Continuous glucose monitoring metrics and pregnancy outcomes in insulin-treated diabetes : A post-hoc analysis of the GlucoMOMS trial

Funding Information: BWM is supported by a NHMRC investigatorgrant (GNT1176437) and BWM reports consultancy, travel support and research funding from Merck. All other authors declare no conflict of interest. The GlucoMOMS trial was funded by ZonMw, the Dutch Organisation for Health Research and Development, project number 80‐82310‐97‐11157. Continuous Glucose Monitors were purchased at a discount price at Medtronic®, Heerlen, The Netherlands. Neither ZonMw nor Medtronic had a role in study design, data collection, data analysis, data interpretation, or writing of the reports of either the original study or the current post hoc analysis. 10 Publisher Copyright: © 2023 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.Peer reviewedPublisher PD

Aspects determining the risk of pesticides to wild bees: risk profiles for focal crops on three continents

In order to conduct a proper risk assessment of pesticides to bees, information is needed in three areas: the toxicity of the pesticide;the probability of bee exposure to that pesticide; andthe population dynamics of the bee species in question.Information was collected on such factors affecting pesticide risk to (primarily wild) bees in several crops in Brazil, Kenya and The Netherlands. These data were used to construct ‘risk profiles’ of pesticide use for bees in the studied cropping systems. Data gaps were identified and potential risks of pesticides to bees were compared between the crops. Initially, risk profiling aims to better identify gaps in our present knowledge. In the longer term, the established risk profiles may provide structured inputs into risk assessment models for wild and managed bees, and lead to recommendations for specific risk mitigation measures. Keywords: pesticide, exposure, risk, wild bees, risk profil

High prevalence of impaired awareness of hypoglycemia and severe hypoglycemia among people with insulin-treated type 2 diabetes: The Dutch Diabetes Pearl Cohort

Objective People with type 2 diabetes on insulin are at risk for hypoglycemia. Recurrent hypoglycemia can cause impaired awareness of hypoglycemia (IAH), and increase the risk for severe hypoglycemia. The aim of this study was to assess the prevalence and determinants of self-reported IAH and severe hypoglycemia in a Dutch nationwide cohort of people with insulin-treated type 2 diabetes. Research design and methods Observational study of The Dutch Diabetes Pearl, a cohort of people with type 2 diabetes treated in primary, secondary and tertiary diabetes care centers. The presence of IAH and the occurrence of severe hypoglycemia in the past year, defined as an event requiring external help to re

SUGAR-DIP trial: Oral medication strategy versus insulin for diabetes in pregnancy, study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

Introduction In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM. Methods The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle. Ethics and dissemination The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals

Cystic Fibrosis-Related Diabetes in Adults: Where Can We Go From Here?

Cystic fibrosis (CF), a dysfunction of the exocrine glands, is one of the most frequently diagnosed genetic diseases. It is characterized by chronic pulmonary disease and pancreatic deficiency. Cystic fibrosis-related diabetes (CFRD) is a complication of CF and develops from impaired glucose tolerance via postprandial hyperglycemia with fasting normoglycemia to full-blown diabetes with fasting and postprandial hyperglycemia. CFRD is related to decreased life expectancy, most notably in female patients, as well as to decreased pulmonary function and body weight reduction, which can be improved with adequate insulin therapy. Insulin therapy is accepted in full-blown diabetes but the treatment required by lesser degrees of abnormal glucose metabolism is unknown and needs to be clarified. Chronic organ complications of diabetes are seen only in full-blown diabetes with a particular tendency to affect the autonomous nervous system. Continuous glucose measurement techniques have opened new fields of investigation, particularly in relation to CF-related complications. Insulin therapy needs to be intensified and insulin pump therapy should receive more attention. While improvements in therapy, including lung transplantation, have resulted in increased life expectancies, other issues, such as fertility problems and pregnancy, have raised new questions. All of these need to be addressed to find new treatment options for CFRD patients. In this article we aim to illustrate how these new questions in the treatment of adult patients with CFRD could be answered

Pesticides in the Southern Agricultural Growth Corridor of Tanzania (SAGCOT) : a scoping study of current and future use, associated risks and identification of actions for risk mitigation

SAGCOT, the ‘Southern Agricultural Growth Corridor of Tanzania’, is a coordinated initiative to boost agricultural output in southern Tanzania through public and private investment, to improve food security, reduce rural poverty and sustain the environment. The ‘Sustainability and Inclusion Strategy for Growth Corridors in Africa’ (SUSTAIN-Africa) programme by the International Union for Conservation of Nature (IUCN) develops and demonstrates climate resilient solutions for water security and inclusive land resource and agricultural development in growth corridors and areas of intensive economic development in Africa. To develop an efficient, competitive and sustainable agricultural sector in SAGCOT, possible adverse effects of pesticide use need to be addressed and minimized. For this purpose a scoping study was conducted, consisting of a literature survey, a scoping mission and a stakeholder workshop. The study revealed that there are many issues related to pesticide management and pesticide risks that need attention when the SAGCOT is further developed and pesticide use increases. The most important recommendations of the study are (1) better implementation and enforcement of current rules and regulations for pesticides, (2) training and awareness creation for pesticide users, (3) creation of a multi-stakeholder platform for exchange on best pest and pesticide management practices in the SAGCOT, (4) a regulatory body at the local government authority level to enforce/monitor pesticide management and life cycle, and (5) development of a monitoring and evaluation framework on pesticides for the SAGCOT

Effect modification in the association between glycated haemoglobin and cardiovascular disease and mortality in patients with type 2 diabetes

AIM: To identify patients with type 2 diabetes (T2D) who may benefit from lower or higher glycated haemoglobin (HbA1c) targets, based on readily available patient characteristics. MATERIALS AND METHODS: Patients with T2D were included in the present study from the Second Manifestations of ARTerial disease (SMART) cohort. Several patient characteristics were evaluated for effect modification in the relationship between HbA1c and cardiovascular disease and all-cause mortality, using multiplicative interaction analyses and stratified Cox proportional hazard analyses. Combinations of patient characteristics, as used in existing treatment algorithms, were similarly evaluated. RESULTS: Of 1753 patients, 323 experienced a vascular event during a median of 6.6 years of follow-up and 375 patients died. For the association between HbA1c and cardiovascular events, no effect modifiers were found. Body mass index (BMI) and weight showed significant interaction for the association between HbA1c and mortality ( P  = .04). Analyses, stratified for 25 kg/m(2) or 30 or 35 kg/m(2) , showed quite dissimilar hazard ratios without reaching statistical significance. Combinations of patient characteristics used in existing treatment algorithms, did not influence the relationship between HbA1c and cardiovascular disease or mortality ( P  = .46 to P  = .92). CONCLUSIONS: Using easily obtainable patient characteristics, whether alone or in combinations used in existing treatment algorithms, it was not possible, except for BMI or weight, considered continuously, to identify patients with T2D who had a differential association between HbA1c and cardiovascular events or all-cause mortality in our cohort

HDL cholesterol as a residual risk factor for vascular events and all cause mortality in patients with type 2 diabetes

OBJECTIVE: To evaluate whether low HDL cholesterol (HDL-c) levels are a risk factor for cardiovascular disease and mortality in patients with type 2 diabetes and whether it remains a residual risk factor when attaining low LDL cholesterol (LDL-c) treatment goals or when LDL-c is treated with intensive lipid-lowering therapy. RESEARCH DESIGN AND METHODS: We performed a prospective cohort study of 1,829 patients with type 2 diabetes included in the Second Manifestations of ARTerial disease (SMART) cohort. Cox proportional hazard models were used to evaluate the risk of HDL-c on cardiovascular events and all-cause mortality. Analyses were performed in strata of LDL-c levels (2.5 mmol/L) and lipid-lowering therapy intensity and were adjusted for age, sex, BMI, smoking, alcohol, LDL-c, triglycerides, systolic blood pressure, estimated glomerular filtration rate, glucose, and HbA1c. RESULTS: A total of 335 new cardiovascular events and 385 deaths occurred during a median follow-up of 7.0 years (interquartile range 3.9-10.4). No relation was found between plasma HDL-c and cardiovascular events (hazard ratio [HR] 0.97, 95% CI 0.93-1.01) or all-cause mortality (HR 0.99, 95% CI 0.96-1.03). Subgroup analysis supported effect modification by plasma LDL-c levels. In patients with LDL-c levels 2.5 mmol/L (HR 0.96, 95% CI 0.91-1.00). CONCLUSIONS: In high-risk patients with type 2 diabetes with LDL-c levels <2.0 mmol/L, higher HDL-c at baseline is unexpectedly related to a higher risk for cardiovascular events and all-cause mortality in contrast to high-risk patients with type 2 diabetes with LDL-c levels between 2.0 and 2.5 mmol/L