Journal Watch

Prepared for IDDT by Jim Young

March 2014

Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes
Karen L. Margolis et al. Diabetes Care.  Doi: 10.2337/dc13-2334

This study compared the effects of combinations of standard and intensive treatment of glycaemia and either blood pressure (BP) or lipids with reference to the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. The trial enrolled 10,251 patients with type 2 diabetes aged 40 to 79 years at high risk for cardiovascular disease (CVD) events. It was found that in the BP trial, compared with combined standard treatment, intensive BP or intensive glycemia treatment alone improved major CVD outcomes, without additional benefit from combining the two. In the lipid trial, neither intensive lipid nor glycemia treatment produced an overall benefit, but intensive glycemia treatment increased mortality.


Pathways to diagnosis: a qualitative study of the experiences and emotional reactions of parents of children diagnosed with type 1 diabetes
David Rankin et al. Pediatric Diabetes. Doi: 10.1111/pedi.12124

This study looked at the reasons for delays in seeking treatment and parents’ emotional reactions to diagnosis. The methodology involved in-depth interviews with 54 parents of children (aged 12 yrs or under) with type 1 diabetes (T1D). The parents described a ‘prompt’ and a ‘delayed’ pathway to their child being diagnosed. Parents who considered the diagnosis to be ‘prompt’ reported how they, or other people, had recognized their child had developed symptoms of T1D which resulted in a rapid presentation to health care professionals. In contrast, parents who perceived their child’s diagnosis to be ‘delayed’ did not recognize signs of T1D and attributed their child’s deteriorating health to other conditions. These parents often only sought medical help when symptoms became extreme. The authors posit that campaigns to raise awareness should ensure that parents are made aware of symptoms and that T1D can develop during childhood. They also suggest that health care professionals could discuss with parents the events preceding their child’s diagnosis to better determine their emotional support needs.


Does higher quality of primary healthcare reduce hospital admissions for diabetes complications?
Calderón-Larrañaga et al. Diabetic Medicine. Doi: 10.1111/dme.12413

This observational study of the population in England during the period 2004 to 2009 looked at diabetes prevalence and the associations between hospital admission rates for complications and primary healthcare quality. It was found that increasing deprivation and diabetes prevalence were risk factors for admission, while most healthcare covariates, i.e. a larger practice population, better patient-perceived urgent and non-urgent access to primary care and better HbA1c target achievement were protective. It was noted that diabetes admissions decreased significantly during the period 2004–2009. [A covariate is a variable that is possibly predictive of the outcome under study. A covariate may be of direct interest or it may be a confounding or interacting variable]


Psychological care in a National Health Service: challenges for people with diabetes
Cathy E. Lloyd et al. Current Diabetes Reports. Doi: 10.1007/s11892-013-0416-6

The authors highlight a growing interest in psychological problems in people with diabetes and the increasing concern that these problems are often unreported, unidentified and treated. They posit that this has serious implications for both the self-management of diabetes and the individual’s quality of life. In their review they consider the question of screening for depression in people with diabetes within the NHS, the inadequacies of psychological care for patients with diabetes, and the criteria for assessing the validity of screening for depression. The screening strategy currently recommended for implementation in primary care in the UK is outlined. They emphasise the need for rigorous evaluation of screening initiatives when applied in the context of overall case management. The review also describes the barriers and challenges to optimizing care for patients with co-morbid diabetes and depression.


Genital and urinary tract infections in diabetes: Impact of pharmacologically-induced glucosuria
Suzanne Geerlings et al. Diabetes Research and Clinical Practice. Doi:10.1016/j.diabres.2013.12.052

The authors of this paper remind us that there is a predisposition to genital infections and urinary tract infections (UTIs) in type 2 diabetes mellitus (T2DM). This tendency to develop these infections could be even higher in patients with T2DM treated with the emerging class of sodium–glucose cotransporter-2 (SGLT2) inhibitors.  Studies have shown that pharmacologically-induced glucosuria with SGLT2 inhibitors raises the risk of developing genital infections and, to a relatively lesser extent, UTIs. However, they report that a definitive dose relationship between the incidence of these infections and SGLT2 doses is not evident in the existing data. Therefore, the precise role of glucosuria as a causative factor for these infections is yet to be fully elucidated.


Insulin pump use in young children in the T1D Exchange clinic registry is associated with lower HbA1c levels than injection therapy
Scott M Blackman et al. Pediatric Diabetes. Doi: 10.1111/pedi.12121

In this study insulin delivery via injection and continuous subcutaneous insulin infusion (CSII) via insulin pump were compared young children under 6 years with type 1 diabetes (T1D). It was found that the use of CSII correlated with longer T1D duration higher parental education. Wide variation in pump use was observed which suggests that prescriber preference is a substantial determinant of CSII use. It was also found that HbA1c was lower in pump vs. injection users, whilst the frequency of a severe hypoglycemia (SH) event did not differ in pump vs. injection users.  However, the frequency of parent-reported diabetic ketoacidosis (DKA) event in the prior year was greater in pump users than injection users. No differences between pump and injection users were observed for clinic-reported DKA events. The authors assert that their data support the use of insulin pumps in this youngest age group, and suggest that metabolic control may be improved without increasing the frequency of SH, but care should be taken as to the possibly increased risk of DKA.


Insulin pump use in pregnancy is associated with lower HbA1c without increasing the rate of severe hypoglycaemia or diabetic ketoacidosis in women with type 1 diabetes
Melissa M. Kallas-Koeman et al. Diabetologia. Doi: 10.1007/s00125-014-3163-6

In this large multicentre study glycaemic control and outcomes of 387 consecutive pregnancies in women with type 1 diabetes who attended specialised clinics at three centres between 2006 to 2010 were assessed. It was noted that women using insulin pumps (129 out of 387) were older and had a longer duration of diabetes, more retinopathy, smoked less in pregnancy, and had more preconception care. It was found that among 113 pregnancies over 20 weeks’ gestation in women on insulin pumps and 218 in women on multiple daily injections (MDI), there was a significant difference in HbA1c in the first trimester, which persisted until the third trimester. The rates of diabetic ketoacidosis were similar in women on insulin pumps vs MDI, and despite lower HbA1c, women on insulin pumps did not have an increased incidence of severe hypoglycaemia or more weight.


A comparison of biphasic insulin aspart and insulin glargine administered with oral antidiabetic drugs in type 2 diabetes mellitus
P. Rys et al. International Journal of Clinical Practice. Doi: 10.1111/ijcp.12337

Because it is uncertain whether the addition of biphasic insulin analogues to oral antidiabetic drugs (OADs) is as effective and safe as basal insulin in patients with type 2 diabetes mellitus (T2DM), the investigators performed a systematic literature search to compare glycaemic control and clinical outcomes in T2DM patients inadequately controlled with OADs whose treatment was intensified by adding biphasic insulin aspart (BIAsp 30) or insulin glargine (IGlar). It was found that BIAsp 30 added to OAD therapy resulted in a better glycaemic control as compared with IGlar in T2DM patients. BIAsp 30 use was associated with slightly larger weight gain but no rise in risk of severe hypoglycaemic episodes was noted.


Does the prevailing hypothesis that small-fiber dysfunction precedes large-fiber dysfunction apply to type 1 diabetic patients?
Ari Breiner et al. Diabetes Care. Doi: 10.2337/dc13-2005

The authors recount that the prevailing hypothesis is that the early subclinical small-fiber injury that precedes large-fiber damage in diabetic sensorimotor polyneuropathy (DSP) is based on lower intraepithelial nerve fiber density in patients with type 2 prediabetes despite normal nerve conduction studies. To confirm that the same hypothesis stands for patients with type 1 diabetes the researchers examined whether subjects without DSP include a spectrum with both normal and abnormal small-fiber measures; and if subjects with DSP have concurrent evidence of abnormal small-fiber measures. Their findings supported the hypothesis that in type 1 diabetes small-fiber dysfunction occurs early in DSP. However, they say that further research will be required to determine which combination of small-fiber tests is suitable as a surrogate marker in clinical trials.


National Paediatric Diabetes Audit
Healthcare Quality Improvement Partnership

This is the first stand alone Hospital Admissions and Complications annual report from the National Paediatric Diabetes Audit (NPDA), prepared by the Royal College of Paediatrics and Child Health (RCPCH). The report covers the period 2011-2012 for paediatric diabetes units in England and Wales. The introduction says that the findings from the report are reassuring in that the incidence of admissions to hospital with diabetic ketoacidosis (DKA) have either stabilised or fallen in most age categories compared to previous years both when expressed as rates compared to the general population and compared to the population  of children and young people with diabetes. However, it asserts that “we cannot ‘rest on our laurels’ as DKA still remains one of the major causes of hospital admission. Furthermore, DKA is present in almost one in five newly diagnosed children and young people with diabetes. A surprise finding is that over half of all admissions to hospital in children and young people with diabetes are coded as ‘without complications’.