Diabetes Care: “Lagniappe” and “Seeing Is Believing”!

With this issue, our editorial team celebrates its 4.5-year mark in overseeing the scientific aspects of Diabetes Care. As you have come to expect, we have been consistent in our attempts to update you on our progress by informing you of all the changes, innovations, and successes of the journal. We still feel that each issue provides new information that does more than provide an incremental contribution to new knowledge—it also offers providers translational perspectives that relate new findings to everyday clinical practice and poses new questions to the research community.

We feel this past year has been nothing short of spectacular for the journal! A year ago, in the July 2015 issue, we titled our report “Status of Diabetes Care: New Challenges, New Concepts, New Measures—Focusing on the Future!” as we felt the journal was at that time very much on an uphill trajectory (1). In the January 2016 issue, we titled our report “Building Momentum: Taking on the Real ‘Issues’ of Diabetes Care!” (2). In that issue, we described what has become an incredibly well-received initiative at the journal: frequent special thematic monthly issues that focus on timely and important clinical care and clinical research topics.

The thematic issues to date, which at that time numbered 10, were summarized in a table in the January 2016 issue (2). For example, our October 2015 issue focused on the recommendations and other guidelines for care from the American Diabetes Association (ADA) in the form of Position Statements, Scientific Statements, and Consensus Reports, described collectively as “Guiding Principles for Diabetes Care” (3). We ended the calendar year by dedicating our December 2015 issue to highlight insulin use after 90 years (4). In that issue, we provided a collection of articles that demonstrated the diversity of recent innovations in the clinical use of insulin and suggested that insulin remains the “little black dress” fit for all diabetes managements.

To sustain our momentum, we opened the 2016 calendar year with a January issue dedicated to gestational diabetes mellitus (5). Our May 2016 issue focused on diabetes and cardiovascular disease (6). The June 2016 issue was devoted to providing the latest data supporting bariatric/metabolic surgery as a new treatment option in the management of type 2 diabetes (7). The centerpiece of the June 2016 collection was the new evidence-based guidelines for surgical treatment of type 2 diabetes, which are based on a large body of evidence including randomized clinical trials showing that in most cases surgery can markedly reduce blood sugar levels or maintain adequate glycemic control despite major reduction in medication usage (8). Finally, in this July 2016 issue, we present a collection of articles providing state-of-the-art updates on the artificial pancreas (AP). These include reports on multinational home-use AP trials, studies in young children, use of multihormonal approaches to mitigate meal-related hyperglycemia, and discussions of AP study designs and outcome measures (see the special article collection “Artificial Pancreas” in this issue) (9).

As related above, our continuing quest is to keep the journal fresh and to increase your anticipation of each monthly issue. To this end, we propose the concept of a “lagniappe” added to each of our efforts (10). This is a regional term used primarily in the local geographic area influenced by New Orleans, LA. Given the culture of the area, the term is thought of as being more “Cajun” or Louisiana Creole French. Taken literally, it means providing you “a little something extra!” (10). This term was very fitting for the theme of our most recent Diabetes Care Symposium, held at the ADA Scientific Sessions in New Orleans, both because of the location of the meeting and with respect to the novelty and diversity of topics that were presented.

Our Diabetes Care Symposium, held each year during the ADA’s Scientific Sessions, has clearly become our editorial team’s most visible signature event. As has become our pattern, each year we refine the format and content of this event. Thus, it is not surprising that this year, at our 5th Annual Diabetes Care Symposium, we did provide “a little something extra.” Specifically, the symposium covered an incredible array of topics that are now presented as articles and featured in a special section in this issue of Diabetes Care (see “Diabetes Care Symposium” in this issue). Specifically, these topics ranged from a discussion of the National Institutes of Health Precision Medicine Initiative by Fradkin et al. (11) to a discussion of the role of precision medicine in diabetes by Florez (12). The symposium featured two stellar talks by Ele Ferrannini (13) and Sunder Mudaliar (14), who provided complementary and supporting perspectives on updates and insights on the molecular mechanisms to explain the surprising cardiovascular protection findings from the BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME). The symposium also included an update by the Action to Control Cardiovascular Risk in Diabetes Follow-On (ACCORDION) Eye/ACORDION study groups (15). They reported on the first study in persons with type 2 diabetes of 10 years’ duration and established cardiovascular disease (unlike the newly diagnosed participants of the UK Prospective Diabetes Study [UKPDS]) that prior intensive glycemic control continued to reduce diabetic retinopathy progression, despite similar A1C levels when the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study ended (15). Finally, Purnell et al. (16) reported on remission rates after laparoscopic surgery from the Longitudinal Assessment of Bariatric Surgery (LABS) study.

As we have also stated in progress reports this year, the continued success of our symposium at the Scientific Sessions was such that the journal was honored to be asked to coordinate such a symposium at the International Diabetes Federation (IDF) World Diabetes Congress, 30 November–4 December 2015, in Vancouver, BC, Canada. The IDF-ADA Translational Symposium was entitled “Translational Diabetes Research with Immediate Clinical Impact,” and the articles for that symposium were also featured in a special symposium section in the January 2016 issue of Diabetes Care (2).

Another feature of the ADA’s symposium that was started last year was the recognition of those individuals who have devoted their lives to diabetes research and care and whom we have featured in our Profiles in Progress initiative. Several times a year Diabetes Care publishes an article honoring a researcher or provider who has made notable contributions in the field of diabetes and who has served as a role model and mentor for many of our readers. In a brief ceremony this year held at the symposium, we recognized Drs. Trevor Orchard, Philip E. Cryer, Abbas E. Kitabchi, and Maria Buse as recipients of our Profiles in Progress honor, who were featured in our September, December, March, and June issues, respectively.

“Lagniappe,” as you will see below, is also a perfect term to characterize this month’s issue, given its array of timely and provocative articles. These include a comprehensive and thought-provoking perspective on diabetes prevention strategies and issues resulting from our annual Diabetes Care Editors’ Expert Forum that was convened to discuss these issues. This article represents the latest thoughts and comments on diabetes prevention from the world leaders and investigators of the landmark prevention trials (17). As outlined in the opening, the narrative provides a summary of seminal prevention trials, followed by a discussion of considerations for selecting appropriate populations for intervention and the clinical implications of the various diagnostic criteria for prediabetes. The narrative continues by outlining knowledge gaps in need of elucidation. In a thought-provoking section, the authors discuss a possible new avenue for securing regulatory approval for a prevention-related indication for metformin as well as specific considerations for future pharmacologic interventions to delay the onset of type 2 diabetes. The narrative concludes with descriptions of some innovative, pragmatic translational initiatives already underway around the world (17).

Also in this issue is a debate on whether to relax restrictions on metformin use in renal dysfunction, which is most timely given a recent U.S. Food and Drug Administration decision. This takes the form of a Point-Counterpoint discussion on the “pros” and “cons” of relaxing the renal restrictions for metformin use. In taking the Point perspective, Drs. Kalantar-Zadeh and Kovesdy provide their argument that while there is little evidence of the potential benefits of metformin in kidney disease, just considering the sheer numbers of metformin users and the high fatality rate of its associated lactic acidosis, they suggest that the appropriate practice is to avoid metformin use in any person with an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m² or in those at high risk of acute kidney injury irrespective of underlying eGFR (18). However, in the Counterpoint narrative, Drs. Bakris and Molitch (19) argue that the data from a very large analysis demonstrate clearly that serum creatinine should be supplanted with eGFR as criteria for metformin use and, second, that the incidence of lactic acidosis is elevated only in those with a reduced eGFR who become dehydrated for various reasons or exposed to some toxin resulting in acute kidney injury. Their position seems in line with the most recent U.S. Food and Drug Administration recommendation.

Finally, in our attempt to continue to innovate and provide unique educational messages for our readers, we have added another new and exciting manuscript category and format to the journal. This category is called “Clinical Images in Diabetes.” As outlined in detail in our revised instructions for authors, Clinical Images in Diabetes is intended to provide modern pictorial views on the pathogenesis of diabetes or its complications, with the aim of linking the clinical course of diabetes and related pathologies with their underlying physiological mechanisms. By presenting highly novel clinical summaries regarding one to no more than three patient descriptions per article, Clinical Images in Diabetes serves as a valuable educational tool to better understand the pathophysiology of diabetes, enhance disease diagnosis, and offer guidance for optimized clinical treatments. The overall intent is to better understand the course of disease by aligning the clinical course to the pathophysiology of disease suggested by imaging analysis provided by biopsies, whole-body imaging, videos, and other technologies.

Our first “lagniappe,” in the form of a Clinical Images in Diabetes contribution, appears in this issue of Diabetes Care as presented by Jacobsen et al. (20) from the University of Florida. They discuss a clinical course of a particular patient while providing representative immunohistochemistry images. The patient is a 26-year-old African American female whose severe presentation and progression of autoantibody-positive diabetes with incongruous C-peptide and histologic findings provide another unique example of disease variability and heterogeneity.

In closing, we hope you agree that Diabetes Care has had a great year. Our editorial team remains proud of the quality and diversity of the information published recently and our continuing effort to provide “a little something extra” when possible. Of course, we recognize the enormous contribution of you, the authors, for submitting novel manuscripts and greatly appreciate the legion of reviewers who have donated their time and expertise to make sure that manuscripts are rigorously reviewed and strengthened. Yes, we have been at this for 4.5 years, but we have yet to feel the momentum slowing. We will continue to work hard to improve the journal and present the best original findings in new ways. We offer the present issue as an example of these efforts, including both a little something extra and some images that may test the saying that “seeing is believing.”