Dyslipidaemia in adults with type 1 diabetes—when to treat?

Dyslipidaemia is an important modifiable risk factor contributing to the increased risk of atherosclerotic cardiovascular disease in diabetes. However, determining when to initiate statin therapy in young adults with type 1 diabetes mellitus (T1DM) can often be challenging. This is due to a relative paucity of data in this area to guide management and for developing T1DM‐specific risk engines. Current recommendations from international guidelines offer differing approaches to cardiovascular risk stratification and management of dyslipidaemia in T1DM. We present a clinical vignette and comment on the use of nontraditional methods of cardiovascular risk stratification. The strategy for managing dyslipidaemia in young T1DM should be individualized, and recommendations from guidelines should serve to inform clinical judgement.     

Is diabetes‐specific health literacy associated with diabetes‐related outcomes in older adults?

Background: The present study examined the association between a measure of diabetes‐specific health literacy and three different Type 2 diabetes outcome indicators in a national sample of older adults. Methods: Data were taken from the Health and Retirement Study (HRS) 2003 Diabetes module and the HRS 2002 core wave. Analysis was performed on data from 1318 respondents aged 42–96 years [mean (±SD) 67.96 ± 8.65 years] who submitted responses on all relevant independent variable measures along with an HbA1c test kit. The index of diabetes‐specific health literacy was constructed from responses to 10 diabetes self‐care regimen items (α = 0.927). Results: Using a multivariate regression strategy to analyze weighted data, the diabetes‐specific health literacy index was significantly and positively associated with self‐graded assessment of diabetes self‐care (R² = 0.231). However, diabetes‐specific health literacy was not independently associated with the HbA1c level or the average number of days five recommended self‐management behaviors were practiced each week. Conclusions: No previous single study has focused on the relationship between diabetes‐specific health literacy and multiple diabetes‐related outcomes. The direct association of diabetes‐specific health literacy with patients’ assessment of their self‐care practice acumen is useful information for the design of effective patient intervention and/or communication strategies. Health literacy is a broad, multidimensional construct that bridges basic literacy skills and various health and illness contexts. Because it is so important to adults engaged in the self‐management of chronic illness, indicators of disease‐specific knowledge and/or understanding should be included in efforts to measure health literacy.     

Vitamin D and increasing incidence of type 1 diabetes—evidence for an association?

There has been an important shift in the views about the actions of vitamin D during the past decade. In addition to its well‐established role in the regulation of calcium metabolism, vitamin D deficiency has been associated with the risk of several extra‐skeletal diseases, including type 1 diabetes among other chronic conditions. It is notable that 1,25(OH)₂D is known to regulate the expression of over 200 different genes, including the ones related to apoptosis and immune modulation. Increased vitamin D intake is currently considered as one of the most promising candidates for the prevention of type 1 diabetes, and it has been suggested that changes in vitamin D intake during the past decades have contributed to the recent trends in the incidence of the disease. This study reviews the evidence for the role of vitamin D in type 1 diabetes development, demonstrating that support has been obtained from various lines of investigation and that the possible biological mechanisms are plausible. However, much of the evidence has been obtained from animal experiments or observational studies in humans and there is an urgent need for well‐designed, randomized, controlled trials to show whether the observed associations are indeed causal.     

Is insulin pump therapy effective in Type 1 diabetes?

There continues to be uncertainty about the effectiveness in Type 1 diabetes of insulin pump therapy (continuous subcutaneous insulin infusion, CSII) vs. multiple daily insulin injections (MDI). This narrative review discusses the reasons for this uncertainty, summarizes the current evidence base for CSII and suggests some future research needs. There are difficulties in interpreting trials of CSII because effectiveness varies widely due to factors such as differing baseline control, suboptimal use of best CSII practices, and psychological factors, for example, high external locus of control, non‐adherence and lack of motivation. Many summary meta‐analyses are also misleading because of poor trial selection (e.g. short duration, obsolete pumps, low baseline rate of hypoglycaemia) and reliance on mean effect size for decision‐making. Both MDI and CSII can achieve strict glycaemic control without hypoglycaemia in some people with Type 1 diabetes, especially those who are motivated and have undergone structured diabetes education, and with high levels of ongoing input from healthcare professionals. CSII is particularly effective in those people with Type 1 diabetes who have not achieved target HbA_1c levels without disabling hypoglycaemia using best attempts with MDI, and here there can be valuable and substantial improvement. Insulin pumps are safe, effective and accepted when used in newly diagnosed diabetes, particularly in children, where MDI may not be practicable. Future research needs include more studies on mortality associated with insulin pumps where registry data have suggested lower rates vs. MDI; and psychological strategies to improve non‐adherence and suboptimal glycaemic outcomes on CSII.     

Does prednisone use in pregnant women with rheumatoid arthritis induce insulin resistance in the offspring?

Clinical Rheumatology - The use of long-term corticosteroids during pregnancy has been growing over the past decades. Corticosteroids can be given when an auto-inflammatory disease like rheumatoid...     

Are newer insulin analogues better for people with Type 1 diabetes?

Achieving optimal blood glucose control in Type 1 diabetes is a delicate balance between ensuring tight glycaemic control and achieving this without the expense of hypoglycaemia and weight gain, two major factors impacting quality of life. This is a real challenge for people with Type 1 diabetes and underpins many of the struggles they face in self-managing on a day-to-day basis. The main goals of insulin delivery are to try to simulate the physiology of β-cell insulin secretion as closely as possible and to overcome the challenges of peripheral insulin administration by achieving rapidity of onset with mealtime insulins and stability of the glucose-lowering effects of long-acting insulins. Since the early days of human insulin use, there have been many developments in insulin formulations that aim to achieve these goals as much as possible, thus contributing to better glycaemic control whilst minimizing hypoglycaemia. In the present review we discuss the currently available insulin analogues and the challenges of achieving glucose control using current analogues in those on multiple daily injections, and appraise the evidence base for newer-generation insulin analogues, such as insulin degludec, glargine U300, faster-acting insulin aspart and BioChaperone lispro. We also highlight new insulins in development and unmet needs in people with Type 1 diabetes.     

Left ventricular mass in offspring of diabetic mothers: at 5–7 years old

International Journal of Diabetes in Developing Countries - Newborns of mothers with diabetes have increased risk for cardiac left ventricular (LV) hypertrophy. Diabetic pregnancy is also...     

What are the risk factors for aggravation of esophageal varices in patients with hepatocellular carcinoma?

BACKGROUND AND AIM: The risk factors for aggravation of esophageal varices (EV) in patients with hepatocellular carcinoma (HCC) are poorly understood. The aim of this study was to evaluate the effects of HCC on the appearance of the red color (RC) sign on EV and also investigate whether risk factors for the appearance of the RC sign differed between patients with and without HCC. METHODS: A total of 243 patients with cirrhosis (127 with HCC, 116 without HCC) without the RC sign, with no previous variceal hemorrhage, and not on prophylactic treatment for EV were enrolled. The endpoint was defined as being either when the RC sign was first noted, or when variceal bleeding occurred. In patients without HCC, follow-up was discontinued if HCC was discovered. The risk factors were analyzed by Cox proportional hazards regression. RESULTS: In patients with HCC, portal vein tumor thrombus was a statistically independent risk factor (risk ratio [RR] 4.58, 95% confidence interval [CI] 1.32-15.86), although the presence of HCC was not. A large HCC (> or =50 mm) tended to be a risk factor, but this was not statistically significant (RR 2.50, 95%CI 0.98-6.39). Child-Pugh classification and low platelet count were common risk factors regardless of whether HCC was present or not. CONCLUSIONS: Portal vein tumor thrombus, but not the presence of HCC, was a significant risk factor for aggravation of EV in patients with HCC. Cirrhotic patients with portal vein tumor thrombus should receive more aggressive management of portal hypertension to prevent aggravation of EV.     

Are hypertriglyceridemia and low HDL causal factors in the development of insulin resistance?

Insulin resistance often occurs with dyslipidemia as part of the metabolic syndrome and the current dominant paradigm is that insulin resistance leads to dyslipidemia. However, dyslipidemia may also cause insulin resistance; this was postulated 30 years ago, but has never been substantiated. Establishing whether dyslipidemia plays a causal role in the etiology of insulin resistance is important since it could reveal new avenues for combating type 2 diabetes. In this review we summarize recent evidence from epidemiological, genetic and intervention studies to re-address this old hypothesis.