Achieved levels of HbA1c and likelihood of hospital admission in people with type 1 diabetes in the Scottish population: a study from the Scottish Diabetes Research Network Epidemiology Group

OBJECTIVE

People with type 1 diabetes have increased risk of hospital admission compared with those without diabetes. We hypothesized that HbA_1c would be an important indicator of risk of hospital admission.

RESEARCH DESIGN AND METHODS

The Scottish Care Information–Diabetes Collaboration, a dynamic national register of diagnosed cases of diabetes in Scotland, was linked to national data on admissions. We identified 24,750 people with type 1 diabetes during January 2005 to December 2007. We assessed the relationship between deciles of mean HbA_1c and hospital admissions in people with type 1 diabetes adjusting for patient characteristics.

RESULTS

There were 3,229 hospital admissions. Of the admissions, 8.1% of people had mean HbA_1c <7.0% (53 mmol/mol) and 16.3% had HbA_1c <7.5% (58 mmol/mol). The lowest odds of admission were associated with HbA_1c 7.7–8.7% (61–72 mmol/mol). When compared with this decile, a J-shaped relationship existed between HbA_1c and admission. The highest HbA_1c decile (10.8–18.4%/95–178 mmol/mol) showed significantly higher odds ratio (95% CI) for any admission (2.80, 2.51–3.12); the lowest HbA_1c decile (4.4–7.1%/25–54 mmol/mol) showed an increase in odds of admission of 1.29 (1.10–1.51). The highest HbA_1c decile experienced significantly higher odds of diabetes-related (3.31, 2.94–3.72) and diabetes ketoacidosis admissions (10.18, 7.96–13.01).

CONCLUSIONS

People with type 1 diabetes with highest and lowest mean HbA_1c values were associated with increased odds of admission. People with high HbA_1c (>10.8%/95 mmol/mol) were at particularly high risk. There is the need to develop effective interventions to reduce this risk.People with type 1 diabetes are at increased risk of hospital admission compared with the general population (1–3). A previous study in Tayside, Scotland found that 25% of people with type 1 diabetes had had at least one hospital admission in 1995, 2.89-fold higher than the general population (2). Hospital admissions are key drivers of the increased costs of diabetes born by health care systems as well as reflecting preventable morbidity suffered by patients.HbA_1c has a central clinical role in counseling patients regarding risks of hypoglycemia, vascular, and other complications of diabetes (4). National guidelines promote targets for glycemic control based on HbA_1c and attempt to minimize both risk of complications as well as risk of hypoglycemia (5).We hypothesized that HbA_1c would be an important indicator of risk of hospital admission and might be useful in defining that part of the population likely to suffer morbidity and incur an increase in hospital costs in the short and medium term. Such information could inform design of interventional programs promoting reduction in morbidity and costs of diabetes; prioritizing health policies; and identifying which subgroup of patients, determined by HbA_1c, would benefit most.We examined the association between HbA_1c levels and risk of hospital admission in the Scottish type 1 diabetic population.     

Sir Kenelm Digby (1603-1665): diplomat, entrepreneur, privateer, duellist, scientist and philosopher

Kenelm Digby was a man with widely differing interests. He studied at Oxford but left without a degree. At the age of 20, he was involved in a dramatic street brawl in Madrid; the following year saw him as a successful privateer in the Mediterranean and adjacent Atlantic waters, and he was then appointed a naval administrator with lucrative trade monopolies. He practised medicine without formal qualifications and gained notoriety by promoting the use of 'sympathetic' powder for healing wounds. Befriended by King James I and his son who succeeded him, he became chancellor to Queen Henrietta and was knighted by King James I on 21 October 1623 and appointed to the Privy Council. At one time, he even spent a brief time in prison, but he later became a founding member of the Royal Society and published two major philosophical treatises as well as a popular cookbook. He designed and manufactured wine bottles with tapered necks for simpler pouring and square sides for easy stacking. He dabbled in mathematics and corresponded with Fermat of 'Last Theorem' fame. In 1641, he challenged a French nobleman who publicly cast a slur on the British King to a 'digladiation' (a sword duel) and quickly dispatched him. He was a friend and admirer of Sir Thomas Browne whose 'Religio Medici' he helped to publish. The Cowlishaw Library holds a 1659 5th edition copy of this remarkable book, with Digby's name on the spine. Truly, Digby must qualify as a Renaissance man.     

The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes

BACKGROUND: The incidence of type 2 diabetes increases with age. It is unknown whether interventions to prevent diabetes are as effective in elderly persons as in younger adults. METHODS: The Diabetes Prevention Program (DPP) demonstrated that an intensive lifestyle intervention (ILS) or metformin could prevent or delay diabetes. A predefined secondary outcome of DPP was to determine if treatment effects varied by age. RESULTS: At baseline, participants aged 60-85 years were leaner and had the best insulin sensitivity and lowest insulin secretion compared to younger age groups. Diabetes incidence rates did not differ by age in the placebo group, but ILS was more effective with increasing age (6.3, 4.9, and 3.3 cases per 100 person-years, in the 25-44, 45-59, and 60-85 year age groups, respectively; p(trend) =.007). Participants aged 60-85 years had the most weight loss and metabolic equivalent (MET)-hours of physical activity. The metformin group showed a trend toward higher diabetes incidence among older participants (6.7, 7.7, and 9.3 cases per 100 person-years in the 25-44, 45-59, and 60-85 year age groups, respectively; p(trend) =.07); and diabetes risk increased with age (hazard ratio [age 60-85 vs 25-44] 1.63, p =.02), after adjusting for the greater weight loss in the 60-85 year age group. CONCLUSIONS: Lifestyle modification was exceptionally effective in preventing diabetes in older individuals; this finding was largely explained by greater weight loss and physical activity. The limited effectiveness of metformin in older persons may reflect age-related differences in insulin action and secretion. A lifestyle modification program can be recommended for older individuals at high risk for type 2 diabetes.     

Overview of lung transplantation and criteria for selection of candidates

Lung or heart-lung transplantation is a viable option for diverse end-stage pulmonary parenchymal or pulmonary vascular disorders. However, mortality associated with lung transplant (LT) is appreciable, with 3 and 5 year survival rates of approximately 60 and 50%, respectively. Thus LT is reserved for patients with life-threatening disease refractory to medical therapy. Four diagnoses (i.e., chronic obstructive pulmonary disease; idiopathic pulmonary fibrosis; cystic fibrosis; alpha-1-antitrypsin deficiency emphysema) account for approximately 80% of LT recipients; diverse interstitial and pulmonary vascular disorders account for the remaining cases. Given the potential morbidity and mortality associated with LT, the decision to refer patients for LT is difficult. Which patients are acceptable candidates for LT? What are the projected benefits of LT? What criteria should be used to estimate mortality with medical therapy alone? Given the uncertainty of waiting time, when should patients be listed for LT? Identifying appropriate candidates for LT and determining when to list for LT is determined by a risk analysis of the likelihood of mortality during the projected waiting period versus the likely mortality following LT. In this review, we discuss the major diseases treated with LT and the appropriate criteria for LT.     

Sexual Behavior, Psychosocial and Knowledge Differences between Consistent, Inconsistent and Non-Users of Condoms: A Study of Female Bar and Hotel Workers in Moshi, Tanzania

Understanding psychosocial, sexual behavior and knowledge differences between never, inconsistent and consistent condom users can improve interventions to increase condom use in resource-poor countries, but they have not been adequately studied. We examined these differences in a cohort of 961 female hotel and bar workers in Moshi, Tanzania. Forty-nine percent of women reported no condom use; 39% reported inconsistent use, and 12% reported consistent use. Women with multiple sexual partners in the past five years were less likely to be consistent rather than inconsistent users as were women who had ever exchanged sex for gifts or money. Inconsistent users had higher condom knowledge and higher perceived acceptability of condom use than did never users, but they did not differ from consistent users by these factors. There are important differences between women by level of condom use. These findings can help inform interventions to increase condom use.