Prediabetes diagnosis and treatment: A review

Prediabetes is an intermediate state of hyperglycemia with glycemic parameters above normal but below the diabetes threshold. While, the diagnostic criteria of prediabetes are not uniform across various international professional organizations, it remains a state of high risk for developing diabetes with yearly conversion rate of 5%-10%. Observational evidence suggests as association between prediabetes and complications of diabetes such early nephropathy, small fiber neuropathy, early retinopathy and risk of macrovascular disease. Several studies have shown efficacy of lifestyle interventions with regards to diabetes prevention with a relative risk reduction of 40%-70% in adults with prediabetes. While there is increasing evidence to prove the efficacy of pharmacotherapy in prevention of diabetes in adults with prediabetes, pharmaceutical treatment options other than metformin are associated with adverse effects that limit their use for prediabetes. There are no reports of systematic evaluation of health outcomes related to prediabetes in children. The effects of pharmacotherapy of prediabetes on growth and pubertal development in children remains unknown. Secondary intervention with pharmacotherapy with metformin is advocated for high-risk individuals but criteria for such consideration benefit of early intervention, long term cost effectiveness of such interventions and the end point of therapy remain unclear. Pharmacotherapy must be used with caution in children with prediabetes. Prediabetes is a condition defined as having blood glucose levels above normal but below the defined threshold of diabetes. It is considered to be an at risk state, with high chances of developing diabetes. While, prediabetes is commonly an asymptomatic condition, there is always presence of prediabetes before the onset of diabetes. The elevation of blood sugar is a continuum and hence prediabetes can not be considered an entirely benign condition. This aim of this review is to describe the challenges associated with diagnosis of prediabetes, the possible adverse medical outcomes associated with prediabetes and the treatment options and rationale for their use in context of prediabetes.     

Home glucometer monitoring markedly improves diagnosis of post renal transplant diabetes mellitus in renal transplant recipients

BACKGROUND: Definitions of de novo posttransplant diabetes mellitus (PTDM) have varied widely in the renal transplant literature, and most have not used the American Diabetes Association (ADA) definition of diabetes (fasting plasma glucose [FPG] > or = 126 mg/dl on two occasions, or a casual plasma glucose level >200 mg/dl). Most patients are monitored for PTDM by 12-hour FPG levels drawn for clinic visits. In contrast, we describe the diagnosis of PTDM by home glucometer monitoring METHODS: We screened 89 consecutive nondiabetic renal transplant recipients for PTDM by ADA criteria and home glucometer monitoring during the first 3 months posttransplant RESULTS: Of 23 patients with impaired fasting glucose levels of 111-126 mg/dl, 14 (61%) met ADA criteria for diabetes mellitus of based on home glucometer monitoring. The incidence of de novo PTDM was 31% during this period. Predictors of PTDM in a Cox proportional hazards model were race and acute rejection, with a trend towards BMI. Clinic visit FPG levels did not differ between PTDM and non-PTDM patients. All diagnoses were made based on prelunch or supper FPG >200 mg/dl. CONCLUSIONS: Overnight FPG are inadequate for diagnosis of PTDM. All renal transplant recipients with impaired FPG should, at minimum, have home FPG testing.     

Impact of Different Criteria on Type 2 Diabetes Remission Rate After Bariatric Surgery

Background

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) achieve similar type 2 diabetes mellitus (T2DM) remission rates. Since a great variability exists in defining T2DM remission, an expert panel proposed partial and complete remission criteria that include the maintenance of fasting plasma glucose (FPG) and glycosylated hemoglobin (A1c) objectives for at least 1 year. The 2-year T2DM remission rate and time needed to reach it after LSG or LRYGB were compared using different remission criteria.

Methods

This was a prospective cohort study of 55 T2DM subjects operated on with LSG (n?=?21) or LRYGB (n?=?34). Four models for defining remission were used: Buchwald criteria (FPG <100 mg/dl or A1c <6 %), American Diabetes Association (ADA) complete (FPG <100 mg/dl plus A1c <6 % maintained for at least 1 year), ADA partial (FPG <125 mg/dl with A1c <6.5 % maintained for at least 1 year), and ADA complete without time requirement.

Results

Both groups were comparable, except for higher A1c levels in the LSG group. The remission rate ranged from 43.6 % using ADA complete remission to 92.7 % with Buchwald criteria, with no differences between surgical procedures. Differences were found in the time to achieve remission only when ADA complete remission criteria (5.1?±?2.9 months LRYGB and 9.0?±?3.8 months LSG, p?=?0.014) and ADA without time requirement criteria (4.9?±?2.7 months LRYGB and 8.4?±?3.9 months LSG, p?=?0.005) were used.

Conclusions

T2DM remission rate varies widely depending on the criteria used for its definition. Remission occurred sooner after LRYGB when the strictest criteria to define remission were used.     

Type 2 diabetes after gestational diabetes: The influence of changing diagnostic criteria

A previous diagnosis of gestational diabetes(GDM)carries a lifetime risk of progression to type 2 diabetes of up to 60%.Identification of those women at higher risk of progression to diabetes allows the timely introduction of measures to delay or prevent diabetes onset.However,there is a large degree of variability in the literature with regard to the proportion of women with a history of GDM who go on to develop diabetes.Heterogeneity between cohorts with regard to diagnostic criteria used,duration of follow-up,and the characteristics of the study population limit the ability to make meaningful comparisons across studies.As the new International Association for Diabetes in Pregnancy Study Group criteria are increasingly adopted worldwide,the prevalence of GDM is set to increase by two-to three-fold.Here,we review the literature to examine the evolution of diagnostic criteria for GDM,the implications of changing criteria on the proportion of women with previous GDM progressing to diabetes,and how the use of different diagnostic criteria may influence the development of appropriate follow-up strategies.     

Prevalence and influences of diabetes and prediabetes among adults living with HIV in Africa: a systematic review and meta-analysis

Introduction

In people living with human immunodeficiency virus (PLHIV), traditional cardiovascular risk factors, exposure to HIV per se and antiretroviral therapy (ART) are assumed to contribute to cardiometabolic diseases. Nevertheless, controversy exists on the relationship of HIV and ART with diabetes. To clarify the relationship between HIV and type 2 diabetes, this review determined, in PLHIV in Africa, diabetes and prediabetes prevalence, and the extent to which their relationship was modified by socio-demographic characteristics, body mass index (BMI), diagnostic definitions used for diabetes and prediabetes, and HIV-related characteristics, including CD4 count, and use and duration of ART.

Methods

For this systematic review and meta-analysis (PROSPERO registration CRD42021231547), a comprehensive search of major databases (PubMed-MEDLINE, Scopus, Web of Science, Google Scholar and WHO Global Health Library) was conducted. Original research articles published between 2000 and 2021 in English and French were included, irrespective of study design, data collection techniques and diagnostic definitions used. Observational studies comprising at least 30 PLHIV and reporting on diabetes and/or prediabetes prevalence in Africa were included. Study-specific estimates were pooled using random effects models to generate the overall prevalence for each diagnostic definition. Data analyses used R statistical software and “meta” package.

Results

Of the 2614 records initially screened, 366 full-text articles were assessed for eligibility and 61 were selected. In the systematic review, all studies were cross-sectional by design and clinic-based, except for five population-based studies. Across studies included in the meta-analysis, the proportion of men was 16–84%. Mean/median age was 30–62 years. Among 86,412 and 7976 participants, diabetes and prediabetes prevalence rates were 5.1% (95% CI: 4.3–5.9) and 15.1% (9.7–21.5). Self-reported diabetes (3.5%) was lower than when combined with biochemical assessments (6.2%; 7.2%).

Discussion

While not statistically significant, diabetes and prediabetes were higher with greater BMI, in older participants, urban residents and more recent publications. Diabetes and prediabetes were not significantly different by HIV-related factors, including CD4 count and ART.

Conclusions

Although HIV-related factors did not modify prevalence, the diabetes burden in African PLHIV was considerable with suboptimal detection, and likely influenced by traditional risk factors. Furthermore, high prediabetes prevalence foreshadows substantial increases in future diabetes in African PLHIV.     

Impact of diabetes on outcomes in hand surgery

Diabetes mellitus is associated with the development of several pathologic conditions of the hand, including carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility or cheiroarthropathy. In recent years, across a variety of surgical disciplines, increased emphasis has been placed on the impact of diabetes on treatment outcomes. This review provides an overview of the current literature regarding the effect of diabetes on outcomes of hand surgery for these common diabetes-related conditions. Taken as a whole, the best current evidence supports the efficacy of surgical interventions for the management of these conditions in diabetic individuals; however, additional research is required to determine whether the treatment outcomes are equivalent to those of nondiabetic patients, and whether diabetes is associated with an increased risk of complications.     

Diabetic nephropathy-pathophysiology and management

Diabetes mellitus is the leading cause ofend-stage renal disease in the United States. Between 1996 and 2001, the prevalence ofdiabetes in the Medicare population increasedby 31%. Patients with diabetes account forapproximately one-third of all cases ofend-stage renal disease (ESRD). This number isexpected to rise dramatically as a result ofthe growing incidence of diabetes and the agingpopulation. A major complication of diabetesincludes end-stage renal disease as a resultfrom diabetic nephropathy. The earliestclinical evidence that nephropathy exists isthe appearance of low, yet abnormal, levels ofalbumin in the urine, referred to asmicroalbuminuria. This can progress toproteinuria representing overt diabeticnephropathy. Prevention remains the best way toreduce mortality and maintain a high quality oflife in these individuals as recent clinicaltrials confirm that it is possible to not onlyslow down the progression of diabeticnephropathy, but even prevent it from becominga significant problem. This article reviewsthe pathogenesis, diagnostic screening, andtreatment strategies of diabetic nephropathy.     

Update on pre-diabetes: Focus on diagnostic criteria and cardiovascular risk

Pre-diabetes, which is typically defined as blood glucose concentrations higher than normal but lower than the diabetes threshold, is a high-risk state for diabetes and cardiovascular disease development. As such, it represents three groups of individuals: Those with impaired fasting glucose (IFG), those with impaired glucose tolerance (IGT) and those with a glycated haemoglobin (HbA_1c) between 39-46 mmol/mol. Several clinical trials have shown the important role of IFG, IGT and HbA_1c-pre-diabetes as predictive tools for the risk of developing type 2 diabetes. Moreover, with regard to cardiovascular disease, pre-diabetes is associated with more advanced vascular damage compared with normoglycaemia, independently of confounding factors. In view of these observations, diagnosis of pre-diabetes is mandatory to prevent or delay the development of the disease and its complications; however, a number of previous studies reported that the concordance between pre-diabetes diagnoses made by IFG, IGT or HbA_1c is scarce and there are conflicting data as to which of these methods best predicts cardiovascular disease. This review highlights recent studies and current controversies in the field. In consideration of the expected increased use of HbA_1c as a screening tool to identify individuals with alteration of glycaemic homeostasis, we focused on the evidence regarding the ability of HbA_1c as a diagnostic tool for pre-diabetes and as a useful marker in identifying patients who have an increased risk for cardiovascular disease. Finally, we reviewed the current evidence regarding non-traditional glycaemic biomarkers and their use as alternatives to or additions to traditional ones.     

Diabetes Mellitus and Renal Transplantation in Adults: Is There Enough Evidence for Diagnosis,Treatment, and Prevention of New-Onset Diabetes After Renal Transplantation?

BackgroundNew-onset diabetes after renal transplantation (NODAT) is one of the most frequent metabolic complications after transplantation; it is present in ～25% of kidney transplant recipients, increasing their cardiovascular risk and inducing graft damage. The medical approach of this entity is still a matter of controversy, so our aim was to review the evidence available and offer a practical approach for diagnosis, treatment, and follow-up.MethodsA systematic review of the literature in the Medline, Embase, Cochrane, and Lilacs databases was carried out with the use of the terms “Diabetes Mellitus,” “Kidney Transplantation,” “Drug Therapy,” “Prognosis,” “Therapeutics,” and “Risk Factors.” Randomized controlled trials, meta-analyses, and observational studies were included.ResultsThe main risk factors were elevated body mass index, family history of diabetes, recipient >60 years old, hepatitis C virus infection, and treatment with tacrolimus/corticosteroids or sirolimus. Some small studies suggest that thiazolidinediones, sulfonylureas, glinides, and dipeptidyl peptidase 4 inhibitors could be useful in the treatment of the disease. NODAT constitutes a prognostic factor for the renal transplant. Although there is a higher risk of developing diabetes in kidney transplant recipients than in the general population, both populations share the same diagnostic criteria.ConclusionsThere is no consensus on the treatment regimen for these patients. It is necessary to review the diagnostic criteria and the screening methods for NODAT, given the higher susceptibility of kidney transplant recipients to develop this entity; therefore, an earlier intervention could be implemented to decrease the negative effects that this disease has on the kidney graft and the recipient.     

Clinical outcomes following burn injury across the continuum of chronic glycemic control

Diabetes has been associated with poor outcomes following burn injury. There is limited data related to prediabetes in burn injury, and no studies to date have compared clinical outcomes inpatients without diabetes, with prediabetes, and with diabetes. Therefore, this study aimed to compare clinical outcomes after burn injury across the continuum of pre-injury glucose control. A propensity score weighted cohort study of adult patients admitted for initial management of burn injury was performed. Patients were categorized as no diabetes, prediabetes or diabetes based on their admission hemoglobin A1c and past medical history. The primary outcome was length of stay per percent Total Body Surface Area (TBSA) burn. Secondary outcome measures included length of stay, all-cause hospital mortality, disposition at discharge, re-grafting of same site, and amputations. A total of 2450 patients were screened; 1137 patients were included for evaluation (236 diabetes, 191 prediabetes, 710 no diabetes). After inverse probability weighing to adjust for potentially confounding factors, patients in the diabetes group had longer length of stay/%TBSA burn than both the no diabetes group (ratio of geometric means (95% CI) = 1.65 (1.25, 2.18), p < 0.001) and the prediabetes group (ratio (95% CI) = 1.49 (1.10, 2.02), p = 0.01). No statistically significant differences in secondary outcomes were observed between groups other than a higher rate of amputations in the diabetes group (2.7%) compared to the no diabetes (0.7%, p = 0.047) and prediabetes (0%, p = 0.04) groups. Further studies are needed to delineate the differences across the continuum of pre-injury glucose control in order to identify mechanisms to optimize burn-related outcomes.     

Some of the experimental and clinical aspects of the effects of the maternal diabetes on developing hippocampus

Diabetes mellitus during pregnancy is associated with an increased risk of multiple congenital anomalies in progeny.There are sufficient evidence suggesting that the children of diabetic women exhibit intellectual and behavioral abnormalities accompanied by modification of hippocampus structure and function.Although,the exact mechanism by which maternal diabetes affects the developing hippocampus remains to be defined.Multiple biological alterations,including hyperglycemia,hyperinsulinemia,oxidative stress,hypoxia,and iron deficiency occur in pregnancies with diabetes and affect the development of central nervous system(CNS) of the fetus.The conclusion from several studies is that disturbance in glucose and insulin homeostasis in mothers and infants are major teratogenic factor in the development of CNS.Insulin and Insulin-like growth factor-1(IGF-1) are two key regulators of CNS function and development.Insulin and IGF-1 receptors(IR and IGF1 R,respectively) are distributed in a highly specific pattern with the high density in some brain regions such as hippocampus.Recent researches have clearly established that maternal diabetes disrupts the regulation of both IR and IGF1 R in the hippocampus of rat newborn.Dissecting out the mechanisms responsible for maternal diabetes-related changes in the development of hippocampus is helping to prevent from impaired cognitive and memory functions in offspring.     

Glycation as the glucose link to diabetic complications

Hyperglycemia is considered a key causal factor in the development of diabetic vascular complications and can mediate its adverse effects through multiple pathways. This was confirmed for microangiopathy in the Diabetes Control and Complications Trial study for type 1 diabetes and corroborated for type 2 diabetes by the United Kingdom Prospective Diabetes Study published in 1998. Prevention of diabetic complications requires at least control of glycemia. This article briefly summarizes the evidence that strongly supports the role of hyperglycemia in vascular complications. After outlining the role of the polyol pathway, protein kinase C, and oxidative stress, the author focuses on one of the key biochemical mechanisms for this pathologic process: the direct deleterious action of glucose and other sugars on proteins, known as glycation or nonenzymatic glycosylation. Results of animal studies and phase III clinical trials reveal that the inhibition of this process attenuates the development of a range of these complications.     

Renal Hyperfiltration in Prediabetes Confirmed by Fasting Plasma Glucose and Hemoglobin A1c

Background: The aim of the study was to confirm that glomerular hyperfiltration, an early and reversible stage of kidney damage, is associated in patients with prediabetes and prehypertension. Methods: In total, 5003 people aged between 35 and 69 years who had participated in the Shizuoka part of the Japan Multi-Institutional Collaborative Cohort (J-MICC) study took part in the study. Prevalence of hyperfiltration [the estimated glomerular filtration rate (eGFR) above the age- /sex-specific 95th percentile] was compared among different stages of prediabetes [fasting plasma glucose (FPG) < 100, 100–109, 110–125, and ≥126 mg/dL; and/or hemoglobin A1c (HbA1c) < 5.7, 5.7–6.0, 6.1–6.4 and ≥6.5% for no prediabetes, stage 1 prediabetes, stage 2 prediabetes, and overt diabetes, respectively] and prehypertension (blood pressure <120/80, 120–129/80–84, 130–139/85–89, and ≥140/90 mmHg for no prehypertension, stage 1 prehypertension, stage 2 prehypertension, and overt hypertension, respectively). Results: The prevalence of hyperfiltration increased with increasing stages of prediabetes (odds ratios: 1.25, 1.68, and 2.37 using FPG, and 1.26, 2.15, and 2.45 using HbA1c for stage 1 prediabetes, stage 2 prediabetes, and diabetes, respectively, relative to no prediabetes). Prehypertension, however, was not associated with hyperfiltration. Conclusion: The results confirmed that the prevalence of glomerular hyperfiltration increased with increasing stages (i.e., worsening) of prediabetes. Because both FPG and HbA1c showed similar association with hyperfiltration, either of these can be used to identify subjects who are at increased risk of nephropathy. Therefore, the functioning of kidneys should be monitored in subjects with prediabetes. Prompt treatment of hyperglycemia is necessary in subjects with hyperfiltration to prevent it to cause nephropathy.     

Evolving spectrum of diabetic nephropathy

Diabetes remains an important health issue as more patients with chronic and uncontrolled diabetes develop diabetic nephropathy(DN), which classically presents with proteinuria followed by a progressive decrease in renal function.However, an increasing proportion of DN patients have a decline in kidney function and vascular complications without proteinuria, known as nonproteinuric DN(NP-DN). Despite the increased incidence of NP-DN, few clinical or experimental studies have thoroughly investigated the pathophysiological mechanisms and targeted treatment for this form of DN. In this review, we will examine the differences between conventional DN and NP-DN and consider potential pathophysiological mechanisms, diagnostic markers, and treatment for both DN and NP-DN. The investigation of the pathophysiology of NP-DN should provide additional insight into the cardiovascular factors influencing renal function and disease and provide novel treatments for the vascular complications seen in diabetic patients.     

The Women’s Leadership Gap in Diabetes: A Call for Equity and Excellence

Women are broadly underrepresented in scientific leadership positions and their accomplishments are not provided equal recognition compared with those of men, but the imbalance in the field of diabetes is unknown. Hence, we analyzed multiple aspects of historical and present-day female representation in the diabetes field.We quantified gender representation at annual American Diabetes Association (ADA) meetings; editorial board service positions for ADA and the European Association for the Study of Diabetes (EASD) journals; principal investigators for ADA, JDRF, and National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases P30 grant funding; and ADA, JDRF, and EASD award recipients. There are many women in the field of diabetes: registration for the ADA Scientific Sessions has been 43% female since 2016, and for over five decades, women comprised 83% of ADA Presidents of Health Care and Education. Yet, only 9% of ADA Presidents of Medicine and Science have been women. Women were well represented on editorial boards for journals focused on diabetes education (Diabetes Spectrum, 89% female) and primary care (Clinical Diabetes, 49% female) but not for the more academically targeted Diabetes Care (34% female), Diabetes (21% female), and Diabetologia (30% female). Only one-third of ADA Pathway to Stop Diabetes and JDRF grants have been awarded to women, and females only lead 2 of 18 (11%) of the P30-supported Diabetes Research Centers. Finally, only 2–12% of major ADA, JDRF, and EASD awards were given to women, without significant change over time. Despite increasing recognition of gender imbalance in research and medicine, many disparities in the field of diabetes persist. We call for decreasing barriers for advancement of female investigators and creating environments that promote their retention and equitable recognition for their contributions to the field.     

胃癌BillrothⅡ式胃切除术对合并2型糖尿病患者的治疗价值

目的探讨胃癌BillrothⅡ式胃切除术对合并2型糖尿病患者糖代谢的影响。方法回顾性观察7例体重指数（BMl）〈35kg／m^2合并2型糖尿病的病人因胃癌接受Billroth Ⅱ式胃切除手术前后血糖控制情况以及糖尿病治疗的变化。结果7例均成功完成了根治性BillrothⅡ式胃切除术，4例行腹腔镜手术，3例行开腹手术。术后未发生严重并发症。术前空腹血糖（FPG）6．6～9．0mmol／L，平均8．1mmol／L；糖化血红蛋白（HbAlc）6．8％～9．5％，平均7．8％。术后1～8个月复查FPG4．8～7．9mmol／L，平均6．4mmol／L；HbAlc5．5％～7．2％，平均6．3％。据美国糖尿病协会（ADA）糖尿病疗效判断标准，4例治愈，3例改善。结论胃癌BillrothⅡ式胃切除术可治疗胃癌患者合并的2型糖尿病。     

Oral manifestations in patients with diabetes mellitus

The purpose of this article was to increase the knowledge about oral manifestations and complications associated with diabetes mellitus. An overview was performed on Google, especially in recent reliable papers in relation to diabetes mellitus and its oral manifestations(keywords were "diabetes mellitus","oral manifestations", and "oral complications"). Data were collected and the results were declared. Diabetes mellitus is one of the most common chronic disorders characterized by hyperglycemia. This disease can have many complications in various regions of the body, including the oral cavity. The important oral manifestations and complications related to diabetes include xerostomia, dental caries, gingivitis, periodontal disease, increased tendency to oral infections, burning mouth, taste disturbance, and poor wound healing. Oral complications in diabetic patients are considered major complications and can affect patients' quality of life. There is evidence that chronic oral complications in these patients have negative effects on blood glucose control, so prevention and management of the oral complications are important.     

New Diabetes Diagnostic Threshold of Hemoglobin A1c and the 3-Year Incidence of Retinopathy

The new diagnostic threshold of hemoglobin A_1c was made based on evidence from cross-sectional studies, and no longitudinal study supports its validity. To examine whether hemoglobin A_1c of 6.5% or higher defines a threshold for elevated risk of incident retinopathy, we analyzed longitudinal data of 19,897 Japanese adults who underwent a health checkup in 2006 and were followed up 3 years later. We used logistic regression models and restricted cubic spline models to examine the relationship between baseline hemoglobin A_1c levels and the prevalence and the 3-year incidence of retinopathy. The restricted cubic spline model indicated a possible threshold for the risk of incident retinopathy at hemoglobin A_1c levels of 6.0–7.0%. Logistic regression analysis found that individuals with hemoglobin A_1c levels of 6.5–6.9% were at significantly higher risk of developing retinopathy at 3 years compared with those with hemoglobin A_1c levels of 5.0–5.4% (adjusted odds ratio, 2.35 [95% CI 1.08–5.11]). Those with hemoglobin A_1c levels between 5.5 and 6.4% exhibited no evidence of elevated risks. We did not observe a threshold in the analysis of prevalent retinopathy. Our longitudinal results support the validity of the new hemoglobin A_1c threshold of 6.5% or higher for diagnosing diabetes.Diabetes is an increasingly important global public health concern (1). An estimated 285 million people, or 6.4% of the world’s population, lived with diabetes in 2010, and the number is expected to grow to 438 million by 2030 (1). In the U.S., 8.3% of children and adults are living with diabetes (2); likewise, in Japan, 7.8% of the population has diabetes (3).Recently, the International Expert Committee suggested use of a hemoglobin A_1c (HbA_1c) level of 6.5% or higher as the threshold for diagnosing diabetes (4,5). This criterion was subsequently adopted by the American Diabetes Association, European Association for the Study of Diabetes, and World Health Organization (4,5). In making its decision, the expert panel was informed by evidence from several cross-sectional studies that showed the association between HbA_1c level and the prevalence of retinopathy (4–12). The outcome of retinopathy has been historically accepted as the best criterion for comparing glycemic measures among several complications of diabetes (13,5), because it is a specific complication of diabetes that can be measured objectively (13,14). Few longitudinal studies have examined the association between HbA_1c levels and the risk of retinopathy in the general population, and these studies do not support the validity of this new diagnostic threshold (6,15–17). Many of the previous studies did not adjust for independent risk factors and confounders for retinopathy, such as age and hypertension.To examine the validity of the new HbA_1c thresholds, we tested the hypothesis that HbA_1c level of 6.5% or higher would define a threshold for increased 3-year incidence of retinopathy in a large cohort of Japanese adults.     

Impaired glucose tolerance, but not impaired fasting glucose, is associated with increased levels of coronary heart disease risk factors: results from the Baltimore Longitudinal Study on Aging

Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) identify individuals at high risk for progression to diabetes. Whether IFG and IGT have comparable coronary heart disease (CHD) risk factor profiles, independent of their progression to diabetes, is unclear. We determined CHD risk factor levels in 937 nondiabetic individuals at baseline and biannually over a mean follow-up period of 9.5 years. Subjects had no known CHD at baseline and had > or =2 (mean 4.2) oral glucose tolerance tests during follow-up. We classified glucose tolerance categories using American Diabetes Association diagnostic criteria or modified criteria that redefined IFG as 100-126 mg/dl, creating a similar baseline prevalence of IFG and IGT. Subjects who developed diabetes during follow-up were excluded from our analysis. Baseline CHD risk factors were similar in subjects with normal glucose tolerance (NGT) and IFG, but significantly more atherogenic in those with IGT or IFG + IGT. These findings were unchanged when the modified criteria were used, suggesting that IGT is phenotypically different from IFG and is associated with increased levels of CHD risk factors. Subjects with isolated IFG had similar levels of CHD risk factors as NGT subjects, even when IFG was redefined with a lower threshold. Although CHD risk factors were increased in the IGT group, the incidence of CHD events was not significantly different among groups, perhaps owing to the limited number of events. The differences in CHD risk factors among prediabetic groups may have clinical implications for screening strategies and CHD risk stratification of individuals with IFG and IGT.     

Regional anaesthesia in patients with diabetes

Diabetes is the most common metabolic condition worldwide and about 20% of surgical patients will have this condition. It is a major risk-factor for worse outcomes after surgery including mortality; infective and non-infective complications; and increased length of stay. However, diabetes is a modifiable risk-factor, and programs to improve medical management have the potential to reduce peri-operative complications and the risk of harm. Regional anaesthesia has well-documented benefits in promoting the restoration of function but there are legitimate concerns that the incidence of complications of regional anaesthesia in patients with diabetes is higher. The aim of this review is to explore in detail the various potential advantages and disadvantages of regional anaesthesia in patients with diabetes. This, in turn, will allow practitioners to undertake more informed shared decision-making and potentially modify their anaesthetic technique for patients with diabetes.