Systemic anticoagulation in the setting of vascular extremity trauma

Introduction There is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities. Methods We analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data. Results Between February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4–91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p = 0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p = 0.002). Patients treated with ISA also stayed longer in the ICU (median 3 days vs. 1 day, p = 0.001) and hospital (median 9.5 days vs. 6 days, p = 0.01). Discussion In this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries

Design and Psychometrics for New Measures of Health-Related Quality of Life in Adults with Type 1 Diabetes: Type 1 Diabetes and Life (T1DAL)

AIMS: To use a three-phase process to develop and validate new self-report measures of diabetes-specific health-related quality of life (HRQOL) for adults with type 1 diabetes. We report on four versions of the Type 1 Diabetes and Life (T1DAL) measure for people age 18-25, 26-45, 46-60, and over 60 years. METHODS: We first conducted qualitative interviews to guide measure creation, then piloted the draft measures. We evaluated psychometric properties at six T1D Exchange Clinic Network sites via completion of T1DAL and validated measures of related constructs. Participants completed the T1DAL again in 4-6 weeks. We used psychometric data to reduce each measure to 23-27 items in length. Finally, we obtained participant feedback on the final measures. RESULTS: The T1DAL-Adult measures demonstrated good internal consistency (α=0.85-0.88) and test-retest reliability (r=0.77-0.87). Significant correlations with measures of general quality of life, generic and diabetes-specific HRQOL, diabetes burden, self-management, and glycemic control demonstrated validity. Factor analyses yielded 4-5 subscales per measure. Participants were satisfied with the final measures and reported they took 5-10 minutes to complete. CONCLUSIONS: The strong psychometric properties of the newly developed self-report T1DAL measures for adults with type 1 diabetes make them appropriate for use in clinical research and care

The obesity epidemic in 32,936 youth with type 1 diabetes (T1D) in the German/Austrian DPV and US T1D Exchange (T1DX) registries

Objective To examine the current extent of the obesity problem in 2 large pediatric clinical registries in the US and Europe and to examine the hypotheses that increased body mass index (BMI) z-scores (BMIz) are associated with greater hemoglobin A1c (HbA1c) and increased frequency of severe hypoglycemia in youth with type 1 diabetes (T1D). Study design International (World Health Organization) and national (Centers for Disease Control and Prevention/German Health Interview and Examination Survey for Children and Adolescents) BMI references were used to calculate BMIz in participants (age 2-<18 years and ≥1 year duration of T1D) enrolled in the T1D Exchange (n = 11 435) and the Diabetes Prospective Follow-up (n = 21 501). Associations between BMIz and HbA1c and severe hypoglycemia were assessed. Results Participants in both registries had median BMI values that were greater than international and their respective national reference values. BMIz was significantly greater in the T1D Exchange vs the Diabetes Prospective Follow-up (P < .001). After stratification by age-group, no differences in BMI between registries existed for children 2-5 years, but differences were confirmed for 6- to 9-, 10- to 13-, and 14- to 17-year age groups (all P < .001). Greater BMIz were significantly related to greater HbA1c levels and more frequent occurrence of severe hypoglycemia across the registries, although these associations may not be clinically relevant. Conclusions Excessive weight is a common problem in children with T1D in Germany and Austria and, especially, in the US. Our data suggest that obesity contributes to the challenges in achieving optimal glycemic control in children and adolescents with T1D

Incident Diabetes Complications among Women with type 1 diabetes based on Parity

Objectives To assess risk factors and incidence of diabetes complications in women with type 1 diabetes (T1D) based on parity. Research design/methods Data were collected from women (16–40 years old) in the T1D Exchange completing pregnancy/childbirth questionnaires during 2011–2013 and 2016–2018. Incidence of risk factors and diabetes complications were compared between women with a first pregnancy at/within 1-year of enrollment (n = 28) and never pregnant women by year 5 (n = 469). Results There was a trend for lower HbA1c (adjusted p = .14) and higher rates of overweight/obesity, triglyceride/HDL > 2, log (triglyercide/HDL), and hypertension among parous women compared with nulliparous women. There were no significant differences in rates of advanced nephropathy, albuminuria or cardiovascular disease. Conclusions Four-5 years after delivery, parous women with T1D tended to have lower HbA1c levels despite higher body mass indices and more frequent adverse lipid profiles and hypertension compared with nulliparous women. Further studies based on these trends are warranted

Risk Factors Associated With Severe Hypoglycemia in Older Adults With Type 1 Diabetes

OBJECTIVE Severe hypoglycemia is common in older adults with long-standing type 1 diabetes, but little is known about factors associated with its occurrence

The mangled extremity score and amputation

BackgroundThe Mangled Extremity Severity Score (MESS) was developed 25 years ago in an attempt to use the extent of skeletal and soft tissue injury, limb ischemia, shock, and age to predict the need for amputation after extremity injury. Subsequently, there have been mixed reviews as to the use of this score. We hypothesized that the MESS, when applied to a data set collected prospectively in modern times, would not correlate with the need for amputation.MethodsWe applied the MESS to patient data collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment registry. This registry contains prospectively collected demographic, diagnostic, treatment, and outcome data.ResultsBetween 2013 and 2015, 230 patients with lower extremity arterial injuries were entered into the PROspective Vascular Injury Treatment registry. Most were male with a mean age of 34 years (range, 4-92 years) and a blunt mechanism of injury at a rate of 47.4%. A MESS of 8 or greater was associated with a longer stay in the hospital (median, 22.5 (15, 29) vs 12 (6, 21); p = 0.006) and intensive care unit (median, 6 (2, 13) vs 3 (1, 6); p = 0.03). Of the patients' limbs, 81.3% were ultimately salvaged (median MESS, 4 (3, 5)), and 18.7% required primary or secondary amputation (median MESS, 6 (4, 8); p &lt; 0.001). However, after controlling for confounding variables including mechanism of injury, degree of arterial injury, injury severity score, arterial location, and concomitant injuries, the MESS between salvaged and amputated limbs was no longer significantly different. Importantly, a MESS of 8 predicted in-hospital amputation in only 43.2% of patients.ConclusionTherapeutic advances in the treatment of vascular, orthopedic, neurologic, and soft tissue injuries have reduced the diagnostic accuracy of the MESS in predicting the need for amputation. There remains a significant need to examine additional predictors of amputation following severe extremity injury.Level of evidenceProspective, prognostic study, level III

Continuous Glucose Monitoring Profiles in Healthy Non-Diabetic Participants: A Multicenter Prospective Study

CONTEXT: Use of continuous glucose monitoring (CGM) is increasing for insulin-requiring patients with diabetes. While data on glycemic profiles of healthy, non-diabetic individuals exists for older sensors, assessment of glycemic metrics with new generation CGM devices is lacking. OBJECTIVE: To establish reference sensor glucose ranges in healthy, non-diabetic individuals across different age groups, using a current generation CGM sensor. DESIGN: Multicenter, prospective study. SETTING: 12 centers within the T1D Exchange Clinic Network. PATIENTS OR PARTICIPANTS: Non-pregnant, healthy, non-diabetic children and adults (age ≥6 years); with non-obese body mass index. INTERVENTION: A blinded Dexcom G6 CGM, with once daily calibration, was worn for up to 10 days in each participant. MAIN OUTCOME MEASURE: CGM metrics of mean glucose, hyperglycemia, hypoglycemia, and glycemic variability. RESULTS: 153 participants (age 7-80 years) were included in the analyses. Mean average glucose was 98-99 mg/dL (5.4-5.5 mmol/L) for all age groups except those over 60 years in whom mean average glucose was 104 mg/dL (5.8 mmol/L). The median % time between 70-140 mg/dL (3.9-7.8 mmol/L) was 96% (IQR 93%-98%). Mean within-individual coefficient of variation (CV) was 17±3%. Median time spent with glucose levels \u3e140mg/dL was 2.1% (30 min/day) and/dL (3.9 mmol/L) was 1.1% (15 min/day). CONCLUSION: By assessing across age groups in a healthy, non-diabetic population, normative sensor glucose data have been derived, and will be useful as a benchmark for future research studies

Comparing autoantibody status

ObjectiveTo compare characteristics of autoantibody (aAb)-positive and -negative cases of type 1 diabetes (T1D) &lt;18 years old in the T1D Exchange clinic registry.MethodsAn aAb-positive status (n = 6239) required at least one of the aAbs to be positive; an aAb-negative status (n = 485) required negative results on testing of at least two different aAbs.ResultsThe percentage of males was higher (58% vs. 51%; P = 0.002) and total daily insulin dose lower (P = 0.003) in aAb-negative compared with aAb-positive groups, but both groups had similar distributions of race-ethnicity, diagnosis age, family history of T1D, ketoacidosis at diagnosis, body mass index at diagnosis and at most recent office visit, and current HbA1c.ConclusionsMale gender and lower total daily insulin dose were more likely in aAb-negative than aAb-positive children with T1D, but no other distinguishing characteristics were identified. Further examination of characteristics of aAb-negative cases may help characterize the heterogeneous nature of T1D