IntroductionEven with recent treatment advances, type 2 diabetes (T2D) remains poorly controlled for many patients, despite the best efforts to adhere to therapies and lifestyle modifications. ...Although estimates vary, studies indicate that in >10% of individuals with difficult-to-control T2D, hypercortisolism may be an underlying contributing cause. To better understand the prevalence of hypercortisolism and the impact of its treatment on T2D and associated comorbidities, we describe the two-part Hyper c ortisolism in P at ients with Difficult to Control Type 2 Di a betes Despite Receiving Standard-of-Care Therapies: Preva l ence and Treatment with Korl y m® (Mifepri st one) (CATALYST) trial.Methods and analysisIn part 1, approximately 1000 participants with difficult-to-control T2D (haemoglobin A1c (HbA1c) 7.5%–11.5% despite multiple therapies) are screened with a 1 mg dexamethasone suppression test (DST). Those with post-DST cortisol >1.8 µg/dL and dexamethasone level ≥140 ng/dL are identified to have hypercortisolism (part 1 primary endpoint), have morning adrenocorticotropic hormone (ACTH) and dehydroepiandrosterone sulfate (DHEAS) measured and undergo a non-contrast adrenal CT scan. Those requiring evaluation for elevated ACTH are referred for care outside the study; those with ACTH and DHEAS in the range may advance to part 2, a randomised, double-blind, placebo-controlled trial to evaluate the impact of treating hypercortisolism with the competitive glucocorticoid receptor antagonist mifepristone (Korlym®). Participants are randomised 2:1 to mifepristone or placebo for 24 weeks, stratified by the presence/absence of an abnormal adrenal CT scan. Mifepristone is dosed at 300 mg once daily for 4 weeks, then 600 mg daily based on tolerability and clinical improvement, with an option to increase to 900 mg. The primary endpoint of part 2 assesses changes in HbA1c in participants with hypercortisolism with or without abnormal adrenal CT scan. Secondary endpoints include changes in antidiabetes medications, cortisol-related comorbidities and quality of life.Ethics and disseminationThe study has been approved by Cleveland Clinic IRB (Cleveland, Ohio, USA) and Advarra IRB (Columbia, Maryland, USA). Findings will be presented at scientific meetings and published in peer-reviewed journals.Trial registration number NCT05772169.
Background
Although guidelines and performance measures exist for patients with diabetes mellitus, achievement of these metrics is not well known. The Diabetes Collaborative Registry® (DCR) was ...formed to understand the quality of diabetes mellitus care across the primary and specialty care continuum in the United States.
Methods and Results
We assessed the frequency of achievement of 7 diabetes mellitus–related quality metrics and variability across the Diabetes Collaborative Registry® sites. Among 574 972 patients with diabetes mellitus from 259 US practices, median (interquartile range) achievement of the quality metrics across the practices was the following: (1) glycemic control: 19% (5–47); (2) blood pressure control: 80% (67–88); (3) angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers in patients with coronary artery disease: 62% (51–69); (4) nephropathy screening: 62% (53–71); (5) eye examination: 0.7% (0.0–79); (6) foot examination: 0.0% (0.0–2.3); and (7) tobacco screening/cessation counseling: 86% (80–94). In hierarchical, modified Poisson regression models, there was substantial variability in meeting these metrics across sites, particularly with documentation of glycemic control and eye and foot examinations. There was also notable variation across specialties, with endocrinology practices performing better on glycemic control and diabetes mellitus foot examinations and cardiology practices succeeding more in blood pressure control and use of angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers.
Conclusions
The Diabetes Collaborative Registry® was established to document and improve the quality of outpatient diabetes mellitus care. While target achievement of some metrics of cardiovascular risk modification was high, achievement of others was suboptimal and highly variable. This may be attributable to fragmentation of care, lack of ownership among various specialists concerning certain domains of care, incomplete documentation, true gaps in care, or a combination of these factors.
The recent availability of a continuous glucose monitor offers the opportunity to match the demands of intensive diabetes management with a period of equally intensive blood glucose monitoring. The ...present study evaluates the performance of the MiniMed continuous glucose monitoring system (CGMS) in patients with diabetes during home use.
Performance data and demographic information were obtained from 135 patients who were (mean +/- SD) 40.5+/-14.5 years old, had an average duration of diabetes of 18.0+/-9.8 years, 50% were female, 90% were Caucasian, and 87% of whom had been diagnosed with type 1 diabetes. Patients were selected by their physician, trained on the use of the CGMS and wore the device at home for 3 days or more. The performance of the CGMS was evaluated against blood glucose measurements obtained using each patient's home blood glucose meter. Evaluation statistics included correlation, linear regression, mean difference and percent absolute difference scores, and Clarke error grid analysis.
The CGMS values were compared to 2477 SMBG tests (r = 0.91, slope = 0.93, intercept = 14.5 mg/dL, mean absolute difference = 18.0%+/-19.8%). Clarke error grid analysis showed 96.2% of the data pairs falling within the clinically acceptable regions (zones A and B).
These results demonstrate the agreement of the CGMS to blood glucose meter values, under conditions of home use, in patients selected by their physicians as candidates for continuous monitoring. The detailed glucose information provided by the CGMS should make successful management of diabetes more easily achieved.
To determine whether fatty kidney disease deserves be designated as a distinct clinical entity similar to fatty liver disease.
Analysis and interpretation of the literature in a novel conceptual ...framework.
The kidney contributes to hyperglycemia, hypertension, inflammatory cytokines, and thus to diabetes and metabolic syndrome. Fat accumulation in and around the kidney drives this process and contributes to progression of chronic kidney disease itself. Weight loss improves these complications of fatty kidney. Diagnosis currently must be inferred from comorbidities but ultimately should be made by imaging once the importance of fatty kidney disease is established, much like fatty liver disease.
Fatty kidney disease merits designation as a specific clinical entity similar to fatty liver disease. Greater attention to this may help encourage research into ameliorating the negative consequences of fatty kidney disease and developing new therapies.
= blood pressure;
= chronic kidney disease;
= computed tomography;
= end-stage renal disease;
= free fatty acid;
= fatty kidney disease;
= glomerular filtration rate;
= metabolic syndrome;
= magnetic resonance imaging;
= nonalcoholic fatty liver disease;
= renin-angiotensin system;
= sodium-glucose cotransporter 2;
= sympathetic nervous system;
= type 2 diabetes;
= triglyceride.
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