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      2019 John Insall Award: Fructosamine is a better glycaemic marker compared with glycated haemoglobin (HbA1C) in predicting adverse outcomes following total knee arthroplasty : a prospective multicentre study

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          Abstract

          Aims

          The best marker for assessing glycaemic control prior to total knee arthroplasty (TKA) remains unknown. The purpose of this study was to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly.

          Patients and Methods

          This prospective multi-institutional study evaluated primary TKA patients from four academic institutions. Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death. The Youden’s index was used to determine the cut-off for fructosamine and HbA1c associated with complications. Two additional cut-offs for HbA1c were examined: 7% and 7.5% and compared with fructosamine as a predictor for complications.

          Results

          Overall, 1119 patients (441 men, 678 women) were included in the study. Fructosamine level of 293 µmol/l was identified as the optimal cut-off associated with complications. Patients with high fructosamine (> 293 µmol/l) were 11.2 times more likely to develop PJI compared with patients with low fructosamine (p = 0.001). Re-admission and re-operation rates were 4.2 and 4.5 times higher in patients with fructosamine above the threshold (p = 0.005 and p = 0.019, respectively). One patient (1.7%) from the elevated fructosamine group died compared with one patient (0.1%) in the normal fructosamine group (p = 0.10). These complications remained statistically significant in multiple regression analysis. Unlike fructosamine, all three cut-offs for HbA1c failed to show a significant association with complications.

          Conclusion

          Fructosamine is a valid and an excellent predictor of complications following TKA. It better reflects the glycaemic control, has greater predictive power for adverse events, and responds quicker to treatment compared with HbA1c. These findings support the screening of all patients undergoing TKA using fructosamine and in those with a level above 293 µmol/l, the risk of surgery should be carefully weighed against its benefit. Cite this article: Bone Joint J 2019;101-B(7 Supple C):3–9.

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          Most cited references23

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          Projecting the Future Diabetes Population Size and Related Costs for the U.S.

          OBJECTIVE We developed a novel population-level model for projecting future direct spending on diabetes. The model can be used in the federal budget process to estimate the cost implications of alternative policies. RESEARCH DESIGN AND METHODS We constructed a Markov model simulating individuals' movement across different BMI categories, the incidence of diabetes and screening, and the natural history of diabetes and its complications over the next 25 years. Prevalence and incidence of obesity and diabetes and the direct spending on diabetes care and complications are projected. The study population is 24- to 85-year-old patients characterized by the Centers for Disease Control and Prevention's National Health and Nutrition Examination Survey and National Health Interview Survey. RESULTS Between 2009 and 2034, the number of people with diagnosed and undiagnosed diabetes will increase from 23.7 million to 44.1 million. The obesity distribution in the population without diabetes will remain stable over time with ∼65% of individuals of the population being overweight or obese. During the same period, annual diabetes-related spending is expected to increase from $113 billion to $336 billion (2007 dollars). For the Medicare-eligible population, the diabetes population is expected to rise from 8.2 million in 2009 to 14.6 million in 2034; associated spending is estimated to rise from $45 billion to $171 billion. CONCLUSIONS The diabetes population and the related costs are expected to at least double in the next 25 years. Without significant changes in public or private strategies, this population and cost growth are expected to add a significant strain to an overburdened health care system.
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            Pitfalls in hemoglobin A1c measurement: when results may be misleading.

            Since the beginning of clinical use in the 1970s, hemoglobin A1c (A1c) has become the standard tool for monitoring glycemic control in patients with diabetes. The role of the A1c test was broadened in 2010, when the American Diabetes Association added A1c as a diagnostic criterion for diabetes. Because of hemoglobin A1c's integral role in diagnosis and treatment, it is important to recognize clinical scenarios and interfering factors that yield false results. The purpose of this review is to describe the A1c measurement, outline clinical scenarios or factors that may yield false results, and describe alternative laboratory biomarkers.
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              The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management.

              Knowledge of one's actual and target health outcomes (such as HbA(1c) values) is hypothesized to be a prerequisite for effective patient involvement in managing chronic diseases such as diabetes. We examined 1) the frequency and correlates of knowing one's most recent HbA(1c) test result and 2) whether knowing one's HbA(1c) value is associated with a more accurate assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control. We conducted a cross-sectional survey of a sample of 686 U.S. adults with type 2 diabetes in five health systems who had HbA(1c) checked in the previous 6 months. Independent variables included patient characteristics, health care provider communication, and health system type. We examined bivariate and multivariate associations between each variable and the respondents' knowledge of their last HbA(1c) values and assessed whether knowledge of HbA(1c) was associated with key diabetes care attitudes and behaviors. Of the respondents, 66% reported that they did not know their last HbA(1c) value and only 25% accurately reported that value. In multivariate analyses, more years of formal education and high evaluations of provider thoroughness of communication were independently associated with HbA(1c) knowledge. Respondents who knew their last HbA(1c) value had higher odds of accurately assessing their diabetes control (adjusted odds ratio 1.59, 95% CI 1.05-2.42) and better reported understanding of their diabetes care (P < 0.001). HbA(1c) knowledge was not associated with respondents' diabetes care self-efficacy or reported self-management behaviors. Respondents who knew their HbA(1c) values reported better diabetes care understanding and assessment of their glycemic control than those who did not. Knowledge of one's HbA(1c) level alone, however, was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve patients' diabetes self-management. Strategies to provide information to patients must be combined with other behavioral strategies to motivate and help patients effectively manage their diabetes.
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                Author and article information

                Journal
                The Bone & Joint Journal
                The Bone & Joint Journal
                British Editorial Society of Bone & Joint Surgery
                2049-4394
                2049-4408
                July 2019
                July 2019
                : 101-B
                : 7_Supple_C
                : 3-9
                Affiliations
                [1 ]Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
                [2 ]Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
                [3 ]University of Louisville School of Medicine, Louisville, Kentucky, USA.
                [4 ]Columbia University Medical Center, New York, New York, USA.
                [5 ]NYU Langone MC Hospital for Joint Diseases, New York, New York, USA.
                Article
                10.1302/0301-620X.101B7.BJJ-2018-1418.R1
                2ff2d293-5989-4b63-91ac-25c0414c3612
                © 2019
                History

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