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Aim

To assess the factors associated with antihyperglycaemic medication initiation in UK patients with newly diagnosed type 2 diabetes.

Methods

In a retrospective cohort study, patients with newly diagnosed type 2 diabetes were identified during the index period of 2003-2005. Eligible patients were ≥ 30 years old at the date of the first observed diabetes diagnosis (referred to as index date) and had at least 2 years of follow-up medical history (N = 9,158). Initiation of antihyperglycaemic medication (i.e., treatment) was assessed in the 2-year period following the index date. Adjusted Cox regression models were used to examine the association between time to medication initiation and patient age and other factors.

Results

Mean (SD) HbA1c at diagnosis was 8.1% (2.3). Overall, 51% of patients initiated antihyperglycaemic medication within 2 years (65%, 55%, 46% and 40% for patients in the 30- < 45, 45- < 65, 65- < 75, 75+ age groups, respectively). Among the treated patients, median (25th, 75th percentile) time to treatment initiation was 63 (8, 257) days. Of the patients with HbA1c ≥ 7.5% at diagnosis, 87% initiated treatment within 2 years. These patients with a higher HbA1c also had shorter time to treatment initiation (adjusted hazard ratio (HR) = 2.44 [95% confidence interval (CI): 1.61, 3.70]; p < 0.0001). Increasing age (in years) was negatively associated with time to treatment initiation (HR = 0.98 [95% CI: 0.97, 0.99]; p < 0.001). Factors significantly associated with shorter time to treatment initiation included female gender and use of cardiovascular medications at baseline or initiated during follow up.

Conclusions

In this UK cohort of patients with newly diagnosed type 2 diabetes, only 51% had antihyperglycaemic medication initiated over a 2-year period following diagnosis. Older patients were significantly less likely to have been prescribed antihyperglycaemic medications. Elevated HbA1c was the strongest factor associated with initiating antihyperglycaemic medication in these patients.

Introduction

To identify reasons why primary care physicians (PCPs) do not treat older patients newly diagnosed with type 2 diabetes mellitus (T2DM) with antihyperglycemic agents following diagnosis.

Methods

US PCPs were surveyed via the internet regarding their reasons for not treating patients aged >65 years diagnosed with T2DM and had not yet initiated antihyperglycemic therapy for ≥6 months after diagnosis. PCPs were requested to provide relevant clinical information for untreated older patients and select applicable reasons for not initiating treatment from a list of 35 possibilities, grouped into five categories.

Results

A total of 508 PCPs completed the online survey and provided complete clinical data for 770 patients. The reasons provided by the first-ranked physician for not initiating antihyperglycemic therapy were related to diet and exercise (57.5%); mild hyperglycemia (23.8%); patient’s concerns (13.4%); concerns about antihyperglycemic agents (3.0%); and comorbidities and polypharmacy (2.3%). The “diet and exercise” category was the most common first-ranked non-treatment reason, regardless of recent hemoglobin A1c (HbA1c) stratum. Reasons within the “patient’s concerns,” “concerns related to antihyperglycemic agents,” and “comorbidities and polypharmacy” categories tended to be selected more often as first-ranked reasons by physicians for patients with higher HbA1c values. Of the 158 patients whose physicians planned to initiate antihyperglycemic therapy within the next month, 54.4% already had a most recent HbA1c value above their physician-stated threshold for treatment initiation.

Conclusion

In the PCPs studied, there was a tendency to select appropriate reasons for non-treatment with antihyperglycemic agents given their patients’ glycemic status. However, there was inertia related to the initiation of pharmacological therapy in some older patients with newly diagnosed T2DM. Important factors included physicians’ perceptions of “mild” hyperglycemia and the HbA1c threshold for using antihyperglycemic agents.

Objectives To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes.

Design We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current “real world” costs of delivering the intervention estimated for a hypothetical primary care trust.

Setting Primary care trusts in the United Kingdom.

Participants Patients with newly diagnosed type 2 diabetes.

Intervention A six hour structured group education programme delivered in the community by two professional healthcare educators.

Main outcome measures Incremental costs and quality adjusted life years (QALYs) gained.

Results On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is £209 (95% confidence interval −£704 to £1137; €251, −€844 to €1363; $326, −$1098 to $1773), the incremental gain in QALYs per person is 0.0392 (−0.0813 to 0.1786), and the mean incremental cost per QALY is £5387. Using “real world” intervention costs, the lifetime incremental cost of the DESMOND intervention is £82 (−£831 to £1010) and the mean incremental cost per QALY gained is £2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of £20 000 per QALY is 66% using trial based intervention costs and 70% using “real world” costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year.

Conclusion Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.

Background

Despite the major public health impact of diabetes, recent population-based data regarding its prevalence and comorbidity are sparse.

Methods

The prevalence and comorbidity of diabetes mellitus were analyzed in a nationally representative sample (N = 9133) of the non-institutionalized German adult population aged 50 years and older. Information on physician-diagnosed diabetes and 20 other chronic health conditions was collected as part of the national telephone health interview survey ‘German Health Update (GEDA)’ 2009. Overall, 51.2% of contacted persons participated. Among persons with diabetes, diabetes severity was defined according to the type and number of diabetes-concordant conditions: no diabetes-concordant condition (grade 1); hypertension and/or hyperlipidemia only (grade 2); one comorbidity likely to represent diabetes-related micro- or macrovascular end-organ damage (grade 3); several such comorbidities (grade 4). Determinants of diabetes severity were analyzed by multivariable ordinal regression.

Results

The 12-month prevalence of diabetes was 13.6% with no significant difference between men and women. Persons with diabetes had a significantly higher prevalence and average number of diabetes-concordant as well as diabetes-discordant comorbidities than persons without diabetes. Among persons with diabetes, 10.2%, 46.8%, 35.6% and 7.4% were classified as having severity grade 1–4, respectively. Determinants of diabetes severity included age (cumulative odds ratio 1.05, 95% confidence interval 1.03-1.07, per year) and number of discordant comorbidities (1.40, 1.25-1.55). With respect to specific discordant comorbidities, diabetes severity was correlated to depression (2.15, 1.29-3.56), respiratory disease (2.75, 1.72-4.41), musculoskeletal disease (1.53, 1.06-2.21), and severe hearing impairment (3.00, 1.21-7.41).

Conclusions

Diabetes is highly prevalent in the non-institutionalized German adult population 50 years and older. Diabetes comorbidities including diabetes-concordant and diabetes-discordant conditions need to be considered in epidemiological studies, in order to monitor disease burden and quality of diabetes care. Definitional standards of diabetes severity need to be refined and consented.

OBJECTIVE--To examine the association between smoking, alcohol consumption, and the incidence of non-insulin dependent diabetes mellitus in men of middle years and older. DESIGN--Cohort questionnaire study of men followed up for six years from 1986. SETTING--The health professionals' follow up study being conducted across the United States. SUBJECTS--41,810 male health professionals aged 40-75 years and free of diabetes, cardiovascular disease, and cancer in 1986 and followed up for six years. MAIN OUTCOME MEASURE--Incidence of non-insulin dependent diabetes mellitus diagnosed in the six years. RESULTS--During 230,769 person years of follow up 509 men were newly diagnosed with diabetes. After controlling for known risk factors men who smoked 25 or more cigarettes daily had a relative risk of diabetes of 1.94 (95% confidence interval 1.25 to 3.03) compared with non-smokers. Men who consumed higher amounts of alcohol had a reduced risk of diabetes (P for trend < 0.001). Compared with abstainers men who drank 30.0-49.9 g of alcohol daily had a relative risk of diabetes of 0.61 (95% confidence interval 0.44 to 0.91). CONCLUSIONS--Cigarette smoking may be an independent, modifiable risk factor for non-insulin dependent diabetes mellitus. Moderate alcohol consumption among healthy people may be associated with increased insulin sensitivity and a reduced risk of diabetes.

Objectives To determine the incidence of any and referable diabetic retinopathy in people with type 2 diabetes mellitus attending an annual screening service for retinopathy and whose first screening episode indicated no evidence of retinopathy.

Design Retrospective four year analysis.

Setting Screenings at the community based Diabetic Retinopathy Screening Service for Wales, United Kingdom.

Participants 57 199 people with type 2 diabetes mellitus, who were diagnosed at age 30 years or older and who had no evidence of diabetic retinopathy at their first screening event between 2005 and 2009. 49 763 (87%) had at least one further screening event within the study period and were included in the analysis.

Main outcome measures Annual incidence and cumulative incidence after four years of any and referable diabetic retinopathy. Relations between available putative risk factors and the onset and progression of retinopathy.

Results Cumulative incidence of any and referable retinopathy at four years was 360.27 and 11.64 per 1000 people, respectively. From the first to fourth year, the annual incidence of any retinopathy fell from 124.94 to 66.59 per 1000 people, compared with referable retinopathy, which increased slightly from 2.02 to 3.54 per 1000 people. Incidence of referable retinopathy was independently associated with known duration of diabetes, age at diagnosis, and use of insulin treatment. For participants needing insulin treatment with a duration of diabetes of 10 years or more, cumulative incidence of referable retinopathy at one and four years was 9.61 and 30.99 per 1000 people, respectively.

Conclusions Our analysis supports the extension of the screening interval for people with type 2 diabetes mellitus beyond the currently recommended 12 months, with the possible exception of those with diabetes duration of 10 years or more and on insulin treatment.

Newly diagnosed insulin-dependent diabetic Nigerian Africans were studied prospectively over a 6-year period and were analyzed for sex, age at diagnosis, and month of onset of symptoms. Insulin-dependent diabetes mellitus (IDDM) rarely occurred in patients younger than the age of 10. A female preponderance occurred in those aged 20 and younger, and a male preponderance occurred in those aged 20 and older. The onset of symptoms occurred predominantly in the dry months of the year (October to March), peaking in February. The educational level and current employment status of the patients were compared with age- and sex-matched controls. The diabetics were found to have significantly less education, and approximately one third (34.9%) were unemployed compared with 10% of the controls. Control of the disease was found to be poor in three fourths of the patients. Various factors that prevent young diabetics in developing countries from living a full life are discussed.

This study was aimed to investigate the prevalence of diabetic retinopathy and its associated factors in rural Korean patients with type 2 diabetes. A population-based, cross-sectional diabetic retinopathy survey was conducted from 2005 to 2006 in 1,298 eligible participants aged over 40 yr with type 2 diabetes identified in a rural area of Chungju, Korea. Diabetic retinopathy was diagnosed by a practicing ophthalmologist using funduscopy. The overall prevalence of diabetic retinopathy in the population was 18% and proliferative or severe non-proliferative form was found in 5.0% of the study subjects. The prevalence of retinopathy was 6.2% among those with newly diagnosed type 2 diabetes and 2.4% of them had a proliferative or severe non-proliferative diabetic retinopathy. The odds ratio of diabetic retinopathy increased with the duration of diabetes mellitus (5-10 yr: 5.2- fold; > 10 yr: 10-fold), postprandial glucose levels (> 180 mg/dL: 2.5-fold), and HbA1c levels (every 1% elevation: 1.34-fold). The overall prevalence of diabetic retinopathy in rural Korean patients was similar to or less than that of other Asian group studies. However, the number of patients with proliferative or severe non-proliferative diabetic retinopathy was still high and identified more frequently at the time of diagnosis. This emphasizes that regular screening for diabetic retinopathy and more aggressive management of glycemia can reduce the number of people who develop diabetic retinopathy.

Background:

Metformin is widely accepted as first-line pharmacotherapy for patients with type 2 diabetes mellitus when glycemic control cannot be achieved by lifestyle interventions alone. However, uncertainty exists regarding the optimal second-line therapy for patients whose diabetes is inadequately controlled by metformin monotherapy. Increased use of newer, more costly agents, along with the rising incidence of type 2 diabetes, carries significant budgetary implications for health care systems. We conducted this analysis to determine the relative costs, benefits and cost-effectiveness of options for second-line treatment of type 2 diabetes.

Methods:

We used the United Kingdom Prospective Diabetes Study Outcomes Model to forecast diabetes-related complications, quality-adjusted life-years and costs of alternative second-line therapies available in Canada for adults with type 2 diabetes inadequately controlled by metformin. We obtained clinical data from a systematic review and mixed treatment comparison meta-analysis, and we obtained information on costs and utilities from published sources. We performed extensive sensitivity analyses to test the robustness of results to variation in inputs and assumptions.

Results:

Sulphonylureas, when added to metformin, were associated with the most favourable cost-effectiveness estimate, with an incremental cost of $12 757 per quality-adjusted life-year gained, relative to continued metformin monotherapy. Treatment with other agents, including thiazolidinediones and dipeptidyl peptidase-4 inhibitors, had unfavourable cost-effectiveness estimates compared with sulphonylureas. These results were robust to extensive sensitivity analyses.

Interpretation:

For most patients with type 2 diabetes that is inadequately controlled with metformin monotherapy, the addition of a sulphonylurea represents the most cost-effective second-line therapy.

In India, Adenanthera pavonina is traditionally used in the treatment of diabetes mellitus and lipid disorders. In the present study, the antihyperglycaemic and lipid lowering effect of Adenanthera pavonina seed aqueous extract (APSAE) was evaluated using streptozotocin induced diabetes in rats. Streptozotocin was given at the dose of 55 mg/kg, i.p. After induction of diabetes, APSAE was administered for 30 days p. o. and simultaneously different biochemical parameters like plasma glucose, HbA1c, serum triglyceride, cholesterol, LDL-cholesterol and HDL-cholesterol were estimated. Diabetic control showed significant increase (P < 0.01) in plasma glucose, serum triglyceride, cholesterol, LDL-cholesterol and significant decrease (P < 0.01) in serum HDL-cholesterol and HbA1c. Treatment with APSAE showed significant reduction (P < 0.01) in plasma glucose when compared with diabetic control. The elevated levels of serum triglyceride and cholesterol levels were significantly reduced (P < 0.01) by APSAE. APSAE treatment for 30 days showed significant decrease in serum LDL-cholesterol (P < 0.01) and significant increase in serum HDL cholesterol level (P < 0.01). Moreover, diabetic control there was significant decrease in HbA1c which was significantly increased (P < 0.05) by treatment with APSAE. Hence, from the result obtained in the present study it can be confirmed that Adenanthera pavonina has the potential to treat diabetes condition and associated lipid disorders.

Zingiber officinale (ginger) has been used as herbal medicine to treat various ailments worldwide since antiquity. Recent evidence revealed the potential of ginger for treatment of diabetes mellitus. Data from in vitro, in vivo, and clinical trials has demonstrated the antihyperglycaemic effect of ginger. The mechanisms underlying these actions are associated with insulin release and action, and improved carbohydrate and lipid metabolism. The most active ingredients in ginger are the pungent principles, gingerols, and shogaol. Ginger has shown prominent protective effects on diabetic liver, kidney, eye, and neural system complications. The pharmacokinetics, bioavailability, and the safety issues of ginger are also discussed in this update.

Prostate cancer and the androgen deprivation therapy (ADT) thereof are involved in diabetes in terms of diabetes-associated carcinogenesis and ADT-related metabolic disorder, respectively. The aim of this study is to systematically review relevant literature. About 218,000 men are estimated to be newly diagnosed with prostate cancer every year in the United States. Approximately 10% of them are still found with metastasis, and in addition to them, about 30% of patients with nonmetastatic prostate cancer recently experience ADT. Population-based studies have shown that dissimilar to other malignancies, type 2 diabetes is associated with a lower incidence of prostate cancer, whereas recent large cohort studies have reported the association of diabetes with advanced high-grade prostate cancer. Although the reason for the lower prevalence of prostate cancer among diabetic men remains unknown, the lower serum testosterone and PSA levels in them can account for the increased risk of advanced disease at diagnosis. Meanwhile, insulin resistance already appears in 25–60% of the patients 3 months after the introduction of ADT, and long-term ADT leads to a higher incidence of diabetes (reported hazard ratio of 1.28–1.44). Although the possible relevance of cytokines such as Il-6 and TNF-α to ADT-related diabetes has been suggested, its mechanism is poorly understood.

Few data exist on the impact of diabetes mellitus, particularly the insulin-dependent subtype, in many parts of Africa. The importance of diabetes as a public health problem in the East African Islands of Zanzibar was assessed through prospective registration of all newly diagnosed diabetic individuals who attended the diabetic clinic at Mnazimmoja Hospital from January 1986 to December 1989. A total of 323 diabetic patients, 192 men and 131 women, were diagnosed. Two hundred fifty-three (78.3%) individuals had noninsulin-dependent diabetes mellitus (NIDDM), 61 (18.9%) had insulin-dependent diabetes mellitus (IDDM), and 9 (2.8%) had diabetes of uncertain type. Two hundred twenty-six (70%) of the patients were town residents, 62 (19.2%) had office jobs, and 84 (26%) were laborers. The majority of the patients presented with the classic symptoms of diabetes. A positive family history of diabetes was found in 35 (13.8%) and 4 (6.6%) of the NIDDM and IDDM cases respectively. Hypertension was diagnosed in 29 (11.5%) of all NIDDM individuals while obesity was present in only 41 (16.2%) of all NIDDM patients. These data suggest that diabetes is a problem of major public health importance in the Islands of Zanzibar.

Background

There have been few prospective observational studies which recruited older newly-diagnosed cancer patients, and of these only some have reported information on the number needed to screen to recruit their study sample, and the number and reasons for refusal and drop-out. This paper reports on strategies to recruit older newly-diagnosed cancer patients prior to treatment into an observational prospective pilot study and to retain them during a six-month period.

Methods

Medical charts of all patients in the Segal Cancer Centre aged 65 and over were screened and evaluated for inclusion. Several strategies to facilitate recruitment and retention were implemented. Reasons for exclusion, refusal and loss to follow-up were recorded. Descriptive statistics were used to report the reasons for refusal and loss to follow-up. A non-response analysis using chi-square tests and t-tests was conducted to compare respondents to those who refused to participate and to compare those who completed the study to those who were lost to follow-up. A feedback form with open-ended questions was administered following the last interview to obtain patient's opinions on the length of the interviews and conduct of this pilot study.

Results

3060 medical charts were screened and 156 eligible patients were identified. Of these 112 patients participated for a response rate of 72%. Reasons for refusal were: feeling too anxious (40%), not interested (25%), no time (12.5%), too sick (5%) or too healthy (5%) or other reasons (5%). Ninety-one patients participated in the six-month follow-up (retention 81.3%), seven patients refused follow-up (6.2%) and fourteen patients died (12.5%) during the course of the study. The median time to conduct the baseline interview was 45 minutes and 57% of baseline interviews were conducted at home. Most patients enjoyed participation and only five felt that the interviews were too long.

Conclusion

It was feasible to recruit newly-diagnosed cancer patients prior to treatment although it required considerable time and effort. Once patients were included, the retention rate was high despite the fact that most were undergoing active cancer treatment.

Objectives:

This study aimed to compare the effects of metformin and glibenclamide on high sensitivity serum C-reactive protein (hs-CRP) and oxidative stress, represented by serum malondialdehyde (MDA) and total antioxidant status (TAS) in newly-diagnosed patients with Type 2 diabetes mellitus (DM) at baseline and after 2 months of therapy in comparison to controls.

Methods:

The subjects, recruited from Al-Wafaa Centre for Diabetes Management and Research, Iraq, November 2009 to January 2011, were 103 newly-diagnosed Type 2 DM patients; 53 were prescribed metformin and 50 glibenclamide. The control group was 40 apparently healthy volunteers. Blood samples were taken from all subjects after overnight fasting. Sera were separated and assays of hs-CRP, MDA and TAS were done. After 2 months monotherapy, the blood samples and assays were repeated.

Results:

There were significant differences between patients prescribed metformin and glibenclamide and the controls with regard to serum hs-CRP, MDA and TAS. There was a significant reduction in the serum MDA and a significant raise in the serum TAS levels, with no significant effects on serum hs-CRP levels after metformin therapy, but no significant effects on these parameters after glibenclamide therapy. The percentage of variation in these parameters after both drugs, showed a significant raise in serum TAS levels with the metformin therapy with no significant effects in serum MDA and hs-CRP.

Conclusion:

Metformin positively affected the oxidant/antioxidant balance in newly-diagnosed Type 2 DM patients with no significant effects on acute phase reaction protein. Glibenclamide had no significant effects on oxidant/antioxidant balance and acute phase reaction protein.

Introduction

To determine the foot self-care practices performed by Filipino American (FA) women with type 2 diabetes mellitus (DM).

Method

The Summary of Diabetes Self Care Activities - Revised and Expanded measure was administered to 118 FA adult female immigrants with type 2 DM.

Results

Younger FA women (<65 years), participants with higher education, those who immigrated to the United States (US) at younger ages, and participants diagnosed with type 2 DM at younger ages reported they washed their feet every day during the past week. Moreover, FA women who immigrated to the US at younger ages and participants who were diagnosed with the disease at younger ages reported that they dried their feet (in between toes) daily during the previous week. Further, FA women who were diagnosed with type 2 DM at younger ages were more likely to report that they checked their feet every day during the past week, when compared with participants who were diagnosed with the disease at older ages. Finally, most FA women did not inspect the inside of their shoes.

Conclusion

Foot self-care practices were less frequently performed by older FA women with type 2 DM (≥65 years), making them more prone to the development of foot problems such as ulcers, infections, and disfigurations. Optimum foot self-care practices must be encouraged in older FA women to prevent such foot problems, and subsequent amputations.

Introduction

To determine the foot self-care practices performed by Filipino American (FA) women with type 2 diabetes mellitus (DM).

Method

The Summary of Diabetes Self Care Activities - Revised and Expanded measure was administered to 118 FA adult female immigrants with type 2 DM.

Results

Younger FA women (<65 years), participants with higher education, those who immigrated to the United States (US) at younger ages, and participants diagnosed with type 2 DM at younger ages reported they washed their feet every day during the past week. Moreover, FA women who immigrated to the US at younger ages and participants who were diagnosed with the disease at younger ages reported that they dried their feet (in between toes) daily during the previous week. Further, FA women who were diagnosed with type 2 DM at younger ages were more likely to report that they checked their feet every day during the past week, when compared with participants who were diagnosed with the disease at older ages. Finally, most FA women did not inspect the inside of their shoes.

Conclusion

Foot self-care practices were less frequently performed by older FA women with type 2 DM (≥65 years), making them more prone to the development of foot problems such as ulcers, infections, and disfigurations. Optimum foot self-care practices must be encouraged in older FA women to prevent such foot problems, and subsequent amputations.

Type I diabetes mellitus appears to result from an insidious immunologic destruction of pancreatic β-cells in genetically susceptible persons exposed to one or a series of environmental insults. This genetic susceptibility is related to alleles located on the sixth chromosome in the HLA-DR or an adjacent region. With superimposition of a viral or other environmental triggering event, cell-and antibody-mediated events are activated that lead to the specific autorejection of β-cells and consequent insulin deficiency. Immunosuppressive strategies to impede or halt complete destruction of β-cells, using cyclosporine, have already been initiated in both animals and humans with diabetes mellitus. Because of the potential toxicity of all current immunosuppressive regimens, such therapies cannot, at this time, be considered for wide-scale use in persons with type I diabetes. Reported inductions, however, of insulin independence in patients with newly diagnosed type I diabetes using cyclosporine or other agents underscore the role of the immune system in the pathogenesis of the disease and highlight the need to develop safer, more specific immunomodulation designed to avoid complete β-cell destruction.

Background and Aims

Potential treatment effect modifiers (TEMs) are specific diseases or conditions with a well-described mechanism for treatment effect modification. The prevalence of TEMs in older adults with type 2 diabetes mellitus (DM) is unknown. Objectives were to (1) determine the prevalence of pre-specified potential TEMs; (2) demonstrate the potential impact of TEMs in the older adult population using a simulated trial; (3) identify TEM combinations associated with number of hospitalizations to test construct validity.

Methods

Data are from the nationally-representative United States National Health and Examination Survey, 1999–2004: 8,646 Civilian, non-institutionalized adults aged 45–64 or 65+ years, including 1,443 with DM. TEMs were anemia, congestive heart failure, liver inflammation, polypharmacy, renal insufficiency, cognitive impairment, dizziness, frequent mental distress, mobility difficulty, and visual impairment. A trial was simulated to examine prevalence of potential TEM impact. The cross-sectional association between TEM patterns and number of hospitalizations was estimated to assess construct validity.

Results

The prevalence of TEMs was substantial such that 19.0% (95%CI: 14.8–23.2) of middle-aged adults and 38.0% (95% CI: 33.4–42.5) of older adults had any two. A simulated trial with modest levels of interaction suggested the prevalence of TEMs could nullify treatment benefit in 3.9–27.2% of older adults with DM. Compared to having DM alone, hospitalization rate was increased by several combinations of TEMs with substantial prevalence.

Conclusions

We provide national benchmarks that can be used to evaluate TEM prevalence reported by clinical trials of DM, and correspondingly their external validity to older adults.

Background

Patients with type 2 diabetes have an increased risk of cardiovascular disease. Few studies have evaluated the cardiovascular disease (CVD) risk simultaneously using the United Kingdom Prospective Diabetes Study (UKPDS) risk engine and non-invasive vascular tests in patients with newly diagnosed type 2 diabetes.

Methods

Participants (n=380; aged 20 to 81 years) with newly diagnosed type 2 diabetes were free of clinical evidence of CVD. The 10-year coronary heart disease (CHD) and stroke risks were calculated for each patient using the UKPDS risk engine. Carotid intima media thickness (CIMT), flow mediated dilation (FMD), pulse wave velocity (PWV) and augmentation index (AI) were measured. The correlations between the UKPDS risk engine and the non-invasive vascular tests were assessed using partial correlation analysis, after adjusting for age, and multiple regression analysis.

Results

The mean 10-year CHD and 10-year stroke risks were 14.92±11.53% and 4.03±3.95%, respectively. The 10-year CHD risk correlated with CIMT (P<0.001), FMD (P=0.017), and PWV (P=0.35) after adjusting for age. The 10-year stroke risk correlated only with the mean CIMT (P<0.001) after adjusting for age. FMD correlated with age (P<0.01) and systolic blood pressure (P=0.09). CIMT correlated with age (P<0.01), HbA1c (P=0.05), and gender (P<0.01).

Conclusion

The CVD risk is increased at the onset of type 2 diabetes. CIMT, FMD, and PWV along with the UKPDS risk engine should be considered to evaluate cardiovascular disease risk in patients with newly diagnosed type 2 diabetes.

Background

Levels of knowledge about diabetes mellitus (DM) among newly diagnosed diabetics in Bangladesh are unknown. This study assessed the relationship between knowledge and practices among newly diagnosed type 2 DM patients.

Methods

Newly diagnosed adults with type 2 diabetes (N = 508) were selected from 19 healthcare centers. Patients’ knowledge and self-care practices were assessed via interviewer-administered questionnaires using a cross-sectional design. Knowledge questions were divided into basic and technical sections. Knowledge scores were categorized as poor (mean + 1 SD). Chi square testing and multivariate logistic regression were conducted to examine the relationship between diabetes-related knowledge and self-care practices.

Results

Approximately 16%, 66%, and 18% of respondents had good, average, and poor (GAP) basic knowledge respectively and 10%, 78%, and 12% of respondents had GAP technical knowledge, about DM. About 90% of respondents from both basic and technical GAP did not test their blood glucose regularly; a significant relationship existed between basic knowledge and glucose monitoring. Technical knowledge and foot care were significantly related, though 81% with good technical knowledge and about 70% from average and poor groups did not take care of their feet. Approximately 85%, 71%, and 52% of the GAP technical knowledge groups, consumed betel nuts; a significant relationship existed between technical knowledge and consumption of betel nuts. Around 88%, 92%, and 98% of GAP technical knowledge groups failed to follow dietary advice from a diabetes educator. About 26%, 42%, and 51% of GAP basic and technical sometimes ate meals at a fixed time (p < 0.05). Approximately one-third of respondents in each basic knowledge group and 29%, 32%, and 32% of GAP technical knowledge groups partially followed rules for measuring food before eating. Total basic knowledge (TBK) and business profession were significant independent predictors of good practice. OR for TBK: 1.28 (95% CI: 1.03 to 1.60); OR for business profession 9.05 (95% CI: 1.17 to 70.09).

Conclusions

Newly diagnosed type 2 diabetics had similar levels of basic and technical knowledge of DM. Health education and motivation should create positive changes in diabetes-control-related self-care practices.

Introduction

The significance of non-alcoholic fatty liver disease (NAFLD) among patients with diabetes is unknown. We sought to determine whether a diagnosis of NAFLD influenced mortality among a community-based cohort of patients with type 2 diabetes mellitus.

Methods

337 residents of Olmsted County, Minnesota with diabetes mellitus diagnosed between 1980–2000 were identified using the Rochester Epidemiology Project and the Mayo Laboratory Information System and followed for 10.9 ± 5.2 years (range 0.1–25). Survival was analysed using Cox proportional hazards modelling with NAFLD treated as a time-dependent covariate.

Results

Among the 337 residents, 116 were diagnosed with NAFLD 0.9 ±4.6 years after diabetes diagnosis. Patients with NAFLD were younger, and more likely to be female, and obese. Overall 99/337 (29%) patients died. In multivariate analysis to adjust for confounders, overall mortality was significantly associated with a diagnosis of NAFLD (hazard ratio [HR] 2.2; 95% confidence Interval [CI] 1.1, 4.2; p = 0.03), presence of ischemic heart disease (HR 2.3; 95% CI 1.2, 4.4), and duration of diabetes (HR per 1 year, 1.1; 95% CI 1.03, 1.2). The most common causes of death in the NAFLD cohort were malignancy (33% of deaths), liver-related complications (19% of deaths), and ischemic heart disease (19% of deaths). In adjusted multivariate models, NAFLD was borderline associated with an increased risk of dying from malignancy (HR 2.3; 95% CI 0.9, 5.9; p = 0.09), and not from cardiovascular disease (HR 0.9; 95% CI 0.3, 2.4; p = 0.81)

Conclusions

The diagnosis of NAFLD is associated with an increased risk of overall death among patients with diabetes mellitus.

Type 2 diabetes mellitus affects 5.9% of the world adult population, with older people and some ethnic groups disproportionately affected. Treatment of older people with diabetes differs in many ways from that in younger adults since the majority have type 2 disease and are at particular risk of macrovascular rather than disabling microvascular disease. Insulin therapy, the most effective of diabetes medications, can reduce any level of elevated HBA1c if used in adequate doses. However, some clinicians are often reluctant to initiate insulin therapy in older people with diabetes mainly out of their concerns about adverse reactions to insulin, particularly hypoglycemia. There is evidence suggesting that insulin aspart appears to act similarly to regular human insulin in older people with type 2 diabetes mellitus. Insulin aspart can be used in the treatment of older people with diabetes, but this should be individualized. There is evidence that it improves postprandial glucose control, improves long-term metabolic control, reduces risk of major nocturnal hypoglycemia and increases patient satisfaction compared with soluble insulin.

OBJECTIVE--To assess the effect of pressure from patients on patterns of general practitioners' outpatient referrals. DESIGN--Survey of general practitioners' referrals to hospital outpatient departments during one week. SETTING--One health district. SUBJECTS--All (160) general practitioners in the health district. MAIN OUTCOME MEASURES--Specialty of the referral, the reason for it, and its status (NHS or private) and the general practitioner's assessment of the degree of pressure exerted by the patient for the referral (much, little, or none). RESULTS--122 (76%) general practitioners completed the survey. Younger general practitioners (aged less than or equal to 45) and those qualifying in the United Kingdom and Republic of Ireland reported greater pressure from patients to refer (p less than 0.03, p less than 0.001 respectively). Pressure was also greater for patients referred privately (p less than 0.001), for those referred for reassurance (p less than 0.05), and for those referred to clinics in psychiatry, rheumatology, dermatology, and orthopaedics. General practitioners with a higher referral rate (with total consultations in the week as the denominator) were more likely to report pressure (p less than 0.01). CONCLUSIONS--The pressure from patients to refer reported by general practitioners is related both to general practitioners' characteristics and to the nature of the referral. Pressure to refer seems to explain some of the variation in referral rates among general practitioners.

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The present work identifies a high incidence of oral cancer in south Karnataka. The primary reason for this could be due to extensive addiction to tobacco alone or tobacco and alcohol in most of these patients. The next in intensity was cancer of the breast and cervix among the cancer patients surveyed in south Karnataka. Majority of these patients had no specific addiction and the exact reason for this high incidence remains unclear. Only a small percentage of patients exhibited other types of organ related cancer. It has been reported that the incidence percentage of diabetes mellitus and cancer in India, parallel each other. However, we observed a low incidence of diabetes mellitus patients also having cancer in south Karnataka. Though the exact reason for this remains unclear an attempt has been made here to explain this phenomenon, hypothetically using information in literature, which suggests a suppression of cellular regenerative activity by sugar and sugar phosphates. Cellular regenerative activity is well known to be a prerequisite for cancer.