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CHAR-GRILLED PRAWNS WITH GREEN MANGO SALAD

It's Christmas, the middle of summer, and the outdoors beckons. For me, on a hot day, the traditional Christmas fare of roast turkey, baked potatoes and gravy, with plum pudding and custard for dessert, is about as tempting as a dental appointment. With a little planning and preparation you can impress your family and friends with a beautiful and healthy menu perfectly suited to our climate - and which allows maximum time for the more important tasks of socialising, opening presents and enjoying the spirit of Christmas. King prawns, fresh fish, salads and seasonal fruit are ideal for Christmas lunch. Cooking time is minimal, the aromas of the char-grill enticing, everything is light and fresh. Combine this with some pre-prepared zesty dressings and sauces and perhaps a platter of leg ham and Christmas 2001 will take on a whole new flavour. For dessert, look to cherries served on ice or perhaps plums, paw-paw, apricots, pineapple, strawberries or blueberries. Goat's cheese, cheddar or blue cheese would be an ideal finale, especially when teamed with a sticky dessert wine. Lash out on handmade chocolates to go with coffee. A summer juice of melon, lime and mint is health-giving and goes well with seafood. However, I will start with a sparkling shiraz or Champagne and enjoy a fruity riesling or pinot with the barbecued fish. Merry Christmas.




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Mango Pavlova with Coconut Ice Cream

Nothing like a Pavlova and fresh seasonal fruit. The coconut ice cream provides a refreshing finish.




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Upside down local tomato, goats cheese and onion tart

Always a winner taking advantage of the local summer tomatoes . Who doesn't like flaky puff pastry?




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Loukanika Homemade Sausages with leek and fennel

Kathy Tsaples, author of Sweet Greek Life, shared this recipe on Foodie Tuesday, a weekly segment on ABC Radio Melbourne's Drive program at 3.30pm.




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Loukanika Homemade Sausages with orange

Kathy Tsaple, author of Sweet Greek Life, shared this recipe on Foodie Tuesday, a weekly segment on ABC Radio Melbourne's Drive program at 3.30pm.




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Pan con Chocolate - Chocolate Pate

Shannon Martinez & Mo Wyse, authors of 'Smith & Daughters A Cookbook (that happens to be vegan)', shared this recipe on Foodie Tuesday, a weekly segment on ABC Radio Melbourne's Drive program at 3.30pm.




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Lady finger parfait with warm chocolate sauce and crushed Honey Macadamias

The local lady finger bananas are so sweet and moorish!




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Picante de pescado sauce

Alejandro Saravia from Pastuso, shared this recipe on Foodie Tuesday, a weekly segment on ABC Radio Melbourne's Drive program at 3.30pm.





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Greek Santorini tomato fritters with yogurt and dill dip

400g ripe roma (plum) or pomodorino (baby plum) tomatoes 1 1/2 tablespoons chopped mint 1 teaspoon dried oregano 90g plain flour 1 teaspoon baking powder 1 teaspoon salt Light olive oil, or sunflower oil for pan-frying 250g Greek-style yogurt 1 tablespoon finely chopped dill Lemon wedges, to serve




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Raw and char-grilled broccoli salad with macadamia and semi-hard goats cheese

This salad is inspired by a good chef friend of mine who cooked with me last weekend. Such a healthy way to enjoy broccoli which is so delicious at the moment. It's wonderful to utilize the whole vegetable and the added fibre in the stalk which we use in the salad.Feel free to explore with certain quantities in this recipe therefore I encourage you to taste and adjust to your own personal taste. You can also add chopped green olives which add an extra dimension.




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Parmesan and Herby Crumbed Pork Loin with raw cabbage salad and lemon

4 x 150 x g of pork loin steaks as your butcher to cut 3 x cup (210 g) Panko Breadcrumbs (Japanese bread crumb) 1/2 cup (80g) Plain flour Chopped flat leaf parsley, thyme, rosemary 2 Eggs, lightly beaten 1/2cup (80g) finely grated Parmesan CABBAGE SLAW 500 grams of Cabbage finely shredded Squeezed of Lemon juice 1/4 cup (60 ml) quality cider vinegar add to taste. May need less. 2 Tablespoon of Macadamia Oil 1 Tablespoon chop parsley Aioli just a little bit to bind Sea salt and cracked pepper 100 ml Macadamia oil for cooking 4 juicy lemon wedges to squeeze over Pork




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Autumn roasted vegetables with lemon thyme and a drizzle of macadamia honey

Nothing beats beautifully roasted vegetables caramelized in their own sugar content to accompany a simple roast dinner or even on their own with a nice salad. The addition of perfumed lemon thyme and macadamia gives a nice touch.




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Indian mango kulfi with maple, oat and ginger crumb

Mango kulfi: 1 cup condensed milk 60g butter 1 tsp. vanilla extract 250 ml (1 cup) mango puree, frozen mangos are fine Oat-ginger crumb: 1/2 cup coconut oil 20g butter 125 ml 1/2 cup maple syrup 90 g (1 cup) rolled oats 1 tbsp. ground ginger 1/4 cup desiccated coconut




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Chocolate and Hazelnut Cake

There is nothing more indulgent than a piece of chocolate cake, beautiful with fresh raspberries and a dollop of cream on the side. My partner in crime made this cake last week, its fudgy texture is both delicious and surprisingly not too rich in flavour like chocolate cakes can be.




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Indian 5 spiced potatoes

3 tbsps. coconut oil oil 2 tbsps. panch phoran spice mix 1 large onion, finely chopped 2 long green chillies, sliced lengthways 6 curry leaves 2 garlic cloves, crushed 1 tbsps. grated ginger 1 tsp. ground turmeric 4 large potatoes, peeled and diced Panch phoran spice mix: 3 tbsp. brown mustard seeds 3 tbsp. fennel seeds 3 tbsp. Nigella seeds 3 tbsp. cumin seeds salt, to taste chopped coriander leaves, to serve




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Indian cauliflower rice and coriander pesto

Cauliflower rice: 1 head cauliflower, cut into florets 2 tbsps. ghee Coriander pesto: 1 large bunch coriander 1 garlic clove 1/4 cup cashews 2 tbsps. parmesan, finely grated 1 lime, zested and juiced 3 tbsps. coconut oil




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French salted caramel ganache tart

An indulgent French chocolate and salted caramel tart. Decorate with fresh raspberries and pistachio nuts for great colour and a sweet zing.




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Rice and macadamia salad

This salad is our go-to staple. Everyone loves it. It's healthy, colourful and so, so easy. It can also be made entirely with local ingredients.




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Japanese sweet ginger meatballs

1 bunch of spring onions, finely chopped 250 g minced beef 250 g minced pork 20 g grated ginger 1 egg 2 tsps. roasted sesame oil 1 tbsp. cornflour, plus extra for dusting sunflower oil, for shallow frying 1 tbsp. white sesame seeds salt and ground white pepper For the sweet ginger sauce: 30 g grated ginger 3 tbsps. soy sauce 125 ml dashi stock or 1 tsp instant dashi powder mixed with water 2 tbsps. sugar 3 tbsps. mirin 3 tbsps. rice vinegar 1 tsp cornflour




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Rich and warm teff pudding

Here's a healthy, rich and super tasty teff pudding for a stylish breakfast, brunch or anytime snack.




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CASSAVA LEAVES AND UGALI

Cassava leaves and Ugali - a traditional Congolese dish ... and much, much more. Gigi Mapatano




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Spring cleansing beetroot and pomegranate salad

Beets have strong detoxifying properties, as they are high in chlorine, which assists in the cleansing of the liver, kidneys and bloodstream. They are also rich in potassium, which balances the metabolism. The mighty beets nourish the blood, tonify the heart, calm the spirit and nervousness, and they lubricate the intestines and cleanse the liver! Oh my giddy Aunt!




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Start-Up Visas: A Passport for Innovation and Growth?

Over the last decade, a number of governments have launched start-up visa programs in the hopes of attracting talented immigrant entrepreneurs with innovative business ideas. With the track record for these programs a mixed one, this report explains how embedding start-up visas within a broader innovation strategy could lead to greater success.




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The Colombian Response to the Venezuelan Migration Crisis: A Dialogue with Colombia’s Migration Czar

Felipe Muñoz, Advisor to the President of Colombia for the Colombian-Venezuelan Border, discusses how Colombia is coping with the influx of Venezuelan migrants, plans for future policy decisions surrounding this migration, and developments in regional and international cooperation.




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As More Migrants from Africa and Asia Arrive in Latin America, Governments Seek Orderly and Controlled Pathways

Growing numbers of African and Asian migrants are moving through Latin America, many hoping to reach the United States or Canada after expensive, arduous, and often dangerous journeys that can take months or even years. As more extracontinental migrants transit through South and Central America, Colombia, Panama, and Costa Rica have developed the most comprehensive policies to manage these flows, sometimes working in coordination with the U.S. government.




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Latin American Responses to the Venezuelan and Nicaraguan Migration Crises

Leading policymakers and key stakeholders from Latin America, as well as representatives of major international institutions, offer their views on the challenges ahead as Latin American governments seek to chart strategies for responding to large-scale forced migration flows, such as those from Venezuela and Nicaragua.




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Respuestas latinoamericanas a las crisis migratorias venezolanas y nicaragüenses

Responsables de políticos principales y partes interesadas de América Latina, así como representantes de instituciones internacionales claves, ofrecen sus puntos de vista sobre los desafíos futuros mientras gobiernos latinoamericanos buscan establecer las estrategias para responder a flujos migratorios forzados a gran escala, como los de Venezuela y Nicaragua.




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    Refugee Sponsorship Programs: A Global State of Play and Opportunities for Investment

    From Argentina to New Zealand and points beyond, a growing number of countries have begun exploring refugee sponsorship as a way to expand protection capacity at a time of rising need, involving individuals and communities more directly in resettlement. This brief takes stock of what both new and well-established programs need to succeed, and outlines opportunities for private philanthropic actors to support them.




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    Welcome Wears Thin for Colombians in Ecuador as Venezuelans Become More Visible

    Though Colombians displaced by a decades-long civil war found a welcome refuge in Ecuador, life has become more difficult for them in recent years, in part as a result of the influx of Venezuelans seeking safety. This article draws on surveys of migrants in Quito, comparing and contrasting the experiences of Colombians and Venezuelans, and assessing their perceptions of discrimination, victimization, trust in institutions, and hopes for the future.




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    La Bienvenida Se Agota para Colombianos en Ecuador Mientras Venezolanos Se Hacen Más Visibles

    Aunque colombianos encontraron un refugio cálido en Ecuador después de ser desplazados de su país por una guerra civil que duro décadas, la vida se ha vuelto más difícil para ellos en los últimos años, en parte como resultado del flujo de venezolanos que buscan seguridad. Este artículo se basa en encuestas de migrantes en Quito, comparando y contrastando las experiencias de colombianos y venezolanos, y evaluando sus percepciones de discriminación, victimización y esperanzas para el futuro.




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    Is the Door Closing? Latin American and Caribbean Responses to Venezuelan Migration

    This webinar marks the release of MPI's Latin American and Caribbean Migration Portal that offers up-to-date, authoritative research and data on migration trends and policies, and a report examining the policy responses of 11 countries in Latin America and the Caribbean to increased Venezuelan and Nicaraguan migration.




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    ¿Se Están Cerrando las Puertas? Respuestas a la Migración Venezolana en América Latina y el Caribe

    MPI llevó a cabo un seminario en línea para marcar el lanzamiento de: Un portal sobre Migración en América Latina y el Caribe; y un informe que examina los efectos de las políticas migratorias y de integración en 11 países en América Latina y el Caribe ante el aumento de la migración venezolana y nicaragüense.




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    An Uneven Welcome: Latin American and Caribbean Responses to Venezuelan and Nicaraguan Migration

    Large-scale displacement from Venezuela and Nicaragua is reshaping the migration landscape in much of Latin America and the Caribbean. This report, accompanied by the launch of a new Migration Portal offering research and analysis on the region, examines the immigration and integration policy responses of 11 countries, including pathways to legal status and measures to integrate newcomers into schools, health-care systems, and labor markets.




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    Bienvenidas asimétricas: Respuestas de América Latina y el Caribe a la migración venezolana y nicaragüense

    El gran desplazamiento forzado de personas en Venezuela y Nicaragua está transformando el panorama migratorio en gran parte de América Latina y el Caribe. Este informe examina las respuestas de las políticas de inmigración e integración de once países, incluyendo vías de regularización y medidas para integrar a los recién llegados en las escuelas y mercados laborales. Este informe acompaña el lanzamiento de un Portal Sobre Migración que ofrece investigación y análisis actualizados sobre tendencias y políticas de inmigración en la región.




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    COVID-19 in Latin America: Tackling Health Care & Other Impacts for Vulnerable Migrant Populations

    This MPI webinar brought together public health and migration experts to analyze the impact that COVID-19 preventative measures will have on vulnerable immigrants and refugees in Latin America, with a particular look at Colombia as a case study. Speakers also discussed how policymakers and international organizations can include migrant populations in their emergency response plans.




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    Venezuelan Immigrants in the United States

    Until recently, the Venezuelan immigrant population in the United States was relatively small compared others from South America. But it has grown significantly, reaching 394,000 in 2018, as Venezuela's destabilization has driven large-scale emigration. Compared to other immigrants in the United States, Venezuelans have higher levels of education but are also more likely to live in poverty, as this Spotlight explores.




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    Sammy and Bishoo spark India collapse

    Darren Sammy and Devendra Bishoo shared five wickets to trigger India's collapse on the second day of the opening Test against the West Indies in New Delhi.




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    Pakistan shines on pitch with series win

    Pakistan highlighted its talent on the pitch to draw the third and final Test against Sri Lanka in Sharjah and win the series 1-0, just days after three former team-mates were jailed for spot-fixing.




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    Bangkok floods force Socceroos switch

    Australia's World Cup qualifier against Thailand next week has been moved to another stadium in Bangkok because of flooding in the city, Football Federation Australia said.




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    Efficacy and Safety of Dapagliflozin in the Elderly: Analysis From the DECLARE-TIMI 58 Study

    OBJECTIVE

    Data regarding the effects of sodium–glucose cotransporter 2 inhibitors in the elderly (age ≥65 years) and very elderly (age ≥75 years) are limited.

    RESEARCH DESIGN AND METHODS

    The Dapagliflozin Effect on Cardiovascular Events (DECLARE)–TIMI 58 assessed cardiac and renal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. Efficacy and safety outcomes were studied within age subgroups for treatment effect and age-based treatment interaction.

    RESULTS

    Of the 17,160 patients, 9,253 were <65 years of age, 6,811 ≥65 to <75 years, and 1,096 ≥75 years. Dapagliflozin reduced the composite of cardiovascular death or hospitalization for heart failure consistently, with a hazard ratio (HR) of 0.88 (95% CI 0.72, 1.07), 0.77 (0.63, 0.94), and 0.94 (0.65, 1.36) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.5277). Overall, dapagliflozin did not significantly decrease the rates of major adverse cardiovascular events, with HR 0.93 (95% CI 0.81, 1.08), 0.97 (0.83, 1.13), and 0.84 (0.61, 1.15) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.7352). The relative risk reduction for the secondary prespecified cardiorenal composite outcome ranged from 18% to 28% in the different age-groups with no heterogeneity. Major hypoglycemia was less frequent with dapagliflozin versus placebo, with HR 0.97 (95% CI 0.58, 1.64), 0.50 (0.29, 0.84), and 0.68 (0.29, 1.57) in age-groups <65, ≥65 to <75, and ≥75 years, respectively (interaction P value 0.2107). Safety outcomes, including fractures, volume depletion, cancer, urinary tract infections, and amputations were balanced with dapagliflozin versus placebo, and acute kidney injury was reduced, all regardless of age. Genital infections that were serious or led to discontinuation of the study drug and diabetic ketoacidosis were uncommon, yet more frequent with dapagliflozin versus placebo, without heterogeneity (interaction P values 0.1058 and 0.8433, respectively).

    CONCLUSIONS

    The overall efficacy and safety of dapagliflozin are consistent regardless of age.




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    Performance of the ESC 0/1-h and 0/3-h Algorithm for the Rapid Identification of Myocardial Infarction Without ST-Elevation in Patients With Diabetes

    OBJECTIVE

    Patients with diabetes mellitus (DM) have elevated levels of high-sensitivity cardiac troponin (hs-cTn). We investigated the diagnostic performance of the European Society of Cardiology (ESC) algorithms to rule out or rule in acute myocardial infarction (AMI) without ST-elevation in patients with DM.

    RESEARCH DESIGN AND METHODS

    We prospectively enrolled 3,681 patients with suspected AMI and stratified those by the presence of DM. The ESC 0/1-h and 0/3-h algorithms were used to calculate negative and positive predictive values (NPV, PPV). In addition, alternative cutoffs were calculated and externally validated in 2,895 patients.

    RESULTS

    In total, 563 patients (15.3%) had DM, and 137 (24.3%) of these had AMI. When the ESC 0/1-h algorithm was used, the NPV was comparable in patients with and without DM (absolute difference [AD] –1.50 [95% CI –5.95, 2.96]). In contrast, the ESC 0/3-h algorithm resulted in a significantly lower NPV in patients with DM (AD –2.27 [95% CI –4.47, –0.07]). The diagnostic performance for rule-in of AMI (PPV) was comparable in both groups: 0/1-h (AD 6.59 [95% CI –19.53, 6.35]) and 0/3-h (AD 1.03 [95% CI –7.63, 9.7]). Alternative cutoffs increased the PPV in both algorithms significantly, while improvements in NPV were only subtle.

    CONCLUSIONS

    Application of the ESC 0/1-h algorithm revealed comparable safety to rule out AMI comparing patients with and without DM, while this was not observed with the ESC 0/3-h algorithm. Although alternative cutoffs might be helpful, patients with DM remain a high-risk population in whom identification of AMI is challenging and who require careful clinical evaluation.




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    Myocardial Ischemic Burden and Differences in Prognosis Among Patients With and Without Diabetes: Results From the Multicenter International REFINE SPECT Registry

    OBJECTIVE

    Prevalence and prognostic impact of cardiovascular disease differ between patients with or without diabetes. We aimed to explore differences in the prevalence and prognosis of myocardial ischemia by automated quantification of total perfusion deficit (TPD) among patients with and without diabetes.

    RESEARCH DESIGN AND METHODS

    Of 20,418 individuals who underwent single-photon emission computed tomography myocardial perfusion imaging, 2,951 patients with diabetes were matched to 2,951 patients without diabetes based on risk factors using propensity score. TPD was categorized as TPD = 0%, 0% < TPD < 1%, 1% ≤ TPD < 5%, 5% ≤ TPD ≤ 10%, and TPD >10%. Major adverse cardiovascular events (MACE) were defined as a composite of all-cause mortality, myocardial infarction, unstable angina, or late revascularization.

    RESULTS

    MACE risk was increased in patients with diabetes compared with patients without diabetes at each level of TPD above 0 (P < 0.001 for interaction). In patients with TPD >10%, patients with diabetes had greater than twice the MACE risk compared with patients without diabetes (annualized MACE rate 9.4 [95% CI 6.7–11.6] and 3.9 [95% CI 2.8–5.6], respectively, P < 0.001). Patients with diabetes with even very minimal TPD (0% < TPD < 1%) experienced a higher risk for MACE than those with 0% TPD (hazard ratio 2.05 [95% CI 1.21–3.47], P = 0.007). Patients with diabetes with a TPD of 0.5% had a similar MACE risk as patients without diabetes with a TPD of 8%.

    CONCLUSIONS

    For every level of TPD >0%, even a very minimal deficit of 0% < TPD < 1%, the MACE risk was higher in the patients with diabetes compared with patients without diabetes. Patients with diabetes with minimal ischemia had comparable MACE risk as patients without diabetes with significant ischemia.




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    Microvascular and Cardiovascular Outcomes According to Renal Function in Patients Treated With Once-Weekly Exenatide: Insights From the EXSCEL Trial

    OBJECTIVE

    To evaluate the impact of once-weekly exenatide (EQW) on microvascular and cardiovascular (CV) outcomes by baseline renal function in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL).

    RESEARCH DESIGN AND METHODS

    Least squares mean difference (LSMD) in estimated glomerular filtration rate (eGFR) from baseline between the EQW and placebo groups was calculated for 13,844 participants. Cox regression models were used to estimate effects by group on incident macroalbuminuria, retinopathy, and major adverse CV events (MACE). Interval-censored time-to-event models estimated effects on renal composite 1 (40% eGFR decline, renal replacement, or renal death) and renal composite 2 (composite 1 variables plus macroalbuminuria).

    RESULTS

    EQW did not change eGFR significantly (LSMD 0.21 mL/min/1.73 m2 [95% CI –0.27 to 0.70]). Macroalbuminuria occurred in 2.2% of patients in the EQW group and in 2.5% of those in the placebo group (hazard ratio [HR] 0.87 [95% CI 0.70–1.07]). Neither renal composite was reduced with EQW in unadjusted analyses, but renal composite 2 was reduced after adjustment (HR 0.85 [95% CI 0.74–0.98]). Retinopathy rates did not differ by treatment group or in the HbA1c-lowering or prior retinopathy subgroups. CV outcomes in those with eGFR <60 mL/min/1.73 m2 did not differ by group. Those with eGFR ≥60 mL/min/1.73 m2 had nominal risk reductions for MACE, all-cause mortality, and CV death, but interactions by renal function group were significant for only stroke (HR 0.74 [95% CI 0.58–0.93]; P for interaction = 0.035) and CV death (HR 1.08 [95% CI 0.85–1.38]; P for interaction = 0.031).

    CONCLUSIONS

    EQW had no impact on unadjusted retinopathy or renal outcomes. CV risk was modestly reduced only in those with eGFR ≥60 mL/min/1.73 m2 in analyses unadjusted for multiplicity.




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    Glycated Hemoglobin, Prediabetes, and the Links to Cardiovascular Disease: Data From UK Biobank

    OBJECTIVE

    HbA1c levels are increasingly measured in screening for diabetes; we investigated whether HbA1c may simultaneously improve cardiovascular disease (CVD) risk assessment, using QRISK3, American College of Cardiology/American Heart Association (ACC/AHA), and Systematic COronary Risk Evaluation (SCORE) scoring systems.

    RESEARCH DESIGN AND METHODS

    UK Biobank participants without baseline CVD or known diabetes (n = 357,833) were included. Associations of HbA1c with CVD was assessed using Cox models adjusting for classical risk factors. Predictive utility was determined by the C-index and net reclassification index (NRI). A separate analysis was conducted in 16,596 participants with known baseline diabetes.

    RESULTS

    Incident fatal or nonfatal CVD, as defined in the QRISK3 prediction model, occurred in 12,877 participants over 8.9 years. Of participants, 3.3% (n = 11,665) had prediabetes (42.0–47.9 mmol/mol [6.0–6.4%]) and 0.7% (n = 2,573) had undiagnosed diabetes (≥48.0 mmol/mol [≥6.5%]). In unadjusted models, compared with the reference group (<42.0 mmol/mol [<6.0%]), those with prediabetes and undiagnosed diabetes were at higher CVD risk: hazard ratio (HR) 1.83 (95% CI 1.69–1.97) and 2.26 (95% CI 1.96–2.60), respectively. After adjustment for classical risk factors, these attenuated to HR 1.11 (95% CI 1.03–1.20) and 1.20 (1.04–1.38), respectively. Adding HbA1c to the QRISK3 CVD risk prediction model (C-index 0.7392) yielded a small improvement in discrimination (C-index increase of 0.0004 [95% CI 0.0001–0.0007]). The NRI showed no improvement. Results were similar for models based on the ACC/AHA and SCORE risk models.

    CONCLUSIONS

    The near twofold higher unadjusted risk for CVD in people with prediabetes is driven mainly by abnormal levels of conventional CVD risk factors. While HbA1c adds minimally to cardiovascular risk prediction, those with prediabetes should have their conventional cardiovascular risk factors appropriately measured and managed.




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    Novel Biomarkers for Change in Renal Function in People With Dysglycemia

    OBJECTIVE

    Diabetes is a major risk factor for renal function decline and failure. The availability of multiplex panels of biochemical markers provides the opportunity to identify novel biomarkers that can better predict changes in renal function than routinely available clinical markers.

    RESEARCH DESIGN AND METHODS

    The concentration of 239 biochemical markers was measured in stored serum from participants in the biomarker substudy of Outcome Reduction With Initial Glargine Intervention (ORIGIN) trial. Repeated-measures mixed-effects models were used to compute the annual change in eGFR (measured as mL/min/1.73 m2/year) for the 7,482 participants with a recorded baseline and follow-up eGFR. Linear regression models using forward selection were used to identify the independent biomarker determinants of the annual change in eGFR after accounting for baseline HbA1c, baseline eGFR, and routinely measured clinical risk factors. The incidence of the composite renal outcome (i.e., renal replacement therapy, renal death, renal failure, albuminuria progression, doubling of serum creatinine) and death within each fourth of change in eGFR predicted from these models was also estimated.

    RESULTS

    During 6.2 years of median follow-up, the median annual change in eGFR was –0.18 mL/min/1.73 m2/year. Fifteen biomarkers independently predicted eGFR decline after accounting for cardiovascular risk factors, as did 12 of these plus 1 additional biomarker after accounting for renal risk factors. Every 0.1 mL/min/1.73 m2 predicted annual fall in eGFR predicted a 13% (95% CI 12, 14%) higher mortality.

    CONCLUSIONS

    Adding up to 16 biomarkers to routinely measured clinical risk factors improves the prediction of annual change in eGFR in people with dysglycemia.




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    Visit-to-Visit HbA1c Variability Is Associated With Cardiovascular Disease and Microvascular Complications in Patients With Newly Diagnosed Type 2 Diabetes

    OBJECTIVE

    To investigate the association between visit-to-visit HbA1c variability and cardiovascular events and microvascular complications in patients with newly diagnosed type 2 diabetes.

    RESEARCH DESIGN AND METHODS

    This retrospective cohort study analyzed patients from Tayside and Fife in the Scottish Care Information–Diabetes Collaboration (SCI-DC) who were observable from the diagnosis of diabetes and had at least five HbA1c measurements before the outcomes were evaluated. We used the previously reported HbA1c variability score (HVS), calculated as the percentage of the number of changes in HbA1c >0.5% (5.5 mmol/mol) among all HbA1c measurements within an individual. The association between HVS and 10 outcomes was assessed using Cox proportional hazards models.

    RESULTS

    We included 13,111–19,883 patients in the analyses of each outcome. The patients with HVS >60% were associated with elevated risks of all outcomes compared with the lowest quintile (for example, HVS >80 to ≤100 vs. HVS ≥0 to ≤20, hazard ratio 2.38 [95% CI 1.61–3.53] for major adverse cardiovascular events, 2.4 [1.72–3.33] for all-cause mortality, 2.4 [1.13–5.11] for atherosclerotic cardiovascular death, 2.63 [1.81–3.84] for coronary artery disease, 2.04 [1.12–3.73] for ischemic stroke, 3.23 [1.76–5.93] for heart failure, 7.4 [3.84–14.27] for diabetic retinopathy, 3.07 [2.23–4.22] for diabetic peripheral neuropathy, 5.24 [2.61–10.49] for diabetic foot ulcer, and 3.49 [2.47–4.95] for new-onset chronic kidney disease). Four sensitivity analyses, including adjustment for time-weighted average HbA1c, confirmed the robustness of the results.

    CONCLUSIONS

    Our study shows that higher HbA1c variability is associated with increased risks of all-cause mortality, cardiovascular events, and microvascular complications of diabetes independently of high HbA1c.




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    The Prevalence and Determinants of Cognitive Deficits and Traditional Diabetic Complications in the Severely Obese

    OBJECTIVE

    To determine the prevalence of cognitive deficits and traditional diabetic complications and the association between metabolic factors and these outcomes.

    RESEARCH DESIGN AND METHODS

    We performed a cross-sectional study in severely obese individuals before bariatric surgery. Lean control subjects were recruited from a research website. Cognitive deficits were defined by the National Institutes of Health (NIH) Toolbox (<5th percentile for lean control subjects). Cardiovascular autonomic neuropathy (CAN) was defined by an expiration-to-inspiration (E-to-I) ratio of <5th percentile for lean control subjects. Retinopathy was based on retinal photographs and nephropathy on the estimated glomerular filtration rate (<60 mg/dL) and/or the albumin-to-creatinine ratio (ACR) (≥30 mg/g). NIH Toolbox, E-to-I ratio, mean deviation on frequency doubling technology testing, and ACR were used as sensitive measures of these outcomes. We used multivariable linear regression to explore associations between metabolic factors and these outcomes.

    RESULTS

    We recruited 138 severely obese individuals and 46 lean control subjects. The prevalence of cognitive deficits, CAN, retinopathy, and nephropathy were 6.5%, 4.4%, 0%, and 6.5% in lean control subjects; 22.2%, 18.2%, 0%, and 6.1% in obese participants with normoglycemia; 17.7%, 21.4%, 1.9%, and 17.9% in obese participants with prediabetes; and 25.6%, 31.9%, 6.1%, and 16.3% in obese participants with diabetes. Waist circumference was significantly associated with cognitive function (–1.48; 95% CI –2.38, –0.57) and E-to-I ratio (–0.007; 95% CI –0.012, –0.002). Prediabetes was significantly associated with retinal function (–1.78; 95% CI –3.56, –0.002).

    CONCLUSIONS

    Obesity alone is likely sufficient to cause cognitive deficits but not retinopathy or nephropathy. Central obesity is the key metabolic risk factor.




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    Association of BMI, Fitness, and Mortality in Patients With Diabetes: Evaluating the Obesity Paradox in the Henry Ford Exercise Testing Project (FIT Project) Cohort

    OBJECTIVE

    To determine the effect of fitness on the association between BMI and mortality among patients with diabetes.

    RESEARCH DESIGN AND METHODS

    We identified 8,528 patients with diabetes (self-report, medication use, or electronic medical record diagnosis) from the Henry Ford Exercise Testing Project (FIT Project). Patients with a BMI <18.5 kg/m2 or cancer were excluded. Fitness was measured as the METs achieved during a physician-referred treadmill stress test and categorized as low (<6), moderate (6–9.9), or high (≥10). Adjusted hazard ratios for mortality were calculated using standard BMI (kilograms per meter squared) cutoffs of normal (18.5–24.9), overweight (25–29.9), and obese (≥30). Adjusted splines centered at 22.5 kg/m2 were used to examine BMI as a continuous variable.

    RESULTS

    Patients had a mean age of 58 ± 11 years (49% women) with 1,319 deaths over a mean follow-up of 10.0 ± 4.1 years. Overall, obese patients had a 30% lower mortality hazard (P < 0.001) compared with normal-weight patients. In adjusted spline modeling, higher BMI as a continuous variable was predominantly associated with a lower mortality risk in the lowest fitness group and among patients with moderate fitness and BMI ≥30 kg/m2. Compared with the lowest fitness group, patients with higher fitness had an ~50% (6–9.9 METs) and 70% (≥10 METs) lower mortality hazard regardless of BMI (P < 0.001).

    CONCLUSIONS

    Among patients with diabetes, the obesity paradox was less pronounced for patients with the highest fitness level, and these patients also had the lowest risk of mortality.