1c Values Research Articles

La hemoglobina glucosilada como marcador de riesgo de hiperuricemia en la población general

Background and objectives To evaluate the association between high levels of glycemia and low serum uric acid levels in two independent population-based samples. Patients and methods The first sample was taken from the Pizarra Study, a population-based prospective study of 1.226 persons classified according to their glycometabolic status, as measured from an oral glucose tolerance test. Variables recorded included anthropometric data, serum fasting insulin, uric acid (UA) and HOMA-IR. The second sample was obtained from the Central Laboratory Database, which includes 81,754 laboratory requests for HbA 1c carried out over 30 months. We selected those that included measurements of UA, triglycerides and albuminuria. Results In the Pizarra Study, the fasting glucose levels showed a bell-shaped relation with serum UA levels in men and more especially in women (P < 0.0001). In the second sample, the UA levels in women showed a bell-shaped relation with HbA 1c, increasing as the HbA 1c rose to 7% and then falling with the further increase of HbA 1c (P < 0.0001). Men experienced a linear decrease in UA levels as the HbA 1c rose (r = −0.19; P < 0.0001), though only with effect from HbA 1c values > 7%. The odds ratio for hyperuricemia (≥ 6 mg/dL in women and ≥ 7 mg/dL in men) fell continuously as the HbA 1c levels rose. Conclusions This study, undertaken in two different populations, showed that serum UA levels are non-linearly correlated with the levels of glucose, HbA 1c and HOMA-IR, especially in women. The risk of hyperuricemia and gout may be higher in persons with prediabetic states or with better-controlled diabetes than in persons with poorly-controlled diabetes.

Impact of clinical factors and CYP2C9 variants for the risk of severe sulfonylurea-induced hypoglycemia

The established risk factors for severe sulfonylurea-induced hypoglycemia (SH) include low hemoglobin (Hb)A(1c), advanced age, long duration of diabetes, multimorbidity, and polypharmacy. As the genetically polymorphic cytochrome P450 (CYP), enzyme CYP2C9 is mainly responsible for the hepatic metabolism of sulfonylureas (SUs), we hypothesized that the slow-metabolizer genotypes *2/*2, *2/*3, and *3/*3 might be overrepresented in type 2 diabetic patients with SH. In a prospective population-based case-control study, CYP2C9 allelic variants of 102 diabetic patients with SH were compared with a matched group of 101 SU-treated patients without a history of SH. The 203 Caucasian patients had been treated with the SUs glimepiride, glibenclamide, or gliquidone. SH was defined as a symptomatic event requiring treatment with intravenously administered glucose and was confirmed by a blood glucose measurement of <50mg/dl (<2.8mmol/l). As two control groups, we selected 337 Caucasian diabetic patients receiving antidiabetic drugs per os and 1,988 healthy Caucasian volunteers who had been genotyped earlier. In the univariate analysis, only a low HbA(1c) value (p = 0.0004) was shown as a risk factor for SH. There was no overrepresentation of the CYP2C9 *2/*2, *2/*3, and *3/*3 variants in the SH group (2%) compared with the control group (5%). However, in the control group, patients with CYP2C9 genotypes, predicting slower metabolism of SU drugs, were treated with significantly lower doses (p = 0.027) than were extensive metabolizers, whereas in the patient group with severe hypoglycemia, the dose was the same for all genotype groups. In the present cohort of 102 patients with SH, a low HbA(1c) value was related to the risk for SH. There was no overrepresentation observed of the CYP2C9 slow-metabolizer genotypes in the hypoglycemic patients group, but the drug exposure in the slow-metabolizer genotypes was estimated to be higher in hypoglycemic patients, which might partly have contributed to their risk for SH.

First nuclear DNA amounts in diploid (2n = 2x = 14) Corchorus spp. by flow cytometry: genome sizes in the cultivated jute species (C. capsularis L. and C. olitorius L.) are ∼300% smaller than the reported estimate of 1100–1350 Mb

We report the 2C values (nuclear DNA content) and haploid genome (1C) sizes of the Corchorus species (2n = 2x = 14), with a special reference to the two cultivated jute species, viz., C. capsularis L. (the white jute) and C. olitorius L. (the tossa jute). Flow cytometric analysis of propidium iodide-stained nuclei showed that the 2C values were between 0.502 and 0.695 pg for C. capsularis, and between 0.643 and 0.718 pg for C. olitorius. For both the cultivated species, however, mutants had higher amounts of nuclear DNA than that of the cultivars. Amongst the wild Corchorus species, the lowest 2C value was observed in C. fascicularis (0.384 pg), while the highest in C. pseudo-olitorius (0.712). The current 2C values of both the cultivated jute species are in disagreement with earlier estimates of 2.3 and 2.8 pg in C. capsularis and C. olitorius, respectively. Of the Corchorus species studied, C. fascicularis has the smallest haploid genome (~188 Mb) followed by C. aestuans (~194 Mb). Our results show that, on an average, genome sizes (1C values) of C. capsularis and C. olitorius are ~280 Mb and ~324 Mb, respectively, which are ~300% smaller than their corresponding reported estimates. The white jute cv. JRC-212 (or Branca) has the smallest genome (~246 Mb) among the economically important crop species.

Umbilical cord oxidative stress in infants of diabetic mothers and its relation to maternal hyperglycemia

There is growing body of evidence that oxidative stress plays an important role in the pathogenesis of diabetes mellitus (DM) and in development of maternal and fetal complications of diabetic pregnancies. The aim of the present study was to investigate total antioxidant capacity (TAC), total oxidant status (TOS), and oxidative stress index (OSI) in infants of diabetic mothers (IDM) and to reveal the influence of maternal hyperglycemia on these parameters. A prospective controlled study was conducted between March 2010 and November 2010. Umbilical cord blood was taken from IDM and controls for TAC and TOS measurement, and OSI was calculated. IDM were divided into two groups, either of mothers treated with insulin during pregnancy or of those treated with a carbohydrate-restricted diet. Thirty-six IDM and 14 infants born to non-diabetic mothers were enrolled. Infants of insulin-treated mothers (group 1) and infants of mothers managed with a carbohydrate-restricted diet (group 2) had significantly higher TOS (p < 0.001 and p = 0.001, respectively) and OSI (p < 0.001 and p = 0.001, respectively) levels compared to controls. However, TAC levels were similar in all three groups. Maternal HbA(1c) values were correlated to TOS (p < 0.001, r = 0.694) and OSI (p < 0.001, r = 0.683). Oxidative stress is increased in IDM, and a significant relation exists between the degree of maternal hyperglycemia in pregnancy and oxidative stress in the newborn at birth.

Combined Assessment of Myocardial Perfusion and Function by ECG-Gated Myocardial Perfusion Single-Photon Emission Computed Tomography for the Prediction of Future Cardiac Events in Patients With Type 2 Diabetes Mellitus

The mid-term prognostic significance of ECG-gated single-photon emission computed tomography (SPECT) remains unclear in Japanese patients with type 2 diabetes mellitus (DM). In the present study rates of future cardiac events (nonfatal acute myocardial infarction (AMI), cardiac death (CD) and severe heart failure (HF) requiring hospitalization) were compared in patients with and without DM. 1,810 patients (563 DM and 1,247 non-DM) we followed for a mean of 26.3±15.5 months. Summed stress score (SSS), summed difference score (SDS), poststress ejection fraction (EF) and resting end-diastolic volume (EDV) were calculated. In total, 20 cases of AMI (9 in DM (1.59%) and 11 in non-DM (0.88%)), 20 of CD (7 in DM patients (1.24%) and 13 in non-DM (1.04%)) and 54 of severe HF (31 in DM (5.5%) and 23 in non-DM (1.84%)) occurred. Univariate Cox analysis showed that, in DM patients, predictors of total cardiac events were poststress EF (Wald 60.4; P<0.001), resting EDV (Wald 53.8; P<0.001), SSS (Wald 39.6; P<0.001), SDS (Wald 26.1; P<0.001), history of prior MI (Wald 4.32; P<0.05) and hemoglobin A(1c) value (Wald 4.30; P<0.05). Multivariate Cox analysis showed that poststress EF (Wald 9.85; P<0.01) and SDS (Wald 6.19; P<0.01) were independent predictors of total cardiac events. Combined assessment of perfusion and function by ECG-gated SPECT may predict future cardiac events in type 2 DM patients.

Shrinking genomes? Evidence from genome size variation inCrepis(Compositae)

Large-scale surveys of genome size evolution in angiosperms show that the ancestral genome was most likely small, with a tendency towards an increase in DNA content during evolution. Due to polyploidisation and self-replicating DNA elements, angiosperm genomes were considered to have a 'one-way ticket to obesity' (Bennetzen & Kellogg 1997). New findings on how organisms can lose DNA challenged the hypotheses of unidirectional evolution of genome size. The present study is based on the classical work of Babcock (1947a) on karyotype evolution within Crepis and analyses karyotypic diversification within the genus in a phylogenetic context. Genome size of 21 Crepis species was estimated using flow cytometry. Additional data of 17 further species were taken from the literature. Within 30 diploid Crepis species there is a striking trend towards genome contraction. The direction of genome size evolution was analysed by reconstructing ancestral character states on a molecular phylogeny based on ITS sequence data. DNA content is correlated to distributional aspects as well as life form. Genome size is significantly higher in perennials than in annuals. Within sampled species, very small genomes are only present in Mediterranean or European species, whereas their Central and East Asian relatives have larger 1C values.

Changes in glycosylated hemoglobin after initiation of hydroxychloroquine or methotrexate treatment in diabetes patients with rheumatic diseases

Prior research demonstrates that hydroxychloroquine (HCQ) lowers glycosylated hemoglobin (HbA(1c) ) in diabetes patients without rheumatic disease. We examined medical records of patients with diabetes mellitus (DM) and concomitant rheumatic illness to measure changes in HbA(1c) after starting HCQ or methotrexate (MTX). We used electronic medical records to identify patients beginning treatment with either HCQ or MTX who had a diagnosis of DM (or a pretreatment HbA(1c) value of ≥7%) and at least 1 HbA(1c) measurement both before and within 12 months after initiation of treatment. Using a structured medical record abstraction, we examined rheumatic disease diagnosis, cumulative steroid use, duration (months) between drug initiation and lowest HbA(1c) value, a change in DM medication, body mass index (BMI), age, and sex. Adjusted linear regression models determined changes in HbA(1c) from pretreatment values to the lowest posttreatment values within 12 months. We identified 45 patients taking HCQ and 37 patients taking MTX who met the inclusion criteria. Rheumatoid arthritis had been diagnosed in approximately half of the patients in each group. Age, sex, and mean pretreatment HbA(1c) levels were similar across groups. The mean BMI of those taking HCQ (35.4 kg/m(2) ) was slightly higher than that of those taking MTX (32.2 kg/m(2) ) (P = 0.13). Glucocorticoid use appeared more common in those taking MTX (46%) than in those taking HCQ (29%) (P = 0.17). The mean reduction in HbA(1c) from pretreatment values to the lowest posttreatment values was 0.66% (95% confidence interval [95% CI] 0.26, 1.05) in those taking HCQ compared with 0.11% (95% CI -0.18, 0.40) in those taking MTX. In fully adjusted analyses, the reduction in HbA(1c) among those taking HCQ was 0.54% greater than the reduction among those taking MTX (P = 0.041). HCQ initiation was associated with a significantly greater reduction in HbA(1c) as compared with MTX initiation among diabetes patients with rheumatic disease.

Glucose regulation influences treatment outcome in ranibizumab treatment for diabetic macular edema

Purpose To evaluate the effect of glucose regulation on intravitreal ranibizumab injection for clinically significant diabetic macular edema (DME). Methods This retrospective study enrolled 65 eyes of 65 patients with persistent DME treated with intravitreal ranibizumab injection. The main outcome measures were the change in best corrected visual acuity (BCVA), the central subfield macular thickness (CSMT) recorded with optical coherence tomography (OCT), and its correlation with the serum hemoglobin A 1c values (HbA 1c). Results The study included 24 (36.9%) female and 41 (63.1%) male patients with a mean age of 58.90±9.45 years. The mean HbA 1c of the enrolled patients was 8.25±1.74% (range 5.7–12.7%). The median value of BCVA at baseline examination was 20/80 (52 letters), and the median CSMT was 468 μm (range 255–964 μm). In the final control after 4–6 weeks following injection, the median value of BCVA increased to 20/50 (59.50 letters) and the median CSMT decreased to 310 μm (range 129–652 μm). This change in BCVA and macular thickness was found to be significant ( P<.001 for both). There was no correlation between BCVA and the change in macular thickness (coefficient=0.04, P=.78). The serum HbA 1c values were found to be negatively correlated with the change in CSMT (coefficient=−0.50, P<.001). Conclusions The results of intravitreal ranibizumab injection for DME demonstrated a beneficial effect on visual acuity and a decrease in CSMT which is inversely correlated with the serum HbA 1c level.

Degree of control and delayed intensification of antihyperglycaemic treatment in type 2 diabetes mellitus patients in primary care in Spain

Objectives Primary aim: to determine the degree of control of HbA 1c at the time of treatment intensification (TI) in T2DM patients. Secondary aims: fasting plasma glucose levels; estimation of the elapsed time between HbA 1c exceeding 7% and TI; antidiabetic combinations used, % patients with good cardiometabolic control (LDL-c < 100 mg/dL; SBP < 130 and DPB < 80 mmHg and HbA 1c < 7%). Research design and methods One-cohort, multicenter, retrospective, observational study conducted in Spain. Patients diagnosed with T2DM that had switched from monotherapy to combination antidiabetic therapy were evaluated at baseline and after one year of follow-up. Results A total of 1202 T2DM patients were analyzed. At the time of TI: mean HbA 1c 8.1%; median time of uncontrolled disease: 2.0 years. After one-year of TI: significant reduction in mean HbA 1c (8.1% vs.7.0%, p < 0.001) and a mean fasting plasma glucose levels reduction (181.1 mg/dL vs.144.1 mg/dL, p < 0.001) was also observed. The percentage of patients under glycemic control (HbA 1c < 7%) increased from 12.2% to 51.6% ( p < 0.001). Most common antidiabetic combinations: metformin + sulfonylurea (44.1%) and metformin + thiazolidindione (15.9%). Conclusions In the population of T2DM patients analyzed, TI was carried out when HbA 1c values were above those recommended in clinical guidelines (≤7%), with a delay of two years to address the second step of therapy, despite the consensus recommendation of the ADA/EASD of 3 months. TI was shown to be effective since addition of a second antidiabetic drug led to an average reduction of HbA 1c of approximately 1%. Metformin was the drug most commonly used as monotherapy being the most frequent combination metformin + sulfonylurea.

HbA 1c in the prediction of type 2 diabetes compared with fasting and 2-h post-challenge plasma glucose: The Asturias study (1998–2005)

Aim Fasting plasma glucose (FPG) and the 2-h post-challenge plasma glucose (2hPG) are commonly used to identify those at risk of type 2 diabetes. However, the role of HbA 1c in this prediction has still not been ascertained. Methods The Asturias study is a prospective population-based survey of diabetes and cardiovascular risk factors. Baseline examination, carried out during 1998–1999, involved 1034 individuals, aged 30–75 years, randomly selected to determine the prevalence of type 2 diabetes and prediabetes in the principality of Asturias (northern Spain). In 2004–2005, these same subjects were invited to a follow-up examination, and 700 participated. The present study includes only those who did not have diabetes at baseline. All participants with no known diabetes underwent an OGTT. Baseline HbA 1c levels were measured by HPLC. Results Diabetes had developed in 44 participants at the time of follow-up. Quartiles of baseline HbA 1c values were 3.4–4.8 (Q1), 4.9–5.1 (Q2), 5.2–5.4 (Q3) and 5.5–6.9 (Q4), and the incidence rates of diabetes by quartiles were 1.0 (0.1–7.1), 4.0 (1.5–10.7), 7.9 (4.0–15.9) and 32.6 (22.9–46.4) cases/1000 person-years, respectively. ROC curve analysis comparing HbA 1c, FPG and 2hPG in the prediction of diabetes showed areas under the curve (ROC–AUC) of 0.80 (0.74–0.86), 0.83 (0.77–0.90) and 0.79 (0.72–0.87), respectively. The combination of FPG and HbA 1c had the best predictive performance with an ROC–AUC of 0.88 (0.82–0.93). Conclusion Our study indicates that HbA 1c is strongly predictive of new-onset diabetes in this northern Spanish population, and was similar to FPG and 2hPG in predictive capability. Also, the combined measurement of FPG and HbA 1c improved their individual predictive performance.

Alexithymia is associated with glycaemic control of children with type 1 diabetes

Aim This study examined the respective contributions of the demographics, medical variables and alexithymia characteristics of young diabetics to their glycaemic control. The goal was to replicate the role of the ‘difficulty describing feelings’ factor of alexithymia in the prediction of poor glycaemic control as has been found in adult diabetic populations. Method The study included 45 type 1 diabetic children, aged 8–12 years (24 girls and 21 boys). Participants completed a sociodemographic questionnaire and provided medical information on their diabetes. HbA 1c values (glycated haemoglobin), and the number of severe hypoglycaemic episodes and hospitalizations for hyperglycaemia, were collected for the previous 12 months (3 months for severe hypoglycaemias). Alexithymia characteristics were measured by means of the Alexithymia Questionnaire for children. Results Hierarchical regression analyses confirmed that both demographic (marital status and parental education; P < 0.05) and medical (duration of diabetes and daily self-monitoring of blood glucose frequency; P < 0.01) variables are associated with HbA 1c levels. More important, one alexithymia factor (difficulty describing feelings) was found to be an additional predictor over and above the other variables ( P < 0.01), explaining an additional 12% of the total variance in HbA 1c levels. Conclusion Confirming results already observed in diabetic adults, the present findings show, for the first time, that children who have difficulties in expressing their feelings to others are more at risk of poor glycaemic control. In future, it will be useful to identify the diabetic young people who have such difficulties and to consider interventions designed specifically for them.

Comparison of HbA1c Analyzers: D-10, Variant II Turbo, Cobas Integra 800, and Afinion AS100

The purpose of this study was to evaluate the performance and agreement among HbA(1c) values measured using selected analyzers certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). HbA(1c) determined using D-10 (Bio-Rad, USA), Variant II Turbo (Turbo; Bio-Rad, USA), Cobas Integra 800 (Integra; Roche, Switzerland) and Afinion AS100 (Afinion; Axis-Shield, Norway) were compared with each other. Precision and method comparisons with Deming regression were evaluated according to CLSI recommendations. We also compared the HbA(1c) values obtained with each analyzer using either IFCC or NGSP methods by correlation analysis and kappa statistics. The repeatability and method/device precisions of D-10 and Afinion were acceptable. The correlation coefficients of HbA(1c) were 0.986 for D-10 vs. Afinion, 0.997 for D-10 vs. Turbo, 0.988 for D-10 vs. Integra, and 0.991 for Integra vs. Afinion. The average biases of HbA(1c) Afinion (IFCC) and HbA(1c) Integra (IFCC) against HbA(1c) D-10 (NGSP) were -1.90% and -1.79%, respectively. Kappa agreement statistics for the three diabetic control group HbA(1c) values of "less than 6.5%," "6.5%-7.5%," and "greater than 7.5%" for D-10 vs. Turbo, D-10 vs. Integra, and D-10 vs. Afinion were 0.872, 0.836, and 0.833, respectively. The strong correlations and good clinical agreements of HbA(1c) between each analyzer expressed in terms of either NGSP or IFCC-derived NGSP indicate that these analyzers can be used interchangeably.

The high prevalence of malnutrition in elderly diabetic patients: implications for anti‐diabetic drug treatments

Type 2 diabetes usually occurs in the context of obesity and associated insulin resistance. Current treatment recommendations are based on lifestyle modifications and incremental drug therapy. However, this approach could lead to inappropriate priorities upon ageing, when diabetes may be compounded by malnutrition and reduced insulin resistance. We prospectively evaluated glycaemic and nutritional parameters in 146 consecutive diabetic patients (age 82.5 +/- 7.3 years, mean +/- sd) admitted to our geriatric service. We also implemented nutritional support therapy and a drug therapy adjustment protocol. Oral hypoglycaemic agent withdrawal was attempted in cases of good glycaemic control (HbA(1c) < 7.5% (<47 mmol/mol) or fasting blood glucose < 7.5 mmol/l). Mean BMI and HbA(1c) were 29.6 +/- 7.1 kg/m(2) and 6.9 +/- 1.2% (52 +/- 9 mmol/mol), respectively. Of the patients, 51.4% were taking 1-3 oral hypoglycaemic agents, 30.8% were on insulin and 9.6% on were on insulin and oral hypoglycaemic therapy. Low Mini Nutritional Assessment scores and serum marker levels indicated a high prevalence of malnutrition and/or chronic disease, even in obese patients. Mini Nutritional Assessment scores were positively associated with HbA(1c) values. Among patients treated by oral hypoglycaemic agents, complete drug withdrawal was achieved in 65.8%, much more often than new treatments were added (P = 0.002). Glycaemic control did not worsen after approximately 30 days, despite in-hospital nutritional therapy. Successful oral hypoglycaemic therapy withdrawal was associated with lower Mini Nutritional Assessment scores. Malnutrition is highly prevalent in elderly diabetic inpatients and, paradoxically, contributes to 'good' glycaemic control. Malnutrition should be screened for in these patients and, when present, should prompt a revision in diet and drug therapy. In particular, the possibility of reducing unnecessary drug therapy should be considered.

Impact of postprandial and fasting glucose concentrations on HbA 1c in patients with type 2 diabetes

Aim This study aimed to assess the relative contributions of postprandial and fasting glucose concentrations to overall hyperglycaemia. Methods Patients with type 2 diabetes ( n = 973) carried out self-monitored blood glucose (SMBG) profiles on entry into the European Exenatide (EUREXA) trial. Glucose area under the curve was calculated for postprandial excursions (AUC ppg) and total daytime concentrations > 6.1 mmol/L (AUC total), as well as for the percentage of glycaemia due to postprandial excursions (% ppg). In addition, OGTT scores were assessed for each patient. Results were evaluated according to defined HbA 1c categories. Results There was a significant linear relationship between HbA 1c and the derived variables of AUC ppg, AUC total and % ppg ( P < 0.001 for each), with explained variance greatest for AUC total ( r 2 = 37.4%). AUC ppg increased only slightly up to an HbA 1c of 7.0%, but showed a steeper increase in higher HbA 1c categories. Also, the increase in AUC total with increasing HbA 1c was much more pronounced. As a result, the postprandial glucose excursion as a proportion of total glucose (% ppg) decreased across HbA 1c categories from 61.0% at HbA 1c < 6.5% to 22.0% at HbA 1c ≥ 9.0%. HOMA-IR remained virtually unchanged through all HbA 1c categories, while HOMA-B showed no large changes up to HbA 1c 7.0%, but then decreased at higher HbA 1c values. The ΔI30/ΔG30 ratio decreased in the HbA 1c 7.0–7.9% category, but did not change greatly at higher HbA 1c categories. Conclusion With increasing HbA 1c, there was a decrease in the contribution of postprandial hyperglycaemia to total glycaemia, and fasting hyperglycaemia became more important. This is consistent with impaired insulin release, particularly first-phase release, at higher HbA 1c levels.

Insulin usage in type 2 diabetes mellitus patients in UK clinical practice: a retrospective cohort-based analysis using the THIN database

This retrospective cohort-based study assessed the change in glycated haemoglobin A1C (HbA 1C) in patients with type 2 diabetes, with existing prescriptions for oral antidiabetic drugs (OADs), prescribed insulin versus those prescribed subsequent OADs. A cohort of patient records drawn from the The Health Improvement Network (THIN) database was stratified by maximum concurrent number of OADs. Of 128,568 unique patient records identified, 67.7% (n=87,057) had received at least one OAD, 17.4% (n=15,138) of these patients progressed to insulin therapy. Mean HbA1C at insulin initiation was 9.5% (one OAD), 9.6% (two), 9.7% (three) and 10.1% (four), with an average HbA 1C increase of 0.7% prior to insulin initiation. The greatest improvement in HbA1C was achieved with insulin therapy. A threshold HbA 1C value of 8.5% above which OAD escalation is unlikely to achieve a target HbA1C ≤ 7.0% is seen. In patients not achieving HbA1C targets with OADs only, insulin-based regimens should be considered in preference to adding more or multiple OADs. Br J Diabetes Vasc Dis 2010;10:178—182.

Six-month exenatide improves HOMA hyperbolic product in type 2 diabetic patients mostly by enhancing beta-cell function rather than insulin sensitivity

Objective This study aimed to determine whether or not the improvement of glycaemic control with 6-month exenatide therapy in type 2 diabetic patients with secondary failure to combined oral therapy is related to amelioration of β-cell function and/or insulin sensitivity and their combined product. Research design and methods Thirty-three patients with type 2 diabetes were investigated. Their β-cell function and insulin sensitivity were measured using Homoeostasis Model Assessment [HOMA-B, HOMA-S and HOMA hyperbolic product (BxS)]. Additional endpoints included changes in weight, HbA 1c and plasma adiponectin, as well as baseline clinical and biological characteristics, as potential predictors of HbA 1c response. Results After 6 months, unadjusted HOMA-B increased from 33 ± 24% to 43 ± 23% ( P = 0.0210), whereas there was no significant change in HOMA-S (from 58 ± 35% to 61 ± 40%). The hyperbolic product increased by a relative 70% (from 15 ± 7% to 22 ± 15%; P = 0.0055). Body mass index decreased from 32.2 ± 5.1 kg/m 2 to 31.0 ± 4.8 kg/m 2 ( P < 0.0001) and HbA 1c from 8.8 ± 1.0% to 7.6 ± 1.2% ( P < 0.0001). No change was observed in adiponectin concentrations. Higher baseline HbA 1c values were a significant predictor of therapeutic response. Conclusion Exenatide significantly increased HOMA-B and hyperbolic product over a 6-month treatment period with no overall change in insulin sensitivity, despite weight loss. Thus, improved β-cell function rather than increased insulin sensitivity accounts for the bulk of HbA 1c reduction following 6 months of exenatide treatment.

Computerized Physician Order Entry- Based Hyperglycemia Inpatient Protocol and Glycemic Outcomes: The CPOE-HIP Study

To evaluate the impact of implementing a computerized physician order entry (CPOE)-based hyperglycemia inpatient protocol (HIP) on glycemic outcomes. This retrospective, cross-sectional study compared blood glucose values, hemoglobin A(1c) values, diabetes medication profles, and demographic data of diabetic patients admitted to medicine services between March 15, 2006, and April 11, 2006 (before CPOE-HIP protocol was adopted), with data of diabetic patients admitted between October 3, 2007, and October 30, 2007 (1 year after CPOE-HIP protocol was implemented). A total of 241 diabetic patients comprised the pre-CPOE-HIP group and 197 patients comprised the post-CPOE-HIP group. After the protocol was adopted, there was a decrease of 10.8 mg/dL in the mean glucose concentration per patient-day (175.5 +/- 81.2 mg/dL vs 164.7 +/- 82 mg/dL, P<.001). Additional glycemic control improvements included a 5% increase in patient-days with serum glucose concentrations between 70 and 150 mg/dL (41.1% vs 46.1%, P = .008) and a 3.1% decrease in patient-days with glucose concentrations above 299 mg/dL (16.9% vs 13.8%, P = .023). The percentage of patient-days with glucose concentrations less than or equal to 50 mg/dL was not significantly different (0.95% vs 1.27%,P = .15). Compliance with the American Diabetes Association recommendation for hemoglobin A1c inpatient testing frequency increased from 37.3% to 64.5% (P<.001). The length of stay did not differ between the groups. Implementation of a hospital-wide, CPOE-based, hyperglycemia management protocol had a favorable impact on glucose targets, decreasing excessively high glucose levels without increasing clinically meaningful hypoglycemic events. Compliance with hemoglobin A(1c) testing recommendations also improved.

The status of glycemic control: A cross-sectional study of outpatients with type 2 diabetes mellitus across primary, secondary, and tertiary hospitals in the jiangsu province of China

Objectives: The aims of the study were to determine the following: the status of glycemic control in patients with type 2 diabetes mellitus (DM) at primary, secondary, and tertiary hospitals in the Jiangsu province of China; and the factors associated with achieving glyce-mic targets. Methods: This study, in which patients were enrolled from July 20 to 31, 2009, at 56 diabetes centers, used a multiple-stage, stratified sampling method to select a representative sample of the population with DM in Jiangsu. The sampling process was stratified by geographic and demographic regions, and by the outpatient numbers in the hospitals. A primary hospital was defined as a community medical institution that provided primary health services; a secondary hospital was a local medical institution that provided comprehensive health services; and a tertiary hospital was a regional medical institution that provided comprehensive and specialist health services. In primary hospitals, patients with DM were treated by general physicians; at secondary and tertiary hospitals, they were seen by specialists. Also, primary and tertiary hospitals treated patients in cities, whereas secondary hospitals treated patients from towns or rural areas. Patients with a medical history of type 2 DM for >6 months and registration at each diabetes center for ≥6 months, and who were residents of Jiangsu province, were recruited. During the patient enrollment visit, information about DM complications and comor-bidities, as well as DM management, was obtained by retrospectively reviewing medical records; basic patient data (eg, date of birth, sex, weight, height) were obtained by patient interview. Blood samples were collected for assessment of glycosylated hemoglobin (HbA 1c) at a central laboratory. Results: Of 3046 sampled subjects, the analysis was performed in 2966 subjects with complete data. The mean (SD) HbA 1c value for analyzed patients was 7.2% (1.6%). The proportion of patients with tight glycemic control was 40.2% (1193/2966) when a threshold of HbA 1c <6.5% was used, and 56.1% (1665/2966) when a threshold of HbA 1c <7.0% was used. Compared with patients who had inadequate glycemic control, those with tight control were younger ( P < 0.001), had shorter duration of DM ( P < 0.001), had lower body mass index (BMI) ( P = 0.005 for HbA 1c <6.5% and P = 0.01 for HbA 1c <7.0%), had more education ( P < 0.001) and income ( P = 0.003 for HbA 1c <6.5% and P = 0.008 for HbA 1c <7.0%), were more likely to monitor their glucose ( P = NS for HbA 1c <6.5% and P = 0.043 for HbA 1c <7.0%) and attend DM education ( P = 0.027 for HbA 1c <6.5% and P = 0.002 for HbA 1c <7.0%) at least once a month, and were more likely to receive oral antidiabetic drugs (OADs) ( P < 0.001). Age, BMI, and DM duration did not differ significantly between hospital types. Compared with primary (36.2%) and secondary hospitals (36.5%), tertiary hospitals (42.2%) had more patients with HbA 1c <6.5% ( P = 0.043); tertiary hospitals also had more patients with once-monthly glucose self-monitoring ( P = 0.001), patients with higher income ( P < 0.001) and education ( P < 0.001), and those who were more likely to use ≥2 OADs or insulin with OADs ( P < 0.001). Conclusion: The overall status of glycemic control was unsatisfactory during the study period, although patients at tertiary hospitals appeared to have better control than those at primary or secondary hospitals.

Are elderly patients with diabetes being overtreated in French long-term-care homes?

Aim In France, diabetes prevalence and ageing of the population are both on the increase, yet little information on diabetes in elderly patients living in geriatric institutions is available. Moreover, institutionalized diabetic patients are not included in the French recommendations for the management of diabetes in the elderly. For this reason, the aim of the present study was to evaluate diabetes management in older, institutionalized patients. Methods The medical records of 100 diabetic patients, aged 65 years and over, and living in seven geriatric institutions in the Côte d’Or region of France, were studied from May 2008 to January 2009. Results Prevalence of diabetes in these seven geriatric institutions was 15.46 ± 4.9%, higher than in the general population. The diabetic patients had a mean age of 81.85 ± 11.93 years, and 32% had glycated haemoglobin (HbA 1c) less or equal to 6.5%, indicating a high risk of severe hypoglycaemia. A diet for diabetes was prescribed in 54% of the patients, but HbA 1c levels did not differ between patients following and not following the diet (7.26 ± 1.36% vs 7.11 ± 1.10%, respectively; P = 0.27). Creatinine was assessed in 87% of the patients, and 16% were ophthalmologically followed-up. Daily capillary blood glucose monitoring was performed in 100% of the patients taking insulin and in 17% of those taking oral antidiabetic treatment ( P < 0.0001). Conclusion Our data show that, among older institutionalized patients, the prevalence of diabetes is high and the control of diabetes too tight, with a potential risk of hypoglycaemia. Antidiabetic treatment should be reduced when the HbA 1c value is less than 7.5% in this frail and functionally dependent population. Furthermore, a diabetic diet, prescribed for more than half this population, is useless for glycaemic control and may even impinge on quality of life.

The structure of parental involvement and relations to disease management for youth with type 1 diabetes.

To test structural models of parental involvement in type 1 diabetes and to examine associations of parental involvement with adherence and metabolic control. Two hundred and fifty-two young adolescents (10-14 years) completed reports of adherence and parents' involvement: acceptance, independence encouragement, communication, general and diabetes-specific monitoring, frequency of help, and intrusive support. HbA(1c) values came from medical records. A model of relationship quality, behavioral involvement, and monitoring as three separate yet interrelated factors best fit the data. Higher reports of mothers' and fathers' monitoring and fathers' relationship quality uniquely related to better adherence, whereas higher reports of fathers' behavioral involvement uniquely related to poorer adherence. Higher reports of paternal monitoring were related to lower HbA(1c). Adolescent perceptions of components of parental involvement are interrelated, yet separate constructs for both mothers and fathers. Parental monitoring was an important predictor of management of type 1 diabetes during adolescence.