesTo investigate the relationship between PON1 gene (Gln¹⁹²–Arg) polymorphism and the presence, extent and severity of CAD in type 2 DM.MethodsThe study comprised 180 patients recruited from those undergoing coronary angiography for suspected CAD, who were divided according to the presence or absence of CAD and DM into four groups: Group I (n = 40 patients) nondiabetic subjects without CAD, Group II (n = 45 patients) diabetic patients without CAD, Group III (n = 47 patients) nondiabetic patients with CAD and Group IV (n = 48 patients) diabetic patients with CAD. PON1(Gln¹⁹²–Arg) genotype was assessed using polymerase chain reaction (PCR) followed by AlwI digestion.ResultsThe frequency of Gln allele (type A) was significantly higher in Group I and Group II compared to Group III and Group IV (62.5%, 60% vs. 38.3%, 31.25%, respectively, p < 0.001) while the frequency of Arg allele (type B + type AB) was significantly higher in ischemic groups (III and IV) compared to nonischemic groups (I and II) (61.7%, 68.75% vs. 37.5%, 40%, respectively, p < 0.001). Patients with CAD and DM (Group IV) have significantly higher severity score and vessel score than those with CAD only (Group III) (9.7 ± 2.97, 2.44 ± 0.56 vs. 6.99 ± 3.71, 1.67 ± 0.89, respectively, p < 0.001) Patients with vessel score 3 had significantly higher severity score and higher Arg allele frequency than patients with vessel score 2, the latter group had also significantly higher severity score and Arg allele frequency than patients with vessel score 1 (8.9 ± 2.79 vs. 5.21 ± 2.13 and 80.49% vs. 67.86%), (5.21 ± 2.13 vs. 3.11 ± 0.89 and 67.86% vs. 53.85%), p < 0.001 for all. In multivariate logistic regression analysis of different variables for prediction of CAD, age [OR 2.99, CI (1.11–10.5), p < 0.01], smoking [OR 4.13, CI (1.37–11.7), p < 0.001], low-density lipoprotein (LDL) cholesterol > 100 mg/dL [OR 4.31, CI (1.25–12.5), p < 0.001], high-density lipoprotein (HDL) cholesterol < 40 mg/dL [OR 5.11, CI (1.79–16.33), p < 0.001] and PON1 192 Arg allele [OR 4.62, CI (1.67–13.57), p < 0.001] were significantly independent predictors of CAD.ConclusionArg allele of PON1 192 gene polymorphism is an independent risk factor for CAD and is associated not only with the presence of CAD but also with its extent and severity and its impact is clearly more pronounced in diabetic patients.     

Effects of patient volume on quality of outpatient diabetes care

In this study we aimed to evaluate the effects of practice size (patient volume) and diabetes caseload in outpatient services on the quality of diabetes care in a teaching hospital. We analyzed the medical records of 2038 diabetic patients treated at a medical center in central Taiwan between January and June 2007. Outpatient practice size (including diabetic and non-diabetic patients) per clinic decreased the odds of glycated hemoglobin (A1C) testing (13% less for every 10 increase in outpatient encounters; p < 0.001), and the percentage of A1C values < 7% (8% less for every 10 increase in outpatient encounters; p = 0.03) in diabetic patients treated by non-endocrinologists. However, a higher caseload of patients with diabetes was associated with an increased lipid profile measurement (19% more for every 5 increase in diabetic patients; p < 0.001). In diabetic patients treated by endocrinologists, a higher patient volume was associated with increased odds of low-density-lipoprotein cholesterol (LDL-C) levels < 100 mg/dl, although there was no effect on the measurement and values of A1C. In conclusion, our study demonstrated some evidence of patient volume–outcome relationship in the management of diabetes in different specialties. This finding can have some implications to the health care system and the referral policy.     

Determinants of glycemic control: Phase 2 analysis from nationwide diabetes report of National Program for Prevention and Control of Diabetes (NPPCD-2018)

BackgroundDiabetes is one of the leading causes of morbidity and mortality worldwide, especially among middle and low income nations. Many diabetic complications and comorbidities are attributable to poor glycemic control. The aim of this study was to update and extend the national diabetes reports on the status of comorbidities, diabetes care and complications in Iran. Moreover, we investigated the risk factors of poor glycemic control in the Iranian population.MethodsNational database of 99,651 patients with diabetes who attended university-affiliated clinics between April 1, 2017 and February 30, 2018 was used to carry out a cross-sectional study. Stepwise backward selection logistic regression model was used to examine the associated factors of glycemic control.ResultsIn this study 73.0% and 56.5% of the enrolled population with diabetes, had hypertension and hyperlipidemia, respectively. The prevalence of patients who received education for nutrition therapy or diabetes self-management was 16.3% and 23.3% respectively. Poor glycemic control was associated with male gender (OR = 1.06, p = 0.001), obesity (OR = 1.03, p = 0.05), duration of diabetes (OR = 1.018, p < 0.001), smoking (OR = 1.08, p = 0.041), hypertension (OR = 1.53, p < 0.001), hyperlipidemia (OR = 1.15, p < 0.001), insulin therapy (OR = 1.26, p < 0.001) and combination of insulin and oral anti-diabetic agents compared to oral anti-diabetic agents alone (OR = 2.36, p < 0.001).ConclusionWe demonstrated that the prevalence of diabetes comorbidities is high in Iranian population and that a great proportion of Iranian patients with diabetes had not reached the goal of glycemic control. Our findings provide a starting point from which to investigate the obstacles that prevent patients with diabetes from reaching metabolic targets.     

Foot examinations of diabetes patients by primary health care nurses in Auckland,New Zealand

AimsTo identify factors associated with patients receiving foot examinations by primary health care nurses.MethodsA cross-sectional survey of 287 randomly sampled primary health care nurses, from a total of 1091 in Auckland, completed a postal self-administered questionnaire and telephone interview. Biographical and diabetes management details were collected for 265 diabetes patients consulted by the nurses on a randomly selected day.ResultsA response rate of 86% was achieved. Nurses examined patient's feet in 46% of consultations. Controlling for demographic variables, foot examinations were associated with age, odds ratio (1.25, 95% CI 0.57–2.74) for patients aged 51–65 years and >66 years (2.50, 1.08–5.75) compared with those ≤50 years, consultations by district compared with practice nurses (14.23, 95% CI 3.82–53.05), special programme consultations compared with usual follow-up consults (8.81, 95% CI 2.99–25.93) and length of consultation (1.89, 0.72–4.97) for 15–30 min and (4.45, 95% CI 1.48–13.41) >30 min compared with consultations ≤15 min, or for wound care (2.58, 1.01–6.61).ConclusionsDiabetes foot examinations by primary health care nurses varies greatly, and are associated with characteristics of the patient (age, need for wound care) and the consultation (district nurses, diabetes programme and duration).     

Assessment of risk factors in diabetic foot ulceration and their impact on the outcome of the disease

AimsThe current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease.MethodsThree hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease.ResultsThe following variables were significant factors for foot ulceration: Male gender (P = 0.009), previous foot ulcer (P = 0.003), peripheral vascular disease (P = 0.004), and peripheral neuropathy (P = 0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P = 0.004), poor glycaemic control (P = 0.006) and anaemia (P = 0.003) and presence of infection (P < 0.001).ConclusionsPeripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.     

Asthma education taught by physical education teachers at grade schools: A randomised cluster trial

ObjectiveAssess whether the Asthma, Sport and Health (ASAH) programme taught by teachers improves asthmatics’ quality of life, asthma knowledge, and reduces school absenteeism.DesignRandomised cluster trial parallel group.Participants2293 students (203 asthmatic) in the Intervention School group (IS) and 2214 in the Comparison School (CS) (224 asthmatic) belonging to primary school.InterventionImplementation of the educational programme “Asthma, Sport and Health” at grade schools, taught by physical education teachers.Main outcomeQuality of life according to the Pediatric Asthma Quality of Life Questionnaire (PAQLQ).Secondary outcomesAsthma knowledge, asthma control, school absenteeism.ResultsAfter implementing the programme in the IS group, global quality of life improved significantly (p < 0.001) as did their domains, symptoms (p < 0.001), emotional function (p < 0.001) and activity limitations (p < 0.01), while in the CS group improvement was seen in global life quality (p < 0.01) without any significant changes in the domains for emotional function and activity limitations. Asthma knowledge only increased in IS, among asthmatic students from 16.51 (CI 95% 16.04–16.98) to 18.16 (CI 95% 17.69–18.62) (p < 0.001) and students without asthma from 15.49 (CI95% 15.36–15.63) to 17.50 (CI95% 17.36–17.64) (p < 0.001). The multiple regression analysis showed that quality of life and its domains depend on asthma knowledge and above all, having well-controlled asthma. We found no decrease in school absenteeism.ConclusionsThe ASAH programme improved certain quality of life aspects regarding asthma (emotional function and limitation of activities) and asthma knowledge, but it failed to reduce school absenteeism NCT01607749.