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Rapid Rise in Hypertension and Nephropathy in Youth With Type 2 Diabetes: The TODAY clinical trial

TODAY Study Group
Jun 1, 2013; 36:1735-1741
TODAY Study




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Liraglutide, a Long-Acting Human Glucagon-Like Peptide-1 Analog, Given as Monotherapy Significantly Improves Glycemic Control and Lowers Body Weight Without Risk of Hypoglycemia in Patients With Type 2 Diabetes

Tina Vilsbøll
Jun 1, 2007; 30:1608-1610
BR Emerging Treatments and Technologies




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Cardiovascular Outcomes Trials in Type 2 Diabetes: Where Do We Go From Here? Reflections From a Diabetes Care Editors Expert Forum

William T. Cefalu
Jan 1, 2018; 41:14-31
Diabetes Care Expert Forum




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Standardizing Clinically Meaningful Outcome Measures Beyond HbA1c for Type 1 Diabetes: A Consensus Report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endo

Gina Agiostratidou
Dec 1, 2017; 40:1622-1630
Continuous Glucose Monitoring and Risk of Hypoglycemia




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Intensive Diabetes Treatment and Cardiovascular Outcomes in Type 1 Diabetes: The DCCT/EDIC Study 30-Year Follow-up

The Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study Research Group
May 1, 2016; 39:686-693
Cardiovascular Disease and Diabetes




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Can a Shift in Fuel Energetics Explain the Beneficial Cardiorenal Outcomes in the EMPA-REG OUTCOME Study? A Unifying Hypothesis

Sunder Mudaliar
Jul 1, 2016; 39:1115-1122
Diabetes Care Symposium




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Improvement in Outcomes of Clinical Islet Transplantation: 1999-2010

Franca B. Barton
Jul 1, 2012; 35:1436-1445
Diabetes Care Symposium




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CV Protection in the EMPA-REG OUTCOME Trial: A "Thrifty Substrate" Hypothesis

Ele Ferrannini
Jul 1, 2016; 39:1108-1114
Diabetes Care Symposium




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Latin American business leaders optimistic about region’s post-pandemic economy

Despite worrying economic projections, business leaders in Latin America remain optimistic about post-pandemic economy.




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Report: South Korea tested new ballistic missile with larger warhead

South Korea's military tested a ballistic missile capable of carrying a 2-ton warhead in March, according to local reports on Thursday.




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Ex-South Korea comfort woman accuses activist of exploiting women, funds

A former South Korean comfort woman accused an influential activist group of misappropriating funds and using past victims to advance their cause.




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South Korea sees new cluster of COVID-19 cases tied to nightclubs

Just days after South Korea loosened its social distancing guidelines, a new COVID-19 cluster of infections has sprung up in the capital city of Seoul tied to several nightclubs.




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Cardiovascular Outcomes Trials in Type 2 Diabetes: Where Do We Go From Here? Reflections From a Diabetes Care Editors Expert Forum

William T. Cefalu
Jan 1, 2018; 41:14-31
Diabetes Care Expert Forum




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South American Immigrants in the United States

South Americans represent a small, but growing share of immigrants in the United States, composing 7 percent of country’s total foreign-born population. Recent growth has been marked by an uptick in arrivals from increasingly failing Venezuela, with an increase of 61,000 Venezuelan immigrants from 2016 to 2017. This article offers an interesting data snapshot of South American immigrants in the United States.




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As Governments Build Advanced Surveillance Systems to Push Borders Out, Will Travel and Migration Become Unequal for Some Groups?

As governments seek to push their borders out by amassing ever more data on travelers and migrants, their creation of increasingly complex border surveillance systems and use of risk-assessment technologies could ease mobility for some while rendering other groups immobile based on hypothetical risk profiles and decisions that are not publicly known and cannot be challenged, as this article explores.




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Policy Options for Responding to Changing Migration Flows at the Southwest Border

Testimony of Andrew Selee, President of MPI, before Senate Committee on Homeland Security and Governmental Affairs on April 4, 2019 regarding response to changing migration flows at the Southwest border.




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ADA releases coronavirus handout for dentists based on CDC guidelines

The handout covers strategies for helping prevent the transmission of suspected respiratory disease in the dental health care setting and answers frequently asked questions related to the virus, based on guidelines from the Centers for Disease Control and Prevention.




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Tampa Bay Lightning team dentist puts players’ mouths back together again

When Dr. Gil Rivera became a dentist, he had no idea his career would take him to the bloodied and bruised front lines of the NHL, but nearly 18 years later, he continues to treat the ravaged mouths of professional hockey players as the team dentist of the Tampa Bay Lightning.




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Connecticut Foundation for Dental Outreach postpones Mission of Mercy dental clinic amid coronavirus concerns

The Connecticut Foundation for Dental Outreach has postponed the Connecticut Mission of Mercy Free Dental Clinic scheduled for March 20-21 in Danbury, Connecticut, "out of abundant caution" amid the coronavirus disease outbreak.




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ADA begins to address coding, billing procedures during COVID-19 outbreak

The ADA is releasing a guide intended to help dental offices navigate issues related to coding and billing for virtual check-ins in the midst of the COVID-19 outbreak.




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ADA, other organizations outline economic response needs to survive pandemic

The ADA and nearly 100 other organizations are asking Congress and the White House to help businesses survive the coronavirus crisis by reducing their costs and increasing their cash flow as much as possible in the coming weeks.




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ADA leadership answers members’ questions about minimizing risk of COVID-19 transmission

A panel of ADA experts answered members’ questions in a video released April 8 regarding the Association’s interim guidance for minimizing the risk of COVID-19 transmission while performing emergency and urgent dental care.




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New ADA course to answer army of questions about coding accurately

As the source of dental procedure codes, the ADA has created a new online training course to ensure that dentists and their team members confidently understand CDT codes and how to use them correctly.




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Oil prices ease on renewed concern about a weaker economy

Crude oil prices fell Monday amid renewed concerns about potentially declining crude oil demand resulting from weaker economic outlook.




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Oil prices rise amid ongoing concern about Venezuela

Oil prices rose Wednesday amid expectations that Venezuelan oil shipments would see some disruption following U.S. sanctions.




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BP to be more transparent about climate efforts amid investor concerns

BP on Friday announced plans to increase disclosure on its efforts to fight climate change after requests from two groups of investors.




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Diabetes Is Associated With Worse Long-term Outcomes in Young Adults After Myocardial Infarction: The Partners YOUNG-MI Registry

OBJECTIVE

We sought to determine the prevalence of diabetes and associated cardiovascular outcomes in a contemporary cohort of young individuals presenting with their first myocardial infarction (MI) at age ≤50 years.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed records of patients presenting with a first type 1 MI at age ≤50 years from 2000 to 2016. Diabetes was defined as a hemoglobin A1c ≥6.5% (48 mmol/mol) or a documented diagnosis of or treatment for diabetes. Vital status was ascertained for all patients, and cause of death was adjudicated.

RESULTS

Among 2,097 young patients who had a type 1 MI (mean age 44.0 ± 5.1 years, 19.3% female, 73% white), diabetes was present in 416 (20%), of whom 172 (41%) were receiving insulin. Over a median follow-up of 11.2 years (interquartile range 7.3–14.2 years), diabetes was associated with a higher all-cause mortality (hazard ratio 2.30; P < 0.001) and cardiovascular mortality (2.68; P < 0.001). These associations persisted after adjusting for baseline covariates (all-cause mortality: 1.65; P = 0.008; cardiovascular mortality: 2.10; P = 0.004).

CONCLUSIONS

Diabetes was present in 20% of patients who presented with their first MI at age ≤50 years and was associated with worse long-term all-cause and cardiovascular mortality. These findings highlight the need for implementing more-aggressive therapies aimed at preventing future adverse cardiovascular events in this population.




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Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt

OBJECTIVE

To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern states in which residents have high rates of diabetes.

RESEARCH DESIGN AND METHODS

Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50–64 years, the percentage of women, Distressed Communities Index value, and rurality.

RESULTS

In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states.

CONCLUSIONS

ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt.




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Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits

OBJECTIVE

We examined detailed renal and cardiovascular (CV) outcomes after gastric bypass (GBP) surgery in people with obesity and type 2 diabetes mellitus (T2DM), across several renal function categories, in a nationwide cohort study.

RESEARCH DESIGN AND METHODS

We linked data from the National Diabetes Register and the Scandinavian Obesity Surgery Register with four national databases holding information on socioeconomic variables, medications, hospitalizations, and causes of death and matched 5,321 individuals with T2DM who had undergone GBP with 5,321 who had not (age 18–65 years, mean BMI >40 kg/m2, mean follow-up >4.5 years). The risks of postoperative outcomes were assessed with Cox regression models.

RESULTS

During the first years postsurgery, there were small reductions in creatinine and albuminuria and stable estimated glomerular filtration rate (eGFR) in the GBP group. The incidence rates of most outcomes relating to renal function, CV disease, and mortality were lower after GBP, being particularly marked for heart failure (hazard ratio [HR] 0.33 [95% CI 0.24, 0.46]) and CV mortality (HR 0.36 [(95% CI 0.22, 0.58]). The risk of a composite of severe renal disease or halved eGFR was 0.56 (95% CI 0.44, 0.71), whereas nonfatal CV risk was lowered less (HR 0.82 [95% CI 0.70, 0.97]) after GBP. Risks for key outcomes were generally lower after GBP in all eGFR strata, including in individuals with eGFR <30 mL/min/1.73 m2.

CONCLUSIONS

Our data suggest robust benefits for renal outcomes, heart failure, and CV mortality after GBP in individuals with obesity and T2DM. These results suggest that marked weight loss yields important benefits, particularly on the cardiorenal axis (including slowing progression to end-stage renal disease), whatever the baseline renal function status.




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The Effects of Intensive Glycemic Control on Clinical Outcomes Among Patients With Type 2 Diabetes With Different Levels of Cardiovascular Risk and Hemoglobin A1c in the ADVANCE Trial

OBJECTIVE

To study whether the effects of intensive glycemic control on major vascular outcomes (a composite of major macrovascular and major microvascular events), all-cause mortality, and severe hypoglycemia events differ among participants with different levels of 10-year risk of atherosclerotic cardiovascular disease (ASCVD) and hemoglobin A1c (HbA1c) at baseline.

RESEARCH DESIGN AND METHODS

We studied the effects of more intensive glycemic control in 11,071 patients with type 2 diabetes (T2D), without missing values, in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial, using Cox models.

RESULTS

During 5 years’ follow-up, intensive glycemic control reduced major vascular events (hazard ratio [HR] 0.90 [95% CI 0.83–0.98]), with the major driver being a reduction in the development of macroalbuminuria. There was no evidence of differences in the effect, regardless of baseline ASCVD risk or HbA1c level (P for interaction = 0.29 and 0.94, respectively). Similarly, the beneficial effects of intensive glycemic control on all-cause mortality were not significantly different across baseline ASCVD risk (P = 0.15) or HbA1c levels (P = 0.87). The risks of severe hypoglycemic events were higher in the intensive glycemic control group compared with the standard glycemic control group (HR 1.85 [1.41–2.42]), with no significant heterogeneity across subgroups defined by ASCVD risk or HbA1c at baseline (P = 0.09 and 0.18, respectively).

CONCLUSIONS

The major benefits for patients with T2D in ADVANCE did not substantially differ across levels of baseline ASCVD risk and HbA1c.




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Continuous Glucose Monitoring in Pregnancy: Importance of Analysing Temporal Profiles to Understand Clinical Outcomes

OBJECTIVE

To determine if temporal glucose profiles differed between 1) women who were randomized to real-time continuous glucose monitoring (RT-CGM) or self-monitored blood glucose (SMBG), 2) women who used insulin pumps or multiple daily insulin injections (MDIs), and 3) women whose infants were born large for gestational age (LGA) or not, by assessing CGM data obtained from the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT).

RESEARCH DESIGN AND METHODS

Standard summary metrics and functional data analysis (FDA) were applied to CGM data from the CONCEPTT trial (RT-CGM, n = 100; SMBG, n = 100) taken at baseline and at 24- and 34-weeks gestation. Multivariable regression analysis determined if temporal differences in 24-h glucose profiles occurred between comparators in each of the three groups.

RESULTS

FDA revealed that women using RT-CGM had significantly lower glucose (0.4–0.8 mmol/L [7–14 mg/dL]) for 7 h/day (0800 h–1200 h and 1600 h–1900 h) compared with those with SMBG. Women using pumps had significantly higher glucose (0.4–0.9 mmol/L [7–16 mg/dL]) for 12 h/day (0300 h to 0600 h, 1300 h to 1800 h, and 2030 h to 0030 h) at 24 weeks with no difference at 34 weeks compared with MDI. Women who had an LGA infant ran a significantly higher glucose by 0.4–0.7 mmol/L (7–13 mg/dL) for 4.5 h/day at baseline; by 0.4–0.9 mmol/L (7–16 mg/dL) for 16 h/day at 24 weeks; and by 0.4–0.7 mmol/L (7–13 mg/dL) for 14 h/day at 34 weeks.

CONCLUSIONS

FDA of temporal glucose profiles gives important information about differences in glucose control and its timing, which are undetectable by standard summary metrics. Women using RT-CGM were able to achieve better daytime glucose control, reducing fetal exposure to maternal glucose.




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A Randomized Trial Evaluating the Efficacy and Safety of Fast-Acting Insulin Aspart Compared With Insulin Aspart, Both in Combination With Insulin Degludec With or Without Metformin, in Adults With Type 2 Diabetes (Onset 9)

OBJECTIVE

To evaluate the efficacy and safety of fast-acting insulin aspart (faster aspart) compared with insulin aspart (IAsp), both with insulin degludec with or without metformin, in adults with type 2 diabetes not optimally controlled with a basal-bolus regimen.

RESEARCH DESIGN AND METHODS

This multicenter, double-blind, treat-to-target trial randomized participants to faster aspart (n = 546) or IAsp (n = 545). All available information, regardless of treatment discontinuation or use of ancillary treatment, was used for evaluation of effect.

RESULTS

Noninferiority for the change from baseline in HbA1c 16 weeks after randomization (primary end point) was confirmed for faster aspart versus IAsp (estimated treatment difference [ETD] –0.04% [95% CI –0.11; 0.03]; –0.39 mmol/mol [–1.15; 0.37]; P < 0.001). Faster aspart was superior to IAsp for change from baseline in 1-h postprandial glucose (PPG) increment using a meal test (ETD –0.40 mmol/L [–0.66; –0.14]; –7.23 mg/dL [–11.92; –2.55]; P = 0.001 for superiority). Change from baseline in self-measured 1-h PPG increment for the mean over all meals favored faster aspart (ETD –0.25 mmol/L [–0.42; –0.09]); –4.58 mg/dL [–7.59; –1.57]; P = 0.003). The overall rate of treatment-emergent severe or blood glucose (BG)–confirmed hypoglycemia was statistically significantly lower for faster aspart versus IAsp (estimated treatment ratio 0.81 [95% CI 0.68; 0.97]).

CONCLUSIONS

In combination with insulin degludec, faster aspart provided effective overall glycemic control, superior PPG control, and a lower rate of severe or BG-confirmed hypoglycemia versus IAsp in adults with type 2 diabetes not optimally controlled with a basal-bolus regimen.




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Long-term Metabolic and Socioeducational Outcomes of Transient Neonatal Diabetes: A Longitudinal and Cross-sectional Study

OBJECTIVE

Transient neonatal diabetes mellitus (TNDM) occurs during the 1st year of life and remits during childhood. We investigated glucose metabolism and socioeducational outcomes in adults.

RESEARCH DESIGN AND METHODS

We included 27 participants with a history of TNDM currently with (n = 24) or without (n = 3) relapse of diabetes, and 16 non-TNDM relatives known to be carriers of causal genetic defects and currently with (n = 9) or without (n = 7) diabetes. Insulin sensitivity and secretion were assessed by hyperinsulinemic-euglycemic clamp and arginine-stimulation testing in a subset of 8 TNDM participants and 7 relatives carrying genetic abnormalities, with and without diabetes, compared with 17 unrelated control subjects without diabetes.

RESULTS

In TNDM participants, age at relapse correlated positively with age at puberty (P = 0.019). The mean insulin secretion rate and acute insulin response to arginine were significantly lower in TNDM and relatives of participants with diabetes than in control subjects (4.7 [3.6–5.9] vs. 13.4 [11.8–16.1] pmol/kg/min, P < 0.0001; and 84.4 [33.0–178.8] vs. 399.6 [222.9–514.9] µIU/mL, P = 0.0011), but were not different between participants without diabetes (12.7 [10.4–14.3] pmol/kg/min and 396.3 [303.3–559.3] µIU/mL, respectively) and control subjects. Socioeducational attainment was lower in TNDM participants than in the general population, regardless of diabetes duration.

CONCLUSIONS

Relapse of diabetes occurred earlier in TNDM participants compared with relatives and was associated with puberty. Both groups had decreased educational attainment, and those with diabetes had lower insulin secretion capacity; however, there was no difference in insulin resistance in adulthood. These forms of diabetes should be included in maturity-onset diabetes of the young testing panels, and relatives of TNDM patients should be screened for underlying defects, as they may be treated with drugs other than insulin.




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Erratum. Predicting 10-Year Risk of End-Organ Complications of Type 2 Diabetes With and Without Metabolic Surgery: A Machine Learning Approach. Diabetes Care 2020;43:852-859




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Commercially Available Insulin Products Demonstrate Stability Throughout the Cold Supply Chain Across the U.S.

OBJECTIVE

A recent publication questioned the integrity of insulin purchased from U.S. retail pharmacies. We sought to independently validate the method used, isotope dilution solid-phase extraction (SPE) liquid chromatography mass spectrometry (LC-MS), and expand analysis to two U.S. Pharmacopeia (USP) methods (high-performance LC with ultraviolet detection and LC-MS).

RESEARCH DESIGN AND METHODS

Each method was used to evaluate nine insulin formulations, purchased at four pharmacies, within five geographic locations in the U.S.

RESULTS

All human and analog insulins measured by the USP methods (n = 174) contained the expected quantity of active insulin (100 ± 5 units/mL). When using isotope dilution SPE-LC-MS, units-per-milliliter values were well below product labeling due to unequal recovery of the internal standard compared with target insulin.

CONCLUSIONS

Insulin purchased from U.S. pharmacies is consistent with product labeling.




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Screening and Treatment Outcomes in Adults and Children With Type 1 Diabetes and Asymptomatic Celiac Disease: The CD-DIET Study

OBJECTIVE

To describe celiac disease (CD) screening rates and glycemic outcomes of a gluten-free diet (GFD) in patients with type 1 diabetes who are asymptomatic for CD.

RESEARCH DESIGN AND METHODS

Asymptomatic patients (8–45 years) were screened for CD. Biopsy-confirmed CD participants were randomized to GFD or gluten-containing diet (GCD) to assess changes in HbA1c and continuous glucose monitoring over 12 months.

RESULTS

Adults had higher CD-seropositivity rates than children (6.8% [95% CI 4.9–8.2%, N = 1,298] vs. 4.7% [95% CI 3.4–5.9%, N = 1,089], P = 0.035) with lower rates of prior CD screening (6.9% vs. 44.2%, P < 0.0001). Fifty-one participants were randomized to a GFD (N = 27) or GCD (N = 24). No HbA1c differences were seen between the groups (+0.14%, 1.5 mmol/mol; 95% CI –0.79 to 1.08; P = 0.76), although greater postprandial glucose increases (4-h +1.5 mmol/L; 95% CI 0.4–2.7; P = 0.014) emerged with a GFD.

CONCLUSIONS

CD is frequently observed in asymptomatic patients with type 1 diabetes, and clinical vigilance is warranted with initiation of a GFD.




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Using the BRAVO Risk Engine to Predict Cardiovascular Outcomes in Clinical Trials With Sodium-Glucose Transporter 2 Inhibitors

OBJECTIVE

This study evaluated the ability of the Building, Relating, Assessing, and Validating Outcomes (BRAVO) risk engine to accurately project cardiovascular outcomes in three major clinical trials—BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), Canagliflozin Cardiovascular Assessment Study (CANVAS), and Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction (DECLARE-TIMI 58) trial—on sodium–glucose cotransporter 2 inhibitors (SGLT2is) to treat patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Baseline data from the publications of the three trials were obtained and entered into the BRAVO model to predict cardiovascular outcomes. Projected benefits of reducing risk factors of interest (A1C, systolic blood pressure [SBP], LDL, or BMI) on cardiovascular events were evaluated, and simulated outcomes were compared with those observed in each trial.

RESULTS

BRAVO achieved the best prediction accuracy when simulating outcomes of the CANVAS and DECLARE-TIMI 58 trials. For the EMPA-REG OUTCOME trial, a mild bias was observed (~20%) in the prediction of mortality and angina. The effect of risk reduction on outcomes in treatment versus placebo groups predicted by the BRAVO model strongly correlated with the observed effect of risk reduction on the trial outcomes as published. Finally, the BRAVO engine revealed that most of the clinical benefits associated with SGLT2i treatment are through A1C control, although reductions in SBP and BMI explain a proportion of the observed decline in cardiovascular events.

CONCLUSIONS

The BRAVO risk engine was effective in predicting the benefits of SGLT2is on cardiovascular health through improvements in commonly measured risk factors, including A1C, SBP, and BMI. Since these benefits are individually small, the use of the complex, dynamic BRAVO model is ideal to explain the cardiovascular outcome trial results.




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microRNA-21/PDCD4 Proapoptotic Signaling From Circulating CD34+ Cells to Vascular Endothelial Cells: A Potential Contributor to Adverse Cardiovascular Outcomes in Patients With Critical Limb Ischemia

OBJECTIVE

In patients with type 2 diabetes (T2D) and critical limb ischemia (CLI), migration of circulating CD34+ cells predicted cardiovascular mortality at 18 months after revascularization. This study aimed to provide long-term validation and mechanistic understanding of the biomarker.

RESEARCH DESIGN AND METHODS

The association between CD34+ cell migration and cardiovascular mortality was reassessed at 6 years after revascularization. In a new series of T2D-CLI and control subjects, immuno-sorted bone marrow CD34+ cells were profiled for miRNA expression and assessed for apoptosis and angiogenesis activity. The differentially regulated miRNA-21 and its proapoptotic target, PDCD4, were titrated to verify their contribution in transferring damaging signals from CD34+ cells to endothelial cells.

RESULTS

Multivariable regression analysis confirmed that CD34+ cell migration forecasts long-term cardiovascular mortality. CD34+ cells from T2D-CLI patients were more apoptotic and less proangiogenic than control subjects and featured miRNA-21 downregulation, modulation of several long noncoding RNAs acting as miRNA-21 sponges, and upregulation of the miRNA-21 proapoptotic target PDCD4. Silencing miR-21 in control subject CD34+ cells phenocopied the T2D-CLI cell behavior. In coculture, T2D-CLI CD34+ cells imprinted naïve endothelial cells, increasing apoptosis, reducing network formation, and modulating the TUG1 sponge/miRNA-21/PDCD4 axis. Silencing PDCD4 or scavenging reactive oxygen species protected endothelial cells from the negative influence of T2D-CLI CD34+ cells.

CONCLUSIONS

Migration of CD34+ cells predicts long-term cardiovascular mortality in T2D-CLI patients. An altered paracrine signaling conveys antiangiogenic and proapoptotic features from CD34+ cells to the endothelium. This damaging interaction may increase the risk for life-threatening complications.




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The Influence of Baseline Diastolic Blood Pressure on the Effects of Intensive Blood Pressure Lowering on Cardiovascular Outcomes and All-Cause Mortality in Type 2 Diabetes

OBJECTIVE

To examine whether low baseline diastolic blood pressure (DBP) modifies the effects of intensive systolic blood pressure (SBP) lowering on cardiovascular outcomes in type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP), a two-by-two factorial randomized controlled trial, examined effects of SBP (<120 vs. <140 mmHg) and glycemic (HbA1c <6% vs. 7.0–7.9% [<42 vs. 53–63 mmol/mol]) control on cardiovascular events in T2DM (N = 4,731). We examined whether effects of SBP control on cardiovascular composite were modified by baseline DBP and glycemic control.

RESULTS

Intensive SBP lowering decreased the risk of the cardiovascular composite (hazard ratio [HR] 0.76 [95% CI 0.59–0.98]) in the standard glycemic arm but not in the intensive glycemic arm (HR 1.06 [95% CI 0.81–1.40]). Spline regression models relating the effects of the intervention on the cardiovascular composite across the range of baseline DBP did not show evidence of effect modification by low baseline DBP for the cardiovascular composite in the standard or intensive glycemic arms. The relation between the effect of the intensive SBP intervention and baseline DBP was similar between glycemic arms for the cardiovascular composite three-way interaction (P = 0.83).

CONCLUSIONS

In persons with T2DM, intensive SBP lowering decreased the risk of cardiovascular composite end point irrespective of baseline DBP in the setting of standard glycemic control. Hence, low baseline DBP should not be an impediment to intensive SBP lowering in patients with T2DM treated with guidelines recommending standard glycemic control.




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New Poll: How Do You Feel About the Level Of Education The School Provides Your Child

I will be starting a monthly poll to engage the readers of this blog and start some discussion. Feel free to comment on this topic. I'm sure many of you have a lot to say. At the end of the month, I'll share and discuss results in a blog post. I'm curious to see how the readers of this blog feel about your own schools. You can find the poll in the sidebar. Thanks for participating!




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Readers Respond About Your Own Experiences In the Schools

The readers of School Psychologist Blog Files were asked in February to share their own experiences and to vote on a poll "How do you feel about the level of education the school provides your child." It's important to understand that everyone's experience is unique. The readers come from different states, different school systems, and different grade levels. Laws and standards vary somewhat between states. Within any state, there are schools that do a better job suiting the needs of children than others. Within any school system, there are those star schools, and the schools that need more attention. Even within the best schools, there are still going to be individuals who have negative experiences. Within the worst schools, there will be those who have positive experiences. Regardless of your school or your situation, I believe that the readers of this blog care deeply about their child's education and have strong emotions about the education (positive or negative.)

The most popular response was "I generally feel good about the level of education, but have some complaints." I was glad to see that many of you are mostly satisfied. I hope that continues throughout your children's school career. Stay involved, speak up when needed, and compliment those who deserve it.

There was a strong outcry from those who endorsed "I feel as if the school is not supportive and I feel as though I am constantly fighting for his or her rights." This was the second most popular answer. While many feel comfortable with their schools, there are many parents out there who have the unsettling feeling of sending their child to a place they do not feel good about. Many of the readers are feeling that getting appropriate services only comes with a fight. Some of you are not having good experiences. I hope that you are able to find some support and insight here from others.

A few of you feel very thankful for the high level of education that your child is receiving. I am thankful to hear that some of the parents here feel exceptionally good about their child's school. Know this is a blessing that many others do not have.

Feel free to share your comments about experiences and offer some insight to others who may have similar experiences.




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Top 5 Questions about ADHD- From Everyday Health

Everyday Health is gathering the responses of several professionals of the top 5 questions they get regarding ADHD. They asked me to participate. The following are the questions and my answers. Check in with Everyday Health next week to see the compilation of responses.

1. Why are there so many theories about the causes of ADHD? What are the most common?

Any disorder that does not have a known cause is open to a number of theories. People naturally want to know why or want to feel as if it can be prevented in the future. Heredity is believed to be the most commonly accepted cause.

2. How can you explain the value of treatment to resistant parents? For example, “I survived my childhood with ADHD --and I was never diagnosed or treated. Why does my child need ADHD treatment?”

Often children with ADHD have gaps in their education. As they are in and out of focus each day, they miss key points in instruction. As new skills build upon old skills, it can be more and more difficult to learn new tasks where there are gaps in the foundation. This difficulty can make focusing even more difficult, further compounding the problem. Treatment can help reduce or prevent this cycle.

3. What role does a child’s school have in helping him or her with ADHD?

The school can help by providing support and accommodations specific to the particular needs of your child IF it can be determined that the symptoms of ADHD are significantly impacting his or her education. Of course, each school has different criteria for determining if there is a significant impact.

4. Are the medications recommended for ADHD safe for children? What are the potential dangers?

There is not a lot of solid research yet on this topic. While the medications are believed to be safe, they have not been around long enough to fully study long term effects. There are also side effects that may make the medications not worth the benefits in some children. All of that being said, I've seen kids who are finally able to focus after starting medication. Taking the medication improves learning, grades, and self esteem, which has numerous positive long term benefits. Medication is not something to take lightly. Parents must think very carefully weigh the unknown risks of taking the medications verses the possible risks of refusing the medications. There is not one answer that fits all children.

5. What are the most common side effects of ADHD meds?

Weight loss, behavioral changes, and headaches are possible side effects.




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Make Homework Routine

By Guest Blogger, Penny Williams of {a mom’s view of ADHD}

ADHD children do better with routine. It’s a proven fact. In a brain characteristically in chaos, the order routine provides is soothing. They need to know what to expect in advance and have time to make the mental transition as well.

Everything goes more smoothly for my son when he knows what’s coming and when, and everything falls apart when our schedule changes unexpectedly. As parents of neurologically different children, we make their world more comfortable by publicizing the family schedule and sticking to a routine as much as a family can. We have a routine for getting up and ready for school in the morning. We have a bedtime routine. We even have an {unpopular} dinnertime routine. Why should homework time be any different?

It has taken me two years to establish a fairly comfortable homework routine for Luke, my 8-year-old, third grade son who has ADHD and sensory integration issues. Two years of a lot of trial and error. And we aren’t set yet, nor do I predict we will be for many years. As the full extent of Luke’s written expression disorder has been revealed this year, the homework routine has changed quite a bit, but for the better.

Like Clockwork

I’ve experimented quite a bit with the time of day that we do homework. It was quickly apparent that waiting until after dinner (and after medications had worn off) was not going to work for Luke (or for me). We then tried right after school and at 4 pm, which is about 30 minutes after we arrive home from school. I liked the idea of some free time for Luke to unwind and a break from schoolwork that the 4 pm schedule offered. However, it hasn’t always worked out. In 30 minutes time he can get engrossed in something fun and then it’s a battle to get him to stop and do homework. I feel a little like a schoolmarm making him do homework the minute we get home, but he does his best work at that time.

Now sure we don’t always come straight home from school. Sometimes I’m working and grandma picks him up. Sometimes we have afterschool activities or just need to run to the grocery store. But Luke knows that we do homework when we return home from school, whatever time that may read on the clock. He has come to expect it.

Even Homework Needs a Home

Give homework papers and supplies a home and keep them in the same spot. When I say, “time to do homework,” Luke immediately goes to his homework spot. Well, not immediately. Even the best laid plan will not cure the typical resistance to homework. We keep Luke’s homework folder, pencils, etc. on his end of the snack bar. Up until a month or so ago, he sat there or just behind at the dining table to do his homework. We kept all needs there so he wouldn’t have the distraction of getting up to fetch something.

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Consider a Homework Toolkit: The toolkit will be some sort of box or desktop organizer, even an actual toolbox, with every single item necessary to complete homework, prepped and ready to go:

  • pencils (sharpened -- sharpening pencils is a favorite procrastination technique of children),

  • pencil sharpener (in case it breaks),

  • pencil grips (if used),

  • markers,

  • colored pencils (sharpened),

  • appropriate scissors,

  • notebook paper,

  • construction paper or blank copy paper,

  • calculator,

  • ruler,

  • dictionary,

  • index cards,

  • highlighter,

  • tape,

  • glue stick,

  • post-it notes,

  • clip board (if not working at a table or desktop),

  • anything else your child may use for homework

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Now that Luke has some technological accommodations for his written expression disability, he does his spelling homework on the computer. When I announce “homework time,” he gets his folder off the snack bar and brings it to my desk to work on my computer. (I am looking for a good place in my office to create a new homework spot now that things have changed.) He’s great with technology, and typing is so much easier for him than hand writing assignments was, so this change has actually allowed me to stop standing over him, constantly nagging, during homework for the first time since he started school. It’s wonderful!

He finishes his spelling assignment and then takes his book to the sofa and I set the timer for reading. If you don’t have a timer or don’t use one with your ADHD child, I super-strongly recommend its implementation. My favorite is the Time Timer, but any household timer will work. When the timer sounds at the end of his 15 minutes, he jumps up, completes his homework log, and then puts the homework folder back in its home on the snack back (with a little prodding and a lot of reminders).


Don’t Make Them Bite Off More Than They can Chew

Homework is designed to prove to a teacher that a child has mastered the subject matter and is sometimes an exercise in repetition for knowledge retention. Every child in the class is given the same homework, regardless of their differences, unless there’s already an IEP or 504 Plan to the contrary. It’s your duty as your child’s advocate and #1 cheerleader to be sure the homework is appropriate for your child. Yes, this is negotiable, either through teamwork with the teacher or through a formal IEP or 504 Plan.

Scaling the amount of homework to your child’s differences and needs is a crucial element in the success of the homework routine. For example, Luke reads for 15 minutes each day while the original 3rd grade homework structure called for 20 minutes. There was a lot of resistance and inability to finish 20 minutes of reading but 15 minutes is just the right amount for Luke. While he is above grade level in reading, he is allowed to have me read aloud to him if that’s what it takes to get the assignment finished. I have found that he often asks me to read to him just to have time together. I agree, but on the condition that we take turns reading aloud by alternating paragraphs. He usually ends up reading most of it himself anyway, just with me alongside him.

Spelling is also a regular homework task. He has 15 words each week and his teacher suggests a list of activities from which to complete three. We alter these activities to accommodate his handwriting issues. He types all activities which means there are some that don’t apply to him (like writing each word in cursive three times). Sometimes there aren’t three on the list that can be typed so I let him pick from activities he’s done previous weeks.

Also, get creative and tailor homework to the way your child learns. Luke is a visual and tactile learner so we make homework visual and hands-on as much as we can – it was easier to do so in the younger grades. Use dried macaroni for math or even spelling. Does your child love to paint? Let them paint their spelling words or their illustration for their writing assignments. Painting letters is actually a common therapy tool for children that struggle with handwriting. What about play dough? I purchased a box of cookie cutters with all the letters and numbers for play dough play. You could do spelling and math with these. It will take longer but make homework more interesting and fun.

Luke’s teacher is perfectly content with our customization of the homework plan. Since they don’t get a grade on homework in third grade, it’s easy to make this change. Similar alterations can be made for middle school and high school homework too though. For instance, a student should be allowed to complete a percentage of the problems on a math worksheet to show they have mastered the content when the entire assignment will take too long or is overwhelming. Shortening the assignments will reduce their anxiety too, making it easier to work and study in the first place.

Don’t Forget Good Study Habits

Good study habits are even more crucial for children with ADHD and learning disabilities. There are some general ground rules that should always be followed:

  1. TV and other distractions must be turned off. However, music in the background actually helps some children focus. It is a distraction for me, but Luke and his sister both do homework better with music on, especially when listening with headphones. Experiment with this and see what is best for your child.

  2. Praise and reward often (typically more often than feels natural).

  3. Take breaks as needed. Who says you have to finish homework in one sitting? Allow your child to get up and stretch, get a snack, jump on the trampoline, etc. Just don’t allow them any screen time during breaks because you won’t likely get back to the homework amicably.

There is so much more than the few ideas I've covered here, especially for older children. Take a look at these other resources on the subject of homework with ADHD children:



Penny Williams is the creator and editor of {a mom's view of ADHD}, where she writes candidly about the everyday experiences of parenting her young ADHD son. In her immersion in all things ADHD since her son's diagnosis, Penny has published, My ADHD Story: Love Notes, Blah, Blah, Blah!, and Teachers We Love: Learning for All in ADDitude Magazine, the #1 national publication dedicated to ADHD. She has been quoted in Parenting.com's Family Health Guide on ADHD and The High Desert Pulse, Summer/Fall 2010, When Ritalin Works.




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What Parents Need to Know About the Special Education Evaluation


I spend most days of my life working with various students who are at different parts in the sped referral process. I attend Child Study Meetings where we decide if we are going to evaluate a student. I observe and screen children and talk with parents and teachers to help the committee make a good decision about whether we should do a special education evaluation.   I evaluate those students (this includes Psychological testing, observations, talking with student/teacher/parent, doing rating scales, etc.). I attend eligibility meetings where we determine if the student is eligible for for special education services. All of this is second nature to me and sometimes I need to stop and remember when a parent comes in, that this is NEW.

When I talk to parents, I find that many parents do not fully understand the special education referral process, even when they nod and act like they do. We as school staff need to do a better job of helping the parents understand the process. Parents also need to speak up and ask questions when there is not understanding.

This is a guide for parents to understand the process of special education testing, the testing components, and some of the test data. It is important to note that schools systems and states will vary to some degree. If you have any questions about the process in your school system, ask your school psychologist, teacher, or principal. Parents have every right to ask questions and usually school personnel are happy to help make this process less anxiety-provoking for you. It is important for parents to understand their rights during the special education process.


Special Education Process

After data shows that interventions have been attempted and if a student is suspected of having a disability, a referral is made to evaluate him or her for special education testing. Once the parents sign the Permission for Testing Forms, timelines begin and the schools have 65 business days to complete the assessments and hold the eligibility meeting. Some states may have a different timeline.

During these 65 days, several testing components will be completed with you and your child. The evaluators will write reports and a copy will be given to parents at the eligibility meeting. However, schools are required to have a copy available for parents to pick up two days before the eligibility meeting. It is advised, that parents take advantage of this and read reports before the meeting to help get familiar with the information and to formulate questions. The reports hold a lot of information that can be overwhelming if you are not familiar with this type of testing. Read Understanding Test Scores to understand the types of tests used and what the scores mean.

Additionally, the meeting is likely to bring forth strong emotions as your child’s difficulties are discussed openly. It can be overwhelming for parents, especially when not prepared. When parents do not read the reports prior to the eligibility meeting, they are the only people at the table who come to the meeting not knowing what to expect.


What if My Child is Found ELIGIBLE for Special Education Services?

Once a child is eligible for special education services, the schools have 30 days to develop an Individualized Education Plan (IEP) for the student. This will consist of accommodations, goals, and describe the services offered. Parents are part of a committee to help create this document. Once it is signed, schools are legally required to follow it. It is reviewed once a year, unless parents or teachers feel that changes are necessary. Every three years, the committee will determine if the student should be reevaluated. This is called a triennial evaluation. Sometimes another full evaluation will be conducted, other times a review of records and updated teacher information is used.


What if My Child is Found INELIGIBLE for Special Education Services?

If your child was found ineligible for special education services and you agree with the eligibility findings, then your child will not receive special education. He or she was evaluated because of a problem that still needs to be addressed within regular education. Ask for a separate meeting with your teacher or a team to determine what accommodations or strategies can be used to help.

If you believe that your child requires special education services and has a disability, but was found ineligible for services, make an appointment to meet with the special education director. If an agreement cannot be reached, you may be able to have an Independent Evaluation at the expense of the school. The results of that testing will be brought back to an eligibility meeting. A child MUST have 2 things before they can receive special education services: They must have a disability and there must be a documented educational impact that the student requires special education services to be successful.






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Check out this Awesome Special Education Infographic by USC Rossier





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Join Me Live to Talk about COVID-19

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