BMJ Open: Association between fasting blood glucose and outcomes and mortality in acute ischaemic stroke patients with diabetes mellitus: a retrospective observational study in Wuhan, China

Yao, T. et al |2020| Association between fasting blood glucose and outcomes and mortality in acute ischaemic stroke patients with diabetes mellitus: a retrospective observational study in Wuhan, China |
A new study published in the BMJ Open, evaluated the predictive value of fasting blood glucose at admission with regard to short-term outcome.  This study adds to the scarce literature in this area. The study used routinely collected clinical data and practical statistical methods to correct the effects of confounding factors. This study was conducted in a single centre with a limited sample size. The data of random blood glucose as a possible meaningful predictor were not fully available in this retrospective study (Source: Yao, et al. 2020)

Abstract

Objective To evaluate the predictive value of fasting blood glucose (FBG) on unfavourable outcomes and mortality in diabetes mellitus (DM) patients after acute ischaemic stroke (AIS).

Study design A hospital-based observational cohort study was conducted. Clinical data, including sex, age, body mass index, vascular risk factors and systolic/diastolic blood pressure, were routinely collected. National Institutes of Health Stroke Scale score was used to assess stroke severity on admission. FBG was determined on the first day after fasting for at least 8 hours. The modified Rankin Scale was used to assess functional outcome at 90 days: 3–6, unfavourable outcome and 6, death.

Setting Renmin Hospital of Wuhan University, Wuhan, China.

Participants Patients who had AIS with DM, who were consecutively admitted within 24 hours of onset from January 2018 to June 2019.

Results For the 568 patients, the median age was 65 years (IQR, 55–74 years). There were 377 (66.4%) men. The median FBG values were 7.37 mmol/L (IQR, 5.99–10.10 mmol/L), and the median glycated haemoglobin (HbA1c) values were 6.6 (IQR, 5.8–8.3). Multivariable logistic and Cox regression analysis of confounding factors showed that FBG at the time of admission was an independent predictor of unfavourable outcome (OR, 1.25 (1.14–1.37); p<0.0001) and mortality (HR, 1.10 (1.03–1.15); p<0.05) at 90 days after onset. Time to death was analysed by Kaplan-Meier curves based on FBG quartiles. The risk of death in the two highest quartile groups (FBG, 7.38–10.10 mmol/L; FBG, ≥10.11 mmol/L) was significantly higher than that in the two lowest quartile groups (FBG, ≤6.00 mmol/L; FBG, 6.01–7.37 mmol/L; p<0.0001).

Conclusions Higher FBG levels are associated with unfavourable outcomes and mortality in Chinese patients who had AIS with DM. Our data contribute to the knowledge regarding the relationship between FBG and prognosis in patients with DM who had AIS.

Full article available in the BMJ Open

Partha Kar: Covid-19—time for parity in commissioning diabetes services

Karr, P. (2020). Covid-19—time for parity in commissioning diabetes services| BMJ |369|m2154

Partha Karr, consultant in diabetes and endocrinology, has written the following in the BMJ:

Recent data on the impact of covid-19 on people with diabetes has produced a range of responses.1 The data suggest that diabetes is an independent risk factor for mortality related to covid-19, with type 1 diabetes carrying a higher risk than type 2. The scientific community has tried to decipher the signals, and reactions in the diabetes community have ranged from relief to anxiety.

Overall, the data don’t present huge surprises, but some nuggets require further investigation. The fact that diabetes is a risk factor for a poor outcome with any infection is not a surprise per se. Splitting risks on the basis of type, although eyebrow raising to some, is again not fundamentally new. As any physiology or medical textbook will tell you, the basic tenets of types 1 and 2 diabetes are different, so it’s not surprising that outcomes are different too. Similarly, higher weight and higher overall glucose levels being additional risk factors isn’t surprising; nor is the association between poor outcomes and socioeconomic deprivation.

Yet two factors deserve closer inspection. One is the link between glucose control and the risk of poor outcome, which seems to be U shaped. The other is the lack of association between duration of diabetes and the risk of poor outcome from covid-19. The basic message, however, is simple: age is the predominant factor associated with poor outcomes, and people under 40 seem to have lower risk. The important message is to focus on modifiable factors, such as weight and glucose control, as you can’t change your age or ethnicity.

Society as a whole needs to try to retain an NHS that can pride itself on providing equality of access and service. Whether you look at these recent data or the work of Ben Goldacre,2 where you live does matter—and the pandemic shows this in stark focus. The work done by Julian Tudor-Hart or Michael Marmot shouldn’t be confined to textbooks but needs to be reflected in efforts to improve services and outcomes.

Data on covid-19 and diabetes also raise the question of how useful it would be to produce a risk calculator to help people with diabetes estimate their risk from covid-19. This could help others, such as employers, schools, and wider society, as we move gradually towards a degree of normality while protecting vulnerable people.

The figures also highlight the need for health systems to learn from data and ensure parity of focus on all types of diabetes, rather than just trying to tick all boxes relevant to diabetes by having a “prevention” strategy. Type 1 diabetes is neither preventable nor simply a “young person’s disease.” About 46% of people with type 1 diabetes are over 50,3 and about 69% of all people with type 1 diabetes have levels of glucose control that raise their risk of complications in general—and, as per the recent study, worse outcomes from covid-19.

Type 1 diabetes deserves as much focus on self-management, education, and access to technology as the focus we see in type 2 diabetes on prevention, appropriate dietary interventions, and modern medicines to improve outcomes. These are different pathologies, under a common nomenclature umbrella, which need parity of investment throughout the NHS—and it’s time for local health economies to recognise and implement that.

A third of people who have died from covid-19 in the UK have had diabetes as one of their comorbidities,1 and statistics also show that diabetes is an independent risk for poor outcomes in people with covid-19. There is no more apt time for healthcare systems to ensure that diabetes gets the attention it deserves. But let’s also ensure that we base the effort to improve diabetes services on the principle of giving everyone equal access, irrespective of where they live or their race. The NHS takes a lot of pride in its system and notions of equality, and it’s time we lived up to what we believe in.

This is taken from the BMJ article

Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring

Yu, Y., et al. |2019| Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up| BMJ367 | doi: https://doi.org/10.1136/bmj.l6398

A recent study that analysed the association between maternal diabetes in pregnancy and early onset of cardiovascular disease (CVD) in the offspring, found that children of mums with diabetes, particularly those who mothers have CVD or diabetic complications, have higher rates of early onset CVD from childhood to early adulthood. 

The full paper is available to read in the BMJ 

Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up

BMJ: Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up

BMJ | November 2019 | Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up| 67| l6398

A study that looked at the associations between maternal diabetes (diagnosed prior to or during pregnancy) and early onset cardiovascular disease (CVD) in offspring during their first four decades of life adds to the evidence around non-genetic intergenerational connections between maternal illness and risk factors for CVD among offspring. The experts who authored the study looked at data from more than 2 million births in Denmark between 1977 and 2016. 

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The findings from this population based study indicate that the children of mothers with diabetes, especially mothers with CVD history or diabetic complications, had increased rates of early-onset CVD throughout the early decades of life. If the associations are causal, then preventing and treating diabetes in women of childbearing age could have a significant impact on the reduction of CVD incidence in the next generation.

The authors argue that their findings highlight the importance of effective strategies for screening and preventing diabetes in women of childbearing age (Source: BMJ).

 

 

Read the full Opinion from BMJ

Yongfu, Y. et al | 2019|  Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up|

Abstract

Objective To evaluate the associations between maternal diabetes diagnosed before or during pregnancy and early onset cardiovascular disease (CVD) in offspring during their first four decades of life.

Design Population based cohort study.

Setting Danish national health registries.

Participants All 2 432 000 liveborn children without congenital heart disease in Denmark during 1977-2016. Follow-up began at birth and continued until first time diagnosis of CVD, death, emigration, or 31 December 2016, whichever came first.

Exposures for observational studies Pregestational diabetes, including type 1 diabetes (n=22 055) and type 2 diabetes (n=6537), and gestational diabetes (n=26 272).

Main outcome measures The primary outcome was early onset CVD (excluding congenital heart diseases) defined by hospital diagnosis. Associations between maternal diabetes and risks of early onset CVD in offspring were studied. Cox regression was used to assess whether a maternal history of CVD or maternal diabetic complications affected these associations. Adjustments were made for calendar year, sex, singleton status, maternal factors (parity, age, smoking, education, cohabitation, residence at childbirth, history of CVD before childbirth), and paternal history of CVD before childbirth. The cumulative incidence was averaged across all individuals, and factors were adjusted while treating deaths from causes other than CVD as competing events.

 

Results During up to 40 years of follow-up, 1153 offspring of mothers with diabetes and 91 311 offspring of mothers who did not have diabetes were diagnosed with CVD. Offspring of mothers with diabetes had a 29% increased overall rate of early onset CVD ; cumulative incidence among offspring unexposed to maternal diabetes at 40 years of age 13.07%, difference in cumulative incidence between exposed and unexposed offspring 4.72% . The sibship design yielded results similar to those of the unpaired design based on the whole cohort. Both pregestational diabetes and gestational diabetes were associated with increased rates of CVD in offspring. We also observed varied increased rates of specific early onset CVDs, particularly heart failure, hypertensive disease, deep vein thrombosis, and pulmonary embolism. Increased rates of CVD were seen in different age groups from childhood to early adulthood until age 40 years. The increased rates were more pronounced among offspring of mothers with diabetic complications. A higher incidence of early onset CVD in offspring of mothers with diabetes and comorbid CVD was associated with the added influence of comorbid CVD but not due to the interaction between diabetes and CVD on the multiplicative scale.

 

Conclusions Children of mothers with diabetes, especially those mothers with a history of CVD or diabetic complications, have increased rates of early onset CVD from childhood to early adulthood. If maternal diabetes does have a causal association with increased CVD rate in offspring, the prevention, screening, and treatment of diabetes in women of childbearing age could help to reduce the risk of CVD in the next generation.

Offspring of mothers with diabetes, especially those mothers with a history of CVD or diabetic complications, have increased rates of early onset CVD from childhood to early adulthood

The article is available in full from The BMJ

See also: Link between diabetes in mothers and heart disease in children

Diabetes Insipidus – the danger of misunderstanding diabetes

BMJ talk medicine | February 2019 | Diabetes Insipidus – the danger of misunderstanding diabetes

Diabetes is synonymous with sugar, but diabetes insipidus, “water diabetes”, can’t be forgotten. Between 2009 and 2016, 4 people died in hospital in England, when lifesaving treatment for the condition was not given.

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This podcast from BMJ talk medicine, includes  some practical tips for non-specialists to aid diagnosis, and how patients should be managed during hospital admission.

Listen via Soundcloud 

See also:

Full BMJ practice article