bluuebunny/crossref_metadata_2025 huggingface dataset:
Association Between Metformin and Prevention of Dementia in T2DM Adult Patients
Authors: dos Santos Natalia Moles , Zocaratto Mariana Araujo , Denipote Valeria Coelho , Mendes Julia Dutra , Spagnuolo Fernando Jose
Published: May 2021

Introduction: In 2020 the World Health Organization estimated that the number of people with dementia was 50 million in the world. Furthermore, it is expected about 10 million new cases every year. Alzheimer’s disease (AD) is the most common form of dementia, which represents more than 50% of the cases. Type 2 diabetes mellitus (T2DM) is a major risk factor for AD and dementia. Even in people without clinical dementia, diabetes is associated with decreased cognitive performance and with increased brain atrophy. If comparing general population and people with diabetes, patients with T2DM had a 73% higher risk of developing dementia and a 56% increased risk of developing AD. Typically, the first medication prescribed for T2DM is metformin and it has been associated with the reduction of cognitive decline and the risk of dementia in patients with T2DM when compared with diabetic patients without medication. A randomized, double-blinded, placebo-controlled study demonstrated that during metformin treatment there was an improvement of executive functioning, learning, memory, and attentional abilities. A possible explanations for the protective effect of metformin in patients with T2DM is that it prevents hyperinsulinemia and the formation of amyloid-β plaques in the brain and the onset of AD. Metformin does not only decrease the plasma glucose level in several mechanisms, but it also characterized to beneficially effect serum lipid profiles, reduce inflammatory cell adhesion to endothelium, and exert anti-inflammatory, anti-apoptotic and anti-oxidative properties. Method: A Clinical Scientific Research was made about correlation among dementia and metformin. Were searched and found in PubMed a total of 61 articles between 2015–2020, but only free access and those who correlated metformin and dementia were used. Results: Studies showed that T2DM patients taking metformin had decreased risk of developing dementia or AD if compared to others diabetic patients that were not taking metformin. However, it is being hard to test antidiabetic therapies in AD, because the mechanisms which tie T2DM to Alzheimer clinical syndrome are not totally known. Therefore, to be as effective as possible it is necessary to treat the patients before they develop extensive amyloid and tau tangle burden. Conclusion: Diabetic patients taking metformin have a protector factor to don’t develop dementia or AD, when compared to those who don’t take metformin since they started the treatment before accumulation of amyloid and tau protein in the brain.
Clinical Effectiveness and Safety of Gliclazide MR and Linagliptin Combination in the Management of Patients With T2DM and Chronic Kidney Disease (CKD) Switched From Glimepiride - a Real-World, Retrospective, Observational Study
Authors: Bhattacharyya Supratik , Khalse Maneesha
Published: May 2021

Background: Type 2 diabetes (T2DM) patients are at high risk of developing to CKD and progressing to adverse outcomes vs Nondiabetics. The aim was to evaluate the effectiveness and safety of gliclazide MR switched from glimepiride in combination with linagliptin considering their associated potential benefits in albuminuria reduction and delaying progression of adverse renal outcomes in T2DM patients with kidney disease as shown in previous data. Methodology: The medical study database of the author’s hospital identified T2DM patients with stage 1–3 CKD with mean eGFR of 50.4 ± 8.56 ml/min/1.73 m2 and were inadequately controlled with glimepiride (mean dose 3.24mg) for the last 3 months. These patients were switched to gliclazide MR with appropriate equivalent dose while DPP-4 inhibitors like linagliptin (5 mg OD) (79%), sitagliptin (14%), vildagliptin (7%), were continued as background therapy. About 59.35% of subjects were on glimepiride 2 mg, 21.93% subjects on glimepiride 3 mg and 18.7% on glimepiride 4 mg. The gliclazide dose was up titrated by 30 mg every 15 days to achieve a target post-prandial glucose (PPG) ≤180 mg/dL. The average dose of gliclazide MR during the study was 44 mg; approximately two-thirds of patients 61% were on 60 mg, 22% on 90mg, and 7% on 30 mg. Patients were counselled to recognize the symptoms and record the hypoglycemic episodes. The statistical analysis included the analysis of changes in glycemic control, risk of hypoglycemia & renal function parameters. The patients were followed up for 24 weeks duration. Results: A total 218 eligible patients (110 female & 108 male) with CKD (stages 1–3) were included. The mean age, body weight, baseline HbA1c, FPG, PPG levels, mean eGFR, and UACR (urine albumin creatinine ratio) were 62.94 ± 8.72 years, 67.9 ± 9.33 kg, 8.51 ±0.81%, 148.53 ± 16.72, 202 ± 18.45 mg/dL, 50.49 ± 8.56 ml/min/1.73 m2 and 154.34 mg/g respectively. Gliclazide MR was initiated substituting glimepiride with appropriate dosing determined by the physician. Two subjects discontinued the therapy due to intolerability. At 24 weeks follow up, HbA1c, FPG, PPG level was reduced by -0.63, -10.33, -30.04%, respectively (p< 0.001). There was a significant reduction in events of overall hypoglycemia (22.25%). Improvement in renal function with respect to eGFR level (+1.77 ml/min/1.73 m2) and albuminuria reduction (-45.56 mg/g) were also observed in patients. Conclusion: This study demonstrates the clinical effectiveness and safety of gliclazide MR with the combination of DPP-4is like linagliptin as an alternate option to glimepiride in diabetes patients with chronic kidney disease.
Detecting Frailty in Elderly Type 2 Diabetes Mellitus (T2DM) Patients in the Southeast of Brazil
Authors: Ramos-Dias João Carlos , Peña Stela Souza , Peng Michelle Li Pin , Oliveira Matheus Rauen , Chamma Rayssa Fabiana , Wanderley Patricia Varotto , Gugoni Lilian Halcsik Sollitari , Barcellos Cristiano Roberto
Published: May 2021

Introduction: Brazil is the fifth country with the highest number of diabetes cases in the world, which has been increasing significantly over the last 35 years. In Brazil, the prevalence of diabetes in 2019 was 16.8 million people, 21.8% of whom are elderly. Diabetes potentialize geriatric syndromes, such as frailty, a state of increased vulnerability to stressors and cumulative decline in multiple physiological systems over lifespan. Objective: To identify frailty in elderly patients with T2DM treated in a tertiary care outpatient clinic in the southeast of Brazil and to estimate their cognition. Methods: This is a cross-sectional analytical study. The patients were classified according to the five Fried frailty phenotype criteria: (1) unintentional weight loss ≥ 4.5 kg or 5% of body weight in the previous year; (2) exhaustion assessed by self-reported fatigue, indicated by two questions on the Center for Epidemiological Studies Depression Scale; (3) weakness measured with a dynamometer in the dominant hand and adjusted according to gender and body mass index (BMI); (4) low level of physical activity measured by weekly energy expenditure in kcal (based on self-reported activities and physical exercises); (5) slowness, according to the time spent walking 4.6 meters adjusted by gender and height. In addition, we also evaluated fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), BMI, calf and waist circumference. To estimate the cognition, we used the 10-point cognitive screener (10-CS) to indicate temporal orientation, category fluency and words recall. Results: 50 elderly patients (39 women and 11 men) with mean age of 69.8 years were evaluated. The mean FPG levels was 168 ± 72 mg/dl and HbA1c > 7% was present in 82% of them. BMI ≥ 25 kg/m2 was observed in 40 patients (80%). All male patients have a normal calf circumference (> 34 cm) and 30/39 female patients (76.9%) have a normal calf circumference (> 33 cm). Waist circumferences ≥ 80 cm in women and ≥ 94 cm in men were present in 100% of women and 90.9% of men. Frailty was observed in 34% (n=17) and cognitive impairment in 40% (n=20) of the patients, according to the five Fried frailty phenotype criteria and CS-10, respectively. Conclusion: Early detection of frailty is very important for considering interventions aimed at elderly people. These interventions could reduce the functional decline and the risk of disability in these individuals over time and, besides that, are able to promote a better quality of life.
Diabetes Does Not Worsen Outcomes of Patients Admitted for Hyperthyroidism: Analysis of the National Inpatient Sample
Authors: Shaka Hafeez , Akuna Emmanuel , Williams Dimeji Olukunmi , Asemota Iriagbonse , Edigin Ehizogie , Asotibe Jennifer Chiagoziem , Velazquez Genaro
Published: May 2021

Introduction: Both diabetes mellitus (DM) and hyperthyroidism are common diseases. However, it is unclear if co-existing DM worsens outcomes in patients with hyperthyroidism. This study aims to compare the outcomes of patients primarily admitted for hyperthyroidism with and without a secondary diagnosis of DM.

Methods: Data were extracted from the National Inpatient Sample (NIS) 2016 and 2017 Database. NIS is the largest inpatient hospitalization database in the United States. The NIS was searched for hospitalizations for adult patients with hyperthyroidism as principal diagnosis with and without DM as secondary diagnosis using ICD 10 codes. The primary outcome was inpatient mortality. Hospital length of stay (LOS), total hospital charges and NSTEMI were secondary outcomes of interest. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders.

Results: There were over 71 million hospitalizations in the combined NIS 2016 and 2017 database. Out of 17,705 hospitalizations for hyperthyroidism, 2,160 (15.9%) had DM. Hospitalizations for hyperthyroidism with DM had similar inpatient mortality [0.35% vs 0.50%, AOR 0.25, 95% CI (0.05–1.30), P= 0.101], total hospital charge [$47,001 vs $36,978 P=0.220], LOS [4.50 vs 3.48 days, P=0.050] and NSTEMI compared to those without DM.

Conclusion: Hospitalizations for hyperthyroidism with DM had similar inpatient mortality, total hospital charges, LOS and odds of undergoing ablation compared to those without obesity.
Effect of Glycemic Control on Outcome of Acute Exacerbation of Chronic Obstructive Pulmonary Disease(AECOPD)
Authors: Guha Abhraneel Parames
Published: May 2021

Introduction: Chronic obstructive pulmonary disease (COPD) is defined as a common preventable and treatable disease that is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. In this article we compared hospital stay between diabetic, non diabetic and prediabetic patients of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who were treated with corticosteroids. We checked in hospital mortality and 30 day mortality in patients with AECOPD patients with diabetes, Its the first article on this topic from eastern India. Materials and Methods: The study was done in tertiary care centre from November 2017 to April 2019. We included 161 patients with age more than 40 years or more. Patients admitted in hospital with COPD with cough, sputum, dyspnea were included. They were divided into diabetic,prediabetic and non diabetic. We included readmission of patients who were diagnosed previously as AECOPD. Statistical Analysis was performed with help of Epi Info (TM) 7.2.2.2 EPI INFO is a trademark of the Centers for Disease Control and Prevention (CDC). It was a prospective observational study. Results: We found significant association between length of hospital stay and those with AECOPD with diabetes.29.6% of patients with diabetes had a stay of more than two weeks. Hospital stay was found to be 10.8+/-2.30 days in those who had mean random blood sugar (RBS) between 140 -170 mg/dl, 12.98 +/- 2.24 days in those who had RBS between 170–200 mg/dl and 12.62 +/- 3.10 days in those who had RBS more than 200 mg/dl. 89.4% of patient had a BMI (Body mass index) of < 25 kg/square meter. 8.1 % died in hospital and 9.5% died within 30 days of discharge. Among those who were treated with steroids, diabetic patients had a stay of 14.55+/- 0.74 days, compared to prediabetic who had a stay of 14.07+/-1.26 days and non diabetics who had 12.5+/-1.33 days. No association was found between hospital mortality and status of diabetes mellitus. No association was found between 30 day mortality and diabetes mellitus in our study. Conclusion: Diabetes Mellitus and AECOPD are major public health challenges. Whether there is an association between them needs to be addressed, specially in this part of the world. Those patients who were diabetic and treated with steroids had a longer stay than non diabetics and prediabetics. We found no association between hospital mortality and 30 day mortality with diabetes mellitus.
Efficacy and Safety of SGLT2 Inhibitors in Diabetic Kidney Transplant Patients: Review of the Current Literature
Authors: Shuster Shirley , Al-Hadhrami Zeyana , Awad Sara , Moore Sarah , Shamseddin Khaled
Published: May 2021

Introduction: SGLT2 inhibitors are oral hypoglycemic medications used in type 2 diabetes mellitus (T2DM). They act by blocking glucose and sodium reabsorption in the proximal renal tubules. In patients with T2DM and cardiovascular disease, SGLT2 inhibitors have been shown to improve glycemic control, promote weight loss, and reduce major adverse cardiovascular events (MACE). They have also been shown to have favorable renal outcomes in patients with chronic kidney disease (CKD) reducing albuminuria and progression to end-stage renal disease; however, all studies have excluded kidney transplant patients. The objective of this review was to determine the efficacy and safety of SGLT2 inhibitors in the kidney transplant population.

Methods: We conducted a literature review to identify studies which assessed the use of SGLT2 inhibitors in kidney transplant patients with either T2DM or new onset diabetes after transplant (NODAT). The outcomes assessed included blood pressure, glycemic control, body weight, kidney function, proteinuria and complications.

Results: Nine studies, which included 144 patients, were extracted for review. These included x4 case series, x3 cohort studies, x1 randomized control trial (RCT), and x1 case report. The largest study was a prospective RCT from Norway, which assessed empagliflozin versus placebo in 44 patients. Majority of patients had NODAT (n=92) or T2DM (n=50). All patients had estimated glomerular filtration rate (eGFR) >30mL/min/1.73m2 and HbA1C >6.5%. The most commonly used SGLT2 inhibitors were empagliflozin (n=82), canagliflozin (n=34), and dapagliflozin (n=28). SGLT2 inhibitor use in kidney transplant patients was found to demonstrate a small or non-significant reduction in blood pressure, modest improvement in glycemic control and decrease in insulin resistance, and moderate-to-significant weight reduction. It also resulted in stable graft function and one study demonstrated a reduction in proteinuria. The most common adverse effect was urinary tract infection (n=13). There were no cases of diabetic ketoacidosis or development of new ischemic lower limb ulcerations or amputations.

Conclusion: Our literature review suggests beneficial outcomes of SGLT2 inhibitor use in diabetic kidney transplant patients, with no significant adverse effects or complications. Given the limited evidence in this population, we are launching a prospective study in kidney transplant patients with either T2DM or NODAT, and with eGFR ≥30mL/min/1.73m2, to assess the efficacy and safety of SGLT2 inhibitor use in this population. To our knowledge, this will be the first prospective study in Canada assessing SGLT2 inhibitor use in diabetic kidney transplant patients.
Enhanced Insulin Signaling Through Its Receptor Is Needed for the Development of Hyperuricemia in Humans
Authors: Haykal Rasha , Kinzer Alexandra , Abel Brent , Startzell Megan S , Cochran Elaine , Brown Rebecca J
Published: May 2021

Background: There is an association between insulin resistance (IR) and hyperuricemia but the direction of causalityand mechanisms are unclear. In obesity and lipodystrophy, IR is “selective”, with lack of insulin signalingcausing hyperglycemia, but enhanced insulin signaling causing dyslipidemia and possibly hyperuricemia. Rare human conditions exist in which there is extreme, non-selective, IR impairing all insulin signalingpathways (e.g. mutations of the insulin receptor, INSR). We hypothesized that hyperinsulinemia withenhanced signaling through the insulin receptor causes hyperuricemia in selective IR, whereas lack ofinsulin signaling through its receptor despite hyperinsulinemia results in normal uricemia in non-selective IR. Method: Cross-sectional retrospective analysis comparing fasting insulin and serum uric acid in patients withsevere IR that was either selective (due to lipodystrophy) or non-selective (due to INSR mutation orautoantibody to the insulin receptor). Visits were chosen based on availability of serum uric acid andinsulin. If multiple visits were available, the visit with the highest insulin value was chosen. Results: We analyzed data of 68 patients with selective IR and 14 patients with non-selective IR. Fasting seruminsulin median [interquartile range] was 23.4 [14, 53] mcU/mL in selective IR vs 215 [73.7, 604] in non-selective IR, p <0.0001. Serum uric acid was 4.8 [2, 6] mg/dL in selective IR vs 3.5 [2, 4] in non-selectiveIR, p=0.0003. Conclusion: Patients with selective IR due to lipodystrophy had elevated serum uric acid, consistent with thehyperuricemia seen in selective IR caused by obesity. By contrast, patients with non-selective IR hadlower serum uric acid despite more severe IR as evidenced by almost 10-fold higher fasting insulin. These observations are consistent with a model in which enhanced insulin signaling through its receptorleads to hyperuricemia in post-receptor IR. Further studies are needed to understand the mechanism bywhich insulin leads to hyperuricemia.
Serum Albumin Modifies the Effect of Peripheral Blood Monocytes on Severity of Diabetic Nephropathy
Authors: Cristancho Cagney
Published: May 2021

Aims: To characterize clinical associations with peripheral blood immune populations, serum inflammatory markers, and diabetic nephropathy in persons with type 2 diabetes mellitus. Methods: We identified a cohort of clinically well-defined patients from a primary care clinic at a medium-sized academic medical center. We queried hospital records between 2018 and 2019 for complete blood counts with differentials, serum inflammatory markers, and urine microalbumin/creatine ratios. 198 patients met these criteria. We assessed univariable and multivariable associations between demographic, clinical, and peripheral blood predictors of kidney end-organ damage as determined by microalbumin/creatinine ratios or estimated glomerular filtration rate. All analyses used linear or logistic regression models. Results: Adjusted analyses demonstrated significant (p<0.01) associations between higher urine albumin-creatinine ratio and peripheral circulating monocytes independent of other established significant risk factors including blood pressure, hemoglobin A1c, age, and gender. We also identify serum albumin as an unexpected but potentially important modifying factor of kidney disease which interacts with monocytes. Conclusion: Circulating monocytes and serum albumin are significantly associated with diabetic nephropathy. These results support the potential role of the innate immune system in diabetic microvascular end-organ damage, and may be readily translatable clinical markers to incorporate into risk-assessment models for prognostication in diabetes.
Trends in Cardiovascular Risk in the United States 1999 - 2018
Authors: Li Hang Long , Cheung Bernard M Y
Published: May 2021

Introduction: As guidelines evolve, lifestyle changes and new drugs are introduced, the long-term trends in cardiovascular risk in the general population are of interest. We evaluated the AHA-ACC-ASCVD risk score (ASCVD-RS) in the US population in the last 20 years.

Methods: Participants in the National Health and Nutrition Examination Survey (NHANES) 1999–2018 aged 40–79 years were included. Pregnant participants and those with missing relevant laboratory/self-reported data were excluded. Temporal trends in ASCVD-RS and its components, and the proportions of participants at high risk (score ≥10%) were characterized using linear regression, adjusted for age, sex, and ethnicity. Data analysis was performed using the R statistical package “survey” (version 3.6.3).

Results: Altogether 12744 NHANES participants (mean age 56.4 years; 55.9% male) were analyzed. From 1999–2018, the proportion of people with diabetes and taking antihypertensives increased significantly (both p<0.001), while total cholesterol level decreased significantly (p<0.001). Levels of high-density lipoprotein-cholesterol (HDL), and the proportion of smokers and individuals with systolic blood pressure ≥120mmHg remained static. The mean ± standard error of ASCVD-RS significantly increased from 11.4±0.7% in 1999–2000 to 12.5±0.5% in 2017–2018 (p=0.014), and the proportion of high-risk participants increased from 39.1% to 44.1% (p=0.020).

Conclusions: Cardiovascular risk in the US population increased slightly in the past 20 years. Despite the increased treatment rate of hypertension and the decrease in total cholesterol, the prevalence of diabetes doubled. More effort should be directed at preventing diabetes through weight control and regular physical activity.
Diabetes Medication Reconciliation at Hospital Discharge
Authors: Shah Nandi , Kulasa Kristen
Published: May 2021

Background: During hospital discharge, patients are at high risk for medication discrepancies as they transition from hospital to home. This study aims to evaluate the prevalence of medication errors at hospital discharge for diabetes medications in patients who received an endocrinology consultation for diabetes and explore interventions to improve the accuracy of discharge medication reconciliation.

Methods: All patients (n=3018) who received an endocrinology consultation for diabetes at a tertiary care medical center from October 2017 to December 2019 were included. A retrospective chart review was performed to collect the following information on each patient: primary service from which the patient was discharged, hospital site, month and year of discharge date, and whether each patient’s medication reconciliation for diabetes medications at hospital discharge was in agreement with the inpatient diabetes team’s recommendations. Patients who were discharged on medications discordant from those recommended by the inpatient diabetes service were subcategorized into three groups: 1) one medication incorrect 2) more than one medication incorrect and 3) the primary service did not notify the consult team of patient’s discharge or request final recommendations for diabetes medications prior to discharge. Based on the findings of this study, an educational intervention was implemented in November 2019 to the Hospital Medicine services regarding diabetes discharge medication reconciliation.

Results: Of the 3018 patients who received an endocrinology consultation for diabetes at a tertiary university medical center, 2279 patients (76%) were discharged on correct medications, 165 patients (5%) were discharged with one incorrect medication, 443 patients (15%) were discharged with more than one incorrect medication, and 121 patients (4%) were discharged without final discharge recommendations from the diabetes service. There was no significant variation based on discharging service or month of the year. After an educational intervention was implemented in November 2019 to the Hospital Medicine service on the existence and use of a comprehensive diabetes discharge order set, the percentage of patients discharged on correct medications improved to 92% (11/12 patients) compared to prior 81% (44/54 patients).

Conclusion: Despite detailed discharge medication recommendations including patient education detailing the recommended regimen by the endocrinology diabetes service, a significant number of patients were discharged by providers across all services on diabetes medications discrepant with the diabetes service’s recommendations. Educational efforts improved the rate of correct medications at discharge on the Hospital Medicine service, and additional educational interventions with other services may be helpful in improving medication reconciliation accuracy.
In-Hospital Outcomes in Patients With Hyperosmolar Hyperglycemic State With and Without Hypertriglyceridemia: Analysis of National Inpatient Sample
Authors: Velazquez Genaro , Shaka Hafeez , Murthi Mukunthan , Asemota Iriagbonse , Velagapudi Sujitha , Marcos-Abdala Hernan Gerardo , Akuna Emmanuel , Edigin Ehizogie
Published: May 2021

Background: In patients hospitalized with Hyperosmolar hyperglycemic state (HHS) the presence of comorbid conditions including hypertension, heart disease, stroke, and dementia have been variably reported to be associated with higher mortality. HTG is increasingly prevalent in patients with DM, especially those with poor glycemic control who are more likely to suffer from HHS. Elevated triglyceride levels have independently been associated with higher mortality in certain conditions like coronary artery disease and acute pancreatitis. However, data on the effect of Hypertriglyceridemia (HTG) on mortality and morbidity in hospitalized patients with HHS is sparse.

Objective: We wanted to compare the outcomes for HHS hospitalizations for patients with and without HTG.

Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 and 2017. About 42 740 hospitalizations who had HHS as primary diagnosis were enrolled and further stratified based on the presence or absence of HTG as secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality and secondary outcomes included length of hospital stay, total Hospital charges, Sepsis, Septic Shock, Acute Kidney Injury (AKI), and Acute Respiratory Failure (ARF). Multivariate regression analysis was done to adjust for confounders.

Results: Out of the 42 740 hospitalizations with HHS, about 17 040 had HTG. The in-hospital mortality for patients with HHS was 305 overall, out of which 70 patients had HTG as secondary diagnosis. Compared with patients without HTG, patients with HTG had lower odds of in- hospital mortality (0.30, 95% CI 0.157–0.56, p<0.005) when adjusted for patient and hospital characteristics. Patients with HHS and HTG had decreased length of hospital stay, less total Hospital charges, lower odds of Sepsis and Septic Shock, but similar odds of AKI and ARF in comparison to patients without HTG.

Conclusion: Our study shows that HTG is associated with lower odds of in-hospital mortality in patients with HHS, even though the odds of AKI and ARF was same in both groups. A similar inverse relationship has already been reported between TG levels and mortality in stroke patients. Though the mechanism of this effect is unclear, one possible explanation could be that patients with HTG are more likely to be treated with statins and fibrates which have known anti-inflammatory effects. Further studies are required to evaluate this possible positive prognostic effect of TG.
Inpatient Glycaemic Control is Poor in Patients Receiving Insulin Therapy
Authors: Reidy Niall , O’Donovan Marion C , Hannon Mark J
Published: May 2021

Patients with diabetes mellitus (DM) are admitted to hospital more frequently than the general population and have longer inpatient stays. Tight inpatient glycaemic control improves outcome but is difficult to achieve, especially in those on insulin. We prospectively reviewed the capillary blood glucose (CBG) control of hospital inpatients receiving insulin to determine their level of control and to examine healthcare providers’ responses to dysglycaemia. Between March and June 2020, all patients on insulin admitted to Bantry General Hospital for more than 24 hrs were reviewed. CBG recordings were individually categorised as either hypoglycaemic (CBG < 4mmol/L), euglycaemic (CBG = 4–9.9mmol/L), mildly hyperglycaemic (CBG = 10-14mmol/L) or severely hyperglycaemic (CBG >14mmol/L). Each patient’s individual insulin dose was reviewed and compared with their concurrent CBG level and categorised as either appropriate or inappropriate. Other factors that were reviewed included whether a HbA1C was performed, whether a referral to the diabetic clinical nurse specialist was made and whether the patient was on glucocorticoid therapy.16 patients were enrolled, average age 77. 497 CBG checks were recorded over 108 patient days. Average length of stay was 6.6 days. All patients had type 2 DM. 10 patients were on basal insulin therapy, 4 were on basal-bolus insulin, 2 were on mixed insulin. CBG was checked sub-optimally (i.e. fewer than 4 times per day) on 35/108 patient days. 355/497 CBG checks were in the euglycaemic range; but only 3 patients were entirely euglycaemic throughout admission.17 hypoglycaemic events occurred in 5 patients. These events were spread unevenly with 1 patient having 10 hypoglycaemic events while the other 7 events were spread between the remaining 4 patients.125 severely hyperglycaemic events occurred in 13 patients. Again, these events were spread unevenly with over half (67/125) events occurring in only 3 patients. Of these 13 patients, 5 were on glucocorticoid therapy. All 5 patients that had hypoglycaemic events also had severely hyperglycaemic events. Of the hypoglycaemic events recorded, only 12/17 were treated appropriately (i.e. with 15-20g of fast-acting carbohydrate and a reduction in subsequent insulin dose). Of the hyperglycaemic events recorded, 77/125 were managed appropriately (i.e. with either a stat dose of bolus insulin being administered or an increase in subsequent insulin doses being made or both). 6 prescribing errors were recorded in total. HbA1c was checked in 5 patients. An inpatient referral was made by the medical team to the diabetes clinical nurse specialist for only 4 patients. Inpatient glycaemic control was suboptimal in the majority of patients. Dysglycaemia, especially hyperglycaemia, remains problematic. Insulin doses were not adjusted often enough or dramatically enough. Further doctor and nurse education is required in this area.
The Weight of Words: A Mixed Methods Study to Understand Indian Doctors’ Perspectives and Experiences of Patient Communication
Authors: Selvan Chitra , Lathia Tejal , Chawak Shweta , Akula Niveditha , Chittam Mahati
Published: May 2021

Background: Effective doctor communication can lead to increased treatment adherence and improved self-management among individuals living with diabetes. Yet, there is limited research in India which examines how doctors communicate, especially in terms of verbal and nonverbal communication. Aims: (1) To examine communication in clinic (verbal, nonverbal and basic content) among Indian doctors specialized in diabetes and endocrine care, and (2) to explore doctors’ styles of verbal and nonverbal communication. Methods: Using a mixed methods design, a survey containing quantitative (n=834) and qualitative (n=648) elements was filled out by doctors specialized in the fields of diabetes and endocrinology in India. Questions in the quantitative section included questions such as addressing patients’ illness-related concerns, acknowledging challenges of using insulin, and non-verbal behaviours. The qualitative section focussed on elaborating some responses made to the quantitative section, such as questions about explaining the cause of illness, listing words and phrases that may potentially impact patients, and explaining why the patients need to be initiated on insulin. The data was analysed using descriptive statistics and qualitative content analysis, respectively. Results: The findings of the quantitative study showed that the majority of the doctors (i) always greeted their patient as they entered the room (43.2%), (ii) addressed the risk of developing diabetes with patients’ siblings/children (87.9%), (iii) always acknowledged the challenges of using insulin (42.8%), and (iv) never asked patients’ experiences at the end of the consultation (31.9%). All common communication cues were rated as extremely important; eye contact (48.7%), tone of voice (41.5%), body language (39.6%), and words and phrases (41.8%). The qualitative findings revealed that doctors preferred to use verbal communication such as using authoritative language, educating patients using facts, analogies and behavioural information, employing empathetic language on occasion. Doctors also reported using negative words that portrayed fear, blame and disengagement in order to promote adherence. Discussion and Conclusion: The findings suggest that doctors rely on verbal rather than nonverbal communication when interacting with patients, with fear messages being a favoured means of ensuring adherence. It is possible that this may be because, while recognizing the value of nonverbal methods, doctors lack training in using these techniques in communication. Therefore, developing a communication skill training program for Indian doctors focussed on empathic and nonverbal communication can help to improve consultation and patient outcomes (e.g., adherence, patient satisfaction).
Deceptive Late Maternal Euglycaemia
Authors: Irene Arockia Silviya , Lata Anthikat Sankaranarayanan
Published: May 2021

Background: Strict glycemic control is the most critical factor determining outcome in Gestational Diabetes mellitus. But having capillary blood glucose readings within the target levels, in the late trimester may be deceptive. If fetal hyperinsulinaemia and fetopathy have already set in, maternal glucose may be spuriously normal. We support this hypothesis based on our experience with 4 GDM patients who apparently reported normal blood glucose in late trimester, yet ended up with neonatal complications. Materials and Methods: Records of mothers of four neonates (Infant of diabetic mother) admitted in neonatal ICU with GDM associated complications were retrospectively analyzed. Diagnosis of GDM was made as per the ADA guidelines. The blood glucose values of the 9-point readings (Fasting, pre-lunch, pre-dinner, 1hr and 2hr post breakfast, lunch and dinner) every 3 to 5 days, which the patients shared online were plotted and studied. Mode of delivery and neonatal outcome were noted. Results: All patients (mean age 28.5years, range 24–31) presented to us only in third trimester though two of them had deranged OGTT during first trimester screening elsewhere. The average HbA1c at the time of presentation was 5.425 (Range 4.8 to6.3). Only one of them was on insulin for a short term, which she stopped on her own as the readings continued to be in range even after stopping insulin. Of the 529 last trimester readings shared by the patients, 91.3% were within the target range of FBS< 92mg/dl, 1and 2 post meals <140 and 120 respectively, and pre meals < 95mg/dl. Three of them were induced (Two at 40 weeks and one at 38.4 weeks) for labour. The obstetrical outcomes were as follows: one had LSCS due to non-descent of head, second had vacuum assisted delivery, third had shoulder dystocia and fourth had normal delivery. The neonatal outcomes in respective cases were large for date baby with hypocalcaemia, transient HOCM with hypocalcaemia, shoulder dystocia with perinatal depression, PDA with respiratory distress. Conclusion: GDM should be intervened before the establishment of diabetic fetopathy. Missing the initial spikes in maternal glucose and the consequent surreptitious transfer of glucose to fetus can initiate such fetopathy. There is rerouting or detour of the maternal glucose, to the fetal system, for its disposal. Hence low or normal blood glucose readings in a known GDM patient should alert the clinician about the possibility of fetal glucose steal.1 Highly suspicious cases can be monitored for polyhydramnios and fetal and maternal weight gain. The best ways to prevent this are pre-conceptional screening for IGT and universal screening for GDM with OGTT in each trimester.

Reference: 1.

Desoye, Gernot & Nolan, Christopher. (2016). The fetal glucose steal: an underappreciated phenomenon in diabetic pregnancy. Diabetologia. 59. 10.1007/s00125-016-3931-6.aq`
Maternal Chronotype and Pregnancy Outcomes in Gestational Diabetes
Authors: Sampaio Facanha Cristina F , De Bruin Veralice Sales , Alencar Victoria S , Machado Paula S , Rocha Thaine M , Lopes Fernando Henrique A , Macedo Rejane B , Viana Antonio B , De Bruin Pedro Felipe
Published: May 2021

Introduction: Gestational diabetes mellitus (GDM) is an increasingly frequent complication of pregnancy and its presence is related to the development of adverse maternal and fetal outcomes. Pregnancy is deeply influenced by the circadian rhythm and the misalignment of the maternal rhythm can lead to disturbances in the temporal organization of physiological and metabolic functions. Previously, the association between circadian rhythm disorders and diabetes has been well described in pregnancy. Objective: To investigate the influence of chronotype on the development of maternal and fetal complications during pregnancy in GDM. Methodology: Prospective cohort study of patients with GDM. Clinical data and behavior questionnaires were collected by face- to- face interview. Questionnaires evaluated the chronotype (Morning-Eveningness-Questionnaire- MEQ), sleep quality (Pittsburgh Sleep Quality Index- PSQI), daytime sleepiness (Epworth Sleepiness Scale -ESS), depressive symptoms (Edinburgh Postnatal Depression Scale-EDPS) and insomnia (Insomnia Severity Index- ISI). Sleep diaries (14 days) and actigraphic record (5 to 7 days) were obtained. Results: Overall, 305 2nd to 3rd trimester GDM patients were evaluated. Eighty-nine GDM patients completed the sleep diary and 53 performed a valid actigraphic registry. Amongst these, 49.5% were identified as morning chronotypes (MEQ≥59), 43.6% intermediate types (MEQ from 42 to 58) and 6.9% had evening type preference (MEQ<41). Evening preference patients were younger (p< 0.005), had more unstable marital status (P = 0.04), had worse sleep quality (p = 0.02); latter sleep midpoint (p= 0.01), higher prevalence of insomnia (p< 0.005) and depression (p= 0.004) before and during pregnancy. No differences were found in total sleep duration as recorded by sleep diary (p=0.4) or actigraphic measurements (p=0.83). Evening type preference in GDM was associated with pre-eclampsia (p= 0.02) and neonatal ICU admission (p= 0.03). Conclusion: This study suggests that the presence of the evening-type chronotype in pregnant women with GDM is associated with adverse pregnancy outcomes such as the development of hypertensive syndromes, insomnia and depressive symptoms. In addition, a higher prevalence of newborns admitted to the neonatal ICU was found in the offspring of GDM patients with evening preference.
Recurrent Abortion in Multigravid Type 1 Diabetes Mellitus Woman With Subclinical Hypothyroidism Hashimoto’s Thyroiditis and Antiphospholipid Syndrome as a Manifestation of Type III Autoimmune Polyglandular Syndrome: A Case Report
Authors: Kamila Tasya , Pranandi Muhammad , Putra Robby Pratomo , Nasarudin Jerry , Mokoagow Muhammad Ikhsan , Epriliawati Marina , Kshanti Ida Ayu
Published: May 2021

Recurrent Abortion in Multigravid Type 1 Diabetes Mellitus Woman With Subclinical Hypothyroidism Hashimoto’s Thyroiditis and Antiphospholipid Syndrome as a Manifestation of Type III Autoimmune Polyglandular Syndrome: A Case Report

Background: Type 1 Diabetes Mellitus, Antiphospholipid Syndrome, and autoimmune thyroid disease such as Hashimoto’s Thyroiditis had been reported for increasing risk of miscarriages. Meanwhile, the type III Autoimmune Polyglandular Syndrome comprises of autoimmune hypothyroidism and immune mediated diabetes mellitus. Here we report a manifestation of the syndrome presented as a recurrent pregnancy loss in newly diagnosed subclinical hypothyroidism phase of Hashimoto’s Thyroiditis and Antiphospholipid Syndrome, in multigravid woman with long standing Type 1 Diabetes Mellitus.

Clinical Case: A 31 years old woman, 20 weeks pregnant, with previously known Type 1 Diabetes Mellitus since the age of 11 years old, came to the Emergency Room with diabetic ketoacidosis. She complained of having nausea, vomiting, and diarrhea two days before hospital admission. She also had history of six spontaneous abortions which all occurred at below 20 weeks of gestation, but no further examination was done to find the cause. The patient was examined with fetal ultrasound and showed good fetal condition, fetal heart rate 143 bpm, estimated fetal weight 562 grams, polyhidramnion, and single umbilical artery. The patient denied any symptoms regarding hair loss, cold intolerence, slow movement, slow speech, or constipation. From physical examination, we found normal vital signs, no abnormalities in thyroid physical examination, but dry hyperpigmented skin in both legs. The patient was examined for thyroid function and found elevated TSH (5.625 IU/mL, n = 0,48 - 4,17 mIU/L) and normal free T4 (1,3 ng/dL, n = 0,89 - 1,76 ng/dL). The TPO antibody was 549,59 IU/mL (n<5.61 IU/mL) and lupus anticoagulant was weakly positive (1.2 - 2.5, n<1.2). The patient was finally diagnosed as Hashimoto’s Thyroiditis and Antiphospholipid Syndrome, which was unrecognized at previous medical care, and in addition to previously known Diabetes Mellitus Type 1 could be manifested as Type III Autoimmune Polyglandular Syndrome. The likely cause of recurrent pregnancy loss in this case could be the Hashimoto’s Thyroiditis and Antiphospholipid Syndrome.

Conclusion: Type III Autoimmune Polyglandular Syndrome could be manifested as recurrent pregnancy loss in patient with Type 1 Diabetes Mellitus, therefore the examination of thyroid function and other autoimmune disease such as Antiphospholipid Syndrome should be conducted.
The Performance of Glycated Hemoglobin Versus Oral Glucose Tolerance Test in the Diagnosis of Glycemic Disorders Among Women With Polycystic Ovary Syndrome in Southern Iraq
Authors: Altemimi Mahmood Thamer , Musa Alaa Khattar , Mansour Abbas Ali
Published: May 2021

Background: Obese women with PCOS are at high risk for developing diabetes mellitus (T2DM). A baseline oral glucose tolerance test (2hrs-OGTT) annually is an important to screen for dysglycemia in women with PCOS particularly those with at least one risk factor. Due to its advantages by fasting is not required and less day-to-day variability during periods of stress or illness, glycated hemoglobin (HbA1c) might consider a convenient screening tool. This study aimed to evaluate the performance of HbA1c versus 2hrs-OGTT in the diagnosis of glycemic disorders in women with PCOS and to evaluate the correlation between glycemic disorders, insulin resistance (IR), and anthropometric measures. Patients and methods: One hundred and thirty women of a mean age 26.3 ± 6.85 year were diagnosed with PCOS according to Rotterdam 2003 criteria in Basrah, Southern Iraq. All women were examined for weight, BMI and waist circumference then they were sent for fasting plasma glucose (FPG), 2hrs-OGTT, HbA1c, and fasting insulin to assess IR. Results: By 2hrs-OGTT, impaired glucose tolerance and T2DM were diagnosed in 16.1% and 2.4% of women with PCOS respectively and 6.7% of lean women were prediabetes. HbA1c was underestimate the diagnosis of T2DM (0.8%) and overestimate prediabetes (20%) (p=0.011) and at HbA1c= 5.55%, the specificity was (74.3%) and sensitivity (56.5%) to discriminate normal from abnormal glucose status in women with PCOS (AUC: 0.645; 95% C.I.: 0.503–0.77; p = 0.03). One hundred women (76.9%) were either overweight or obese and most of them had IR (78%). Conclusion: screening of glycemic disorders is a crucial for PCOS by using 2hrs-OGTT regardless risk factor and HbA1c seems to be unsatisfactory screening tool to predict glycemic disorders in women with PCOS.
Effects of Exercise, Metformin, Pioglitazone and Exenatide Treatment on Inflammation Induced Insulin Resistance and Ubiquitin Proteasome System in Diabetes and Obesity
Authors: Akarsu Ersin , Demirel Can , Balci Sibel Oguzkan , Sayiner Zeynel A , Yilmaz İbrahim , Korkmaz Murat , Eraydin Ayten , Tabur Suzan
Published: May 2021

Purpose: The aim of this study is; To examine the destruction of insulin receptor substrate-1 (IRS-1) molecule, which is one of the mechanisms that cause insulin resistance in diabetes and obesity, and its effect to reduce this destruction. For this purpose, the effects of exercise, metformin, exenatide and pioglitazone treatments on IRS-1 ubiquitination in pancreas, muscle and adipose tissue were investigated in an obese and diabetic animal model.

Method: Obese rat model was used in this study. This model is characterised by obesity, diabetes and insulin resistance. This study investigated the molecular mechanisms of IRS-1 breakdown in diabetes. IRS1, SOCS1, SOC3 expressions were evaluated in the liver, muscle and adipose tissue of this model. At the same time, immunohistochemical analyses were performed in terms of IRS1, SOCS1 and SOCS3 in the same tissues.

Results: Gene expression and Immunohistochemical analysis results were evaluated, the increase in IRS1 was noticeable in rats treated with exenatide, especially in the liver tissue despite the greater decrease in SOCS1 (P> 0.05). It was determined that other drugs in this study and used in the treatment of diabetes may also affect this mechanism to different degrees.

Conclusion: Our findings showed that some drugs used in the treatment of diabetes may alter the SOCS effect and / or proteasomal degradation of the IRS-1 protein. This effect was particularly pronounced in liver tissue. However, more comprehensive studies are required to show the contribution of ubiquitination in the destruction of IRS-1 and which drugs are effective on this mechanism.

Acknowledgement: This study was supported by the Scientific And Tecnological Research Council Of Turkey (TÜBİTAK) Project No: 217S089