Aims/hypothesis
The aim of this study was to analyse the risk profile for diabetic retinopathy under real-life conditions in a large cohort of patients with type 1 diabetes.
Methods
Patients (
n
= ...18,891) with childhood, adolescent or adult onset of type 1 diabetes from the prospective German Diabetes Documentation System survey were analysed. A total of 8,784 patients fulfilled the inclusion criterion, which was availability of retinopathy status. Retinopathy grading (any retinopathy, advanced retinopathy), treatment regimens and risk factors were prospectively recorded and tested as covariates by Kaplan–Meier analysis and logistic regression.
Results
Any retinopathy was present in 27.4% and advanced retinopathy (severe non-proliferative or proliferative diabetic retinopathy) in 8.0% of the cohort. After 40 years of diabetes, the cumulative proportion of patients with any retinopathy and advanced retinopathy was 84.1% and 50.2%, respectively. In multiple regression analysis, risk factors for any retinopathy were diabetes duration (OR 1.167 per year), HbA
1c
>7.0% (53 mmol/mol) (OR 2.225), smoking (OR 1.295) and male sex (OR 1.187) (
p
< 0.0001 for all). Young age at onset (5 vs 15 years at disease onset) was protective (0.410,
p
< 0.0001). No glycaemic threshold was detected for retinopathy protection. Risk factors for advanced retinopathy were duration (1.124 per year,
p
< 0.0001), male sex (1.323,
p
= 0.0020), HbA
1c
>7.0% (53 mmol/mol) (1.499,
p
< 0.0001), triacylglycerol >1.7 mmol/l (1.398,
p
= 0.0013) and blood pressure >140/90 mmHg (1.911,
p
< 0.0001).
Conclusions/interpretation
The prevalence of retinopathy remains significant in type 1 diabetes. Any improvement of metabolic control and non-smoking is protective, while hypertension affects progression to severe levels under real-life conditions. These data reinforce the validity of multifactorial concepts for morbidity protection in type 1 diabetes.
Ziegler R, Heidtmann B, Hilgard D, Hofer S, Rosenbauer J, Holl R; for the DPV‐Wiss‐Initiative. Frequency of SMBG correlates with HbA1c and acute complications in children and adolescents with type 1 ...diabetes.
The aim of this study was to correlate the frequency of self‐monitoring of blood glucose (SMBG) to the quality of metabolic control as measured by hemoglobin A1c (HbA1c), the frequency of hypoglycemia and ketoacidosis, and to see whether the associations between SMBG and these outcomes are influenced by the patient's age or treatment regime. We analyzed data from the DPV‐Wiss‐database of 26 723 children and adolescents aged 0–18 yr with type 1 diabetes recorded during 1995–2006. Variables evaluated were gender, age at visit, diabetes duration, therapy regime, insulin dose, body mass index–standard deviation scores (BMI–SDS), HbA1c, rate of hypoglycemia, and ketoacidosis. In the youngest age group of children under the age of 6 yr, the frequency of SMBG was the highest compared with that in children aged 6–12 yr or children aged > 12 yr: 6.0/d vs. 5.3/d vs. 4.4/d (p < 0.001). Frequency of SMBG differed significantly also in the different groups of treatment (p < 0.001), but only for the continuous subcutaneous insulin infusion (CSII) group the frequency was considerably higher: 5.3/d (CSII) vs. 4.7/d (multiple daily injections) vs. 4.6/d (conventional therapy). Adjusted for age, gender, diabetes duration, year of treatment, insulin regimen, insulin dose, BMI‐SDS, and center difference, SMBG frequency was significantly associated with better metabolic control with a drop of HbA1c of 0.20% for one additional SMBG per day (p < 0.001). Increasing the SMBG frequency above 5/d did not result in further improvement of metabolic control. A higher frequency of SMBG measurements was related to better metabolic control. But only among adolescents aged > 12 yr, metabolic control (HbA1c) improved distinctively with two or more blood glucose measurements.
While organisational change in substance use disorder (SUD) treatment has been extensively studied, there is no research describing facility-wide changes related to nutrition interventions. This ...study evaluates staff-perceived barriers to change before and after a wellness initiative.
A pre-intervention questionnaire was administered to participating staff prior to facility-wide changes (n 40). The questions were designed to assess barriers across five domains: (1) provision of nutrition-related treatment; (2) implementation of nutrition education; (3) screening, detecting and monitoring (nutrition behaviours); (4) facility-wide collaboration and (5) menu changes and client satisfaction. A five-point Likert scale was used to indicate the extent to which staff anticipate difficulty or ease in implementing facility-wide nutrition changes, perceived as organisational barriers. Follow-up questionnaires were identical to the pre-test except that it examined barriers experienced, rather than anticipated (n 50).
A multisite SUD treatment centre in Northern California which began implementing nutrition programming changes in order to improve care.
Staff members who consented to participate.
From pre to post, we observed significant decreases in perceived barriers related to the provision of nutrition-related treatment (P = 0·019), facility-wide collaboration (P = 0·036), menu changes and client satisfaction (P = 0·024). Implementation of nutrition education and the domain of screening, detecting and monitoring did not reach statistical significance.
Our results show that staff training, food service changes, the use of targeted curriculum for nutrition groups and the encouragement of discussing self-care in individual counselling sessions can lead to positive shifts about nutrition-related organisational change among staff.
The objective of this study was to determine the prevalence of nutrition services and utilization of registered dietitian nutritionists at substance use disorder treatment centers in Los Angeles. ...This cross-sectional descriptive study utilized phone interviews with facilities within a 25-mile radius of the Los Angeles metropolitan area using the Substance Abuse and Mental Health Services Administration Treatment Services Locator to identify facilities that included a listing of substance abuse as primary focus of care (n = 128). Facilities were asked if they offered any kind of nutrition services, the type of services that were offered, and the credential of the professional providing the services. We compared facilities that offered a residential level of care to those offering outpatient services only. The Fisher’s exact test was used to determine statistical significance. The study showed that only 39 sites (30.5 %) offered any type of nutrition services on site, and the odds of a residential level of care offering nutrition services was 2.7 times higher than outpatient only facilities (p = 0.02). Of the 39 facilities offering nutrition services, only 8 (20.5%) utilized a registered dietitian nutritionist. Overall fewer than 7 % of the facilities utilized the services of a dietitian. Recovery programs for substance use disorder should consider using a registered dietitian nutritionist as a member of the treatment team, which may contribute to better clinical outcomes.
Abstract Background Weight suppression has been defined as diet-induced weight loss, traditionally operationalized as the difference between one’s highest and current weight. This concept has been ...studied in the context of eating disorders, but its value in predicting treatment outcomes has been inconsistent, which may be partially attributed to its calculation. Method The current study operationalizes a novel weight suppression score, reflecting the midpoint between the lowest and highest adult weights among adults (N = 287, ages 21–75, 73.9% women) seeking outpatient treatment for disordered eating. This report compared the traditional weight suppression calculation to the novel weight suppression score in a simulated dataset to model their differential distributions. Next, we analyzed shared and distinct clinical correlates of traditional weight suppression versus the novel weight suppression score using clinical intake data. Results The novel weight suppression score was significantly associated with meeting criteria for both eating disorders and ultra-processed food addiction and was more sensitive to detecting clinically relevant eating disorder symptomatology. However, the novel weight suppression score (vs. traditional weight suppression) was associated with fewer ultra-processed food addiction symptoms. Conclusion The novel weight suppression score may be particularly relevant for those with eating disorders and ultra-processed food addiction, with more relevance to individual eating disorder compared to ultra-processed food addiction symptoms. Consideration of the novel weight suppression score in future research on eating behaviors should extend beyond just those with diagnosed eating disorders.
Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the ...union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion.
We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.
One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures.
Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Increased weight gain has been reported prior to disease onset (accelerator hypothesis) and as a side effect of intensified insulin therapy in type 1 diabetes (T1D). Paediatric studies are ...complicated by the age-dependency and gender-dependency of BMI, and also by a trend towards obesity in the general population. The aim of this study was to evaluate factors related to the increase in BMI during the course of diabetes in children and adolescents with T1D in a large multicentre survey.
Within the DPV database (Diabetespatienten Verlaufsdokumentation) a standardised, prospective, computer-based documentation programme, data of 53,108 patients with T1D, aged <20 years, were recorded in 248 centres. 12,774 patients (53% male, mean age 13.4±3.9, mean diabetes duration 4.7±3.0 years and mean age at diabetes onset 8.7±4.0 years) were included in this analysis. Population-based German reference data were used to calculate BMI-SDS and define overweight and obesity.
12.5% of T1D patients were overweight and 2.8% were obese. Multiple longitudinal regression analysis revealed that female gender, low BMI at diabetes onset, intensified insulin therapy and higher insulin dose, as well as pubertal diabetes onset, long diabetes duration and onset in earlier calendar years among girls, were related to higher BMI-SDS increase during the course of diabetes (p<0.01; all).
Intensified insulin regimen is associated with weight gain during T1D treatment, in addition to demographic variables. Optimisation of diabetes management, especially in females, might limit weight gain in order to reduce overweight and obesity together with comorbidities among paediatric T1D patients.
The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; ...(2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.
Longitudinal observational cohort study.
Academic Level 1 trauma center.
One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018.
Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion.
Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures.
The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion.
Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence.
Aims
Diabetic foot ulcer (DFU) is a leading cause of lower limb amputations in people with diabetes. This study was aimed to retrospectively analyze factors affecting DFU using real‐world data from a ...large, prospective central‐European diabetes registry (DPV Diabetes‐Patienten‐Verlaufsdokumentation).
Materials and Methods
We matched adults with type 1 (T1D) or type 2 diabetes (T2D) and DFU to controls without DFU by diabetes type, age, sex, diabetes duration, and treatment year to compare possible risk factors. Cox regression was used to calculate hazard ratios for amputation among those with DFU.
Results
In our cohort (N = 63 464), male sex, taller height, and diabetes complications such as neuropathy, peripheral artery disease, nephropathy, and retinopathy were associated with DFU (all p < .001). Glycated hemoglobin (HbA1c) was related to DFU only in T1D (mean with 95% confidence interval CI: 7.8 6.9–9.0 % vs 7.5 6.8–8.5 %, p < .001). High triglycerides and worse low‐density lipoprotein/high‐density lipoprotein ratio were also associated with DFU in T1D, whereas smoking (14.7% vs 13.1%) and alcohol abuse (6.4% vs 3.8%, both p < .001) were associated with DFU in T2D. Male sex, higher Wagner grades, and high HbA1c in both diabetes types and insulin use in T2D were associated with increased hazard ratios for amputations.
Conclusions
Sex, body height, and diabetes complications were associated DFU risk in adults with T1D and T2D. Improvement in glycemic control and lipid levels in T1D and reduction of smoking and drinking in T2D may be appropriate interventions to reduce the risk for DFU or amputations.
Highlights
Poor glycemic control and high lipid levels were associated more closely with diabetic foot ulcers in type 1 compared to type 2 diabetes.
Gender differences regarding the association of diabetic foot ulcers with metabolic outcomes were more pronounced in type 1 diabetes.
Smoking and alcohol consumption might be important in developing foot ulcers but play a minor role in prevention of amputations.
The role of oral hypoglycemic medication in development of diabetic foot ulcers should be further analyzed in type 2 diabetes.
Clavicle nonunions often result after nonoperative treatment for the acute fracture. Those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. The aims of the ...present study were to (1) determine healing rates of clavicle nonunions after plate osteosynthesis using either a conventional or locked plate, (2) compare iliac crest bone graft vs. bone morphogenetic protein on nonunion healing, and (3) identify risk factors for the development of a recalcitrant nonunion.
We performed a retrospective analysis of a prospectively collected database of 78 clavicle nonunions treated with open reduction and plate fixation with or without graft augmentation by a single surgeon over 25 years. Seventy-one patients over the age of 18 with at least 12 months of follow-up comprised the study group. We analyzed healing rates after the index clavicle nonunion surgery comparing plate type and graft technique as well as identifying risk factors for developing a recalcitrant nonunion.
A total of 62 patients (87.3%) healed after their index nonunion surgery at our institution. Three patients (4.2%) required additional surgery but healed, and 6 patients (8.5%) remain un-united; these 9 patients (12.7%) were defined as recalcitrant. There was no statistically significant difference in healing rates between plate type (P = .633) or type of bone graft (P = .157). There were no identifiable risk factors for the development of a recalcitrant nonunion.
Plate fixation of clavicle nonunions remains a successful method of treatment. The type of plate or the method of bone graft did not produce different results. There were no demographic, patient, or injury characteristics associated with the development of a recalcitrant nonunion.
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