IntroductionWe aimed to develop algorithms distinguishing type 1 diabetes (T1D) from type 2 diabetes in adults ≥18 years old using primary care electronic medical record (EMRPC) and administrative ...healthcare data from Ontario, Canada, and to estimate T1D prevalence and incidence.Research design and methodsThe reference population was a random sample of patients with diabetes in EMRPC whose charts were manually abstracted (n=5402). Algorithms were developed using classification trees, random forests, and rule-based methods, using electronic medical record (EMR) data, administrative data, or both. Algorithm performance was assessed in EMRPC. Administrative data algorithms were additionally evaluated using a diabetes clinic registry with endocrinologist-assigned diabetes type (n=29 371). Three algorithms were applied to the Ontario population to evaluate the minimum, moderate and maximum estimates of T1D prevalence and incidence rates between 2010 and 2017, and trends were analyzed using negative binomial regressions.ResultsOf 5402 individuals with diabetes in EMRPC, 195 had T1D. Sensitivity, specificity, positive predictive value and negative predictive value for the best performing algorithms were 80.6% (75.9–87.2), 99.8% (99.7–100), 94.9% (92.3–98.7), and 99.3% (99.1–99.5) for EMR, 51.3% (44.0–58.5), 99.5% (99.3–99.7), 79.4% (71.2–86.1), and 98.2% (97.8–98.5) for administrative data, and 87.2% (81.7–91.5), 99.9% (99.7–100), 96.6% (92.7–98.7) and 99.5% (99.3–99.7) for combined EMR and administrative data. Administrative data algorithms had similar sensitivity and specificity in the diabetes clinic registry. Of 11 499 711 adults in Ontario in 2017, there were 24 789 (0.22%, minimum estimate) to 102 140 (0.89%, maximum estimate) with T1D. Between 2010 and 2017, the age-standardized and sex-standardized prevalence rates per 1000 person-years increased (minimum estimate 1.7 to 2.56, maximum estimate 7.48 to 9.86, p<0.0001). In contrast, incidence rates decreased (minimum estimate 0.1 to 0.04, maximum estimate 0.47 to 0.09, p<0.0001).ConclusionsPrimary care EMR and administrative data algorithms performed well in identifying T1D and demonstrated increasing T1D prevalence in Ontario. These algorithms may permit the development of large, population-based cohort studies of T1D.
Objective To examine whether total joint arthroplasty of the hip and knee reduces the risk for serious cardiovascular events in patients with moderate-severe osteoarthritis.Design Propensity score ...matched landmark analysis.Setting Ontario, Canada.Participants 2200 adults with hip or knee osteoarthritis aged 55 or more at recruitment (1996-98) and followed prospectively until death or 2011.Main outcome measure Rates of serious cardiovascular events for those who received a primary total joint arthroplasty compared with those did not within an exposure period of three years after baseline assessment.Results The propensity score matched cohort consisted of 153 matched pairs of participants with moderate-severe arthritis. Over a median follow-up period of seven years after the landmark date (start of the study), matched participants who underwent a total joint arthroplasty during the exposure period were significantly less likely than those who did not to experience a cardiovascular event (hazards ratio 0.56, 95% confidence interval 0.43 to 0.74, P<0.001). Within seven years of the exposure period the absolute risk reduction was 12.4% (95% confidence interval 1.7% to 23.1%) and number needed to treat was 8 (95% confidence interval 4 to 57 patients).Conclusions Using a propensity matched landmark analysis in a population cohort with advanced hip or knee osteoarthritis, this study found a cardioprotective benefit of primary elective total joint arthroplasty.
There is evidence that type 2 diabetes mellitus (DM) may increase postmenopausal breast cancer risk, possibly through hyperinsulinemia and/or insulin resistance. This question has not been adequately ...examined in an exclusively postmenopausal female population. Using Ontario health databases, this retrospective cohort study compared breast cancer incidence between women, aged 55 to 79 years, with newly diagnosed DM (N = 73,796) to women without DM (N = 391,714). After 2.1 million person-years of follow-up from 1994 to 2002, there was a significant age- and income-adjusted increase in breast cancer among women with DM (hazard ratio, HR, 1.08, 95% confidence interval, CI, 1.01-1.16, p = 0.021). Prior breast cancer prevalence was also higher in women with DM versus controls (odds ratio, OR, 1.13, 95% CI 1.08-1.18, p < 0.0001). DM did not affect survival following breast cancer. As DM care becomes more complex, it will be important to ensure that adequate primary care such as breast cancer screening is maintained.
Objective To evaluate the incremental increase in new onset diabetes from higher potency statins compared with lower potency statins when used for secondary prevention.Design Eight population based ...cohort studies and a meta-analysis.Setting Six Canadian provinces and two international databases from the UK and US.Participants 136 966 patients aged ≥40 years newly treated with statins between 1 January 1997 and 31 March 2011.Methods Within each cohort of patients newly prescribed a statin after hospitalisation for a major cardiovascular event or procedure, we performed as-treated, nested case-control analyses to compare diabetes incidence in users of higher potency statins with incidence in users of lower potency statins. Rate ratios of new diabetes events were estimated using conditional logistic regression on different lengths of exposure to higher potency versus lower potency statins; adjustment for confounding was achieved using high dimensional propensity scores. Meta-analytic methods were used to estimate overall effects across sites.Main outcome measures Hospitalisation for new onset diabetes, or a prescription for insulin or an oral antidiabetic drug.Results In the first two years of regular statin use, we observed a significant increase in the risk of new onset diabetes with higher potency statins compared with lower potency agents (rate ratio 1.15, 95% confidence interval 1.05 to 1.26). The risk increase seemed to be highest in the first four months of use (rate ratio 1.26, 1.07 to 1.47).Conclusions Higher potency statin use is associated with a moderate increase in the risk of new onset diabetes compared with lower potency statins in patients treated for secondary prevention of cardiovascular disease. Clinicians should consider this risk when prescribing higher potency statins in secondary prevention patients.
Higher uric acid (UA) is associated with cardiovascular events and mortality. Allopurinol, a UA-lowering therapy, may reduce risk of these outcomes. Despite the high prevalence of elevated UA in ...diabetes, the association between allopurinol and cardiovascular events and mortality in diabetes is unclear.
A population-based cohort was constructed using administrative data in Ontario, Canada. Subjects with diabetes entered on receipt of a new prescription for allopurinol after age 66 (April 1/2002-March 31/2012) and were followed until a composite of all-cause mortality, stroke, myocardial infarction or revascularization. A Cox proportional hazards model was used for each sex, with time-varying allopurinol exposure modeled as yes/no, dose categories and cumulative dose.
Over a median IQR follow-up time of 4.71.8-7.8 years, the composite outcome occurred in 16,262/23,103 males and 10,566/15,313 females. Allopurinol exposure was associated with a reduction in the composite outcome in a dose-response manner but there was no cumulative dose effect (Table 1).
Any allopurinol exposure and higher allopurinol doses were associated with reduced cardiovascular events and mortality in a large diabetes cohort. Potential mechanisms include an acute reduction of oxidative stress and endothelial dysfunction.
Table 1: Hazard Ratios by Sex.Males (n=23,103)Females (n=15,313)Allopurinol ExposureUnadjusted HRAdjusted HRUnadjusted HRAdjusted HRExposed time v. unexposed time0.82 (0.79, 0.84)0.77 (0.75, 0.80)0.88 (0.85, 0.92)0.81 (0.78, 0.84)Dose categories0mg--->0 and ≤100mg1.03 (0.99, 1.08)0.84 (0.80, 0.88)1.(1.01, 1.12)0.86 (0.81, 0.90)>100 and ≤200mg0.82 (0.78, 0.85)0.75 (0.72, 0.78)0.83 (0.79, 0.87)0.76 (0.72, 0.80)>200mg0.71 (0.68, 0.74)0.75 (0.72, 0.78)0.78 (0.73, 0.82)0.81 (0.77, 0.86)Cumulative Dose (per 100g increase)0.99 (0.98, 1.00)1.00 (0.99, 1.01)0.99 (0.98, 1.01)0.99 (0.98, 1.00)
Disclosure
A. Weisman: None. G.A. Tomlinson: None. L. Lipscombe: None. B.A. Perkins: Advisory Panel; Self; Boehringer Ingelheim GmbH. Research Support; Self; Boehringer Ingelheim GmbH, Novo Nordisk Inc.. Advisory Panel; Self; Novo Nordisk Inc., Abbott. Speaker's Bureau; Self; Abbott, Janssen Pharmaceuticals, Inc.. Advisory Panel; Self; Insulet Corporation. Speaker's Bureau; Self; Insulet Corporation, Dexcom, Inc.. G.A. Hawker: None.
Aim
To compare glycaemic control and adverse outcomes between transition‐aged and early adults with type 1 diabetes, and the impact of continuous subcutaneous insulin infusion (CSII) therapy funded ...through a government Assisted Devices Program.
Methods
This retrospective cohort study using healthcare administrative databases from Ontario, Canada included adults aged 18–35 with type 1 diabetes between 1 April 2011 and 31 March 2014. Mean HbA1c was compared between transition‐aged (18–24 years) and early adults (25–35 years), overall and stratified by whether or not they received government‐funded CSII therapy (CSII vs. non‐CSII). Secondary outcomes included rates of hospitalizations/emergency department visits for hyperglycaemia and hypoglycaemia over a 3‐year follow‐up. Comparisons were adjusted for relevant covariates.
Results
Among 7157 participants with type 1 diabetes, mean HbA1c was significantly higher for transition‐aged compared to early adults (71 mmol/mol 8.68% vs. 64 mmol/mol 8.04%, p < 0.0001). This difference was smaller among CSII compared to non‐CSII users (p = 0.02 for interaction between age group and CSII use). The transition‐age group were more likely to experience a hyperglycaemic event compared to early adults (adjusted risk ratio, aRR: 1.56, 95% confidence interval CI: 1.25–1.96), which was attenuated by CSII use (aRR: 1.13, 95% CI: 0.7–1.69).
Conclusions
Transition‐aged adults with type 1 diabetes had a significantly higher mean HbA1c and risk of hyperglycaemic events compared to early adults. This difference was attenuated for CSII users, indicating that a government‐funded CSII programme is associated with narrowing of the gap in glycaemic control and associated adverse outcomes for this population.
Metformin is increasingly being used during pregnancy, with potentially adverse long-term effects on children. We aimed to examine adiposity in children of women with type 2 diabetes from the ...Metformin in Women with Type 2 Diabetes in Pregnancy (MiTy) trial, with and without in-utero exposure to metformin, up to 24 months of age.
MiTy Kids is a follow-up study that included infants of women who participated in the MiTy randomised controlled trial, receiving either oral 1000 mg metformin twice daily or placebo. Caregivers and researchers remained masked to the type of medication (metformin or placebo) mothers received during their pregnancy. Anthropometric measurements, including weight, height, and skinfold thicknesses, were taken at 3, 6, 12, 18, and 24 months. At 24 months, linear regression was used to compare the BMI Z score and sum of skinfolds in the metformin versus placebo groups, adjusted for confounders. Fractional polynomials were used to assess growth trajectories. This study is registered with ClinicalTrials.gov, NCT01832181.
Of the 465 eligible children, 283 (61%) were included from 19 centres in Canada and Australia. At 24 months, there was no difference between groups in mean BMI Z score (0·84 SD 1·52 with metformin vs 0·91 1·38 with placebo; mean difference 0·07 95% CI -0·31 to 0·45, p=0·72) or mean sum of skinfolds (23·0 mm 5·2 vs 23·8 mm 5·4; mean difference 0·8 mm -0·7 to 2·3, p=0·31). Metformin was not a predictor of BMI Z score at 24 months of age (mean difference -0·01 95% CI -0·42 to 0·37, p=0·92). There was no overall difference in BMI trajectory but, in males, trajectories were significantly different by treatment (p=0·048); BMI in the metformin group was higher between 6 and 24 months. Children of women with type 2 diabetes were approximately 1 SD heavier than the WHO reference population.
Anthropometrics were similar in children exposed and those not exposed to metformin in utero; hence, overall, data are reassuring with regard to the use of metformin during pregnancy in women with type 2 diabetes and the long-term health of their children.
Canadian Institute for Health Research.
Screening is best accomplished with a fasting plasma glucose test. Diabetes is diagnosed if the fasting plasma glucose level is 7.0 mmol/L or greater, or if the plasma glucose level is 11.1 mmol/L or ...greater in a 2-hour oral glucose tolerance test (OGTT).2 Either test should be done on 2 occasions before a diagnosis can be made. Impaired fasting glucose is diagnosed if the fasting glucose level is 6.1-6.9 mmol/L, and impaired glucose tolerance is diagnosed if the plasma glucose level is 7.8-11.0 mmol/L in a 2-hour OGTT. Although there are studies suggesting a benefit of treating people who have impaired glucose tolerance to reduce the incidence of progression of diabetes and possibly cardiovascular disease, the evidence is still inadequate to recommend screening for impaired fasting glucose or impaired glucose tolerance. However, people with the latter condition may nonetheless be identified in the course of their health care. These patients should be treated with lifestyle interventions aimed at lowering weight and increasing exercise, because such interventions may lower the incidence of diabetes (level I evidence).31-33 Acarbose treatment can also be considered for these patients, because it has been shown to reduce the incidence of cardiovascular outcomes and hypertension (level I evidence).34 Although the use of metformin33 and acarbose35 in patients with impaired glucose tolerance has been shown to reduce the incidence of diabetes over 3 years, the rate of diabetes dropped when metformin was discontinued.36 Of note, the prevention trials were all of 3 to 6 years' duration, and it is unclear whether the effects of lifestyle or pharmacologie intervention persist beyond that period. Furthermore, it is still uncertain whether diabetes can truly be prevented or whether these strategies simply delay its onset. The impact of delaying diabetes for a few years on preventing microvascular complications would likely be small, since the risk of complications is low in the first 15 years after diabetes diagnosis. The beneficial effects of lifestyle modification on cardiovascular events in people with impaired glucose tolerance also remain to be demonstrated. Finally, the cost-effectiveness of screening for impaired glucose tolerance and offering lifestyle interventions only to those with a positive test result and not to all people with diabetes risk factors has not been examined.
It is vital for individuals with type 2 diabetes (T2DM) to adhere to a healthy dietary pattern to maintain optimal blood glucose levels and overall health. Increasing costs of healthy foods, however, ...are a barrier to maintaining healthful dietary patterns, particularly for individuals with T2DM who are experiencing food insecurity. Poor diet quality may result in difficulties maintaining optimal blood glucose levels, leading to higher rates of diabetes complications, and increased acute care usage and costs. Although the adverse impacts of food insecurity on maintaining optimal blood glucose levels are well documented, effective strategies to this among individuals with T2DM are lacking. One approach is providing subsidies to purchase healthy foods through subsidized healthy food prescription programs. These programs may help reduce food insecurity and improve diet quality, thereby improving blood glucose levels and reducing diabetes complications over time.
A parallel group randomized controlled trial will examine the effectiveness of a subsidized healthy food prescription program compared to a healthy food prescription alone in improving average blood glucose levels (primary outcome), and other secondary outcomes among 404 adults who are experiencing food insecurity and persistent hyperglycemia. The subsidized healthy food prescription program consists of two core elements: 1) A one-time healthy food prescription pamphlet that outlines an evidence-based healthy dietary pattern; 2) A healthy food subsidy of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. At baseline and 6-month follow-up, participants will provide responses to sociodemographic and health-related items, and a variety of patient-reported outcomes. Biochemical and physical measurements will also be obtained.
The study’s theory of change posits that reducing food insecurity and improving diet quality will be key mediators in improving blood glucose levels, which may reduce diabetes complications, and healthcare usage and costs over time.
The results of this study will demonstrate if a subsidized healthy food prescription program results in meaningful changes in average blood glucose levels and other clinically relevant outcomes.
Alberta Innovates, Alberta Health Services.
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