Association between diabetes overtreatment in older multimorbid patients and clinical outcomes: an ancillary European multicentre study.

BACKGROUND Diabetes overtreatment is a frequent and severe issue in multimorbid older patients with type 2 diabetes (T2D). OBJECTIVE This study aimed at assessing the association between diabetes overtreatment and 1-year functional decline, hospitalisation and mortality in older inpatients with multimorbidity and polypharmacy. METHODS Ancillary study of the European multicentre OPERAM project on multimorbid patients aged ≥70 years with T2D and glucose-lowering treatment (GLT). Diabetes overtreatment was defined according to the 2019 Endocrine Society guideline using HbA1c target range individualised according to the patient's overall health status and the use of GLT with a high risk of hypoglycaemia. Multivariable regressions were used to assess the association between diabetes overtreatment and the three outcomes. RESULTS Among the 490 patients with T2D on GLT (median age: 78 years; 38% female), 168 (34.3%) had diabetes overtreatment. In patients with diabetes overtreatment as compared with those not overtreated, there was no difference in functional decline (29.3% vs 38.0%, P = 0.088) nor hospitalisation rates (107.3 vs 125.8/100 p-y, P = 0.115) but there was a higher mortality rate (32.8 vs 21.4/100 p-y, P = 0.033). In multivariable analyses, diabetes overtreatment was not associated with functional decline nor hospitalisation (hazard ratio, HR [95%CI]: 0.80 [0.63; 1.02]) but was associated with a higher mortality rate (HR [95%CI]: 1.64 [1.06; 2.52]). CONCLUSIONS Diabetes overtreatment was associated with a higher mortality rate but not with hospitalisation or functional decline. Interventional studies should be undertaken to test the effect of de-intensifying GLT on clinical outcomes in overtreated patients

The VORTEX project: first results and perspectives

(abridged) Vortex coronagraphs are among the most promising solutions to perform high contrast imaging at small angular separations. They feature a very small inner working angle, a clear 360 degree discovery space, have demonstrated very high contrast capabilities, are easy to implement on high-contrast imaging instruments, and have already been extensively tested on the sky. Since 2005, we have been designing, developing and testing an implementation of the charge-2 vector vortex phase mask based on concentric subwavelength gratings, referred to as the Annular Groove Phase Mask (AGPM). Science-grade mid-infrared AGPMs were produced in 2012 for the first time, using plasma etching on synthetic diamond substrates. They have been validated on a coronagraphic test bench, showing broadband peak rejection up to 500:1 in the L band, which translates into a raw contrast of about $6\times 10^{-5}$ at $2 \lambda/D$. Three of them have now been installed on world-leading diffraction-limited infrared cameras (VLT/NACO, VLT/VISIR and LBT/LMIRCam). During the science verification observations with our L-band AGPM on NACO, we observed the beta Pictoris system and obtained unprecedented sensitivity limits to planetary companions down to the diffraction limit ($0.1''$). More recently, we obtained new images of the HR 8799 system at L band during the AGPM first light on LMIRCam. After reviewing these first results obtained with mid-infrared AGPMs, we will discuss the short- and mid-term goals of the on-going VORTEX project, which aims to improve the performance of our vortex phase masks for future applications on second-generation high-contrast imagers and on future extremely large telescopes (ELTs).Comment: To appear in SPIE proceedings vol. 914

Overtreatment and associated risk factors among multimorbid older patients with diabetes.

BACKGROUND In multimorbid older patients with type 2 diabetes mellitus (T2DM), the intensity of glucose-lowering medication (GLM) should be focused on attaining a suitable level of glycated hemoglobin (HbA1c ) while avoiding side effects. We aimed at identifying patients with overtreatment of T2DM as well as associated risk factors. METHODS In a secondary analysis of a multicenter study of multimorbid older patients, we evaluated HbA1c levels among patients with T2DM. Patients were aged ≥70 years, with multimorbidity (≥3 chronic diagnoses) and polypharmacy (≥5 chronic medications), enrolled in four university medical centers across Europe (Belgium, Ireland, Netherlands, and Switzerland). We defined overtreatment as HbA1c  < 7.5% with ≥1 GLM other than metformin, as suggested by Choosing Wisely and used prevalence ratios (PRs) to evaluate risk factors of overtreatment in age- and sex-adjusted analyses. RESULTS Among the 564 patients with T2DM (median age 78 years, 39% women), mean ± standard deviation HbA1c was 7.2 ± 1.2%. Metformin (prevalence 51%) was the most frequently prescribed GLM and 199 (35%) patients were overtreated. The presence of severe renal impairment (PR 1.36, 1.21-1.53) and outpatient physician (other than general practitioner [GP], i.e. specialist) or emergency department visits (PR 1.22, 1.03-1.46 for 1-2 visits, and PR 1.35, 1.19-1.54 for ≥3 visits versus no visits) were associated with overtreatment. These factors remained associated with overtreatment in multivariable analyses. CONCLUSIONS In this multicountry study of multimorbid older patients with T2DM, more than one third were overtreated, highlighting the high prevalence of this problem. Careful balancing of benefits and risks in the choice of GLM may improve patient care, especially in the context of comorbidities such as severe renal impairment, and frequent non-GP healthcare contacts

The Knight of Malta

BACKGROUND: For most women, participation in decision-making during maternity care has a positive impact on their childbirth experiences. Shared decision-making (SDM) is widely advocated as a way to support people in their healthcare choices. The aim of this study was to identify quality criteria and professional competencies for applying shared decision-making in maternity care. We focused on decision-making in everyday maternity care practice for healthy women. METHODS: An international three-round web-based Delphi study was conducted. The Delphi panel included international experts in SDM and in maternity care: mostly midwives, and additionally obstetricians, educators, researchers, policy makers and representatives of care users. Round 1 contained open-ended questions to explore relevant ingredients for SDM in maternity care and to identify the competencies needed for this. In rounds 2 and 3, experts rated statements on quality criteria and competencies on a 1 to 7 Likert-scale. A priori, positive consensus was defined as 70% or more of the experts scoring >/=6 (70% panel agreement). RESULTS: Consensus was reached on 45 quality criteria statements and 4 competency statements. SDM in maternity care is a dynamic process that starts in antenatal care and ends after birth. Experts agreed that the regular visits during pregnancy offer opportunities to build a relationship, anticipate situations and revisit complex decisions. Professionals need to prepare women antenatally for unexpected, urgent decisions in birth and revisit these decisions postnatally. Open and respectful communication between women and care professionals is essential; information needs to be accurate, evidence-based and understandable to women. Experts were divided about the contribution of professional advice in shared decision-making and about the partner's role. CONCLUSIONS: SDM in maternity care is a dynamic process that takes into consideration women's individual needs and the context of the pregnancy or birth. The identified ingredients for good quality SDM will help practitioners to apply SDM in practice and educators to prepare (future) professionals for SDM, contributing to women's positive birth experience and satisfaction with care

Implications of health and metabolic heterogeneities for glycaemic management in older patients with type 2 diabetes

Type 2 diabetes (T2D) is one of the most prevalent chronic condition in older people, a heterogeneous population in terms of health status. Consequently, risks and benefits of glycaemic control by glucose-lowering treatment may differ considerably between patients and must be wisely balanced to avoid harmful consequences, i.e. hypoglycaemic events. This can be achieved by individualising treatment goals according to patient’s characteristics. This thesis (i) reviewed recommendations from recent Clinical Practice Guidelines for individualised glycaemic management in older people with T2D, (ii) assessed the application of these recommendations in clinical practice, and (iii) described the metabolic heterogeneity in older people with T2D. The results provide strong encouragement to follow more assiduously recommendations for individualising the glycaemic management in older patients with T2D, and to continue research in this field to provide high-level evidence recommendations.(MED - Sciences médicales) -- UCL, 202

Large discrepancy in glycaemic control appropriateness in geriatric patients with type 2 diabetes according to major clinical practice guidelines

Purpose. In geriatric patients with type 2 diabetes (T2D), appropriate glycaemic control is crucial to avoid overtreatment and hypoglycaemia. This study compared glycaemic control appropriateness across three major clinical practice guidelines (CPGs). Methods. Retrospective study of geriatric older inpatients with T2D and glucose-lowering treatment before admission. Patients were classified as appropriately treated, overtreated or undertreated using CPGs from Diabetes Canada 2018 (DC18), the Endocrine Society 2019 (ES19) and the American Diabetes Association 2021 (ADA21). Results. Of the 318 geriatric patients (median age 84 years, 54% women, 66% in poor health), 46%, 25% and 82% were appropriately treated, while 38%, 57% and 0% were overtreated, based on DC18, ES19 and ADA21, respectively. Conclusion. Large discrepancy of glycaemic control appropriateness was detected across these CPGs and concerned mainly overtreatment. This finding relates to the absence in ADA21 of a lower HbA1c value, which may be an obstacle to the prevention of hypoglycaemia

Appropriateness of glucose-lowering therapy in geriatric patients with type 2 diabetes: factors associated with glucose-lowering therapy at high risk of hypoglycaemia.

Authorship: CHRISTIAENS Antoinea,b,c, GERMANIDIS Maried, HENRARD Séverineb,c, BOLAND Benoîtb,d. a Fonds de la Recherche Scientifique (F.R.S.-FNRS); b Institute of Health and Society, UCLouvain; c Clinical Pharmacy Research Group, Louvain Drug Research Institute, UCLouvain; d Geriatric medicine unit, Cliniques universitaires Saint Luc; Brussels, Belgium. Introduction: In order to minimise the risk of hypoglycaemia, glucose-lowering therapy (GLT) should be prescribed carefully and adequately in geriatric patients with type 2 diabetes (T2D). This study aimed at assessing factors associated with GLT-overuse (i.e. high risk of hypoglycaemia (HRH)) in geriatric patients with T2D. Methods: Retrospective study of consecutive inpatients with T2D admitted to a geriatric ward of a university hospital (Brussels; 2008-2015). Inclusion criteria were age ≥75 years, T2D, non-diabetic multimorbidities ≥3, HbA1c measurement and a GLT. GLT agents were divided into hypoglycaemic (sulfonylureas, glinides, insulins) and non-hypoglycaemic agents. GLT-appropriateness was defined according to the new Guidelines on Diabetes management in older adults (1). Pearson’s χ² test and Wilcoxon-Mann-Whitney test were used to compare 2 groups. A multivariable logistic regression was used to assess factors associated with HRH. Conditions of validity of each analysis were fulfilled. Results: Among the 318 geriatric patients with T2D included (median age: 84 years; 54% women), 105 (33.0%) were in intermediate health and 213 (67.0%) in poor health. No significant difference in HbA1c value was found between the 2 groups (median HbA1c value: 6.9%). GLT-overuse (i.e. with HRH) was present in 182 patients (57.2%). HRH was associated in multivariable model with poor health status (OR=1.66, p=0.045), severe kidney failure with glomerular filtration rate (eGFR) lower than 30ml/min (OR=2.05, p=0.034) and atrial fibrillation (OR = 2.15; p=0.003). In addition, patients with HRH had a higher one-year mortality rate than the other ones (44.5% vs. 29.6%, p=0.023). Discussion - Conclusions: In clinical practice, there is a room for improvement, as more than 1 out of 2 geriatric patients with T2D in our study had a high risk of hypoglycaemia due to inappropriate GLT prescription, according to the newest guidelines on therapeutic management of T2D in older adults. In particular, special attention should be paid to geriatric patients with poor health, severe kidney failure (eGFR<30ml/min) or atrial fibrillation, as these conditions were associated with GLT-overuse

Distinction of cardiometabolic profiles among people ≥ 75 years with type 2 diabetes: A latent profile analysis

BACKGROUND. Older patients with type 2 diabetes mellitus represent a heterogeneous group in terms of metabolic profile. It makes glucose-lowering-therapy (GLT) complex to manage, as it needs to be individualised according to the patient profile. This study aimed to identify and characterize subgroups existing among older patients with diabetes. METHODS. Retrospective observational cohort study of outpatients followed in a Belgian diabetes clinic. Included participants were all aged ≥75 years, diagnosed with type 2 diabetes, Caucasian, and had a Homeostasis Model Assessment (HOMA2). A latent profile analysis was conducted to classify patients using the age at diabetes diagnosis and HOMA2 variables, i.e. insulin sensitivity (HOMA2%-S), beta-cell-function (HOMA2%-β), and the product between both (HOMA2%-βxS; as a measure of residual beta-cell function). GLT was expressed in defined daily dose (DDD). RESULTS. In total, 147 patients were included (median age: 80 years; 37.4% women; median age at diabetes diagnostic: 62 years). The resulting model classified patients into 6 distinct cardiometabolic profiles. Patients in profiles 1 and 2 had an older age at diabetes diagnosis (median: 68 years) and a lesser decrease in HOMA2%-S, as compared to other profiles. They also presented with the highest HOMA2%-βxS values. Patients in profiles 3, 4 and 5 had a moderate decrease in HOMA2%-βxS. Patients in profile 6 had the largest decrease in HOMA2%-β and HOMA2%-βxS. This classification was associated with significant differences in terms of HbA1c values and GLT total DDD between profiles. Thus, patients in profiles 1 and 2 presented with the lowest HbA1c values (median: 6.5%) though they received the lightest GLT (median GLT DDD: 0.75). Patients in profiles 3 to 5 presented with intermediate values of HbA1c (median: 7.3% and GLT DDD (median: 1.31). Finally, patients in profile 6 had the highest HbA1c values (median: 8.4%) despite receiving the highest GLT DDD (median: 2.28). Other metabolic differences were found between profiles. CONCLUSIONS. This study identified 6 groups among patients ≥75 years with type 2 diabetes by latent profile analysis, based on age at diabetes diagnosis, insulin sensitivity, absolute and residual β-cell function. Intensity and choice of GLT should be adapted on this basis in addition to other existing recommendations for treatment individualisation

Latent Profile Analysis of the metabolic phenotype classified patients ≥75 years with type 2 diabetes into six distinct groups.

BACKGROUND. Older patients with type 2 diabetes mellitus represent a heterogeneous group in terms of metabolic profile. It makes glucose-lowering-therapy (GLT) complex to manage, as it needs be individualized to patient’s profile. This study aimed to characterize subgroups existing among older diabetic patients. METHODS. Retrospective study of an observational cohort of outpatients followed in a Belgian diabetes clinic. Included patients (n=147; median age=80 years; female=37.4%) were all aged ≥75years, diagnosed with type 2 diabetes, and benefited of a Homeostasis Model Assessment (HOMA2). A latent profile analysis was conducted using HOMA variables (including HOMA2%-βxS as a measure of residual β-cell function) and age at diabetes diagnosis to classify patients. GLT was expressed in daily-defined dose (DDD) RESULTS. The resulting model classified patients into 6 distinct subgroups. Groups 1 and 2, with a median age of 70 years at diabetes diagnosis, had lower values of BMI, HOMA2%-βxS decrease, GLT DDD and HbA1c. Groups 3, 4 and 5 had moderate decrease of HOMA2%-βxS, intermediate GLT DDD and HbA1c. Group 6 had the largest decrease of HOMA2%-βxS and the highest GLT DDD and HbA1c values. Other metabolic differences were found between groups. CONCLUSION. This study identified 6 clinically different subgroups in terms of metabolic profile severity among older patients with type 2 diabetes. Intensity and choice of GLT should be adapted on this basis, in addition to other existing recommendations for treatment individualization