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Background To evaluate the association between diabetic foot disease (DFD) and the incidence of fatal and non-fatal events in individuals with type 2 diabetes (T2DM) from primary-care settings. Methods We built a cohort of people with a first DFD episode during 2010–2015, followed up until 2018. These subjects were 1 to 1 propensity score matched to subjects with T2DM without DFD. The incidence of all-cause mortality, the occurrence of new DFD, amputations, cardiovascular diseases, or composite outcome, including all-cause mortality and/or cardiovascular events during the follow-up period, were calculated. A Cox proportional hazard analysis was conducted to evaluate the hazard ratios (HR) for different events. Results Overall, 11,117 subjects with T2DM with a first episode of DFD were compared with subjects without DFD. We observed higher incidence rates (IRs) for composite outcome (33.9 vs. 14.5 IR per 100 person-years) and a new DFD episode event (22.2 vs. 1.1 IR per 100 person-years) in the DFD group. Compared to those without DFD, those with a first episode of DFD had a higher HR for all events, with excess rates particularly for amputation and new DFD occurrence (HR: 19.4, 95% CI: 16.7–22.6, HR: 15.1, 95% CI: 13.8–16.5, respectively) was found. Conclusions Although DFD often coexists with other risk factors, it carries an intrinsic high risk of morbidity and mortality in individuals with T2DM. DFD should be regarded as a severe complication already at its onset, as it carries a poor clinical prognosis. Graphical Abstract

Background Knowledge of the characteristics of first-ever cardiovascular events in type 1 diabetes may impact primary prevention strategies. This study describes the first-ever manifestation of cardiovascular disease (CVD) in patients with type 1 diabetes (T1D) in Catalonia (Spain) and evaluates differences according to age and sex. Methods Retrospective cohort study of patients with T1D > 30 years without CVD before 2010 registered in the SIDIAP database. The occurrence of a first cardiovascular event up to the end of 2016, the type of CV event and associations with baseline characteristics were analysed. Results Of 8412 patients, 884 suffered a first CV event (incidence rate 1.62 per 100 persons-years). Overall, peripheral vascular disease (39.5%) was the most frequent event. We observed a higher proportion of heart failure in women (21.7%) than in men (10.1%). In women, heart failure was the most frequent event in those > 65 years (40.5%). Decreased glomerular filtration rate (hazard ratio [HR] 5.42 [95% CI 4.32;6.80]), elevated albumin/creatinine ratio (HR 3.39 [95% CI [2.47;4.66], microvascular complications (HR 3.27 [95% CI 2.85;3.75]), and hypertension (HR 3.21 [95% CI [2.80;3.67]) were most strongly associated with a first CV event. HbA1c > 7.0% was associated with incident CVD only in patients aged < 55/60 years. Conclusions Peripheral artery disease in the whole cohort, and heart failure in elder subjects are the most frequent first-ever CVD events in T1D in our region. These findings deserve to be taken into account when considering primary prevention measures and when estimating CV risk in people with T1D.

Background Evidence from prospective cardiovascular (CV) outcome trials in type 2 diabetes (T2DM) patients supports the use of sodium–glucose co-transporter-2 inhibitors (SGLT2i) to reduce the risk of CV events. In this study, we compared the risk of several CV outcomes between new users of SGLT2i and other glucose-lowering drugs (oGLDs) in Catalonia, Spain. Methods CVD-REAL Catalonia was a retrospective cohort study using real-world data routinely collected between 2013 and 2016. The cohorts of new users of SGLT2i and oGLDs were matched by propensity score on a 1:1 ratio. We compared the incidence rates and hazard ratio (HR) for all-cause death, hospitalization for heart failure, chronic kidney disease, and modified major adverse CV event (MACE; all-cause mortality, myocardial infarction, or stroke). Results After propensity score matching, 12,917 new users were included in each group. About 27% of users had a previous history of CV disease. In the SGLT2i group, the exposure time was 60% for dapagliflozin, 26% for empagliflozin and 14% for canagliflozin. The use of SGLT2i was associated with a lower risk of heart failure (HR: 0.59; 95% confidence interval [CI] 0.47–0.74; p < 0.001), all-cause death (HR = 0.41; 95% CI 0.31–0.54; p < 0.001), all-cause death or heart failure (HR = 0.55; 95% CI 0.47–0.63; p < 0.001), modified MACE (HR = 0.62; 95% CI 0.52–0.74; p < 0.001), and chronic kidney disease (HR = 0.66; 95% CI 0.54–0.80; p < 0.001). Conclusions In this large, retrospective observational study of patients with T2DM from a Catalonia, initiation of SGLT-2i was associated with lower risk of mortality, as well as heart failure and CKD.

Background: The impact of dietary niacin on metabolic dysfunction-associated steatotic liver disease (MASLD) is elusive. This sub-study aimed to investigate the relationship between dietary niacin intake and the presence of MASLD in participants from two Catalonian cohorts. Methods: A total of 222 subjects with MASLD were age- and sex-matched to 222 non-MASLD subjects. Dietary nutrients were analyzed using a validated food frequency questionnaire (FFQ). Dietary niacin and other nutrients were adjusted for total energy intake. MASLD was defined by a Fatty Liver Index (FLI) of >60 and by having at least one component of metabolic syndrome. The association between niacin intake (distributed into tertiles) and the presence of MASLD was assessed using multivariate logistic regression. Potential non-linear relationships were also analyzed through restricted cubic spline regression (RCS). Results: Our data revealed that subjects with MASLD had worse metabolic profiles. The dietary intake of niacin did not differ between subjects with and without MASLD. Even after adjusting for different confounding variables, i.e., sociodemographic variables, smoking status, physical activity, and cardiometabolic comorbidities, no significant associations were observed between higher intakes of niacin (tertiles 2 and 3) and the presence of MASLD: odds ratio (95% confidence) second tertile: 0.99 (0.89–1.09); third tertile: 0.98 (0.89–1.10). However, RCS analysis uncovered a significant non-linear dose-response association between dietary niacin intake and odds of MASLD. Specifically, such analysis revealed that MASLD risk was decreased in subjects with niacin intake values of <35 mg/day. Conclusions: Our data showed that dietary niacin intake was associated with lower odds of MASLD in a Mediterranean population; however, our logistic regression analysis failed to reveal significant associations between the intake of niacin and the risk of MASLD. Further research is warranted to establish a causal relationship between dietary niacin interventions and MASLD.

AimThis study’s objective was to assess the risk of severe in-hospital complications of patients admitted for COVID-19 and diabetes mellitus (DM).DesignThis was a cross-sectional study.SettingsWe used pseudonymised medical record data provided by six general hospitals from the HM Hospitales group in Spain.Outcome measuresMultiple logistic regression analyses were used to identify variables associated with mortality and the composite of mortality or invasive mechanical ventilation (IMV) in the overall population, and stratified for the presence or absence of DM. Spline analysis was conducted on the entire population to investigate the relationship between glucose levels at admission and outcomes.ResultsOverall, 1621 individuals without DM and 448 with DM were identified in the database. Patients with DM were on average 5.1 years older than those without. The overall in-hospital mortality was 18.6% (N=301), and was higher among patients with DM than those without (26.3% vs 11.3%; p<0.001). DM was independently associated with death, and death or IMV (OR=2.33, 95% CI: 1.7 to 3.1 and OR=2.11, 95% CI: 1.6 to 2.8, respectively; p<0.001). In subjects with DM, the only variables independently associated with both outcomes were age >65 years, male sex and pre-existing chronic kidney disease. We observed a non-linear relationship between blood glucose levels at admission and risk of in-hospital mortality and death or IMV. The highest probability for each outcome (around 50%) was at random glucose of around 550 mg/dL (30.6 mmol/L), and the risks flattened above this value.ConclusionThe results confirm the high burden associated with DM in patients hospitalised with COVID-19 infection, particularly among men, the elderly and those with impaired kidney function. Moreover, hyperglycaemia on admission was strongly associated with poor outcomes, suggesting that personalised optimisation could help to improve outcome during the hospital stay.

This study aimed to evaluate the predictive value of diabetic retinopathy (DR) and its stages with the incidence of major cardiovascular events and all-cause mortality in type 2 diabetes mellitus (T2DM) persons in our large primary healthcare database from Catalonia (Spain). A retrospective cohort study with pseudo-anonymized routinely collected health data from SIDIAP was conducted from 2008 to 2016. We calculated incidence rates of major cardiovascular events [coronary heart disease (CHD), stroke, or both—macrovascular events] and all-cause mortality for subjects with and without DR and for different stages of DR. The proportional hazards regression analysis was done to assess the probability of occurrence between DR and the study events. About 22,402 T2DM subjects with DR were identified in the database and 196,983 subjects without DR. During the follow-up period among the subjects with DR, we observed the highest incidence of all-cause mortally. In the second place were the macrovascular events among the subjects with DR. In the multivariable analysis, fully adjusted for DR, sex, age, body mass index (BMI), tobacco, duration of T2DM, an antiplatelet or antihypertensive drug, and HbA1c, we observed that subjects with any stage of DR had higher risks for all of the study events, except for stroke. We observed the highest probability of all-cause death events (adjusted hazard ratios, AHRs: 1.34, 95% CI: 1.28; 1.41). In conclusion, our results show that DR is related to CHD, macrovascular events, and all-cause mortality among persons with T2DM.

Aims Chronic kidney disease (CKD) is a major global health concern, often underdiagnosed in primary care settings. This study aimed to assess CKD screening practices using estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) among individuals in a primary care population in Girona Sud, Catalonia. Methods A cross-sectional analysis was conducted using anonymised electronic health records from Girona Sud primary care centres. We included active patients aged ≥ 15 years with a recorded medical history. Demographic, clinical, and laboratory data, including eGFR and UACR, were analysed. CKD was defined as eGFR < 60 ml/min/1.73 m² and/or UACR ≥ 30 mg/g. Descriptive and inferential statistical analyses were performed. Results Among the studied population ( N  = 230,922), 37% had mildly decreased eGFR (60–89 ml/min/1.73 m²), while 3% had more advanced CKD (G3b-G5). Albuminuria was mostly A1 (89%), with moderate (9.4%) and severe (1.8%) cases observed. Screening was more frequent in patients with type 2 diabetes, hypertension, and dyslipidaemia. Renal protective drugs, such as ACE inhibitors, ARBs, and SGLT2 inhibitors, were mainly prescribed in early CKD stages. Conclusions Early-stage CKD is prevalent in our primary care population, particularly among those with cardiometabolic conditions. It is important to optimize the CKD detection and management in primary care. Despite the availability of renal protective treatments, their underutilization in advanced stages of CKD highlights missed opportunities for timely and optimal intervention.

Background Establishing risk factors associated with severity and prognosis in the early stages of the disease is important to identify patients who need specialized care. Creating new clinical tools to improve health decisions and outcomes in the population is essential. Methods This study aimed to identify prognostic factors associated with poor outcomes of COVID-19 at diagnosis in Primary Health Care (PHC).We conducted a retrospective, longitudinal study using the SIDIAP database, part of the PHC Information System of Catalonia. The analysis included COVID-19 cases diagnosed in patients aged 18 and older from March 2020 to September 2022. Follow-up was conducted for 90 days post-diagnosis or until death. Various machine learning models of differing complexities were used to predict short-term events, including mortality and hospital complications. Each model was tailored to maximize the predictive accuracy for poor outcomes, exploring algorithms such as Generalized Linear Models, flexible GLMs with Lasso, Gradient Boosting Models, and Support Vector Machines, with the model demonstrating the highest Area Under the Curve (AUC) selected for optimal performance. Results A total of 2,162,187 COVID-19 cases were identified across five epidemic waves. Key predictors of short-term complications included age and the epidemic wave. Additional significant factors encompassed social deprivation (MEDEA), blood pressure, cardiovascular history, chronic obstructive pulmonary disease (COPD), obesity, and diabetes mellitus. The models exhibited high performance, with AUC values ranging from 0.73 to 0.95. A web application was developed to estimate the risk of adverse outcomes based on individual patient profiles ( https://dapcat.shinyapps.io/CovidScore ). Conclusions In addition to age and epidemic wave, predictors such as social deprivation, diabetes mellitus, obesity, COPD, cardiovascular disease, high blood pressure, and dyslipidemia significantly indicate poor prognosis in COVID-19 patients diagnosed in PHC, and the developed application facilitates risk quantification for individual patients.

BackgroundDiabetic foot and lower limb complications are an important cause of morbidity and mortality among persons with diabetes mellitus. Very few studies have been carried out in the primary care settings. The main objective was to assess the prognosis of diabetic foot ulcer (DFU) in patients from primary care centers in Catalonia, Spain, during a 12-month follow-up period.MethodsWe included participants with type 2 diabetes and a new DFU between February 2018 and July 2019. We estimated the incidence of mortality, amputations, recurrence and healing of DFU during the follow-up period. A multivariable analysis was performed to assess the association of these outcomes and risk factors.ResultsDuring the follow-up period, 9.7% of participants died, 12.1% required amputation, 29.2% had a DFU recurrence, and 73.8% healed. Having a caregiver, ischemia or infection were associated with higher mortality risk (hazard ratio [HR]:3.63, 95% confidence interval [CI]:1.05; 12.61, HR: 6.41, 95%CI: 2.25; 18.30, HR: 3.06, 95%CI: 1.05; 8.94, respectively). Diabetic retinopathy was an independent risk factor for amputation events (HR: 3.39, 95%CI: 1.37; 8.39). Increasing age decreased the risk for a DFU recurrence, while having a caregiver increased the risk for this event (HR: 0.97, 95%CI: 0.94; 0.99). The need for a caregiver and infection decreased the probability of DFU healing (HR: 0.57, 95%CI: 0.39; 0.83, HR: 0.64, 95%CI: 0.42; 0.98, respectively). High scores for PEDIS (≥7) or SINBAD (≥3) were associated with an increased risk for DFU recurrence and a lower probability of DFU healing, respectively.ConclusionsWe observed high morbidity among subjects with a new DFU in our primary healthcare facilities. Peripheral arterial disease, infection, and microvascular complications increased the risk of poor clinical outcomes among subjects with DFU.

Clinical practice guidelines are helpful for clinicians, and their proper implementation could improve the quality of care and management of participants with diabetes. This study aimed to evaluate the degree of adherence to the Clinical Practice Guidelines (CPG) recommendations among obese, frail, or recently diagnosed type 2 diabetes mellitus (T2DM) participants in primary care centers in Spain. We perform a cross-sectional study on a national level in two phases. In the first phase, study participants were recruited, and their clinical data were collected. In the second phase, data related to the participating physicians were collected. In total, 882 participants from 240 physicians were analyzed. According to the study questionnaire, most participants from all three clinical groups had adequate adherence to the CPG. This percentage was highest among the recently diagnosed T2DM (91.6%) and lowest percent of frail T2DM persons (74.7%). The inadequate adherence to the guidelines was observed mainly among the obese and frail participants with T2DM from medical doctors with low CPG knowledge (3.4% and 3.5%, respectively). Regarding the patient's characteristics and degree of adherence to the guidelines, the participants with inadequate adherence were generally older, with higher BMI, poorer HbA1c control, and fewer visits with primary care physicians. Most (57%) primary care physicians had moderate CPG knowledge. In our multivariable logistic model, we did not observe statistically significant odds ratios for different characteristics related to the physicians/consultation and low CPG knowledge. The results of our cross-sectional study observe adequate adherence to the clinical guidelines by the primary care physicians for the majority of the participants with obesity, frailty, or newly diagnosed with T2DM.