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Basal Insulin and Cardiovascular and Other Outcomes in Dysglycemia

New England Journal of Medicine, 2012 · paper · Clinical trials

A randomized trial of 12,537 people with cardiovascular risk factors and impaired glucose regulation or type 2 diabetes, comparing insulin glargine with standard care. Glargine had a neutral effect on cardiovascular outcomes and cancers, while increasing hypoglycemia and weight.

1 finding

Substance Table 1 lists "Impaired glucose tolerance or impaired fasting glucose" as 735 (11.7) and 717 (11.4), but the text says "1456 participants without diabetes at randomization (737 assigned to insulin glargine and 719 assigned to standard care)".
  • p. 4 Table 1, row 'Impaired glucose tolerance or impaired fasting glucose'
    735 (11.7)
  • p. 4 Table 1, same row, standard care
    717 (11.4)
  • p. 4 Results, Other Outcomes
    (737 assigned to insulin glargine and 719 assigned to standard care)
  • p. 1 Abstract, Results
    35% of 1456 participants without baseline diabetes

Only the authors can say what is right here.

Judge's note: Checked Table 1 on p.4 against the Other Outcomes text on the same page and the abstract (1456). With 735/717 the glycemic categories add up to 6262 and 6271, not the arm totals of 6264 and 6273. With 737/719 they add up exactly. The table's percentages fit 735/717. Searching the text turned up no definition of a separate no-diabetes subset (for example participants with normal glucose or missing category) that would explain the 2-per-arm gap. Only the authors can say which count is right.

Second check: another model agreed

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7 minor (typos and the like; most checked by the judge only)
Reference or label Table 3 is titled "Incidence of a First Episode of Severe Hypoglycemia." but also has sections for "Confirmed nonsevere symptomatic hypoglycemia" and "Any nonsevere symptomatic hypoglycemia".
  • p. 9 Table 3 title
    Incidence of a First Episode of Severe Hypoglycemia.
  • p. 9 Table 3 rows
    Any nonsevere symptomatic hypoglycemia

Only the authors can say what is right here.

Judge's note: Checked Table 3 on p.9. Two of its three sections cover nonsevere hypoglycemia, and the text (p.6) cites Table 3 for nonsevere rates and for participants without any symptomatic hypoglycemia. The title describes only the first section.

Second check: another model agreed

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Wording Results: "After 1 year, 50% of the insulin-glargine group had a fasting plasma glucose level of 94 mg per deciliter (5.2 mmol per liter) or less, and that level was maintained (Table 2)"; Table 2 prints a 1-yr glargine FPG median of 93.
  • p. 3 Results, Insulin Use and Achieved Fasting Glucose Levels
    After 1 year, 50% of the insulin-glargine group had a fasting plasma glucose level of 94 mg per deci-
  • p. 6 Table 2, 1 yr row, insulin glargine FPG median
    93
  • p. 3 Results, Insulin Use and Achieved Fasting Glucose Levels
    After 1 year, 50% of the insulin-glargine group had a fasting plasma glucose level of 94 mg per deciliter (5.2 mmol per liter) or less
  • p. 3 Insulin use and achieved fasting glucose levels
    fasting plasma glucose level of 94 mg per deci-

Judge's note: Looked at the p.3 crop and Table 2 on p.6. The Table 2 glargine medians by year are 93, 90, 90, 91, 92, 94 and 94, so 94 is the largest median from year 1 to year 7. Read as a threshold that held at every visit ('94 or less ... maintained'), the sentence is true. It is still not the 1-yr median it seems to describe (93). Either wording could be intended, so this is a minor consistency point.

Second check: another model agreed

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Wording Discussion: "participants in the standard-care group who used oral agents had a median fasting plasma glucose level of 123 mg per deciliter"; in Results, 123 mg/dl is the end-of-study median for the whole standard-care group (11% on insulin, 19% on no oral agents).
  • p. 7 Discussion, first column
    participants in the standard-care group who used oral agents had a median fasting plasma glucose level of 123 mg per deciliter
  • p. 4 Results, top of first column (continuing from p.3)
    level was 123 mg per deciliter (6.8 mmol per liter)

Only the authors can say what is right here.

Judge's note: Results (pp.3–4, text layer lines 271–284) give 123 mg/dl for the standard-care group as a whole at study end. The Discussion (p.7) gives the same figure for the subset using oral agents. No subgroup value is reported, so one of the two population descriptions does not match the number.

Second check: another model agreed

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Wording Discussion: "values of less than 108 mg per deciliter (6.0 mmol per liter) were maintained in more than 75% of the group", but the Table 2 glargine FPG upper quartiles at years 5–7 are 108, 110 and 113.
  • p. 7 Discussion, first column
    values of less than 108 mg per deciliter (6.0 mmol per liter) were maintained in more than 75% of the group
  • p. 6 Table 2, insulin glargine FPG IQR, 5–7 yr
    81–108

Only the authors can say what is right here.

Judge's note: Checked Table 2 on p.6. The glargine IQR upper bounds are 106, 104, 103, 105, 108, 110 and 113 for years 1–7. More than 75% below 108 holds for years 1–4 only. The sentence does not say which period it covers, while the preceding clause speaks of 'at least 5 years'. The text overstates the table.

Second check: another model agreed

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Wording Discussion: "approximately 0.7 more severe episodes and 11 more suspected or confirmed episodes per 100 person-years"; the Table 3 difference for any nonsevere symptomatic hypoglycemia is 16.72−5.16=11.56.
  • p. 7 Discussion, second paragraph
    11 more suspected or confirmed episodes per 100 person-years
  • p. 9 Table 3, Any nonsevere symptomatic hypoglycemia
    3575 (16.72)

Judge's note: Checked Table 3 on p.9. The severe-hypoglycemia difference, 0.69, rounds to the printed 0.7, but the any-nonsevere difference, 11.56, rounds to 12, not 11. The Table 3 rates are also participants with at least 1 episode per 100 person-years, not episodes. The point is minor because the text says 'approximately'.

Second check: another model agreed

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Typo Two consecutive paragraphs on p.8 open points with "Finally": "Finally, the ORIGIN trial was designed to test..." and "Finally, no previously unrecognized adverse...".
  • p. 8 Discussion, limitations paragraph
    Finally, the ORIGIN trial was designed to test
  • p. 8 Discussion, next paragraph
    Finally, no previously unrecognized adverse

Judge's note: Checked p.8. The limitations paragraph ends its list with 'Finally', and the next paragraph opens with 'Finally' as well. The second may be meant to close the whole discussion, but the repetition is a copy-editing slip.

Second check: none (judge only)

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Typo Disclosures: "Dr. Ramachandran, grant support through this institution from Merck Sharp & Dohme" should read "his institution".
  • p. 9 Disclosures, Dr. Ramachandran
    grant support through this institution from Merck Sharp &

Judge's note: Checked the p.9 disclosures. Every other entry says 'through his institution'; 'this' has no antecedent here, so it is a typo.

Second check: none (judge only)

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