Clinical Outcomes In Diabetic Patients Research Articles

Oxidative Stress, Endothelial Dysfunction, and N-Acetylcysteine in Type 2 Diabetes Mellitus.

Significance: Cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality globally. Endothelial dysfunction is closely associated with the development and progression of CVDs. Patients with diabetes mellitus (DM) especially type 2 DM (T2DM) exhibit a significant endothelial cell (EC) dysfunction with substantially increased risk for CVDs. Recent Advances: Excessive reactive oxygen species (ROS) and oxidative stress are important contributing factors to EC dysfunction and subsequent CVDs. ROS production is significantly increased in DM and is critically involved in the development of endothelial dysfunction in diabetic patients. In this review, efforts are made to discuss the role of excessive ROS and oxidative stress in the pathogenesis of endothelial dysfunction and the mechanisms for excessive ROS production and oxidative stress in T2DM. Critical Issues: Although studies with diabetic animal models have shown that targeting ROS with traditional antioxidant vitamins C and E or other antioxidant supplements provides promising beneficial effects on endothelial function, the cardiovascular outcomes of clinical studies with these antioxidant supplements have been inconsistent in diabetic patients. Future Directions: Preclinical and limited clinical data suggest that N-acetylcysteine (NAC) treatment may improve endothelial function in diabetic patients. However, well-designed clinical studies are needed to determine if NAC supplementation would effectively preserve endothelial function and improve the clinical outcomes of diabetic patients with reduced cardiovascular morbidity and mortality. With better understanding on the mechanisms of ROS generation and ROS-mediated endothelial damages/dysfunction, it is anticipated that new selective ROS-modulating agents and effective personalized strategies will be developed for the management of endothelial dysfunction in DM.

Glycemic control and clinical outcomes in diabetic patients with heart failure and reduced ejection fraction: insight from ventricular remodeling using cardiac MRI

BackgroundGlycemic control, as measured by glycosylated hemoglobin (HbA1c), is an important biomarker to evaluate diabetes severity and is believed to be associated with heart failure development. Type 2 diabetes mellitus (T2DM) and heart failure with reduced ejection fraction (HFrEF) commonly coexist, and the combination of these two diseases indicates a considerably poorer outcome than either disease alone. Therefore, glycemic control should be carefully managed. The present study aimed to explore the association between glycemic control and clinical outcomes, and to determine the optimal glycemic target in this specific population.MethodsA total of 262 patients who underwent cardiac MRI were included and were split by HbA1c levels [HbA1c < 6.5% (intensive control), HbA1c 6.5-7.5% (modest control), and HbA1c > 7.5% (poor control)]. The biventricular volume and function, as well as left ventricular (LV) systolic strains in patients in different HbA1c categories, were measured and compared. The primary and secondary outcomes were recorded. The association of different HbA1c levels with adverse outcomes was assessed.ResultsDespite similar biventricular ejection fractions, both patients with intensive and poor glycemic control exhibited prominent deterioration of LV systolic strain in the longitudinal component (P = 0.004). After a median follow-up of 35.0 months, 55 patients (21.0%) experienced at least one confirmed endpoint event. Cox multivariable analysis indicated that both patients in the lowest and highest HbA1c categories exhibited a more than 2-fold increase in the risk for primary outcomes [HbA1c < 6.5%: hazard ratio (HR) = 2.42, 95% confidence interval (CI) = 1.07–5.45; P = 0.033; HbA1c > 7.5%: HR = 2.24, 95% CI = 1.01–4.99; P = 0.038] and secondary outcomes (HbA1c < 6.5%: HR = 2.84, 95% CI = 1.16–6.96; P = 0.022; HbA1c > 7.5%: HR = 2.65, 95% CI = 1.08–6.50; P = 0.038) compared with those in the middle HbA1c category.ConclusionsWe showed a U-shaped association of glycemic control with clinical outcomes in patients with T2DM and HFrEF, with the lowest risk of adverse outcomes among patients with modest glycemic control. HbA1c between 6.5% and 7.5% may be served as the optimal hypoglycemic target in this specific population.

Evaluating the Effect of Diabetic Medications on Rates of Nonunion in Patients Undergoing Foot and Ankle Arthrodesis Treatments

Introduction/Purpose: Diabetes mellitus (DM) is known to negatively impact outcomes following surgical operations and increase the susceptibility of affected individuals to higher rates of nonunion, surgical site infection, ulceration, increased risk of amputation of the extremities, and various other perioperative complications. A number of in vitro studies suggest that the increase in undesired outcomes is largely secondary to the effects of diabetes-induced prolonged inflammation and advanced glycation end products (AGEs) on these patients' vascular systems and skeletal microarchitecture. However, there is a paucity of literature investigating the effects of blood glucose-regulating medications on the clinical outcomes of diabetic patients following fusion procedures. This study aims to determine the impact of commonly prescribed diabetic medications on bone health and bone healing following foot and ankle operations. Methods: A retrospective review was conducted of 114 diabetic patients undergoing ankle, hindfoot, or midfoot arthrodesis by one of two fellowship-trained foot and ankle orthopaedic surgeons from 2015-2022. Patients were identified by having undergone surgery via 27870, 27815, 27825, or 27835 CPT codes, as well as having been diagnosed with diabetes mellitus prior to or at time of surgery. Joints fused included the tibiotalar joint (n=45; 39.5%), subtalar joint (n=62; 54.4%), talonavicular joint (n=31; 27.2%), and calcaneocuboid (n=14; 12.3%). Data collected included demographics, medical history, diabetic medication, postoperative complications, readmission rates, and reoperation rates. 36 patient cases were noted to not have concurrent medications prescribed to control their diabetes, while the other 78 patient cases were concurrently prescribed either metformin (33 cases; 28.9%), insulin (19 cases; 16.7%), both metformin and insulin (18 cases; 15.8%), glipizides (11 cases; 9.6%), dulaglutides (7 cases; 6.1%), semaglutides (9 cases; 7.9%), and sitagliptins (8 cases; 7.0%). Results: The overall cohort was majority male (62.3%) with mean age 60.38 (range 31-76) years, mean BMI 34.00 (range 21.47- 61.38) kg/m2 and mean follow-up 1.90 (range .50-6.25) years. The cohort had a 27.2% superficial infection rate, 28.9% deep infection rate, 41.2% non-union rate, 47.4% reoperation rate, and a 14% 90-day readmission rate. Except for insulin-treated patients, who had significantly higher infection (insulin=45.9%, non-insulin=18.2%; p=.003) and deep infection rates (insulin=45.9%, non-insulin=18.2%; p=.003), there was no statistically significant difference in any outcomes by specific medication or any diabetic medication use. Patients with Charcot arthropathy (n=42) had significantly higher superficial infection (charcot=42.9%, non- Charcot=18.1%; p=.005), deep infection (Charcot=52.4%, non-Charcot=15.3%; p&lt;.001), and 90-day readmission rates (Charcot=26.2%, non-Charcot=6.9%; p=.006). Conclusion: Our results indicate that patients on insulin or patients with Charcot arthropathy may be at increased risk of infection following foot and ankle fusion procedures. Other common medications to control diabetes mellitus were not found to increase risk of adverse outcomes. This finding is useful for surgeons and physicians attempting to optimize the clinical outcomes of diabetic patients undergoing the described procedures. However, further study with a greater sample size is necessary to confirm these findings.

ROLE OF PROBIOTICS IN TYPE 2 DIABETES MELLITUS PATIENTS WITH HYPERTENSION: A REVIEW

Background: Type 2 Diabetes Mellitus (DM) is one of a global health problem. One of the comorbidities that often occurs in patients with type 2 DM is hypertension. Hypertension can increase the risk of cardiovascular complications. One of the causes of type 2 DM and hypertension is gut dysbiosis. An imbalance of gastrointestinal microbiota contributes to chronic inflammation and effects on the insulin action, increases insulin resistance, and leads to endothelial dysfunction. The role of this inflammatory mediator is a new therapeutic target in type 2 DM patients with hypertension. Objective: to describe how probiotic effect in type 2 diabetic patients with hypertension. Methods: All articles were obtained by conducting an electronic search through Pubmed and Google Scholar. Results: Probiotics help to restore the balance of the gastrointestinal microbiota, produce anti-inflammatory mediators, and suppress the pro-inflammatory mediators to control the glycemic profile and blood pressure of patients with type 2 DM with hypertension. All the clinical trial showed that probiotic help to maintaining clinical outcome in diabetic patients with hypertension. Conclusion: Probiotic effective for glycemic control and blood pressure in type 2 DM with hypertension.&#x0D; Keywords: Diabetes; Hypertension; Gut dysbiosis; Probiotics; Inflammation mediators

Abstract 18529: Early Coronary Revascularization Among "Stable" Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: The Role of Diabetes and Age

Introduction: Despite improvement in the management of patients with non-ST-elevation acute coronary (NSTE-ACS), this condition is still linked to a substantially increased mortality and morbidity among diabetic patients. Specifically, it remains uncertain whether patients whose condition can safely be stabilized at hospital admission should routinely receive an early coronary revascularisation. Hypothesis: We tested the hypothesis that a strategy of early coronary revascularization within 24 hours of diagnosis is superior to an initial conservative strategy in terms of clinical outcomes in diabetic patients who met stabilisation criteria at hospital admission. Comparison was made with a cohort of nondiabetic patients. Methods: The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Those with recurrent angina after hospital admission, cardiac arrest, haemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using inverse probability of treatment weighting models. Co-primary end points were all cause 30-day mortality and the composite end point of all cause 30-day mortality and left ventricular (LV) systolic dysfunction. Risk ratios (RRs) with their 95% CIs were employed. Results: Of the 7,473 NSTE-ACS patients identified, 2,220 were diabetics. Early revascularization was associated with survival benefit only in the elderly (≥65 years) both in diabetics (3.7% vs 6.6%; RR: 0.56; 95% CI: 0.32-0.96) and nondiabetic patients (2.8% vs 5.1%: RR: 0.55; 95% CI: 0.34-0.87). In the elderly population, an initial conservative strategy increased the risk of death or LV systolic dysfunction by 15.2% in diabetics compared with nondiabetic patients (37.7% vs 32.7%; RR: 1.15; 95% CI: 1.02-1.30). Conclusions: Early coronary revascularization does not lead to any survival advantage within 30 days from admission in a large number of NSTE-ACS patients who present to hospital in stable conditions. An early invasive management strategy may be best reserved for the elderly either with or without diabetes. The benefit of this strategy appears to be more pronounced in the diabetic population.

Repurposing alagebrium for diabetic foot ulcer healing: Impact on AGEs/NFκB/NOX1 signaling

BackgroundDiabetic foot ulcer (DFU) is a common diabetic complication associated with disability and reduced quality of life. Available therapeutics are not sufficient to combat the spread of DFU. Here we aim to investigate the impact of alagebrium, an advanced glycation end product (AGE)-crosslink breaker, on the healing of DFU. MethodsDiabetes was induced in Wistar rats by STZ, and after four weeks, wound was induced on the foot. Alagebrium (10 mg/kg) was administered orally for 14 days, and wound size was measured every 3 days. Behavioral tests i.e., hot plate and footprint tests, were performed to assess sensory function and gait. Blood was collected to assess HbA1c, serum AGEs, MDA and NOX1. Tissue was collected to assess histological changes and expression of NF-κB, iNOS, TNF-α, VEGF and EGF. In a subsequent set of experiments with similar design, alagebrium was applied topically as a film-forming gel. ResultsSystemic alagebrium treatment accelerated the healing of diabetic wound, improved sensory functions and gait, and ameliorated histological changes. It also reduced serum levels of AGEs, MDA and NOX1, and the tissue expression of NF-κB, iNOS, TNF-α, and increased VEGF and EGF in diabetic rats. Topical alagebrium led to similar beneficial effects i.e., accelerated diabetic wound healing, improved wound histological changes, reduced expression of NF-κB and iNOS and increased VEGF. ConclusionsOur findings suggest repurposing of alagebrium for the management of DFU to accelerate the healing process and improve the clinical outcomes in diabetic patients.

The Value of Fructosamine in Prediction of Angiographic Outcomes in Diabetic Patients Presented with Anterior STEMI Undergoing Their First Primary PCI

Abstract Background Cardiovascular diseases are the leading most common cause of death in industrialized countries. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction and failure of different organs especially heart and blood vessels. Objective To study the predictive value of Fructosamine as a marker of short-term glycemic control over 2-3 weeks on the angiographic and clinical outcomes in diabetic patients presented with anterior STEMI in Ain shams university hospital. Patients and Methods This is an observational study recruiting 100 patients presented with anterior STEMI who underwent their first primary percutaneous coronary intervention (PPCI) from May 2020 to December 2020. Results Angiographic results of patients post PCI were as follows: Regarding Thrombolysis in myocardial infarction (TIMI Flow), 8 patients had TIMI flow 0, 18 had TIMI I, 27 had TIMI II and 37 had TIMI III flow. Regarding myocardial blush grade (MBG) 12 patients had MBG grade 0, 27 had grade I, 20 had grade II and 4 had grade III. During follow up for one-month, Major adverse cardiac events (MACE) occurred in 56% of patients. Measured serum Fructosamine levels were ranging between (233 to 557 µmoll/L) the results showed a strong correlation between serum Fructosamine and TIMI flow MBG. Patients with higher Fructosamine level had worsen TIMI flow and MBG and more occurrence of MACE in diabetic patients after PPCI. Conclusion High Fructosamine level can be used as a predictor for worse outcomes in diabetic patients presented with Anterior STEMI. Abbreviations STEMI: ST segment elevation myocardial infarction; PPCI: primary percutaneous coronary intervention; TIMI: Thrombolysis in myocardial infarction; MBG: Myocardial blush grade; DM: Diabetes Mellitus; MACE: Major adverse cardiac events

Association of insulin use with LV remodeling and clinical outcomes in diabetic patients with heart failure and reduced ejection fraction: assessed by cardiac MRI

BackgroundInsulin is commonly used in type 2 diabetes mellitus (T2DM) to achieve glycemic control. However, recent evidence showed that insulin use is associated with poor outcomes in the context of heart failure (HF). Since heart failure with reduced ejection fraction (HFrEF) accounts for approximately 50% of cases in the general HF population, we aimed to evaluate the effect of insulin treatment on left ventricular (LV) remodeling and contractility abnormalities in a HFrEF cohort and assess whether insulin was a predictor of adverse outcomes in this entity.MethodsA total of 377 HFrEF patients who underwent cardiac MRI were included and divided according to diabetes status and the need for insulin treatment. LV structural and functional indices, as well as systolic strains, were measured. The determinants of impaired myocardial strains were assessed using linear regression analysis. The associated endpoints were determined using a multivariable Cox proportional hazards model.ResultsT2DM patients on insulin displayed a higher indexed LV end-diastolic volume and LV mass than those with T2DM not on insulin or those without T2DM, despite similar LV ejection fractions, accompanied by a higher three-dimensional spherical index (P < 0.01). Worse longitudinal and circumferential peak systolic strain was shown to occur in T2DM patients on insulin (P < 0.01). Insulin treatment was independently associated with impaired magnitudes of systolic strain. The median follow-up duration was 32.4 months (IQR, 15.6–43.2 months). Insulin treatment remained consistently associated with poor outcomes after adjustment for established confounders, with an adjusted hazard ratio of 3.11; (95% CI, 1.45–6.87; P = 0.009) in the overall cohort and 2.16 (95% CI, 1.08–4.59; P = 0.030) in the diabetes cohort.ConclusionsInsulin may further lead to adverse LV remodeling and contractile dysfunction in the context of HFrEF with T2DM. Considerable care should be taken when treating HFrEF patients with insulin.

Global trans-lesional computed tomography-derived fractional flow reserve gradient is associated with clinical outcomes in diabetic patients with non-obstructive coronary artery disease

BackgroundCoronary computed tomography angiography (CCTA)-derived fractional flow reserve (CT-FFR) enables physiological assessment and risk stratification, which is of significance in diabetic patients with nonobstructive coronary artery disease (CAD). We aim to evaluate prognostic value of the global trans-lesional CT-FFR gradient (GΔCT-FFR), a novel metric, in patients with diabetes without flow-limiting stenosis.MethodsPatients with diabetes suspected of having CAD were prospectively enrolled. GΔCT-FFR was calculated as the sum of trans-lesional CT-FFR gradient in all epicardial vessels greater than 2 mm. Patients were stratified into low-gradient without flow-limiting group (CT-FFR > 0.75 and GΔCT-FFR < 0.20), high-gradient without flow-limiting group (CT-FFR > 0.75 and GΔCT-FFR ≥ 0.20), and flow-limiting group (CT-FFR ≤ 0.75). Discriminant ability for major adverse cardiovascular events (MACE) prediction was compared among 4 models [model 1: Framingham risk score; model 2: model 1 + Leiden score; model 3: model 2 + high-risk plaques (HRP); model 4: model 3 + GΔCT-FFR] to determine incremental prognostic value of GΔCT-FFR.ResultsOf 1215 patients (60.1 ± 10.3 years, 53.7% male), 11.3% suffered from MACE after a median follow-up of 57.3 months. GΔCT-FFR (HR: 2.88, 95% CI 1.76–4.70, P < 0.001) remained independent risk factors of MACE in multivariable analysis. Compared with the low-gradient without flow-limiting group, the high-gradient without flow-limiting group (HR: 2.86, 95% CI 1.75–4.68, P < 0.001) was associated with higher risk of MACE. Among the 4 risk models, model 4, which included GΔCT-FFR, showed the highest C-statistics (C-statistics: 0.75, P = 0.002) as well as a significant net reclassification improvement (NRI) beyond model 3 (NRI: 0.605, P < 0.001).ConclusionsIn diabetic patients with non-obstructive CAD, GΔCT-FFR was associated with clinical outcomes at 5 year follow-up, which illuminates a novel and feasible approach to improved risk stratification for a global hemodynamic assessment of coronary artery in diabetic patients.

Assessment of cardiac biochemical markers cystatin C and lipoprotein(a) and their relationship with glycemic control in type 2 diabetes mellitus patients

Introduction: Type 2 diabetes mellitus, is one of the predominant health emergencies of this century. Cardiovascular diseases are associated with raised morbidity and mortality in diabetes, contributing to substantial share of community health expenditure. This study was taken up to determine level of cardiac biomarkers cystatin C (CysC) and lipoprotein(a) (Lp(a)) &amp; their association with glycemic control &amp; lipid profile parameters to assess cardiovascular risk profile in type 2 diabetes mellitus. Materials and methods: This study included 100 type 2 diabetes mellitus patients and 100 apparently healthy controls. Diabetic patients were categorised as good glycemic control (50) - HbA1c ≤ 7.5% and poor glycemic control (50) - HbA1c &gt; 7.5% groups. Biochemical parameters CysC, Lp(a), HbA1c and lipid profile were analysed in all participants. Results: Lp(a) and CysC were significantly increased in diabetic patients than in controls. CysC, total cholesterol (TC), low density lipoprotein (LDL), TC/HDL, LDL/ high density lipoprotein (HDL) ratio were significantly increased and HDL was decreased in poor glycemic control group than good glycemic control. CysC correlated positively with HbA1c, Lp(a), TC and LDL while negatively with HDL which was statistically significant. Correlation observed between Lp(a) and HbA1c was not significant. Conclusion: Our study denotes increased cardiovascular disease risk in diabetic patients particularly in those with poor glycemic control. Evaluation of CysC and Lp(a) together, would ameliorate cardiovascular disease (CVD) risk prediction and facilitate appropriate interventions. This study aids in stratification of high-risk diabetic persons for cardiovascular diseases at early asymptomatic phases which will prevent or delay disease advancement and improve clinical outcomes in diabetic patients.

Diabetic foot and lower limb amputations at central, provincial and tertiary hospitals-underscores the need for organised foot health services at primary healthcare level

BackgroundDiabetic foot amputations are a devastating outcome for any diabetic patient. They are associated with various risk factors, including failure to risk stratify the diabetic foot. Early risk stratification could lower foot complications risk at the primary healthcare level (PHC). In the Republic of South Africa (RSA), PHC clinics are the first entry point to the public healthcare system. Failure to correctly identify, risk categorise, and refer diabetic foot complications at this level may lead to poor clinical outcomes for diabetic patients. This study looks at the incidence of diabetic-related amputations at central and tertiary hospitals in Gauteng to highlight the case of the needed foot health services at the PHC level. MethodsA cross-sectional retrospective study that reviewed prospectively collected theatre records database of all patients who underwent a diabetic-related foot and lower limb amputation between January 2017 and June 2019. Inferential and descriptive statistics were performed, and patient demographics, risk factors and type of amputation were reviewed. ResultsThere were 1862 diabetic-related amputations in the period under review. Most patients (98 %) came from a poor socioeconomic background earning ZAR 0.00–70 000.00 (USD 0.00–4754.41) per annum. Most amputations, 62 % were in males, and the majority, 71 % of amputations, were in patients younger than 65. The first amputation was major in 73 % of the cases, and an infected foot ulcer was a primary amputation cause in 75 % of patients. ConclusionAmputations are a sign of poor clinical outcomes for diabetic patients. Due to the hierarchal nature of healthcare delivery in RSA, diabetic-related foot amputations could imply inadequate care of or access to diabetic foot complications at the PHC level in RSA. A lack of access to structured foot health services at PHC levels impedes early identification of foot complication identification and appropriate referral resulting in amputation in some of the patients.

Beyond the NURSE Acronym: The Functions of Empathy in Serious Illness Conversations.

Empathic communication, defined as both responding to emotions and actively appreciating another's world view, is associated with better outcomes for patients and families, including decreased anxiety and depression, and improved coping 1 Kelley JM Kraft-Todd G Schapira L Kossowsky J Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014; 9: e94207https://doi.org/10.1371/journal.pone.0094207 Crossref PubMed Scopus (420) Google Scholar , 2 Hoffstädt H Stouthard J Meijers MC et al. Patients’ and Clinicians’ Perceptions of Clinician-Expressed Empathy in Advanced Cancer Consultations and Associations with Patient Outcomes. Palliative Medicine Reports. 2020; 1: 76-83https://doi.org/10.1089/pmr.2020.0052 Crossref Google Scholar , 3 Neumann M Wirtz M Bollschweiler E et al. Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach. Patient Educ. Couns. 2007; 69: 63-75https://doi.org/10.1016/j.pec.2007.07.003 Crossref PubMed Scopus (186) Google Scholar , 4 Flickinger TE Saha S Roter D et al. Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ. Couns. 2016; 99: 220-226https://doi.org/10.1016/j.pec.2015.09.001 Crossref PubMed Scopus (68) Google Scholar , 5 Hojat M Louis DZ Markham FW Wender R Rabinowitz C Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad. Med. 2011; 86: 359-364https://doi.org/10.1097/ACM.0b013e3182086fe1 Crossref PubMed Scopus (678) Google Scholar . Despite this, clinicians who have not undergone formal communication training typically focus on information exchange and miss patients’ emotional and social cues. To address this gap, we use the acronym NURSE (Name, Understand, Respect, Support, Explore) 6 Fortin AH Dwamena FC Frankel RM Smith RC Smith's Patient-Centered Interviewing : An Evidence-Based Method. 4th ed. McGraw-Hill Education, New York2019 Google Scholar ,7 Back AL Arnold RM Baile WF Tulsky JA Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005; 55: 164-177https://doi.org/10.3322/canjclin.55.3.164 Crossref PubMed Scopus (430) Google Scholar to teach trainees how to respond to patient emotions. When used effectively, these skills communicate caring and help patients and families navigate their emotions and cope with their circumstances, both of which ultimately help with decision-making. However, we worry that some learners may not progress beyond this model, and may even see these empathic statements as a tool to get emotions to settle down and let the patient can make the “right” decision. This suggests that we - the teachers - need to do a better job explaining the way that emotions and empathy function in the clinician-patient/family interaction. Emotion and decision-making theory 8 Lerner JS Li Y Valdesolo P Kassam KS. Emotion and decision making. Annu. Rev. Psychol. 2015; 66: 799-823https://doi.org/10.1146/annurev-psych-010213-115043 Crossref PubMed Scopus (1081) Google Scholar ,9 Conte B Hahnel UJJ Brosch T. From values to emotions: Cognitive appraisal mediates the impact of core values on emotional experience. Emotion. 2022; https://doi.org/10.1037/emo0001083 Crossref Scopus (1) Google Scholar , as well as our clinical experiences, lead us to conclude that skilled empathy, beyond resolving emotion so the conversation can move forward, helps us in these discussions in at least four additional ways. Empathy helps us uncover and understand patient values, to appropriately pace the conversation, to facilitate healthy grieving, and, ultimately, transforms how we approach our work. Below we describe these four functions of empathy in an encounter in which we meet with a patient with serious illness or their family to discuss medical decisions. . We focus on the hospital setting, where we meet families in crisis and must build a connection quickly. However, these skills may apply to a wide variety of clinical encounters.

Effects of pre-operative oral carbohydrates on insulin resistance and postoperative recovery in diabetic patients undergoing coronary artery bypass grafting: study protocol for a prospective, single-blind, randomized controlled trial

BackgroundPreoperative carbohydrates (CHO) supplement has been widely investigated in nondiabetic patients undergoing a variety of surgeries. It has been proved that preoperative CHO could alleviate postoperative insulin resistance (IR) and improve patients’ well-being in nondiabetic patients. However, it remains controversial whether preoperative CHO could yield similar effects in diabetic patients. Till now, seldom has the administration of preoperative CHO been investigated in diabetic patients and there are limited studies reporting IR and postoperative recovery of diabetic patients undergoing cardiac surgery.Methods and analysisWe present a prospective, single-center, single-blind, randomized, no-treatment controlled trial of preoperative CHO on diabetic patients undergoing off-pump coronary artery bypass grafting (OPCAB). A total of 62 patients will be enrolled and randomized to either Group CHO or Group control (CTRL). Patients in Group CHO will consume CHO fluid containing 50 g carbohydrates orally the evening before surgery (20:00–24:00) while their counterparts in Group CTRL will be fasted after 20:00 the evening before surgery. The primary endpoint is postoperative IR assessed via homeostasis model assessment (HOMA). The secondary endpoints are postoperative levels of potential mediators relating to IR including inflammatory factors and stress reaction characterized by serum cortisol. Exploratory endpoints are in-hospital clinical endpoints. Continuous variables will be compared by Student’s t-test or Mann-Whitney U test. Categorical variables will be compared with χ2 test or Fisher’s exact test. All tests in the present study are two-tailed and P<0.05 is considered statistically significant. All analyses will be performed with R 4.0.4.DiscussionThis is the first prospective randomized controlled trial of preoperative CHO in diabetic patients undergoing cardiac surgery, with the hypothesis that preoperative CHO could improve postoperative IR and promote postoperative recovery. The research may assist in improving the clinical outcomes of diabetic patients undergoing OPCAB.Trial registrationThe trial has been prospectively registered with ClinicalTrials.gov (https://register.clinicaltrials.gov) and Chinese Clinical Trial Registry (http://www.chictr.org.cn). Registry number is NCT05540249 and ChiCTR2000029664 respectively. Registered on Sept. 14, 2022.Clinical trials unitFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.

Bifurcation strategies using second-generation drug-eluting stents on clinical outcomes in diabetic patients.

Diabetes mellitus (DM) is a critical risk factor for the pathogenesis and progression of coronary artery disease, with a higher prevalence of complex coronary artery disease, including bifurcation lesions. This study aimed to elucidate the optimal stenting strategy for coronary bifurcation lesions in patients with DM. A total of 905 patients with DM and bifurcation lesions treated with second-generation drug-eluting stents (DES) from a multicenter retrospective patient cohort were analyzed. The primary outcome was the 5-year incidence of target lesion failure (TLF), which was defined as a composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization. Among all patients with DM with significant bifurcation lesions, 729 (80.6%) and 176 (19.4%) were treated with one- and two-stent strategies, respectively. TLF incidence differed according to the stenting strategy during the mean follow-up of 42 ± 20 months. Among the stent strategies, T- and V-stents were associated with a higher TLF incidence than one-stent strategy (24.0 vs. 7.3%, p < 0.001), whereas no difference was observed in TLF between the one-stent strategy and crush or culotte technique (7.3 vs. 5.9%, p = 0.645). The T- or V-stent technique was an independent predictor of TLF in multivariate analysis (hazard ratio, 3.592; 95% confidence interval, 2.117-6.095; p < 0.001). Chronic kidney disease, reduced left ventricular ejection fraction, and left main bifurcation were independent predictors of TLF in patients with DM. T- or V-stenting in patients with DM resulted in increased cardiovascular events after second-generation DES implantation. https://clinicaltrials.gov/ct2/show/NCT03068494?term=03068494&draw=2&rank=1, identifier: NCT03068494.

Metformin and growth differentiation factor 15 (GDF15) in type 2 diabetes mellitus: A hidden treasure.

Type 2 diabetes mellitus (T2DM) is a chronic endocrine disorder due to the reduction of insulin sensitivity and relative deficiency of insulin secretion. Growth differentiation factor 15 (GDF15) belongs to the transforming growth factor beta (TGF-β) superfamily and was initially identified as macrophage inhibitory cytokine-1 (MIC-1). GDF15 is considered a cytokine with an anti-inflammatory effect and increases insulin sensitivity, reduces body weight, and improves clinical outcomes in diabetic patients. GDF15 acts through stimulation of glial-derived neurotrophic factor (GDNF) family receptor α-like (GFRAL), which is highly expressed in the brain stem to induce taste aversion. Metformin belongs to the group of biguanides that are derived from the plant Galega officinalis. It is interesting to note that metformin is an insulin-sensitizing agent used as a first-line therapy for T2DM that has been shown to increase the circulating level of GDF15. Thus, the present review aims to determine the critical association of the GDF15 biomarker in T2DM and how metformin agents affect it. This review illustrates that metformin activates GDF15 expression, which reduces appetite and leads to weight loss in both diabetic and nondiabetic patients. However, the present review cannot give a conclusion in this regard. Therefore, experimental, preclinical, and clinical studies are warranted to confirm the potential role of GDF15 in T2DM patients.

Diabetic ketoacidosis among patients admitted to a general hospital in Ethiopia: a spatial analysis

Abstract Non-Communicable diseases are rapidly increasing in low- and middle-income countries. The number of patients with diabetes is estimated to reach 4.7 million in Ethiopia by 2045. Ensuring access to care is critical to improving the management and clinical outcome of diabetic patients. The study describes the characteristics of patients with diabetic ketoacidosis (DKA) and evaluates the relationship between the severity of clinical presentation and the travel time to the hospital. A retrospective cohort study was conducted on the charts of patients admitted for DKA at St. Luke Catholic Hospital (SLCH), Wolisso, Oromia Region (Ethiopia), between 01/01/2021 and 31/08/2021. Demographic and clinical data were collected. Negative binomial regression was used to explore the relationship between the incidence of admissions for DKA and travel time to the hospital. Logistic regression was used to estimate the odds of insulin treatment. Results were presented with 95% confidence intervals. During the study period, 651 patients were admitted, including 77 (11.8%) for DKA (33 females (42.9%) and 44 males (57.1%)), with no differences based on diabetes type (p = 0.258). The mean age was 35 years (IQR 19.0-52.0). Mean BMI was 18.4 kg/m2 (IQR 15.6-19.5), with no differences based on diabetes type (p = 0.639). Cumulative incidence of hospitalizations was significantly correlated to travel time to the hospital (p = 0.039) with an Incident Rate Ratio of 1.01%[1.00-1.02]. The cumulative incidence ranged from 7.0%[4.5-10.3] in Wolisso to 30.8%[14.3-51.8] in Ameya, the most distant district. The relative probability of insulin treatment was higher with increasing time to SLCH (OR 1.11[1.02-1.21] p = 0.027). The hospitalization rate for DKA was significantly correlated with the travel time to the hospital. Access to care is therefore a key factor for health that should be taken into account by improvement programs and the spatial analysis of travel time could help focus on priority areas. Key messages • Spatial analysis can be a robust tool to tailor population healthcare needs on its own topography. • Health policies must consider that accessibility can influence the severity of clinical presentation.

Evaluation of the Effects of Being Over 65 Years of Age on Different Clinical Outcomes in Diabetic Patients with COVID-19

Evaluation of the Effects of Being Over 65 Years of Age on Different Clinical Outcomes in Diabetic Patients with COVID-19

The relationship between clinical outcomes of arthroscopic rotator cuff repair and hemoglobin A1c

BackgroundThe clinical outcomes of diabetic patients who underwent arthroscopic rotator cuff repair have been reported. However, few studies have focused on the relationship between these clinical outcomes and postoperative hemoglobin A1c. This study compared clinical outcomes of diabetic patients with a hemoglobin A1c < 7% to those with a hemoglobin A1c ≥ 7% at 12 months post-arthroscopic rotator cuff repair. MethodsThis retrospective study involved 51 consecutive patients who underwent arthroscopic rotator cuff repair from 2015 to 2020. Approximately 26 and 25 shoulders were assigned to a Low group (hemoglobin A1c < 7%) and High group (hemoglobin A1c ≥ 7%) at 12 months postoperatively, respectively. Patients with poorly controlled diabetes were preoperatively hospitalized for perioperative diabetic control. Clinical outcomes were shoulder range-of-motion, Constant Shoulder Score, and University of California, Los Angeles Score preoperatively and at 12 months postoperatively. Complications were also evaluated. ResultsBoth groups showed significant improvement in their range-of-motion, Constant Shoulder Score, and University of California, Los Angeles score at 12 months post-arthroscopic rotator cuff repair (p < 0.05) except external rotation in High group. These improvements were significantly inferior in the High group compared to the Low group (Low/High group; 167.3 ± 7.7°/159.5 ± 16.3° for forward flexion; p = 0.013, 94.9 ± 7.6/90.1 ± 9.9 points for Constant Shoulder Score; p = 0.033, 32.6 ± 3.6/30.6 ± 4.1 points for University of California, Los Angeles score, p = 0.037). Hemoglobin A1c at 12 months postoperatively was also significantly inferior in the High group (Low/High group; 6.5 ± 0.3%/7.6 ± 0.8%; p < 0.05). The rate of rotator cuff retear was not significantly different between groups (Sugaya type4; p = 0.49, type5; p = 0.322) and there were no cases of infection or shoulder stiffness in either group. ConclusionDiabetic patients showed improvement of their range-of-motion and function after arthroscopic rotator cuff repair; however, patients with poorly controlled diabetes had significantly inferior improvement.

Circulating Biomarkers of Endothelial Dysfunction and Inflammation in Predicting Clinical Outcomes in Diabetic Patients with Critical Limb Ischemia.

Critical limb ischemia (CLI) is a severe manifestation of peripheral artery disease characterized by ischemic pain, which is frequently associated with diabetes and non-healing lesions to inferior limbs. The clinical management of diabetic patients with CLI typically includes percutaneous transluminal angioplasty (PTA) to restore limb circulation and surgical treatment of diabetic foot ulcers (DFU). However, even after successful treatment, CLI patients are prone to post-procedure complications, which may lead to unplanned revascularization or foot surgery. Unfortunately, the factors predicting adverse events in treated CLI patients are only partially known. This study aimed to identify potential biomarkers that predict the disease course in diabetic patients with CLI. For this purpose, we measured the circulating levels of a panel of 23 molecules related to inflammation, endothelial dysfunction, platelet activation, and thrombophilia in 92 patients with CLI and DFU requiring PTA and foot surgery. We investigated whether these putative biomarkers were associated with the following clinical endpoints: (1) healing of the treated DFUs; (2) need for new revascularization of the limb; (3) appearance of new lesions or relapses after successful healing. We found that sICAM-1 and endothelin-1 are inversely associated with DFU healing and that PAI-1 and endothelin-1 are associated with the need for new revascularization. Moreover, we found that the levels of thrombomodulin and sCD40L are associated with new lesions or recurrence, and we show that the levels of these biomarkers could be used in a decision tree to assign patients to clusters with different risks of developing new lesions or recurrences.

Classification Model for Diabetic Foot, Necrotizing Fasciitis, and Osteomyelitis.

Simple SummaryNecrotizing fasciitis (NF) and osteomyelitis (OM) are severe complications in patients with diabetic foot ulcers (DFUs). Although NF and OM often cause results including limb amputation and death, definite diagnoses of these are challenging. To aid the prompt and proper diagnosis of NF and OM in patients with DFU, we developed and evaluated a novel prediction model based on machine learning technology. In summary, our prediction model appropriately discriminated the NF and OM from diabetic foot. Moreover, this prediction model has advantages in that it is based on the demographic data and routine laboratory results, which requires no additional examinations which are complicated or expensive.Diabetic foot ulcers (DFUs) and their life-threatening complications, such as necrotizing fasciitis (NF) and osteomyelitis (OM), increase the healthcare cost, morbidity and mortality in patients with diabetes mellitus. While the early recognition of these complications could improve the clinical outcome of diabetic patients, it is not straightforward to achieve in the usual clinical settings. In this study, we proposed a classification model for diabetic foot, NF and OM. To select features for the classification model, multidisciplinary teams were organized and data were collected based on a literature search and automatic platform. A dataset of 1581 patients (728 diabetic foot, 76 NF, and 777 OM) was divided into training and validation datasets at a ratio of 7:3 to be analyzed. The final prediction models based on training dataset exhibited areas under the receiver operating curve (AUC) of the 0.80 and 0.73 for NF model and OM model, respectively, in validation sets. In conclusion, our classification models for NF and OM showed remarkable discriminatory power and easy applicability in patients with DFU.