In an observational study, patients with type 2 diabetes who had glycated hemoglobin, LDL cholesterol, albuminuria, and blood pressure in target ranges and did not smoke had minimal excess risk of ...death, myocardial infarction, and stroke as compared with a general population.
Aim
This paper integrates clinical expertise to earlier research about the behaviours of the healthy, alert, full‐term infant placed skin‐to‐skin with the mother during the first hour after birth ...following a noninstrumental vaginal birth.
Method
This state‐of‐the‐art article forms a link within the knowledge‐to‐action cycle, integrating clinical observations and practice with evidence‐based findings to guide clinicians in their work to implement safe uninterrupted skin‐to‐skin contact the first hours after birth.
Results
Strong scientific research exists about the importance of skin‐to‐skin in the first hour after birth. This unique time for both mother and infant, individually and in relation to each other, provides vital advantages to short‐ and long‐term health, regulation and bonding. However, worldwide, clinical practice lags. A deeper understanding of the implications for clinical practice, through review of the scientific research, has been integrated with enhanced understanding of the infant's instinctive behaviour and maternal responses while in skin‐to‐skin contact.
Conclusion
The first hour after birth is a sensitive period for both the infant and the mother. Through an enhanced understanding of the newborn infant's instinctive behaviour, practical, evidence‐informed suggestions strive to overcome barriers and facilitate enablers of knowledge translation. This time must be protected by evidence‐based routines of staff.
Excess Mortality among Persons with Type 2 Diabetes Tancredi, Mauro; Rosengren, Annika; Svensson, Ann-Marie ...
New England journal of medicine/The New England journal of medicine,
10/2015, Letnik:
373, Številka:
18
Journal Article
Recenzirano
Odprti dostop
This Swedish National Diabetes Register study showed that mortality varies greatly among patients with type 2 diabetes, as compared with the general population. There is excess risk in large patient ...groups, yet lower risks of death depending on age, glycemic control, and renal complications.
The global burden of diabetes has risen dramatically over the past two decades and is expected to affect more than 500 million adults by 2030, with most having type 2 diabetes.
1
Myocardial infarction is the most common cause of death in these patients.
2
,
3
Although factors that are known to reduce the risk of myocardial infarction,
2
,
4
,
5
including the use of lipid-lowering and antihypertensive medications and better glycemic control over time,
6
–
8
have been noted in persons with type 2 diabetes, an excess risk of death still exists.
9
Population-based studies have generally not evaluated the excess risks of death . . .
Patients with type 1 or type 2 diabetes in Sweden were studied to examine trends in mortality and cardiovascular disease incidence between 1998 and 2014. Both outcomes declined substantially, ...although fatal outcomes declined less among patients with type 2 diabetes than among controls.
Diabetes mellitus is a complex and heterogeneous group of chronic metabolic diseases that are characterized by hyperglycemia. Type 1 diabetes occurs predominantly in young people (diagnosis at 30 years of age or younger) and is generally thought to be precipitated by an immune-associated destruction of insulin-producing pancreatic beta cells, leading to insulin deficiency and an absolute need for exogenous insulin replacement.
1
Type 2 diabetes is a progressive metabolic disease that is characterized by insulin resistance and eventual functional failure of pancreatic beta cells.
2
The prevalence of type 2 diabetes has been increasing dramatically over the past few decades,
3
with projections . . .
Glycemic Control and Excess Mortality in Type 1 Diabetes Lind, Marcus; Svensson, Ann-Marie; Kosiborod, Mikhail ...
New England journal of medicine/The New England journal of medicine,
11/2014, Letnik:
371, Številka:
21
Journal Article
Recenzirano
Odprti dostop
In this study, patients with type 1 diabetes and a glycated hemoglobin level of 6.9% or lower (≤52 mmol per mole) were found to have a risk of death from any cause or from cardiovascular causes that ...was twice as high as that for matched controls.
Type 1 diabetes is associated with a substantially increased risk of premature death as compared with that in the general population.
1
–
8
Among persons with diabetes who are younger than 30 years of age, excess mortality is largely explained by acute complications of diabetes, including diabetic ketoacidosis and hypoglycemia
7
–
9
; cardiovascular disease is the main cause of death later in life.
7
–
9
Improving glycemic control in patients with type 1 diabetes substantially reduces their risk of microvascular complications and cardiovascular disease.
10
,
11
Accordingly, diabetes treatment guidelines emphasize good glycemic control,
12
–
15
which is indicated by the glycated hemoglobin level, . . .
To assess the association between the use of sodium glucose cotransporter 2 (SGLT2) inhibitors and seven serious adverse events of current concern.
Register based cohort study.
Sweden and Denmark ...from July 2013 to December 2016.
A propensity score matched cohort of 17 213 new users of SGLT2 inhibitors (dapagliflozin, 61%; empagliflozin, 38%; canagliflozin, 1%) and 17 213 new users of the active comparator, glucagon-like peptide 1 (GLP1) receptor agonists.
The primary outcomes were lower limb amputation, bone fracture, diabetic ketoacidosis, acute kidney injury, serious urinary tract infection, venous thromboembolism, and acute pancreatitis, as identified from hospital records. Hazard ratios and 95% confidence intervals were estimated by using Cox proportional hazards models.
Use of SGLT2 inhibitors, as compared with GLP1 receptor agonists, was associated with an increased risk of lower limb amputation (incidence rate 2.7
1.1 events per 1000 person years, hazard ratio 2.32, 95% confidence interval 1.37 to 3.91) and diabetic ketoacidosis (1.3
0.6, 2.14, 1.01 to 4.52) but not with bone fracture (15.4
13.9, 1.11, 0.93 to 1.33), acute kidney injury (2.3
3.2, 0.69, 0.45 to 1.05), serious urinary tract infection (5.4
6.0, 0.89, 0.67 to 1.19), venous thromboembolism (4.2
4.1, 0.99, 0.71 to 1.38) or acute pancreatitis (1.3
1.2, 1.16, 0.64 to 2.12).
In this analysis of nationwide registers from two countries, use of SGLT2 inhibitors, as compared with GLP1 receptor agonists, was associated with an increased risk of lower limb amputation and diabetic ketoacidosis, but not with other serious adverse events of current concern.
Aims
This study aimed to investigate the association between insulin resistance as determined by the estimated glucose disposal rate (eGDR), and survival in adults with type 1 diabetes (T1D) in ...Sweden.
Material and Methods
Using the Swedish National Diabetes Register, indviduals with T1D were included from January 1, 2005 to December 31, 2012. Outcomes were retrieved from National healthcare registers. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for the associations between eGDR (mg/kg/min) categorized into <4, 4 to 5.99, 6 to 7.99, and ≥8 (reference) and outcomes. Relative survival methods were used to compare survival to a matched Swedish reference population.
Results
Among 17 050 included individuals with T1D, 10.5%, 20.2%, 20.5% and 48.9% had an eGDR of <4, 4 to 5.99, 6 to 7.99, and ≥8, respectively. Individuals with an eGDR <8 were older and had more comorbidities. During a median follow‐up of 7.1 years, there were 946 (6%) deaths; 264 (15%), 367 (11%), 195 (6%) and 120 (1%) deaths occurred in individuals with an eGDR of <4, 4 to 5.99, 6 to 7.99 and ≥8, respectively. After adjustment for a wealth of different covariates including diabetes duration, age, sex and renal function, individuals with an eGDR <4, 4 to 5.99, and 6 to 7.99 had an increased risk of death compared to those with an eGDR ≥8 (adjusted HRs, 95% CIs, P values: 2.78, 2.04 to 3.77, <.001; 1.92, 1.49 to 2.46, <.001; 1.73, 1.34 to 2.21, <.001). Survival in individuals with an eGDR ≥8 was equal to a matched general population.
Conclusions
There is a strong association between eGDR and all‐cause mortality, as well as cardiovascular mortality, in individuals with T1D. Our findings may guide preventive measures by improving risk assessment in individuals with T1D.
People with type 1 diabetes are at elevated risk of mortality and cardiovascular disease, yet current guidelines do not consider age of onset as an important risk stratifier. We aimed to examine how ...age at diagnosis of type 1 diabetes relates to excess mortality and cardiovascular risk.
We did a nationwide, register-based cohort study of individuals with type 1 diabetes in the Swedish National Diabetes Register and matched controls from the general population. We included patients with at least one registration between Jan 1, 1998, and Dec 31, 2012. Using Cox regression, and with adjustment for diabetes duration, we estimated the excess risk of all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, acute myocardial infarction, stroke, cardiovascular disease (a composite of acute myocardial infarction and stroke), coronary heart disease, heart failure, and atrial fibrillation. Individuals with type 1 diabetes were categorised into five groups, according to age at diagnosis: 0–10 years, 11–15 years, 16–20 years, 21–25 years, and 26–30 years.
27 195 individuals with type 1 diabetes and 135 178 matched controls were selected for this study. 959 individuals with type 1 diabetes and 1501 controls died during follow-up (median follow-up was 10 years). Patients who developed type 1 diabetes at 0–10 years of age had hazard ratios of 4·11 (95% CI 3·24–5·22) for all-cause mortality, 7·38 (3·65–14·94) for cardiovascular mortality, 3·96 (3·06–5·11) for non-cardiovascular mortality, 11·44 (7·95–16·44) for cardiovascular disease, 30·50 (19·98–46·57) for coronary heart disease, 30·95 (17·59–54·45) for acute myocardial infarction, 6·45 (4·04–10·31) for stroke, 12·90 (7·39–22·51) for heart failure, and 1·17 (0·62–2·20) for atrial fibrillation. Corresponding hazard ratios for individuals who developed type 1 diabetes aged 26–30 years were 2·83 (95% CI 2·38–3·37) for all-cause mortality, 3·64 (2·34–5·66) for cardiovascular mortality, 2·78 (2·29–3·38) for non-cardiovascular mortality, 3·85 (3·05–4·87) for cardiovascular disease, 6·08 (4·71–7·84) for coronary heart disease, 5·77 (4·08–8·16) for acute myocardial infarction, 3·22 (2·35–4·42) for stroke, 5·07 (3·55–7·22) for heart failure, and 1·18 (0·79–1·77) for atrial fibrillation; hence the excess risk differed by up to five times across the diagnosis age groups. The highest overall incidence rate, noted for all-cause mortality, was 1·9 (95% CI 1·71–2·11) per 100 000 person-years for people with type 1 diabetes. Development of type 1 diabetes before 10 years of age resulted in a loss of 17·7 life-years (95% CI 14·5–20·4) for women and 14·2 life-years (12·1–18·2) for men.
Age at onset of type 1 diabetes is an important determinant of survival, as well as all cardiovascular outcomes, with highest excess risk in women. Greater focus on cardioprotection might be warranted in people with early-onset type 1 diabetes.
Swedish Heart and Lung Foundation.
BACKGROUND:Risk of cardiovascular disease (CVD) and mortality for patients with versus without type 2 diabetes mellitus (T2DM) appears to vary by the age at T2DM diagnosis, but few population studies ...have analyzed mortality and CVD outcomes associations across the full age range.
METHODS:With use of the Swedish National Diabetes Registry, everyone with T2DM registered in the Registry between 1998 and 2012 was included. Controls were randomly selected from the general population matched for age, sex, and county. The analysis cohort comprised 318 083 patients with T2DM matched with just <1.6 million controls. Participants were followed from 1998 to 2013 for CVD outcomes and to 2014 for mortality. Outcomes of interest were total mortality, cardiovascular mortality, noncardiovascular mortality, coronary heart disease, acute myocardial infarction, stroke, heart failure, and atrial fibrillation. We also examined life expectancy by age at diagnosis. We conducted the primary analyses using Cox proportional hazards models in those with no previous CVD and repeated the work in the entire cohort.
RESULTS:Over a median follow-up period of 5.63 years, patients with T2DM diagnosed at ≤40 years had the highest excess risk for most outcomes relative to controls with adjusted hazard ratio (95% CI) of 2.05 (1.81–2.33) for total mortality, 2.72 (2.13–3.48) for cardiovascular-related mortality, 1.95 (1.68–2.25) for noncardiovascular mortality, 4.77 (3.86–5.89) for heart failure, and 4.33 (3.82–4.91) for coronary heart disease. All risks attenuated progressively with each increasing decade at diagnostic age; by the time T2DM was diagnosed at >80 years, the adjusted hazard ratios for CVD and non-CVD mortality were <1, with excess risks for other CVD outcomes substantially attenuated. Moreover, survival in those diagnosed beyond 80 was the same as controls, whereas it was more than a decade less when T2DM was diagnosed in adolescence. Finally, hazard ratios for most outcomes were numerically greater in younger women with T2DM.
CONCLUSIONS:Age at diagnosis of T2DM is prognostically important for survival and cardiovascular risks, with implications for determining the timing and intensity of risk factor interventions for clinical decision making and for guideline-directed care. These observations amplify support for preventing/delaying T2DM onset in younger individuals.
Aims/hypothesis
Research using data-driven cluster analysis has proposed five novel subgroups of diabetes based on six measured variables in individuals with newly diagnosed diabetes. Our aim was (1) ...to validate the existence of differing clusters within type 2 diabetes, and (2) to compare the cluster method with an alternative strategy based on traditional methods to predict diabetes outcomes.
Methods
We used data from the Swedish National Diabetes Register and included 114,231 individuals with newly diagnosed type 2 diabetes.
k
-means clustering was used to identify clusters based on nine continuous variables (age at diagnosis, HbA
1c
, BMI, systolic and diastolic BP, LDL- and HDL-cholesterol, triacylglycerol and eGFR). The elbow method was used to determine the optimal number of clusters and Cox regression models were used to evaluate mortality risk and risk of CVD events. The prediction models were compared using concordance statistics.
Results
The elbow plot, with values of
k
ranging from 1 to 10, showed a smooth curve without any clear cut-off points, making the optimal value of
k
unclear. The appearance of the plot was very similar to the elbow plot made from a simulated dataset consisting only of one cluster. In prediction models for mortality, concordance was 0.63 (95% CI 0.63, 0.64) for two clusters, 0.66 (95% CI 0.65, 0.66) for four clusters, 0.77 (95% CI 0.76, 0.77) for the ordinary Cox model and 0.78 (95% CI 0.77, 0.78) for the Cox model with smoothing splines. In prediction models for CVD events, the concordance was 0.64 (95% CI 0.63, 0.65) for two clusters, 0.66 (95% CI 0.65, 0.67) for four clusters, 0.77 (95% CI 0.77, 0.78) for the ordinary Cox model and 0.78 (95% CI 0.77, 0.78) for the Cox model with splines for all variables.
Conclusions/interpretation
This nationwide observational study found no evidence supporting the existence of a specific number of distinct clusters within type 2 diabetes. The results from this study suggest that a prediction model approach using simple clinical features to predict risk of diabetes complications would be more useful than a cluster sub-stratification.
Graphical abstract
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