bluuebunny/crossref_metadata_2025 huggingface dataset:
Novel Perspectives of Super-High Dose Glybenclamide in an Infant With DEND Syndrome
Authors: Barash Galia , Bassan Haim , Ayelet Livne , Benyamini Lilach , Heyman Eli , Bowman Pamela , Barash Galia
Published: May 2021

Mutations in KCNJ11 gene cause a variety of persistent neonatal diabetes mellitus syndromes (PNDM), with and without developmental delay and epilepsy presentations (developmental delay, epilepsy, and neonatal diabetes - DEND Syndrome). We report a heterozygous mutation for pathogenic KCNJ11 missense variant: c.190G>A, p. (Val64Met), reported once so far, associated with severe epilepsy and neurological deterioration phenotype, responsive to a combination of super high doses of Glibenclamide (Sulfonylurea) and oral steroids. We had the patient attached to continuous glucose monitoring, performed electroencephalogramic tracings, magnetic resonance imaging and whole exome sequencing on parents and patient DNA and Sanger sequencing (SS) on candidate gene mutations. His phenotypic description and management during 18 months, demonstrates this mutation is responsive to super-high doses of SU combined with high dose 6 weeks steroids protocol. In conclusion, we have identified a de novo heterozygous missense mutation as the etiology for severe DEND syndrome in a one day old neonate, presenting with asymptomatic hyperglycemia, responsive to a novel management combination.
The Impact of Multi-Disciplinary Input on Glycaemic Control Over Time in Children on Intensive Insulin Therapy Using Real World Prospectively Collected Data
Authors: Foran Jason , O’Connell Susan M , Cody Declan , Somers Eric
Published: May 2021

Aims: To investigate the factors impacting on glycaemic control over time including treatment type, educational input and patient demographics within an Irish tertiary paediatric diabetes centre. Methods: Using a prospectively maintained database of clinical encounters, data was analysed in age matched pairs from 2007 to 2019. Pairs were matched by insulin treatment type (pump v multiple daily injection (MDI)). Matching was performed on the basis of gender, current age, age at diagnosis and HbA1c at pump commencement. Panel data regression was performed on the entire sample and analysed for the impact of differing insulin regimens by gender, age and duration of diagnosis. This model was then used to assess the impact of intensive re-education sessions on HbA1c. Results: From 999 patients there were 104 matched pairs. Compared to MDI, matched pump patients had a lower HbA1c 6 months after commencement [Difference in HbA1c = 0.60% p <0.01], this effect persisted to 8 years [0.57% p=0.01]. Panel data analysis showed CSII therapy reduces HbA1c by 0.57% relative to MDI therapy (p<0.001). Patients who required intensive re-education showed a HbA1c 0.91% greater than otherwise identical patients prior to re-education, after these sessions HbA1c drops by a statistically significant 0.79% (p<0.001). Conclusions: Compared to matched peers on MDI treatment regimens, patients on pump therapy showed significant improvements in HbA1c which was an effect sustained up to 8 years. Panel data regression confirms these findings and in addition shows that intensive re-education is associated with a significant drop in previously elevated HbA1c levels.
An Unusual Presentation of New Onset Type 1 Diabetes Mellitus With Concurrent Addison’s Disease in an Adolescent Male
Authors: Clemente Ethel G , Mathew Nina , Ergun-Longmire Berrin
Published: May 2021

Introduction: Majority of children and adolescents diagnosed with Type 1 Diabetes Mellitus (T1D) present with the classic symptoms of polyuria, polydipsia and polyphagia, associated with hyperglycemia. Concurrent conditions at the time of T1D diagnosis may alter its presentation and potentially lead to challenges in diagnosis and management.

Clinical Case: We present a 17-year-old male with worsening fatigue and unintentional weight loss for two months, then one week of emesis and abdominal pain. Initial work-up by his primary care provider showed sodium 125 mmol/L (133–145), potassium 5.7 mmol/L (3.5–5.1), HCO3 20 mmol/L (21–31), anion gap 13 mmol/L (9–18), random glucose 141 mg/dL (70–199). Due to hyponatremia and dehydration, he was sent to a local emergency room where he was found to be mildly hypotensive at 87/57 mmHg. He received intravenous fluids for hydration and was sent home. On out-patient follow up, he appeared well despite being hypotensive. His additional labs revealed a random glucose of 330 mg/dl and elevated HbA1C of 8.3% (4.4–5.6). His urine was positive for glucose but negative for ketones. He was admitted for further management of new onset diabetes. On admission, he was well appearing and in no acute distress. Blood pressure was 86/57 mmHg, heart rate was 109 bpm, and other physical exam findings were unremarkable. Although his hyperglycemia improved after initiation of insulin therapy, his electrolyte abnormalities persisted, raising suspicion for adrenal insufficiency. An ACTH stimulation test was performed, with both baseline and 60-minute cortisol levels low at 1 ug/dl and 0.9 ug/dl, respectively, confirming adrenal insufficiency. He responded well to glucocorticoid and mineralocorticoid replacement. His electrolytes and blood pressure normalized. Further testing confirmed elevated levels of Glutamic Acid Decarboxylase antibodies 0.19 nmol/L (less than 0.02), Islet Antigen 2 Antibodies: 3.38 nmol/L (less than 0.02), and 21-Hydroxylase antibodies, consistent with T1D with concomitant Addison’s disease (AD).

Conclusion: About 0.5% of patients with T1D have AD, but the diagnosis of T1D typically precedes AD for several years, thus the coexistence of both autoimmune conditions at diagnosis is rare.
Ketogenic Diet in a Patient With Type 1 Diabetes Mellitus With Hypoglycemia Unawareness
Authors: Sukkari Mohamad Anas , Cotten Lucia , Alam Murtaza , Temponi Emily , John Priya D , Davis Georgia , Vellanki Priyathama
Published: May 2021

Introduction: The high fat, low carbohydrate ketogenic diet has become increasingly popular in recent years for weight loss and glycemic control in patients with type 2 diabetes. Although prior studies have suggested this diet can improve glycemic control and decrease glucose variability, the impact of a ketogenic diet on rates of hypoglycemia in patients with hypoglycemia unawareness is not well described. Case Description: Our patient is a 37 year-old woman with Type 1 diabetes for 13 years complicated by hypoglycemia unawareness with HbA1c of 7.7%. Her insulin treatment regimen included insulin glargine 22 units daily, insulin aspart using a 1:15 carbohydrate ratio for prandial insulin dosing with a correction factor of 90. She had 5 episodes of severe hypoglycemia within the previous 3 months. The patient decided to resume a ketogenic diet given her previous improvement in glycemic control. Ketosis was confirmed using urine ketone strips performed by the patient. After 2 weeks on the ketogenic diet, a professional blinded continuous glucose monitor (CGM) was used for 4 weeks to monitor glycemic control.

CGM data for weeks 1 and 2 showed overall stability of time in target glucose range [TIR, 60% and 69%, respectively], with a slight increase in time spent below range [TBR, 13% and 17%, respectively]. During week 3, the patient experienced a significant decline in TIR to 31%, and associated increase in hypoglycemia (TBR, 13% to 28%). In addition, glycemic variability increased during this time [CV (coefficient of variation), 40.6% during week 1 to 58.1% during week 3]. Patient did not experience symptoms concerning for DKA, and continued to have asymptomatic hypoglycemia despite reductions in her insulin doses during week 3. Following these dose adjustments, CGM data during week 4 were similar to week 1 (TIR 65%, TBR 10%, CV 35%). Patient stopped following the ketogenic diet after 6 weeks due to social factors.

Conclusion: A ketogenic diet was associated with increased frequency of hypoglycemic events. In a patient with Type 1 diabetes and hypoglycemia unawareness, use of ketogenic diet may further increase the risk of severe hypoglycemia.
Alpha and Beta Cell Dysfunction Improves With Effective Insulin Therapy in Treatment Naive Type 2 Diabetes - a Prospective Observational Study
Authors: Ramesh Jayanthy , Makineni Ashok Chakravarthy , Mudimela Madhubabu , Madhira Srivalli
Published: May 2021

Abstract: Type 2 diabetes mellitus is characterized by insulin resistance and progressive beta cell decline. Elevated glucagon levels and impaired incretin axis also contribute to the poor glycemic status. Early intensive glycemic control, reduces long-term vascular complications and may preserve β-cell function. Clinical studies of effect of early insulin therapy on combined alpha and beta cell function are lacking. Objective: To determine the effect of early insulin therapy on combined alpha and beta cell dysfunction (islet cell dysfunction) in newly diagnosed type 2 diabetes. Methods: 56 newly diagnosed type 2 diabetes patients, attending the endocrinology OPD at a tertiary teaching hospital were enrolled in this treatment related follow up study after institutional ethical committee clearance, conducted between May 2017 to December 2018. Patients with HbA1C > 8.5% to <12.5% (n=56) were included in the study. Metabolic (FPG, PPG, HbA1c), and Hormonal parameters (plasma glucagon levels,fasting and 2 hour mixed meal stimulated C peptide and levels) were assessed both at baseline and after 6 months of insulin treatment. Initiating dose of insulin was 0.5 U/kg/day and the dose was titrated according to FPG and 2 hr PPG in order to maintain glycemic goals as per ADA standards. Results: The study included 56 subjects with mean age of 41.24 ± 5.64 years and a mean BMI of 25.5 kg/m2. At the end of 6 months of the study, a significant reduction in the mean FPG, PPG, HbA1C were observed,[FPG (139±14.47 mg/dl), PPG (179.89 ± 19.42mg/dl),HbA1c (7.54± 0.63%)] as compared to baseline mean FPG, (216.30 ± 42.35 mg/dl),2 hour PPG (338.44 ±62.89 mg/dl), HbA1C (10.39 ± 1.56 %) (p <0.001). Baseline glucagon levels were high (197.68± 49.09 pg/ml), and were significantly reduced at 6 months of insulin therapy (107.06±49.09 pg/ml).(p <0.001). In comparison to the baseline a significant increase in both fasting (0.73±0.27 ng/ml) and stimulated c-peptide (1.54±1.02 ng/ml) (p<0.001) levels was observed at end of the study. Conclusion: Combined alpha and beta cell (Islet) dysfunction prevails in newly diagnosed T2DM. And early insulin therapy significantly improves both these defects. The documentation of this novel beneficial effect on islet cell dysfunction in our study strengthens the concept of early insulin therapy in newly diagnosed Type 2 diabetes patients.
Combination Therapy With Premixed & Basal Insulin Analogues in Asian Indians With Type 2 Diabetes
Authors: Srivastava Brijendra Kumar , Anjana R M , Singla Amit , Jebarani S , Viswanathan Mohan
Published: May 2021

Many individuals with type 2 diabetes (T2DM) eventually need insulin for better glycaemic control. Different insulin regimens like basal, premixed, basal plus, split mixed and basal bolus are used in T2DM management. There is not much literature on a combination of premixed insulin in the morning along with basal insulin at night. Such a regimen is preferred by people with T2DM, who do not want to take an afternoon insulin dose due to inconvenience. To study the effect of a premixed insulin given in the morning and long acting basal insulin analogue given at night in T2DM subjects, we looked into this combination. We performed a retrospective study to look into the effects of premixed and basal insulin analogue combination in patients with T2DM (in addition to oral antidiabetic agents). From the diabetes electronic medical records of a tertiary care hospital for diabetes at Chennai in South India, 648 patients on premixed and basal insulin analogue combination, who came for a follow-up visit were included in the final analysis. Baseline characteristics included body weight, BMI, blood pressure, fasting lipid profile, fasting and post prandial plasma glucose and HbA1c were analysed at baseline, and a change in the parameters was studied at the first follow up visit between 5 to 7 months. Mean age of the study population was 60.7± 13.1 years with mean diabetes duration of 20.5 ± 8.0 years. Out of 648 patients included, three fifths were male. Statistically significant improvement was observed in body weight, BMI, HbA1c, systolic blood pressure, lipid profile, fasting blood sugars (P < 0.001) and post prandial blood sugars (P= 0.005) in comparison to baseline values. Significant reduction in HbA1c (1.7 %, p < 0.0001) was observed in those with in the highest tertile of HbA1c (11.3 ± 1.0 %) in comparison to the baseline values. At follow up, nearly a third of study subjects achieved a HbA1c target of < 8% (30.1 % vs 18.4 0%, p =0.0005) in comparison to the baseline values. 28.7 % patients on combination therapy achieved a fasting blood sugar value of < 130 mg/dl at follow up compared to 18.2 % patients at baseline (p <.0001). Similarly, 22 % of the patients on combination therapy also achieved post prandial blood sugars of <180 mg/dl at follow up, compared to 12.2 % (P<.0001) at baseline. This study shows that in T2DM subjects, a simple regimen of premixed and basal insulin analogue combination helps in improving the glycaemic control.
Effect of Oral Calcium Supplementation on Insulin Sensitivity in Patients With Metabolic Syndrome
Authors: Myint Ye , Sein Mya Thanda , Than Khin Saw , Ko Ko , Latt Tint Swe
Published: May 2021

Background: Evidence from epidemiological research suggests that dietary calcium may protect against metabolic abnormality in populations at high risk. Observational studies show the relationship between dietary calcium intake and metabolic syndrome. However evidence for beneficial effect of elemental calcium supplementation on metabolic syndrome is limited. Aims: Present studydetermined whether oral calcium supplementation reduced insulin resistance in patients with metabolic syndrome or not. Methods; Hundred patients who have metabolic syndrome without diabetes mellitus, parathyroid disease, chronic renal failure, pregnancy and lactationwere randomly allocated to the group receiving 1500 mg/ day of elemental calcium as calcium carbonate for 8 weeks and the control group. The primary outcome was change in insulin resistance as measured by homeostasis model assessment of insulin resistance (HOMA-IR). Other outcomes were changes of serum free ionized calcium (FiCa) level with accompanying serum parathyroid hormone (PTH) level. Fasting serum glucose was measured by glucose oxidase method. Serum insulin and PTH level were measured by enzyme linked immunoassay. Total serum ionized calcium was analyzed by Atomic Absorption Spectrophotometry. Serum FiCa(mg/dl) level was calculated by using following formula = [6Ca-(K/3)]/(K+6). Results: Mean age of participants was 47.38±13.2 years in calcium supplement group (n = 50) and 49.46±12.9 years in control group (n=50). Mean body mass index was not significant different between two groups (30.91 ±4.23 vs 30.37 ± 4.62 kg/m2). More female were involved in both group, 72% vs 62% respectively. Baseline biochemical parameters of the participants between two groups were not significantly different. After 8 week intervention period, mean serum FiCa increased significantly from 2.64±1.19 mg/dl to 5.82± 5.59 mg/dl, p<0.0001, serum PTH decreased significantly from 57.88 ±17.05 pg/ml to 35.7±23.12 pg/ml, p<0.0001, HOMA-IR decreased significantly from 5.14 ± 3.71 to 2.94±1.51, p<0.0001. None of these parameters were significantly affected in control group. By comparing biochemical changes of calcium supplement group to control group, Mean (SEM) of paired difference changes were observed in serum FiCa level [3.18(0.81) vs 0.81(0.25)mg/dl, p<0.05], serum PTH level [22.18(3.24) vs 3.58(1.99)pg/ml, p<0.0001] and HOMA-IR [2.19(0.45) vs 0.43(0.21), p<0.05]. It indicated that elemental calcium supplementation not only reduced insulin resistance but also decompensated the higher level of PTH to normal range by replenishing FiCa significantly. Conclusion: Eight-week oral elemental calcium supplementation of 1500mg/day showed beneficial effect on insulin sensitivity in patients with metabolic syndrome.
Effects of Roux-en-Y Gastric Bypass on Type 2 Diabetes Mellitus
Authors: Maraschin Clara K , Blume Carina A , Teló Gabriela H , Trindade Manoel M R , Schaan Beatriz D
Published: May 2021

Abstract: Bariatric surgery is the most effective treatment for classes II and III obesity patients. This surgically induced weight loss is associated with better glycemic control and higher type 2 diabetes mellitus (T2DM) remission rate compared to conventional medical therapy. Roux-en-Y gastric bypass (RYGB) is the most commonly technique performed, and its risks and benefits are well known. We sought to assess the effects of one-year post-RYGB on glycemic control and T2DM remission in a tertiary care teaching public hospital in Porto Alegre, Southern Brazil. This retrospective cohort study included all patients submitted to RYGB between 2010 and 2019 at Hospital de Clínicas de Porto Alegre. Type 2 diabetes mellitus remission was defined as the absence of oral antidiabetic medication and insulin use in association with a glycosylated hemoglobin (HbA1c) <6.5% one-year post-RYGB. This study was approved by the local Ethics Committee (2018-0088). A total of 549 RYGB procedures were performed from 2010 to 2019 among patients aged 42.2 ± 10.7 years, mostly women (84.7%), white (88%), and with a body mass index (BMI) of 49.4 ± 8.5 kg/m². The preoperative prevalence of T2DM was 31.2% (n=171), of which 93.6% used oral antidiabetic medication and 15.6% used insulin. Among T2DM patients, 39% used at least two oral antidiabetic drugs in association, most of them being metformin (91%) and sulfonylureas (19.3%). Preoperative fasting plasma glucose and HbA1c were 143 ± 48.1 mg/dL and 7.3 ± 1.6%, respectively, reducing to 93.6 ± 21.3 mg/dL (p<0.001) and 5.4 ± 0.7% (p=0.002), respectively, one year after RYGB. Excess weight loss one-year post-RYGB was 68.7 ± 17.1%, similar between patients with and without T2DM (p=0.48). At 12 months, 77.4% of T2DM patients discontinued their oral antidiabetic drugs or insulin, and the disease remission rate was 71.3%. Bariatric surgery was effective for T2DM remission among classes II and III obesity patients, which is in accordance with the current literature.

Support: CNPq, FIPE (HCPA)
Efficacy and Safety of a Sodium-Glucose Co-Transporter-2 Inhibitor Versus Placebo as an Add-on Therapy for People With Type 2 Diabetes Inadequately Treated With Metformin: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Authors: Lim Jia Leng , Bergero Georgina , Acharya Yogesh , Shaw James , Liew Aaron
Published: May 2021

Metformin monotherapy is often insufficient to achieve or sustain glycemic targets in people with type 2 diabetes. Therefore, we performed a systematic review and meta-analysis to assess the efficacy, safety and tolerability of sodium-glucose co-transporter-2 inhibitors versus placebo as add-on therapy after metformin in type 2 diabetes. The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was performed in the PubMed, www.clinicaltrials.gov and Cochrane Central Register of Controlled Trials databases for relevant randomized controlled trials up until 30th October 2020 that compared sodium-glucose co-transporter-2 inhibitors versus placebo as add-on therapy to metformin. A random-effects model was used. Thirteen randomized controlled trials (4270 participants) met the inclusion criteria. Compared with placebo, sodium-glucose co-transporter-2 inhibitor treatment, as add-on therapy to metformin, was associated with a significant reduction in HbA1c level (mean difference [MD]: -0.6%, 95% CI: -0.7, -0.5; p<0.01), fasting plasma glucose level (MD: -1.4mmol/l; 95% CI; -1.5, -1.3; p<0.01), weight (MD: -2.0kg; 95% CI: -2.2, -1.8; p<0.01), systolic blood pressure (MD: -4.7mmHg; 95% Cl: -5.4, -3.9; p<0.01) and diastolic blood pressure (MD: -2.0mmHg; 95% Cl: -2.5, -1.5; p<0.01). Significantly more participants achieved HbA1c <7% (odds ratio [OR]: 3.1; 95% CI: 2.6, 3.6; p<0.01) in the sodium-glucose co-transporter-2 inhibitor group. Genital mycotic infections (OR: 2.6; 95% CI: 1.4, 4.6; p<0.01) were more common with sodium-glucose co-transporter-2 inhibitors, but there was no significant statistical difference in urinary tract infections (OR: 1.4; 95% CI: 1.0, 2.0; p=0.06), in hypoglycemia (OR: 1.5; 95% CI: 1.0, 2.4; p=0.07), or in discontinuation rates due to adverse events (OR: 0.9; 95% CI: 0.6, 1.5; p=0.68) between the two groups. In summary, in comparison with placebo, add-on therapy with a sodium-glucose co-transporter-2 inhibitor is significantly more efficacious in lowering HbA1c, fasting plasma glucose, weight and blood pressure in people with type 2 diabetes following inadequate glycemic control with metformin. The rate of discontinuation due to adverse events was similar despite higher risk of genital mycotic infections.
Normalization of HbA1c Following an Ad-Libitum, Non-Ketogenic Low Carbohydrate Diet Along With Antidiabetic Agents
Authors: Torbay Naji , Nawar Rita
Published: May 2021

Background and Aims: Recent scientific research has found that remission of T2DM can be achieved with substantial weight loss following hypocaloric diet or bariatric surgery. The DiRECT study has shown that after 12 months of dietary management, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. The aim of our study was to investigate the impact of an ad-libitum, low carbohydrate non-ketogenic diet (LCNK) on T2DM control and weight loss of patients reporting to our clinic. Materials and Methods: We reviewed the medical charts of 131 T2DM patients (60% male) who were not receiving insulin; the average number of years with T2DM was 8.4years, mean age was 52.8±1.0 years, mean HbA1c was 8.4±0.1 %, and mean BMI was 32.7±0.6 kg/m2. We instructed patients on an ad-libitum LCNK diet providing 130 - 150g of carbohydrate/day coupled with combination therapy of Metformin and any of the currently available antidiabetic drugs (except those known to induce weight gain). Those on sulfonylurea or glitazones had their doses tapered down and eventually discontinued. Results: All patients came for a first follow up visit within 3 months of being instructed on the diet. Significant weight loss was observed in these patients (91.5±1.7 vs. 85.6±1.5 Kg, p<0.001); equivalent to a 6% decrease in weight. An A1C level below 6.5 % was observed in 60% of our patients who came for a first follow-up visit and it correlated with weight loss. Given that 10% of our population gained weight due to poor adherence to the diet; A1C below 6.5 % was achieved in 50% of our 42 patients who lost between 0-5kg, and in 60% of those who lost between 5-10kg (48 patients), and in 63% of those who lost 10-15kg (19 patients), and in 100% of those who lost more than 15kg (4 patients). We observed in them significant decreases in FBS, cholesterol, LDL, TG, and SGPT. Of the 131 patients, 59 came for a second follow-up visit within 7.5 months and an even more significant weight loss was observed (92.0±2.6 vs. 83.8±2.0 Kg, p<0.001); equivalent to a 9 % decrease. An A1C level below 6.5 % was observed in 63% of patients who came for a second follow-up visit. Given that 14% of the 59 gained weight; A1C below 6.5 % was achieved in 42% of our 12 patients who lost between 0-5kg, and in 61% of those who lost between 5-10kg (19 patients), and in 57% of those who lost 10-15kg (8 patients), and in 90% of those who lost more than 15kg (11 patients). Antidiabetic agents were in general progressively decreased and adjusted to individual needs. At the end 27% were only on metformin. Conclusion: A LCNK diet is easy to prescribe and easily followed by T2D patients (no calorie restriction or counting). We recommend its use especially in the primary care setting because it brings diabetes under immediate control by lowering A1C levels below 6.5% in more than 60% of patients as shown by our results, as well as inducing significant weight loss.
Predictors of the Lack of Annual Fasting Blood Sugar Screening in US Adults
Authors: Visaria Aayush , Raju Priyanka , James Joel , Khangura Karen K , Islam Sumaiya , Amanullah Amir , Polamarasetti Pooja
Published: May 2021

Background: Diabetes mellitus is a major cause of morbidity and mortality. Many individuals remain undiagnosed. The purpose of this study was to identify predictors of the lack of annual fasting blood sugar (FBS) testing in a representative cohort of U.S. adults.

Methods: A total of 257,652 adults ≥18 years from the 2011–2018 National Health Interview Surveys (NHIS) were included. Participants were considered to have had FBS testing if they reported a fasting test for diabetes or high blood sugar in the past 12 months. Predictors of screening utilization were selected using the Anderson Model for Healthcare Utilization, including predisposing (age, sex, race/ethnicity), enabling (smoking, alcohol consumption, physical activity, insurance status, education, citizenship status, region of residence), need (BMI group, comorbidities, cardiovascular disease [CVD]), and healthcare-related factors (doctor visits, satisfactory care, affordability, delayed care). We used diabetes status-stratified multivariable logistic regression with a stepwise selection method to determine the most significant predictors. All analyses accounted for the survey design and weights to obtain nationally representative estimates.

Results: Among the 257,652 participants, 115,630 (48%) were male, 27,096 (9.4%) had diabetes, and 141,247 (56%) did not have a FBS test in the past 12 months. Among those with diabetes, 4,529 (16%) did not have a FBS test. Positive predictors of a lack of FBS testing included younger age, male sex, non-Hispanic Black race, ever smoker (≥100 cigarettes), native born, lack of insurance coverage, lack of adequate physical activity, northeast region (relative to west region), no known chronic diseases, and dissatisfactory care. The top 5 most significant predictors of a lack of FBS test in those without diabetes were, in order, 1) no visits to the doctor in the past 12 months (aOR [95% CI]; 5.64 [5.34, 5.96]), 2) insurance status (no coverage vs. coverage; 1.62 [1.54, 1.69]), 3) age group (Ref: ≥65y; 18-35y: 2.45 [2.34, 2.56]; 35-50y: 1.46 [1.40, 1.52]; 50-65y: 1.04 [1.01, 1.08]), 4) BMI group (Ref: Low/Normal; Overweight: 0.79 [0.77, 0.82]; Obese: 0.62 [0.60, 0.64]), and 5) race/ethnicity (Ref: Non-Hispanic White; Non-Hispanic Black: 1.03 [0.98, 1.07], Asian Indian: 0.65 [0.58, 0.74]; Other Asian: 0.91 [0.83, 1.00]; Hispanic/Multiracial: 0.91 [0.86, 0.96]). The top predictors for those with diabetes were similar, although there were significantly greater odds of a lack of FBS testing in Non-Hispanic Blacks vs. Whites (1.24 [1.14, 1.35]).

Conclusion: More than half of the participants reported a lack of FBS testing in the past year; among those with diabetes, nearly 1 in 6 reported not having an annual FBS test. This reaffirms the need for long-term patient-physician relationships and aggressive follow-up in younger, male, uninsured, and/or lean individuals with or without diabetes.
The Cardiovascular Events in Metabolic Surgery Compared to the New Classes of Glucose-Lowering Agents in Patients With Type 2 Diabetes Mellitus: A Systematic Review With Narrative Synthesis
Authors: Shamsi Najla Mahmood , Patel Vinod
Published: May 2021

Globally, Type 2 Diabetes Mellitus has an immense healthcare burden and associated with increased morbidity and mortality due to macrovascular and microvascular complications. Cardiovascular disease including coronary artery disease and stroke are far more common in T2DM patients. Thus, any intervention that reduces the cardiovascular events in patients with diabetes will have positive impact on the patients and the society. Therefore, this systematic review aimed to evaluate the cardiovascular events after metabolic surgery in comparison with the new classes of glucose lowering agents in patients with T2DM. This review included 11 randomised controlled trials that used GLP-1 RA or SGLT-2 I in comparison to usual standard of care. Seven metabolic surgery studies were included, of which two were randomised controlled trials and the other five were observational studies. These were the most relevant studies to the research question. The results suggest that cardiovascular events are lower in metabolic surgery studies when compared to medication trials. It also suggests that glycated haemoglobin reduction is more in the metabolic surgery group compared to the medication group, although it was not proved to be significant difference between the groups after adjusting the duration. The remission of diabetes was very high in the metabolic surgery group while none of medication trials accomplished diabetes recovery. Additionally, weight loss in metabolic surgery group was significantly higher than medication group after adjusting the duration. However, both medication and surgery groups had adverse events. In conclusion, the review suggests that younger adult obese patients with cardiovascular diseases should undergo metabolic surgery. Whereas, older patients with established cardiovascular disease should be advised to take one of the medications that has been proved to reduce cardiovascular events. Future studies that compare metabolic surgery and the new classes of the glucose lowering agents is recommended to confirm the findings in this review.
Exposure to the Endocrine Disruptor, Propylparaben, During Pregnancy and Lactation, Alters Typical Parity-Induced Reorganization of the Mouse Mammary Gland
Authors: Mogus Joshua Philip
Published: May 2021

The mammary gland is a hormone sensitive organ that is susceptible to endocrine disrupting chemicals (EDCs) during several vulnerable periods, including pregnancy and lactation. Mammary gland reorganization during pregnancy and lactation is hormone driven and provides long-term protection against breast cancer risk. It is unknown if EDC exposures during these sensitive windows can alter mammary reorganization to either enhance or offset parity-induced protection against breast cancer. Here, we examined effects of propylparaben (PP), a common preservative used in personal care products and foods with estrogen receptor (ER) agonist properties, on the parous mouse mammary gland. Pregnant BALB/c mice were treated with 0, 20, 100, or 10,000 µg/kg/day PP throughout pregnancy and lactation. These doses were selected for their relevance to human exposures. We also included an unexposed nulliparous female group to evaluate the typical changes associated with parity. Five weeks post-involution (and five weeks after the last PP exposure), mammary glands were collected and assessed for changes in histomorphology, hormone receptor expression, immune cell number, and gene expression. We found that PP reduced many of the typical morphological effects of parity on the mammary gland, resulting in intermediate phenotypes for ductal density and total epithelial structures. Notably, we found increased proliferation in PP-treated mammary glands, despite decreased ductal epithelial volume relative to parous controls. Mammary glands from PP-treated females also had alterations in the expression of ERα-mediated genes, including PgR (the gene that encodes progesterone receptor) and Igf1, with expression levels that were intermediate to both nulliparous and parous control mice. Finally, PP reduced the effect of parity on several immune cell types in the mammary gland including B cells, T-cells, and M2 macrophages. These results suggest that PP, at levels relevant to human exposure, can disrupt the normal response to parity in the mouse mammary gland, including persistent alterations to mammary gland structures. Future studies should address whether PP exposures disturb the protective effects of pregnancy on mammary cancer risk.
The Effects of Intraoperative Caffeine on Postoperative Opioid Consumption and Related Outcomes After Laparoscopic Surgery: A Randomized Controlled Trial
Authors: Vlisides Phillip E. , Li Duan , McKinney Amy , Brooks Joseph , Leis Aleda M. , Mentz Graciela , Tsodikov Alexander , Zierau Mackenzie , Ragheb Jacqueline , Clauw Daniel J. , Avidan Michael S. , Vanini Giancarlo , Mashour George A.
Published: May 2021

BACKGROUND:

Surgical patients are vulnerable to opioid dependency and related risks. Clinical-translational data suggest that caffeine may enhance postoperative analgesia. This trial tested the hypothesis that intraoperative caffeine would reduce postoperative opioid consumption. The secondary objective was to assess whether caffeine improves neuropsychological recovery postoperatively.

METHODS:

This was a single-center, randomized, placebo-controlled trial. Participants, clinicians, research teams, and data analysts were all blinded to the intervention. Adult (≥18 years old) surgical patients (n = 65) presenting for laparoscopic colorectal and gastrointestinal surgery were randomized to an intravenous caffeine citrate infusion (200 mg) or dextrose 5% in water (40 mL) during surgical closure. The primary outcome was cumulative opioid consumption through postoperative day 3. Secondary outcomes included subjective pain reporting, observer-reported pain, delirium, Trail Making Test performance, depression and anxiety screens, and affect scores. Adverse events were reported, and hemodynamic profiles were also compared between the groups.

RESULTS:

Sixty patients were included in the final analysis, with 30 randomized to each group. The median (interquartile range) cumulative opioid consumption (oral morphine equivalents, milligrams) was 77 mg (33–182 mg) for caffeine and 51 mg (15–117 mg) for placebo (estimated difference, 55 mg; 95% confidence interval [CI], −9 to 118; P = .092). After post hoc adjustment for baseline imbalances, caffeine was associated with increased opioid consumption (87 mg; 95% CI, 26–148; P = .005). There were otherwise no differences in prespecified pain or neuropsychological outcomes between the groups. No major adverse events were reported in relation to caffeine, and no major hemodynamic perturbations were observed with caffeine administration.

CONCLUSIONS:

Caffeine appears unlikely to reduce early postoperative opioid consumption. Caffeine otherwise appears well tolerated during anesthetic emergence.
Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines
Authors: Joshi Ravi V. , Wilkey Andrew L. , Blackwell James-Michael , Kwak Jenny , Raphael Jacob , Shore-Lesserson Linda , Greilich Philip E.
Published: May 2021

BACKGROUND:

Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap.

METHODS:

Members of the SCA and its Continuous Practice Improvement (CPI)— Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute’s (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018.

RESULTS:

Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria.

CONCLUSIONS:

The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.
The Ways of Corruption in Infrastructure: Lessons from the Odebrecht Case
Authors: Campos Nicolás , Engel Eduardo , Fischer Ronald D. , Galetovic Alexander
Published: May 2021

In 2016, the Brazilian construction firm Odebrecht was fined $2.6 billion by the US Department of Justice. It was the largest corruption case ever prosecuted under the US Foreign Corrupt Practices Act. Our examination of judicial documents and media reports on this case provides new insights on the workings of corruption in the infrastructure sector. Odebrecht paid bribes for two reasons: to tailor the terms of the auction in its favor, as well as to obtain favorable terms in contract renegotiations. In projects where Odebrecht paid bribes, costs increased by 70.8 percent on average, compared with 5.6 percent for projects with no bribes. We also find that bribes and profits made from bribing were smaller than documented in most previous studies, in the range of one to two percent of the cost of a project.
The United States of Europe: A Gravity Model Evaluation of the Four Freedoms
Authors: Head Keith , Mayer Thierry
Published: May 2021

One of the pillars of the 1957 Treaty of Rome that ultimately led to the European Union is the commitment to the four freedoms of movement (goods, services, persons, and capital). Over the following decades, as the members expanded in numbers, they also sought to deepen the integration amongst themselves in all four dimensions. This paper estimates the success of these policies based primarily on a gravity framework. Distinct from past evaluations, we augment the traditional equation for international flows with the corresponding intra-national flows, permitting us to distinguish welfare-improving reductions in frictions from Fortress-Europe effects. We complement the gravity approach by measuring the extent of price convergence. We compare both quantity and price assessments of free movement with corresponding estimates for the 50 American states.
Migration and Labor Market Integration in Europe
Authors: Dorn David , Zweimüller Josef
Published: May 2021

The European labor market allows for the border-free mobility of workers across 31 countries that cover most of the continent’s population. However, rates of migration across European countries remain considerably lower than interstate migration in the United States, and spatial variation in terms of unemployment or income levels is larger. We document patterns of migration in Europe, which include a sizable migration from east to west in the last twenty years. An analysis of worker-level microdata provides some evidence for an international convergence in wage rates and for modest static gains from migration. We conclude by discussing obstacles to migration that reduce the potential for further labor market integration in Europe.
Country risk for emerging economies: a dynamical index proposal with a case study.
Authors: Mordecki Ernesto , Rodríguez Andrés Sosa
Published: May 2021

We introduce a dynamical country risk index for emerging economies. The proposal is based on the intensity approach of credit risk, i.e. the default is the first jump of a point process with stochastic intensity. Two different models are used to estimate the yield spread. They differ in the relationship between the default-free instantaneous interest rate process and the intensity process. The dynamics of the interest rates is modeled through a multidimensional affine model, and the Kalman filter with an Expectation-Maximization algorithm is used to calibrate it. The USD interest rates constitute part of the input of the model, while prices of relevant domestic bonds in the emerging market complete the input. For an application, we select the Uruguayan bond market as the emerging economy.
Transferências intergovernamentais de desempenho ou resultado: o federalismo fiscal da Nova Administração Pública
Authors: Gama Mascarenhas Caio , Ribas Lídia Maria
Published: May 2021

O trabalho visa analisar as transferências intergovernamentais de desempenho ou resultado (TIDR). O marco teórico utilizado é Anwar Shah. Defende-se que essas transferências fazem parte da moderna economia institucional — em que governos se relacionam conforme princípios da Nova Administração Pública. As TIDR vinculam o financiamento ao desempenho do governo local na prestação de serviços. Essas transferências colocam condições nos resultados a serem alcançados, ao mesmo tempo que oferecem total flexibilidade no desenho de programas e níveis de gastos associados para alcançar esses objetivos. Por meio do método indutivo, procura-se encontrar modelos de tais transferências no ordenamento jurídico brasileiro. Após, abordam-se questões como cooperação e autonomia federativa.
Addressing the gender gap in urinary continence care
Authors: Yates Ann
Published: May 2021

Urinary incontinence is a common condition that affects both men and women, and with profoundly negative effects. Prevalence figures do show that it is more common in younger women than men, but as people age the difference decreases, with research identifying that one in three older men have continence issues. However, even with this increase, there is little direct best practice guidance on addressing male urinary incontinence compared to that for women. Professionals seem to be unaware that men have known existing barriers to accessing health care and this would be especially true of such an embarrassing condition. There seems to be a lack of education in identifying symptoms and assessing and little thought to appropriate management if required. This can also be true of manufacturers that provide continence management equipment. This article will look at some of these themes and highlight the gender gaps and give guidance on how professionals may address these.
Towards a greater understanding of the psychosocial impact of the symptoms of pituitary conditions
Authors: Norman Alison , Jackson Sue , Ferrario Hannah , Percuklievska Nena , McBride Pat
Published: May 2021

Management of pituitary conditions can be problematic with many patients experiencing long-term psychological and social difficulties that impact on their quality of life. This study aimed to identify psychosocial symptoms associated with pituitary conditions that lead to poor quality of life and identify differences in symptomatology between patient groups. A survey using measures of psychological and social symptoms was sent to 2000 members of the Pituitary Foundation in January 2016. The survey was completed by 1062 patients (683 female), aged under 18 to over 65 years, using categorical age ranges. Physical and psychosocial symptoms including appearance issues, fatigue, anxiety and depression were reported. Using correlational and regression analyses, significant variation in symptoms were identified across gender, age range and condition type that were impairing patients' long-term functioning and impacting quality of life. There is a need for greater patient information and advice surrounding psychosocial symptoms of pituitary conditions.
Part 2: exploring views from fathers and perinatal practitioners on the inclusion of fathers by perinatal services
Authors: Fenton SK , Joscelyne T , Higgins S
Published: May 2021

Background

This is the second of a two-part series exploring father's inclusion in the perinatal years. The first paper was published in volume 29, issue 4 of the British Journal of Midwifery. This paper explores the results of the study and discussion in relation to previous literature and to professional practice. Positive father involvement during the perinatal period has important implications for families. However, previous research suggests that fathers experience marginalisation, while staff report a lack of training and time for engaging fathers.

Aims

This study explored fathers' and perinatal professionals' experiences of fathers' involvement during the perinatal period, and ideas for paternal support.

Method

A Delphi method was employed. Thematic analysis from focus groups informed an online survey which was completed by 24 fathers and 22 professionals. A third-round survey finalised group consensus.

Results

Both groups agreed on the importance of fathers. Participants suggested improvement ideas, such as supporting fathers with psychological change. Groups disagreed on some ideas, such as fathers receiving a session alone to discuss concerns.

Discussion

The findings support the inclusion of fathers in perinatal services and a focus on the whole family system. Limitations of this study include low participant diversity and possible selection bias. Implications for further research are discussed.
Obesity matters: the skills that strengthen midwifery practice when caring for obese pregnant women
Authors: Greig Yvonne , Williams Anne F , Coulter-Smith Margaret
Published: May 2021

Obese pregnant women (BMI>30 kg/m²) are at an increased risk of developing complications during pregnancy, labour and birth. Furthermore, their offspring are at risk of short- and long-term health complications. Midwives are ideally situated to inform women about risks and to support them in optimising their health. How midwives raise and maintain dialogue with women about this health issue is not well understood. A qualitative research study was conducted drawing on the principles of social constructionism to explore how midwives practiced and maintained dialogue with women about the risks of living with obesity. Data were analysed thematically, three themes emerged: ‘situational context of practice’, ‘constructing partnerships with women’, ‘midwife as a public health agent’. Midwives appeared to have learnt their communication skills informally ‘on the job’ but utilised institutional questionnaires as a mechanism for opening ‘sensitive’ conversations. This approach appeared to guide appointment dialogue and risked providing woman-centred care to individuals while concurrently inhibiting development of professional autonomy. Providing educational opportunities for midwives with respect to consultation education in midwifery curricula may strengthen midwifery practice with respect to discussing sensitive topics.