We evaluated the ability of the Fatty Liver Index (FLI), a surrogate marker of hepatic steatosis, to predict the development of type 2 diabetes (T2D) at 3 years follow-up in a Spanish cohort with ...prediabetes from a prospective observational study in primary care (PREDAPS).
FLI was calculated at baseline for 1,142 adult subjects with prediabetes attending primary care centers, and classified into three categories: FLI <30 (no steatosis), FLI 30-60 (intermediate) and FLI ≥60 (hepatic steatosis). We estimated the incidence rate of T2D in each FLI category at 3 years of follow-up. The association between FLI and incident T2D was calculated using Cox regression models adjusted for age, sex, educational level, family history of diabetes, lifestyles, hypertension, lipid profile and transaminases.
The proportion of subjects with prediabetes and hepatic steatosis (FLI ≥60) at baseline was 55.7%. The incidence rate of T2D at 3 years follow-up was 1.3, 2.9 and 6.0 per 100 person-years for FLI<30, FLI 30->60 and FLI ≥60, respectively. The most significant variables increasing the risk of developing T2D were metabolic syndrome (hazard ratio HR = 3.02; 95% confidence interval CI = 2.14-4.26) and FLI ≥60 (HR = 4.52; 95%CI = 2.10-9.72). Moreover, FLI ≥60 was independently associated with T2D incidence: the HR was 4.97 (95% CI: 2.28-10.80) in the base regression model adjusted by sex, age and educational level, and 3.21 (95%CI: 1.45-7.09) in the fully adjusted model.
FLI may be considered an easy and valuable early indicator of high risk of incident T2D in patients with prediabetes attended in primary care, which could allow the adoption of effective measures needed to prevent and reduce the progression of the disease.
To explore the relationship between chronic kidney disease (CKD) and diabetic retinopathy (DR) in a representative population of type 2 diabetes mellitus (DM2) patients in Catalonia (Spain).
This was ...a population-based, cross-sectional study. A total of 28,344 patients diagnosed with DM2 who had recorded ophthalmologic and renal functional examinations were evaluated. Data were obtained from a primary healthcare electronic database of medical records. CKD was defined as an estimated glomerular filtration ratio (eGFR) of <60 ml/min/1.73 m2 and/or urine albumin to creatinine ratio (UACR) ≥30 mg/g. DR was categorized as non-vision threatening diabetic retinopathy and vision threatening diabetic retinopathy.
CKD was associated with a higher rate of DR OR, 95% confidence interval CI, 1.5 (1.4-1.7). When we analyzed the association between different levels of UACR and DR prevalence observed that DR prevalence rose with the increase of UACR levels, and this association was significant from UACR values ≥10 mg/g, and increased considerably with UACR values ≥300 mg/g (Odds ratio OR, 95% confidence interval CI, 2.0 (1.6-2.5). This association was lower in patients with eGFR levels 44 to 30 mL/min/1.73 m2 OR, 95% confidence interval CI, 1.3 (1.1-1.6).
These results show that CKD, high UACR and/or low eGFR, appear to be associated with DR in this DM2 population.
Background/aimsRetinal photography with a non-mydriatic camera is the method currently employed for diabetic retinography (DR) screening. We designed this study in order to evaluate the prevalence ...and severity of DR, and associated risk factors, in patients with type 2 diabetes (T2DM) screened in Catalan Primary Health Care.MethodsRetrospective, cross-sectional, population based study performed in Catalonia (Spain) with patients with T2DM, aged between 30 years and 90 years (on 31 December 2012) screened with retinal photography and whose DR category was recorded in their medical records. DR was classified as: no apparent retinopathy (no DR), mild non-proliferative DR (mild NPDR), moderate NPDR, severe NPDR, proliferative DR (PDR) and diabetic macular oedema (DMO). Non-vision threatening DR (non-VTDR) included mild and moderate NPDR; VTDR included severe NPDR, PDR and DMO. Clinical data were obtained retrospectively from the SIDIAP database (System for Research and Development in Primary Care).Results108 723 patients with T2DM had been screened with retinal photography. The prevalence of any kind of DR was 12.3% (95% CI 12.1% to 12.5%). Non-VTDR and VTDR were present in 10.8% (mild 7.5% and moderate NPDR 3.3%) and 1.4% (severe NPDR 0.86%, PDR 0.36% and DMO 0.18%) of the study patients, respectively.ConclusionsThe prevalence of any type of DR in patients with T2DM screened with retinal photography was lower when compared with earlier studies.
Blood pressure (BP) variability is associated with stroke risk, but less is known about subclinical cerebral small vessel disease (CSVD). We aimed to determine whether CSVD relates to short-term BP ...variability independently of BP levels and also, whether they improve CSVD discrimination beyond clinical variables and office BP levels. This was a cohort study on asymptomatic hypertensives who underwent brain magnetic resonance imaging and 24-hour ambulatory BP monitoring. Office and average 24-hour, daytime and nighttime BP levels, and several metrics of BP variability (SD, weighted SD, coefficient of variation, and average real variability ARV) were calculated. Definition of CSVD was based on the presence of lacunar infarcts and white matter hyperintensity grades. Multivariate analysis and integrated discrimination improvement were performed to assess whether BP variability and levels were independently associated with CSVD and improved its discrimination. Four hundred eighty-seven individuals participated (median age, 64; 47% women). CSVD was identified in 18.9%, related to age, male sex, diabetes mellitus, use of treatment, ambulatory BP monitoring–defined BP levels, and ARV of systolic BP at any period. The highest prevalence (33.7%) was found in subjects with both 24-hour BP levels and ARV elevated. BP levels at any period and ARV (24 hours and nocturnal) emerged as independent predictors of CSVD, and discrimination was incrementally improved although not to a clinically significant extent (integrated discrimination improvement, 5.31%, 5.17% to 5.4%). Ambulatory BP monitoring–defined BP levels and ARV of systolic BP relate to subclinical CSVD in hypertensive individuals.
OBJECTIVES
We aimed to study the value of ambulatory blood pressure monitoring (ABPM) in predicting the global progression of cerebral small vessel disease (cSVD).
DESIGN
Longitudinal cohort study.
...SETTING
Data from the population‐based Investigating Silent Strokes in Hypertensives study.
PARTICIPANTS
Individuals with hypertension who were 50 to 70 years of age and stroke free at baseline. In baseline and follow‐up visits, patients underwent magnetic resonance imaging and ABPM.
MEASUREMENTS
Ambulatory systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels were studied as continuous variables and dichotomized according to good or poor control on the basis of 125/75 (24 hours), 130/80 (day), and 110/65 (night) mm Hg cutoff values. Whole cSVD progression was qualitatively scored with 1 point when an incident lesion (incident lacunar infarcts, deep cerebral microbleeds, white matter hyperintensities, and basal ganglia enlarged perivascular spaces) was detected. The score ranged from 0 to 4.
RESULTS
We followed up 233 participants with a median age of 65 years within 4 years. A total of 61 (26.2%) and 23 (9.9%) subjects showed cSVD progression in one and two or more markers, respectively. Baseline ambulatory SBP and DBP and nighttime pulse pressure (PP) values were positively correlated with the number of incident cSVD lesions. Interestingly, patients without incident lesions showed greater differences between office and ambulatory BP, thus suggesting an increased white coat effect. Poor DBP control, nighttime PP, and DBP white coat effect were independently associated with cSVD progression. The inclusion of these metrics in a clinical model resulted in a significant increase in the prediction of incident lesions (integrated discrimination improvement = 9.09%; P value <.001).
CONCLUSION
ABPM may help assess cSVD risk of progression, especially by the identification of poor BP control, masked hypertension, and increased nighttime PP. J Am Geriatr Soc 68:2232–2239, 2020.
The aims of our study was compare adherence measured by the medical possession ratio (MPR), time until discontinuation and describe adverse events after adding a DPP-4i, SGLT-2i, or sulfonylureas ...(SU) to metformin in a primary care population with insufficient glycemic control. We used routinely-collected health data from the SIDIAP database. The included subjects were matched by propensity score. The follow-up period was up to 24 months or premature discontinuation. The primary outcomes were the percentage of subjects with good adherence, treatment discontinuation and adverse events among treatment groups. The proportion of patients with good adherence (MPR> 0.8) after the addition of DPP-4i, SGLT-2i or SU was 53.6%, 68.7%, and 43.0%, respectively. SGLT-2i users were 1.7 times more likely to achieve good adherence compared with DPP-4i users (odds ratio OR:1.72, 98% confidence interval CI:1.51, 1.96), and 2.8 times more likely compared with SU users (OR: 0.35, 98% CI: 0.07, 0.29). The discontinuation hazard ratios were 1.43 (98%CI: 1.26; 1.62) and 1.60 (98%CI: 1.42; 1.81) times higher among SGLT-2i and SU users than DPP-4i users during the follow-up period. No differences were observed for adverse events among the treatment groups. In conclusion, in our real-world setting, the combination of SGLT-2i with metformin was associated with better adherence. The mean time until discontinuation was longer in the SGLT-2i group in comparison with the DPP-4i or SU groups.
Summary
Aim
The aim of this study was to assess glycaemic control and prescribing practices of antihyperglycaemic treatment in patients with diabetes mellitus type 2 aged 75 years or older.
Methods
...We analysed data from health electronic records from 4,581 persons attended at primary healthcare centres of the Institut Català de la Salut (ICS), in the Girona Sud area of Catalonia, Spain, during 2013 and 2016. Variables such as age, gender, body mass index (BMI), diabetes duration, age at diabetes diagnosis, glycated haemoglobin (HbA1c), creatinine, glomerular filtrate rate and the albumin/creatinine ratio in urine were collected. A descriptive analysis of the study variables was done to determinate the percentage of persons on antidiabetic treatment.
Results
We identified 4,421 persons aged 75 years or older who provided data on HbA1c and antidiabetic treatment. Mean age was 82.3 (5.1) years. In 58.1% of patients, the level of HbA1c was below 7.0%, while in 36.8% it was below 6.5%. Between patients with HbA1c below 7.0%, antidiabetic drugs were taken by 70.2%, where 15.2% were either on insulin, sulphonylureas or repaglinide therapy.
Conclusion
Intensive treatment among older adults with diabetes mellitus type 2 is common in primary care clinical practice in our area. Intensive glycaemic control confers an increased risk of hypoglycaemia and little benefit among older individuals with diabetes. Physicians should take care more not to harm those populations and treatment should be de‐intensified to reduce the risk of hypoglycaemia.
To identify actions of healthcare professionals (HCPs) that facilitate the transition to insulin therapy (IT) in type 2 diabetes (T2D) adults.
Included were T2Ds in seven countries (n = 594) who ...reported initial IT reluctance but eventually began IT. An online survey included 38 possible HCP actions: T2Ds indicated which may have occurred and their helpfulness. Also reported were delays in IT start after initial recommendation and any period of IT discontinuation.
Exploratory factor analysis of HCP actions yielded five factors: “Explained Insulin Benefits” (EIB), “Dispelled Insulin Myths” (DIM), “Demonstrated the Injection Process” (DIP), “Collaborative Style” (CS) and “Authoritarian Style” (AS). Highest levels of helpfulness occurred for DIP, EIB and CS; lowest for AS. Participants who rated DIP as helpful were less likely to delay IT than those who rated DIP as less helpful (OR = 0.75, p = 0.01); participants who rated CS and EIB as helpful were less likely to interrupt IT than those who rated these as less helpful (OR = 0.55, p < 0.01; OR = 0.51, p = 0.01, respectively).
Three key HCP actions to facilitate IT initiation were identified as helpful and were associated with more successful initiation and persistence. These findings may aid the development of interventions to address reluctance to initiating IT.
The purpose of this study was to assess the risk of occurrence of Parkinson's disease (PD) among subjects with type 2 diabetes and diabetic retinopathy (DR) in our large primary health care database ...from Catalonia (Spain). A retrospective cohort study with pseudo-anonymized routinely collected health data from SIDIAP was conducted from 2008 to 2016. We calculated the number of events, time to event, cumulative incidence, and incidence rates of PD for subjects with and without DR and for different stages of DR. The proportional hazards regression analysis was done to assess the probability of occurrence between DR and PD. In total, 26,453 type 2 diabetic subjects with DR were identified in the database, and 216,250 subjects without DR at inclusion. During the follow-up period, 1,748 PD events occurred. PD incidence rate and cumulative incidence were higher among subjects with DR (16.95 per 10,000 person-years and 0.83%, respectively). In the unadjusted analysis, subjects with DR were at 1.25 times higher risk (hazard ratio: 1.22, 95% confidence interval: 1.06; 1.41) of developing PD during the study period. However, we did not find any statistically significant HR for DR in any models after adjusting for different risk factors (age, sex, duration of diabetes, smoking, body mass index, glycosylated hemoglobin, comorbidities). In conclusion, in our primary health care population database, DR was not associated with an increased risk of PD after adjusting for different risk factors. In our retrospective cohort study, age, male sex, and diabetes duration were independent risk factors for developing PD.
During the last decade medical students from most Western countries have shown little interest in family practice. Understanding the factors that influence medical students to choose family medicine ...is crucial.
To systematically review and synthesize published evidence about medical students' attitudes and perceptions towards family practice.
A qualitative systematic review. The literature search was undertaken in July 2010 in PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Social Science Citation Index (SSCI), and ProQuest Dissertations & Theses. Two authors independently selected the studies for their inclusion and assessed their quality. The selected studies were thoroughly read. Key themes and categories were identified. A matrix was created for allowing the comparison of each theme across studies.
Ten studies were finally included. Seven broad themes were identified across them: 1) Scope and context of practice was a broad theme comprising linked sub-themes: perception of a varied specialty, broad practice, holistic perspective and flexibility that allows having a family; 2) Lower interest or intellectually less challenging: treating common disease, repetitive, quasi administrative job; 3) Influence of role models, either positive and negative, and society: negative comments from other professionals, peers and family; 4) Lower prestige; 5) Poor remuneration; 6) Medical school influences, being important both the length and quality of the exposure; 7) Post graduate training, where the shorter duration and the lower intensity were perceived as positive aspects. After identifying these seven key themes, were also looked into patterns in the distribution of these themes among studies.
Our qualitative review provides a comprehensive picture of medical students' attitudes towards family practice in the available literature. In general, although some students find family medicine appealing, it is regarded as a career of low interest and prestige. More research is needed on the influence of role models, medical school and post graduate training.
PDF
