Screening for silent ischaemia in diabetes still has no outcome benefit; an EHR prompt multiplies DSMES referrals

The edition in brief

Five randomised trials (3,315 adults with diabetes and no known coronary disease) do not show that routine screening for silent myocardial ischaemia lowers major cardiovascular events: the pooled estimate across four trials was 0.76 (95% CI 0.48 to 1.19). Selective testing remains a judgement call when the result would change management. A joint ISPAD, EASD and ADA consensus report sets out 31 statements on moving young people with diabetes from paediatric to adult services across the pre-transfer, transfer and post-transfer stages. A meta-analysis of nine trials (944 participants) found placental-derived products added to standard care raised 12-week diabetic foot ulcer closure (59.0% vs 35.8%, RR 1.70), though the prediction interval crossed 1 and the benefit may not hold for every product. A small randomised trial in 66 children suggested subcutaneous insulin infusion with electrolyte replacement outperformed intravenous insulin in diabetic ketoacidosis, but it is a single small study with limited reporting and does not alter standard protocols. Finally, a cluster-randomised trial in six primary care practices found an electronic best practice advisory raised referral to diabetes self-management education and support to 12.9% against 1.2% at 12 months, and the gain held at 18 months after standing orders were added.