The artificial pancreas: two alternative approaches to achieve a fully closed-loop system with optimal glucose control

INTRODUCTION

Diabetes mellitus type 1 is a chronic disease that implies mandatory external insulin delivery. The patients must monitor their blood glucose levels and administer appropriate insulin boluses to keep their blood glucose within the desired range. It requires a lot of time and endeavour, and many patients struggle with suboptimal glucose control despite all their efforts.

MATERIALS AND METHODS

This narrative review combines existing knowledge with new discoveries from animal experiments.

DISCUSSION

In the last decade, artificial pancreas (AP) devices have been developed to improve glucose control and relieve patients of the constant burden of managing their disease. However, a feasible and fully automated AP is yet to be developed. The main challenges preventing the development of a true, subcutaneous (SC) AP system are the slow dynamics of SC glucose sensing and particularly the delay in effect on glucose levels after SC insulin infusions. We have previously published studies on using the intraperitoneal space for an AP; however, we further propose a novel and potentially disruptive way to utilize the vasodilative properties of glucagon in SC AP systems.

CONCLUSION

This narrative review presents two lesser-explored viable solutions for AP systems and discusses the potential for improvement toward a fully automated system: A) using the intraperitoneal approach for more rapid insulin absorption, and B) besides using glucagon to treat and prevent hypoglycemia, also administering micro-boluses of glucagon to increase the local SC blood flow, thereby accelerating SC insulin absorption and SC glucose sensor site dynamics.

The Multisystem effects of Long COVID Syndrome and Potential Benefits of Massage Therapy in Long COVID Care

Background

A major complication of infection with Severe Acute Respiratory Coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, is the potential for Long COVID Syndrome. While the pathophysiology of Long COVID Syndrome has yet to be described, the disease presentation is characterized by long-term symptoms with debilitating effects on human health. A better understanding of Long COVID symptomology may open up new avenues for patient treatment such as massage therapy.

Methods

From the PubMed database, cohort studies that examined post-infection COVID sequelae published between January 1st, 2021 and April 30th, 2021 were selected to investigate patient demographics and symptoms. A review of massage therapy literature since 2000 in conjunction with identified Long COVID symptoms was performed.

Results

This systematic review identified 17 cohort studies across the world that investigated the symptomatology of patients suffering from post-COVID sequelae in multiple organ systems. We identified the pulmonary and nervous systems to be the organ systems most affected with post-COVID sequelae, with PTSD, fatigue, dyspnea, cough, sleep disturbances, loss of smell, abdominal pain, and decreased appetite as the most common symptoms reported by >20% of Long COVID patients. Massage therapy was historically found to provide benefits to patients experiencing similar symptoms to those identified in Long COVID.

Conclusions

Recognizing the need for new approaches to treatment for Long COVID Syndrome, we identify massage therapy as a potential therapeutic treatment to positively impact the organ systems affected by Long COVID, especially the high-incident symptoms, and improve patient quality of life.

Synchronized cardioversion resolving refractory supraventricular tachycardia in a neonate: a case report with comprehensive analysis

Introduction and importance

Neonatal supraventricular tachycardia (SVT) poses unique challenges in diagnosis and management, with refractory cases requiring synchronized cardioversion being exceptionally rare. This case report explores the presentation and management of refractory SVT in a neonate, emphasizing the significance of sharing such clinical scenarios.

Case presentation

A 16-day-old neonate, born via emergency caesarean section, presented with respiratory distress, poor feeding, and vomiting. Initial diagnosis of SVT was made on the basis of electrocardiography (ECG) changes. Initial attempts with adenosine failed, leading to the recurrence of tachycardia. Despite amiodarone administration, the tachycardia persisted, prompting synchronized cardioversion. Post-cardioversion, the neonate was managed with oral medications, showing sustained improvement.

Clinical discussion

This case report highlights a neonate with refractory SVT, requiring synchronized cardioversion, presenting a rare and challenging scenario. The report addresses diagnostic challenges, treatment approaches, and potential mechanisms for refractory SVT, such as delayed presentation and resistance to adenosine. Emphasizing individualized care plans and vigilant monitoring, this report is a valuable resource for healthcare professionals, contributing to neonatal cardiology understanding and emphasizing the importance of early recognition and effective interventions. Ongoing follow-up and successful outcomes underscore the need for sustained management strategies.

Conclusion

This case report sheds light on the rarity of refractory SVT in neonates, emphasizing the complexities in diagnosis and management. Successful synchronized cardioversion and subsequent oral therapy highlight the need for a multifaceted approach in neonatal SVT cases. The implications for clinical practice underscore the importance of awareness and continued research in neonatal cardiology and emergency medicine.

Health Literacy, Self-Efficacy and Glycemic Control in Patients With Diabetes Type 2 in a Greek Population

Aim  To investigate the relationship between health literacy (HL), self-efficacy (SE), and achievement of treatment goals in patients with type 2 diabetes mellitus (T2DM). Method The cross-sectional study was conducted with a random sample of patients with T2DM attending the diabetology clinic and the Home Care department of the General Hospital of Drama, Greece. They completed two questionnaires: the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) to measure HL and the Diabetes Management Self-Efficacy Scale (DMSES) for people with T2DM to measure SE. Medical history, demographic characteristics, and values related to glycemic control were also recorded. Linear regression analysis was used to search for the dependence of glycosylated hemoglobin (A1C) values with HL and SE and the dependence between them. Result About 120 patients with T2DM (response rate of 92.3%) were enrolled in the study. The mean age of the participants was 62.5 years [standard deviation (SD) = 10.6 years] and most of them were female (53.3%). A1C was found to be significantly negatively associated with diet, physical activity, and SE score. Also, a statistically significant positive correlation was found between HL and SE. HL was correlated with age, gender, education level, and A1C, with women and older people having lower HL, while conversely higher education level was significantly associated with higher HL. Higher A1C was significantly associated with lower HL. Also, SE partially mediates the relationship between HL and A1C, in a significant way. Conclusion The results of the study confirm the important role of HL and SE in the successful management of T2DM. Multi-level educational interventions for diabetic patients could improve HL and SE and promote diabetes self-management.

Effect of Exercise Conditioning on Countering the Effects of Obesity and Insulin Resistance in Horses-A Review

Obesity is an important health concern in horses, along with humans and companion animals. Adipose tissue is an inflammatory organ that alters the insulin-signaling cascade, ultimately causing insulin dysregulation and impaired glucose metabolism. These disruptions can increase the risk of metabolic disease and laminitis in horses and may also impact energy metabolism during exercise. A single bout of exercise, along with chronic exercise conditioning, increases insulin sensitivity and glucose disposal via both contraction- and insulin-mediated glucose uptake pathways. Regular exercise also increases calorie expenditure, which can facilitate weight (as body fat) loss. This paper explores the metabolic pathways affected by adiposity, as well as discusses the impact of exercise on insulin metabolism in horses.

Sleep quality and its associated factors among patients with type 2 diabetes mellitus in Hunan, China: a cross-sectional study

OBJECTIVES

Type 2 diabetes mellitus (T2DM) is a serious public health issue. Compared with the general population, patients with T2DM have a higher risk of poor sleep quality, which could ultimately result in poor prognosis. Therefore, this study aimed to evaluate sleep quality and its associated factors among patients with T2DM in Hunan, China.

DESIGN

This was a cross-sectional study.

SETTING

A tertiary hospital in Hunan, China.

PARTICIPANTS

Patients with T2DM hospitalised at the Endocrinology Department were consecutively enrolled between March 2021 and December 2022. Sociodemographic characteristics, lifestyle factors and T2DM-related information were collected retrospectively.

PRIMARY AND SECONDARY OUTCOME MEASURES

Sleep quality was evaluated using the Pittsburgh Sleep Quality Index, with a cut-off value of >7 suggesting poor sleep quality. Multivariate logistic regression analysis was used to determine factors associated with poor sleep quality.

RESULTS

Of the 1039 participants included, 1001 provided complete data. The mean age of the study sample was 60.24±10.09 years, and 40.5% (95% CI 37.5% to 43.5%) of patients had poor sleep quality. Multivariate logistic regression analysis showed that female sex (adjusted OR (aOR) 1.70, 95% CI 1.25 to 2.29), unmarried status (aOR 1.72, 95% CI 1.05 to 2.83), diabetic retinopathy (aOR 1.38, 95% CI 1.04 to 1.83), diabetic foot (aOR 1.80, 95% CI 1.11 to 2.93) and a per capita monthly household income of >5000 RMB (aOR 0.66, 95% CI 0.47 to 0.93) were associated with poor sleep quality.

CONCLUSIONS

Nearly two-fifths of patients with T2DM reported poor sleep quality in Hunan, China. Sex, marital status, diabetic retinopathy, diabetic foot and household income were independently associated with sleep quality among patients with T2DM in Hunan, China.

Diagnosis and Management of Paroxysmal Supraventricular Tachycardia

Importance

Paroxysmal supraventricular tachycardia (PSVT), defined as tachyarrhythmias that originate from or conduct through the atria or atrioventricular node with abrupt onset, affects 168 to 332 per 100 000 individuals. Untreated PSVT is associated with adverse outcomes including high symptom burden and tachycardia-mediated cardiomyopathy.

Observations

Approximately 50% of patients with PSVT are aged 45 to 64 years and 67.5% are female. Most common symptoms include palpitations (86%), chest discomfort (47%), and dyspnea (38%). Patients may rarely develop tachycardia-mediated cardiomyopathy (1%) due to PSVT. Diagnosis is made on electrocardiogram during an arrhythmic event or using ambulatory monitoring. First-line acute therapy for hemodynamically stable patients includes vagal maneuvers such as the modified Valsalva maneuver (43% effective) and intravenous adenosine (91% effective). Emergent cardioversion is recommended for patients who are hemodynamically unstable. Catheter ablation is safe, highly effective, and recommended as first-line therapy to prevent recurrence of PSVT. Meta-analysis of observational studies shows single catheter ablation procedure success rates of 94.3% to 98.5%. Evidence is limited for the effectiveness of long-term pharmacotherapy to prevent PSVT. Nonetheless, guidelines recommend therapies including calcium channel blockers, β-blockers, and antiarrhythmic agents as management options.

Conclusion and Relevance

Paroxysmal SVT affects both adult and pediatric populations and is generally a benign condition. Catheter ablation is the most effective therapy to prevent recurrent PSVT. Pharmacotherapy is an important component of acute and long-term management of PSVT.

Neutrophil Gelatinase-Associated Lipocalin (NGAL) as a potential early biomarker for diabetic nephropathy: a meta-analysis

BACKGROUND

Diabetic nephropathy (DN) is a prevalent and chronic, severe complication of diabetes, representing a serious global health concern. Early detection of DN is essential for initiating timely and effective therapeutic interventions and accurately assessing prognosis. Neutrophil Gelatinase-Associated Lipocalin (NGAL), a low molecular weight protein, has emerged as a potential biomarker for DN due to its association with renal injury and its ability to provide early indications of kidney damage. NGAL levels in both serum and urine are elevated in individuals with renal damage, making it a valuable biomarker for detecting early signs of kidney impairment in the context of diabetes. This study aims to investigate the utility of NGAL as an early biomarker for DN and explore its correlation with various clinical parameters associated with the disease. Understanding the relationship between NGAL levels and clinical parameters such as glycemic control, renal function, blood pressure, and duration of diabetes is crucial for comprehensively evaluating the potential of NGAL as a diagnostic and prognostic tool for DN. Furthermore, assessing the sensitivity and specificity of NGAL in detecting early-stage DN will provide valuable insights into its clinical applicability and reliability.

METHODOLOGY

A planned meta-analysis was conducted following PRISMA and MOOSE guidelines. The PubMed database was searched from January 2016 to June 2023 for English-language studies on DN and NGAL. Fifteen eligible studies were included as per the criteria. Data on serum NGAL levels in DN patients and healthy controls were analyzed using Stata 16.0 software.

RESULT

The study revealed a significantly higher mean serum NGAL level in DN patients (168.08 ng/ml, 95% CI: 105.50-230.67) compared to healthy controls (75.02 ng/ml, 95% CI: 43.02-107.03), demonstrating NGAL's potential as a biomarker (P=0.01).

CONCLUSION

NGAL offers a powerful tool for DN diagnosis, staging, and monitoring, surpassing traditional markers in sensitivity. Challenges include defining universal threshold values and ensuring consistent test performance across diverse clinical settings. The study underscores NGAL's potential in transforming DN diagnosis and management.

Nonlinear association of the systemic immune-inflammatory index with mortality in diabetic patients

Background

It has been demonstrated that in diabetic patients, an elevated neutrophil-lymphocyte ratio (NLR) is independently connected with higher cardiovascular and all-cause mortality. It is unclear, however, if the systemic immune-inflammatory index (SII) and the mortality rate among diabetic patients are related. Investigating the linkage between SII and diabetes patients' risk of cardiovascular and all-cause death was the aim of the study.

Methods

4972 diabetics who were chosen from six rounds of the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2016 were the study's participants. The optimal SII threshold with the highest correlation with survival outcomes was identified by applying the Maximum Selection Ranking Statistical Method (MSRSM). To assess the relationship between SII and cardiovascular and all-cause mortality in diabetics, subgroup analysis and Cox regression modeling were employed. Furthermore, smoothed curve fitting was utilized to determine the nonlinear relationship of them.

Results

Over the course of a median follow-up of 69 months (interquartile range [IQR], 54-123 months), 1,172 (23.6%) of the 4,972 diabetic patients passed away. These deaths included 332 (6.7%) cardiovascular deaths and 840 (16.9%) non-cardiovascular deaths. Individuals were categorized into higher (>983.5714) and lower (≤983.5714) SII groups according to MSRSM. In multi-variable adjusted models, subjects with higher SII had a significantly increased chance of dying from cardiovascular disease (HR 2.05; 95% confidence interval (CI):1.42,2.97) and from all causes (HR 1.60; 95% CI:1.22,1.99). Kplan-Meier curves showed similar results. Subgroup studies based on age, sex, BMI, drinking, smoking, and hypertension revealed that the connection maintained intact. The previously stated variables and SII did not significantly interact (p interaction > 0.05). In diabetic patients, smooth curve fitting revealed a nonlinear correlation between SII and mortality.

Conclusion

In diabetic patients, elevated SII is linked to higher cardiovascular and all-cause mortality.

The global prevalence of depression, anxiety, and sleep disorder among patients coping with Post COVID-19 syndrome (long COVID): a systematic review and meta-analysis

BACKGROUND

Post COVID-19 syndrome, also known as "Long COVID," is a complex and multifaceted condition that affects individuals who have recovered from SARS-CoV-2 infection. This systematic review and meta-analysis aim to comprehensively assess the global prevalence of depression, anxiety, and sleep disorder in individuals coping with Post COVID-19 syndrome.

METHODS

A rigorous search of electronic databases was conducted to identify original studies until 24 January 2023. The inclusion criteria comprised studies employing previously validated assessment tools for depression, anxiety, and sleep disorders, reporting prevalence rates, and encompassing patients of all age groups and geographical regions for subgroup analysis Random effects model was utilized for the meta-analysis. Meta-regression analysis was done.

RESULTS

The pooled prevalence of depression and anxiety among patients coping with Post COVID-19 syndrome was estimated to be 23% (95% CI: 20%-26%; I2 = 99.9%) based on data from 143 studies with 7,782,124 participants and 132 studies with 9,320,687 participants, respectively. The pooled prevalence of sleep disorder among these patients, derived from 27 studies with 15,362 participants, was estimated to be 45% (95% CI: 37%-53%; I2 = 98.7%). Subgroup analyses based on geographical regions and assessment scales revealed significant variations in prevalence rates. Meta-regression analysis showed significant correlations between the prevalence and total sample size of studies, the age of participants, and the percentage of male participants. Publication bias was assessed using Doi plot visualization and the Peters test, revealing a potential source of publication bias for depression (p = 0.0085) and sleep disorder (p = 0.02). However, no evidence of publication bias was found for anxiety (p = 0.11).

CONCLUSION

This systematic review and meta-analysis demonstrate a considerable burden of mental health issues, including depression, anxiety, and sleep disorders, among individuals recovering from COVID-19. The findings emphasize the need for comprehensive mental health support and tailored interventions for patients experiencing persistent symptoms after COVID-19 recovery.

Low Selenium and Low Protein Exacerbate Myocardial Damage in Keshan Disease by Affecting the PINK1/Parkin-mediated Mitochondrial Autophagy Pathway

OBJECTIVE

Keshan disease (KD) is a myocardial mitochondrial disease closely related to insufficient selenium (Se) and protein intake. PTEN induced putative kinase 1 (PINK1)/Parkin mediated mitochondrial autophagy regulates various physiological and pathological processes in the body. This study aimed to elucidate the relationship between PINK1/Parkin-regulated mitochondrial autophagy and KD-related myocardial injury.

METHODS

A low Se and low protein animal model was established. One hundred Wistar rats were randomly divided into 5 groups (control group, low Se group, low protein group, low Se + low protein group, and corn from KD area group). The JC-1 method was used to detect the mitochondrial membrane potential (MMP). ELISA was used to detect serum creatine kinase MB (CK-MB), cardiac troponin I (cTnI), and mitochondrial-glutamicoxalacetic transaminase (M-GOT) levels. RT-PCR and Western blot analysis were used to detect the expression of PINK1, Parkin, sequestome 1 (P62), and microtubule-associated proteins1A/1B light chain 3B (MAP1LC3B).

RESULTS

The MMP was significantly decreased and the activity of CK-MB, cTnI, and M-GOT significantly increased in each experimental group (low Se group, low protein group, low Se + low protein group and corn from KD area group) compared with the control group (P<0.05 for all). The mRNA and protein expression levels of PINK1, Parkin and MAP1LC3B were profoundly increased, and those of P62 markedly decreased in the experimental groups compared with the control group (P<0.05 for all).

CONCLUSION

Low Se and low protein levels exacerbate myocardial damage in KD by affecting the PINK1/Parkin-mediated mitochondrial autophagy pathway.

The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes

Background

Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women.

Methods

This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD.

Results

A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD.

Conclusions

The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.

Chapter 1: The Burden of Heart Failure

Heart failure (HF) affects an estimated 6 million American adults, and the prevalence continues to increase, driven in part by the aging of the population and by increases in the prevalence of diabetes. In recent decades, improvements in the survival of patients with HF have resulted in a growing number of individuals living longer with HF. HF and its comorbidities are associated with substantial impairments in physical functioning, emotional well-being, and quality of life, and also with markedly increased rates of morbidity and mortality. As a result, the management of patients with HF has a substantial economic impact on the health care system, with most costs arising from hospitalization. Clinicians have an important role in helping to reduce the burden of HF through timely diagnosis of HF as well as increasing access to effective treatments to minimize symptoms, delay progression, and reduce hospital admissions. Prevention and early diagnosis of HF will play a fundamental role in efforts to reduce the large and growing burden of HF. Recent advances in pharmacotherapies for HF have the potential to radically change the management of HF, offering the possibility of improved survival and quality of life for patients.

The interference between SARS-COV-2 and Alzheimer's disease: Potential immunological and neurobiological crosstalk from a kinase perspective reveals a delayed pandemic

Coronavirus disease 2019 (COVID-19) has infected over 700 million people, with up to 30% developing neurological manifestations, including dementias. However, there is a lack of understanding of common molecular brain markers causing Alzheimer's disease (AD). COVID-19 has etiological cofactors with AD, making patients with AD a vulnerable population at high risk of experiencing more severe symptoms and worse consequences. Both AD and COVID-19 have upregulated several shared kinases, leading to the repositioning of kinase inhibitors (KIs) for the treatment of both diseases. This review provides an overview of the interactions between the immune system and the nervous system in relation to receptor tyrosine kinases, including epidermal growth factor receptors, vascular growth factor receptors, and non-receptor tyrosine kinases such as Bruton tyrosine kinase, spleen tyrosine kinase, c-ABL, and JAK/STAT. We will discuss the promising results of kinase inhibitors in pre-clinical and clinical studies for both COVID-19 and Alzheimer's disease (AD), as well as the challenges in repositioning KIs for these diseases. Understanding the shared kinases between AD and COVID-19 could help in developing therapeutic approaches for both.

Do Pathophysiologic Mechanisms Linking Unhealthy Lifestyle to Cardiovascular Disease and Cancer Imply Shared Preventive Measures? - A Critical Narrative Review

Growing evidence has shown a bidirectional link between the cardiologic and oncologic fields. Several investigations support the role of unhealthy behaviors as pathogenic factors of both cardiovascular disease and cancer. We report epidemiological and research findings on the pathophysiological mechanisms linking unhealthy lifestyle to cardiovascular disease and cancer. For each unhealthy behavior, we also discuss the role of preventive measures able to affect both cardiovascular disease and cancer occurrence and progression.

Gamma knife radiosurgery is effective in patients with thyrotropin-secreting pituitary adenomas

PURPOSE

Thyrotropin (TSH)-secreting pituitary adenoma (TSHoma) is a rare cause of TSH-dependent hyperthyroidism. The first therapeutic option is surgery. Medical treatment with somatostatin analogs is also effective. To obviate the need for lifelong drug therapy, gamma knife radiosurgery (GKRS) might be considered in selected patients. We report the largest series of patients with TSHoma treated by GKRS at a single center.

METHODS

This study was a retrospective analysis of 18 consecutive patients with TSHoma treated by GKRS between 1994 and 2022. Normalization of hyperthyroidism, when present at the time of surgery, and control of tumor growth were the main outcomes of the study.

RESULTS

The median follow-up after GKRS treatment was 114 months (IQR, 57-213 months; range 17-285 months). No patients had growth of the residual tumor after GKRS. Remission of hyperthyroidism occurred in 9 of the 11 (81.8%) patients who were hyperthyroid before GKRS. The probability of hyperthyroidism remission three years after GKRS was 59.1% (95% CI 27.9-90.3%). No major side effects occurred after GKRS. One patient out of the 15 patients (6.7%) with normal baseline adrenal function and follow-up longer than 3 years developed new onset hypoadrenalism, while hypogonadism did not occur in the 13 patients with baseline normal function.

CONCLUSION

Our study shows that GKRS is an effective and safe adjuvant treatment for selected patients with residual or recurring TSHoma. The option of GKRS as an alternative treatment to lifelong medical treatment with somatostatin analogs should be thoroughly discussed with the patients.

Rethinking False Positive Exercise Electrocardiographic Stress Tests by Assessing Coronary Microvascular Function

BACKGROUND

Exercise electrocardiographic stress testing (EST) has historically been validated against the demonstration of obstructive coronary artery disease. However, myocardial ischemia can occur because of coronary microvascular dysfunction (CMD) in the absence of obstructive coronary artery disease.

OBJECTIVES

The aim of this study was to assess the specificity of EST to detect an ischemic substrate against the reference standard of coronary endothelium-independent and endothelium-dependent microvascular function in patients with angina with nonobstructive coronary arteries (ANOCA).

METHODS

Patients with ANOCA underwent invasive coronary physiological assessment using adenosine and acetylcholine. CMD was defined as impaired endothelium-independent and/or endothelium-dependent function. EST was performed using a standard Bruce treadmill protocol, with ischemia defined as the appearance of ≥0.1-mV ST-segment depression 80 ms from the J-point on electrocardiography. The study was powered to detect specificity of ≥91%.

RESULTS

A total of 102 patients were enrolled (65% women, mean age 60 ± 8 years). Thirty-two patients developed ischemia (ischemic group) during EST, whereas 70 patients did not (nonischemic group); both groups were phenotypically similar. Ischemia during EST was 100% specific for CMD. Acetylcholine flow reserve was the strongest predictor of ischemia during exercise. Using endothelium-independent and endothelium-dependent microvascular dysfunction as the reference standard, the false positive rate of EST dropped to 0%.

CONCLUSIONS

In patients with ANOCA, ischemia on EST was highly specific of an underlying ischemic substrate. These findings challenge the traditional belief that EST has a high false positive rate.

Weight change following diagnosis with psychosis: a retrospective cohort study in Greater Manchester, UK

INTRODUCTION

Weight gain in the months/years after diagnosis/treatment of severe enduring mental illness (SMI) is a major predictor of future diabetes, dysmetabolic profile and increased risk of cardiometabolic diseases. There is limited data on the longer-term profile of weight change in people with a history of SMI and how this may differ between individuals. We here report a retrospective study on weight change over the 5 years following an SMI diagnosis in Greater Manchester UK, an ethnically and culturally diverse community, with particular focus on comparing non-affective psychosis (NAP) vs affective psychosis (AP) diagnoses.

METHODS

We undertook an anonymised search in the Greater Manchester Care Record (GMCR). We reviewed the health records of anyone who had been diagnosed for the first time with first episode psychosis, schizophrenia, schizoaffective disorder, delusional disorder (non-affective psychosis = NAP) or affective psychosis (AP). We analysed body mass index (BMI) change in the 5-year period following the first prescription of antipsychotic medication. All individuals had taken an antipsychotic agent for at least 3 months. The 5-year follow-up point was anywhere between 2003 and 2023.

RESULTS

We identified 9125 people with the diagnoses above. NAP (n = 5618; 37.3% female) mean age 49.9 years; AP (n = 4131; 60.5% female) mean age 48.7 years. 27.0% of NAP were of non-White ethnicity vs 17.8% of AP individuals. A higher proportion of people diagnosed with NAP were in the highest quintile of social disadvantage 52.4% vs 39.5% for AP. There were no significant differences in baseline BMI profile. In a subsample with HbA1c data (n = 2103), mean HbA1c was higher in NAP at baseline (40.4 mmol/mol in NAP vs 36.7 mmol/mol for AP). At 5-year follow-up, there was similarity in both the overall % of individuals in the obese ≥ 30 kg/m2 category (39.8% NAP vs 39.7% AP), and % progressing from a normal healthy BMI transitioned to obese/overweight BMI (53.6% of NAP vs 55.6% with AP). 43.7% of those NAP with normal BMI remained at a healthy BMI vs 42.7% with AP. At 5-year follow-up for NAP, 83.1% of those with BMI ≥ 30 kg/m2 stayed in this category vs 81.5% of AP.

CONCLUSION

The results of this real-world longitudinal cohort study suggest that the changes in BMI with treatment of non-affective psychosis vs bipolar disorder are not significantly different, while 43% maintain a healthy weight in the first 5 years following antipsychotic prescription.

ANMCO (Italian Association of Hospital Cardiologists) scientific statement: obesity in adults-an approach for cardiologists

Obesity is a complex, chronic disease requiring a multidisciplinary approach to its management. In clinical practice, body mass index and waist-related measurements can be used for obesity screening. The estimated prevalence of obesity among adults worldwide is 12%. With the expected further increase in overall obesity prevalence, clinicians will increasingly be managing patients with obesity. Energy balance is regulated by a complex neurohumoral system that involves the central nervous system and circulating mediators, among which leptin is the most studied. The functioning of these systems is influenced by both genetic and environmental factors. Obesity generally occurs when a genetically predisposed individual lives in an obesogenic environment for a long period. Cardiologists are deeply involved in evaluating patients with obesity. Cardiovascular risk profile is one of the most important items to be quantified to understand the health risk due to obesity and the clinical benefit that a single patient can obtain with weight loss. At the individual level, appropriate patient involvement, the detection of potential obesity causes, and a multidisciplinary approach are tools that can improve clinical outcomes. In the near future, we will probably have new pharmacological tools at our disposal that will facilitate achieving and maintaining weight loss. However, pharmacological treatment alone cannot cure such a complex disease. The aim of this paper is to summarize some key points of this field, such as obesity definition and measurement tools, its epidemiology, the main mechanisms underlying energy homeostasis, health consequences of obesity with a focus on cardiovascular diseases and the obesity paradox.Level of evidence V: report of expert committees.

Clinical predictors of coronary artery bypass graft surgery in patients hospitalized for Non-ST acute coronary syndrome - Buenos Aires I and ReSCAR22 registries

Objectives

To identify predictors of coronary artery bypass graft surgery (CABG) requirement as a revascularization method in in real-world non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients.

Materials and methods

. An individual pre-specified analysis of patients with NSTE-ACS was performed from two prospective Argentine registries between 2017 and 2022. We analyzed the difference in baseline characteristics between patients who required CABG and those who did not require this intervention. Then, a logistic regression analysis was performed to determine independent predictors in patients who received CABG as a method of revascularization.

Results

A total of 1848 patients with a median age of 54.8 (interquartile range [IQR]: 53.7-56) years and an ejection fraction of 42.1% (IQR: 41.2-43.1) were included. A total of 233 patients required CABG (12.6%). Baseline characteristics between the two groups were similar, except in patients requiring CABG, who were younger (51.5 vs. 55.7 years; p=0.010), more frequently diabetic (38.2% vs. 25.7%; p=0.001) and male (90.1% vs. 73.7%; p=0.001). In addition, they had, to a lesser extent, previous cardiac surgery (2.1% vs. 11.2%; p=0.011). After multivariable analysis, the following were independently associated with CABG: age (Odds Ratio [OR]: 0.99, 95% confidence interval [CI]: 0.98-0.99; p=0.008), male sex (OR: 3.08, 95% CI: 1.87-5.1; p=0.001), history of previous CABG (OR: 0.14, 95% CI: 0.05-0.30; p=0.001) and diabetes (OR: 1.84, 95% CI: 1.31- 2.57; p=0.001).

Conclusions

In this analysis of two NSTEACS registries, younger age, male sex, a diagnosis of diabetes and the absence of previous surgery were independent predictors of the requirement for inpatient CABG.

Cross-sectional and longitudinal associations between empirically derived dietary patterns and frailty among older men: The Concord Health and Ageing in Men Project

BACKGROUND

Diet may be associated with frailty.

OBJECTIVE

We aimed to evaluate the associations between empirically derived dietary patterns and frailty in older men.

DESIGN

Prospective cohort study.

SETTING

The Concord Health and Ageing in Men Project, Sydney, Australia.

PARTICIPANTS

785 community-dwelling older Australian men aged 75 years and older.

METHODS

Men underwent dietary assessment using a validated dietitian-administered diet history questionnaire. Factor analysis identified three dietary patterns. Multinomial logistic regression was conducted between frailty and dietary patterns for cross-sectional analyses and longitudinal analyses over a 3-year follow-up. Frailty was defined by the Fried frailty phenotype.

RESULTS

Of the 785 men, pre-frailty was prevalent in 47.1% (n = 370), and frailty in 8.3% (n = 65). In fully adjusted cross-sectional analyses, the top tertile and a higher 'vegetables-legumes-seafood' dietary pattern score were associated with reduced prevalence of frailty (OR 0.34 [95% CI: 0.12, 0.93, P = .036]) and OR 0.50 [95% CI: 0.30, 0.83, P = .007] respectively). The top tertile of the 'discretionary-starchy vegetables-processed meats' dietary pattern was also associated cross-sectionally with increased prevalence of pre-frailty (OR 1.75 [95% CI: 1.08, 2.83, P = .022]). Of the 296 robust men in fully adjusted longitudinal analyses, the incidence of pre-frailty was 52.4% (n = 155), and frailty was 5.4% (n = 16) over a 3-year follow-up. The middle tertile of the 'vegetables-legumes-seafood' dietary pattern had a non-significant trend towards reduced incident pre-frailty (OR 0.52 [95% CI: 0.27, 1.00, P = .050]).

CONCLUSION

Consumption of a 'vegetables-legumes-seafood' dietary pattern appears to be less favoured by frail older men.

Chronic Stress as a Risk Factor for Type 2 Diabetes: Endocrine, Metabolic, and Immune Implications

BACKGROUND

Chronic stress is a condition of pressure on the brain and whole body, which in the long term may lead to a frank disease status, even including type 2 diabetes (T2D). Stress activates the hypothalamus-pituitary-adrenal axis with release of glucocorticoids (GCs) and catecholamines, as well as activation of the inflammatory pathway of the immune system, which alters glucose and lipid metabolism, ultimately leading to beta-cell destruction, insulin resistance and T2D onset. Alteration of the glucose and lipid metabolism accounts for insulin resistance and T2D outcome. Furthermore, stress-related subversion of the intestinal microbiota leads to an imbalance of the gut-brain-immune axis, as evidenced by the stress-related depression often associated with T2D. A condition of generalized inflammation and subversion of the intestinal microbiota represents another facet of stress-induced disease. In fact, chronic stress acts on the gut-brain axis with multiorgan consequences, as evidenced by the association between depression and T2D. Oxidative stress with the production of reactive oxygen species and cytokine-mediated inflammation represents the main hallmarks of chronic stress. ROS production and pro-inflammatory cytokines represent the main hallmarks of stress-related disorders, and therefore, the use of natural antioxidant and anti-inflammatory substances (nutraceuticals) may offer an alternative therapeutic approach to combat stress-related T2D. Single or combined administration of nutraceuticals would be very beneficial in targeting the neuro-endocrine-immune axis, thus, regulating major pathways involved in T2D onset. However, more clinical trials are needed to establish the effectiveness of nutraceutical treatment, dosage, time of administration and the most favorable combinations of compounds. Therefore, in view of their antioxidant and anti-inflammatory properties, the use of natural products or nutraceuticals for the treatment of stress-related diseases, even including T2D, will be discussed. Several evidences suggest that chronic stress represents one of the main factors responsible for the outcome of T2D.

Iontophoretically controlled insulin delivery via water-soluble conductive polymer PANI:PSS and thermoplastic polyurethane matrix

Transdermal insulin delivery is an alternative route to deliver insulin through the body skin with the challenges to overcome the low drug skin permeability and high molecular weight. Polyaniline doped with poly(4-styrenesulfonic acid) (PANI:PSS), a conductive polymer with the high electrical conductivity, was synthesized and utilized as a drug carrier to improve the drug delivery capability from a porous thermoplastic polyurethane (TPU) matrix. The insulin was electrostatically attached to PANI:PSS based on the ion exchange between insulin and PSS. For the in vitro drug release of insulin loaded PANI:PSS relative to the pristine insulin alone, the amount of insulin released was improved to 84.70% with the time to equilibrium of 2 h under the electrical field of 6 V. For the ex vivo release-skin permeation, the amount insulin released and permeated became lower at 57.02% with time to equilibrium of 2 h, due to the pig skin acting as a barrier for insulin permeation. The modified insulin transdermal delivery, with PANI:PSS as the drug carrier and drug enhancer relative to without, is shown here to influence the insulin release rate, amount, and duration, suitable to treat diabetes patients.

Association of Obesity With Type 2 Diabetes Mellitus: A Hospital-Based Unmatched Case-Control Study

Background The prevalence of type 2 diabetes mellitus (T2DM) and obesity is alarmingly increasing with the accessibility of the modern lifestyle. This study aimed to assess the association of obesity with T2DM among the patients visiting the Medicine Department of Ayub Teaching Hospital, Abbottabad, Pakistan. Method This hospital-based, unmatched case-control study was conducted from March 2022 to September 2022. A total of 200 patients (age ≥ 18) (100 cases and 100 controls) were recruited. Those patients with a history of T2DM were selected as cases, and those without diabetes were selected as controls after taking informed written consent. Patients with BMI ≥ 25 were considered obese. Data were collected through a non-probability convenience sampling technique using a self-structured non-validated questionnaire. Data were organized and analyzed through IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY). Results We found a significant positive association of obesity with T2DM with a crude odds ratio of 3.6 (95% CI: 2.0-6.6), a p-value of 0.000, and an adjusted odd ratio of 3.7 (95% CI: 1.9 - 7.1), with a p-value of 0.004 (adjusted for potential confounders, including gender, age group, stress, and status of physical activeness) using a logistic regression model. Conclusion It is concluded that obesity is strongly associated with developing T2DM and lack of physical activity, people over 45 years, and males with obesity have a higher chance of developing T2DM.

Recent Advances on Selenium Nutrition and Keshan Disease

Keshan disease (KD) is a type of endemic cardiomyopathy with an unknown cause. It is primarily found in areas in China with low selenium levels, from northeast to southwest. The nutritional biogeochemical etiology hypothesis suggests that selenium deficiency is a major factor in KD development. Selenium is important in removing free radicals and protecting cells and tissues from peroxide-induced damage. Thus, low environmental selenium may affect the selenium level within the human body, and selenium level differences are commonly observed between healthy people in KD and nonKD areas. From the 1970s to the 1990s, China successfully reduced KD incidence in endemic KD areas through a selenium supplementation program. After years of implementing prevention and control measures, the selenium level of the population in the KD areas has gradually increased, and the prevalence of KD in China has remained low and stable in recent years. Currently, the pathogenesis of KD remains vague, and the effect of selenium supplementation on the prognosis of KD still needs further study. This paper comprehensively reviews selenium deficiency and its connection to KD. Thus, this study aims to offer novel ideas and directions to effectively prevent and treat KD in light of the current situation.

Geroscience-Centric Perspective for Geriatric Psychiatry: Integrating Aging Biology With Geriatric Mental Health Research

The geroscience hypothesis asserts that physiological aging is caused by a small number of biological pathways. Despite the explosion of geroscience research over the past couple of decades, the research on how serious mental illnesses (SMI) affects the biological aging processes is still in its infancy. In this review, we aim to provide a critical appraisal of the emerging literature focusing on how we measure biological aging systematically, and in the brain and how SMIs affect biological aging measures in older adults. We will also review recent developments in the field of cellular senescence and potential targets for interventions for SMIs in older adults, based on the geroscience hypothesis.

Musculoskeletal Comorbidities among known Diabetes Patients, their Quality of Life, and Healthcare Costs: A Comparative Study From a Tertiary Care Hospital in Uttarakhand

Introduction

Diabetes is a chronic disorder with long-term sequelae and multisystem manifestation. Burden of diabetes in on the rise. Presence of other morbidities can not only have a detrimental effect on the disease treatment and recovery course, but also on the financial burden and quality of life. Present study aims to investigate how musculoskeletal conditions affect individuals with diabetes compared to those without the condition.

Material and Methods

A comparative study was conducted among patients attending the outpatient department of a tertiary care hospital in North India to assess the burden of musculoskeletal disorders in people with and without diabetes. A total of 195 diabetes patients and an equal number of individuals without diabetes were sequentially enrolled from the outpatient department (OPD).

Results

Burden of musculoskeletal comorbidities was significantly higher (46.2%) among people with diabetes than the comparison group (25.1%). The overall odds ratio (OR) for comorbidities of musculoskeletal system was 2.5 times higher in diabetes cases as compared to individuals without diabetes. The OR for rheumatoid arthritis, chronic backache, and osteoarthritis was found to be 3.6, 2.9, and 1.7 respectively. Poor quality of life and higher direct cost of treatment were found among diabetes cases with musculoskeletal comorbidities as against those without these comorbidities.

Conclusion

Presence of musculoskeletal comorbidity is high among diabetes patients, and it has an impact on the quality of life and treatment cost. Screening for musculoskeletal comorbidities should be included as part of the diabetes complication assessment to allow for early detection and treatment.

Is the Current Cut Point for Glycated Haemoglobin (HbA1c) Correct for Diagnosing Diabetes Mellitus in Premenopausal Women? Evidence to Inform Discussion

INTRODUCTION

Women are on average diagnosed with diabetes mellitus at later age than men but have higher mortality. As the diagnosis of diabetes mellitus is primarily based on HbA1c, the use of a non-specific reference range and cut point for diabetes mellitus that does not account for gender differences in diabetes could potentially lead to underdiagnosis of diabetes mellitus in women and missed opportunities for intervention. We investigated whether a contributing factor to the later diagnosis in women may be a difference in distribution of HbA1c in premenopausal women versus men of the same age by comparing HbA1c values in men and women across multiple sites in the UK.

METHODS

We analysed the HbA1c levels of 146,907 individuals who underwent single testing only and had HbA1c ≤ 50 mmol/mol between 2012 and 2019 in one laboratory (cohort 1). This was replicated in six laboratories with 938,678 individuals tested between 2019 and 2021 (cohort 2).

RESULTS

In cohort 1, women < 50 years old had an HbA1c distribution markedly lower than that in men by a mean of 1.6 mmol/mol (p < 0.0001), while the difference in the distribution of HbA1c for individuals aged ≥ 50 years was less pronounced (mean difference 0.9 mmol/mol, p < 0.0001). For individuals under the age of 50, HbA1c in women lagged by up to 10 years compared to men. Similar findings were found in cohort 2. We estimated an additional 17% (n = 34,953) of undiagnosed women aged < 50 years in England and Wales could be reclassified to have diabetes mellitus, which may contribute to up to 64% of the difference in mortality rates between men/women with diabetes mellitus aged 16-50 years.

CONCLUSION

The HbA1c cut point for diagnosis of diabetes mellitus may need to be re-evaluated in women under the age of 50 years. Early identification of diabetes mellitus in women has the potential to improve women's health outcomes in the longer term.

Pregnancy-Associated Atypical Hemolytic Uremic Syndrome: A Case Report with MCP Gene Mutation and Successful Eculizumab Treatment

Pregnancy-associated atypical hemolytic uremic syndrome (P-aHUS) is a rare condition characterized by microangiopathic hemolytic anemia and kidney injury from thrombotic microangiopathy. P-aHUS occurs in approximately 1 in 25,000 pregnancies and is strongly related to complement dysregulation and pregnancy-related disorders, such as preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelet (HELLP) syndrome, resulting in adverse perinatal and fetal outcomes. Complement dysregulation in P-aHUS is commonly attributed to genetic mutations or autoantibodies affecting complement factors, including CFH , CFI , and MCP. We present a case of a 25-year-old primigravida who experienced severe preeclampsia and HELLP syndrome followed by the development of complicated P-aHUS during the early postpartum period. The patient exhibited severe clinical manifestations, including hypertensive emergency, central nervous system involvement, renal impairment, and microangiopathic hemolytic anemia. Timely initiation of eculizumab therapy resulted in successful disease remission. Further genetic analysis revealed a likely rare pathogenic MCP gene variant.

The Interaction of Duchenne Muscular Dystrophy and Insulin Resistance

Duchenne muscular dystrophy (DMD), caused by deficiency of functional dystrophin protein, is a fatal, progressive muscle disease that frequently includes metabolic dysregulation. Herein, we explore the physiologic consequences of dystrophin deficiency within the context of obesity and insulin resistance. We hypothesized that dystrophin deficiency increases the frequency of insulin resistance, and insulin resistance potentiates muscle pathology caused by dystrophin deficiency.

Clinical Significance of the Triglyceride-Glucose Index in Patients Requiring Nonsurgical Intensive Care

The evaluation of triglyceride-glucose (TyG) index has not been sufficient in patients requiring nonsurgical intensive care.A total of 3,906 patients who required intensive care were enrolled. We computed the TyG index using the value on admission by the following formula: ln [triglyceride (mg/dL) × glucose (mg/dL) /2]. Patients were divided into three groups according to the TyG index quartiles: low (quartile 1 [Q1]; TyG index ≤ 8.493, n = 977), middle (Q2/Q3; 8.494 ≤ TyG index ≤ 9.536, n = 1,953), and high (Q4; TyG index > 9.537, n = 976). The median (interquartile range) TyG index was 9.00 (8.50-9.54); acute coronary syndrome (ACS) had the highest TyG index among all etiologies at 9.12 (8.60-9.68). A multivariate logistic regression model showed that ACS (odds ratio [OR], 2.133; 95% confidence interval [CI], 1.783-2.552) were independently correlated with high TyG index. A Cox proportional hazards regression model revealed that, in ACS, the Q2/Q3 and Q4 groups were independent predictors of 30-day all-cause mortality (hazard ratio [HR], 1.778; 95% CI, 1.014-3.118; HR, 2.986; 95% CI, 1.680-5.308; respectively) and that in acute heart failure [AHF], the Q4 group was a converse independent predictor of 30-day all-cause mortality (HR, 0.488; 95% CI, 0.241-0.988).High TyG index was linked to ACS and negative outcomes in the ACS group; in contrast, low TyG index was associated with adverse outcomes in the AHF group.

The Effect of Diabetes Management Shared Care Clinic on Glycated Hemoglobin A1c Compliance and Self-Management Abilities in Patients with Type 2 Diabetes Mellitus

Objective

We aim to evaluate the impact of diabetes management shared care clinic (DMSCC) on glycated hemoglobin A1c (HbA1c) compliance and self-management abilities in patients with type 2 diabetes mellitus (T2DM).

Methods

This study was a prospective cohort study of patients with T2DM participating in the DMSCC. At baseline and after management, the HbA1c levels were measured, the HbA1c compliance rate were calculated, and the Summary of Diabetes Self-Care Activities-6 (SDSCA-6), Diabetes Empowerment Scale-DAWN Short Form (DES-DSF), and Problem Areas in Diabetes Scale-Five-item Short Form (PAID-5) were completed. These pre- and post-management data were compared.

Results

A total of 124 eligible patients were enrolled. After the diabetes management of DMSCC, the average HbA1c decreased and the HbA1c compliance rate increased significantly (P < 0.01). SDSCA-6 showed significant improvement in physical activity, glycemic monitoring, smoking (P < 0.01), and taking medication (P < 0.05). DES-DSF suggested a greater willingness to try to effectively treat diabetes (P < 0.05). PAID-5 indicated significant improvement in diabetes-related emotional distress.

Conclusion

DMSCC can help patients with T2DM reduce HbA1c, increase HbA1c compliance, improve diabetes self-management behaviors, empowerment, and diabetes-related emotional distress and serve as an effective exploration and practice of diabetes self-management education and support.

Cardiometabolic Risk Factors Associated With Type 2 Diabetes Mellitus: A Mechanistic Insight

A complex metabolic condition referred to as Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance (IR) and decreased insulin production. Obesity, dyslipidemia, hypertension, and chronic inflammation are just a few of the cardiometabolic illnesses that people with T2DM are more likely to acquire and results in cardiovascular issues. It is essential to comprehend the mechanistic insights into these risk variables in order to prevent and manage cardiovascular problems in T2DM effectively. Impaired glycemic control leads to upregulation of De novo lipogenesis (DNL), promote hepatic triglyceride (TG) synthesis, worsening dyslipidemia that is accompanied by low levels of high density lipoprotein cholesterol (HDL-C) and high amounts of small, dense low-density lipoprotein cholesterol (LDL-C) further developing atherosclerosis. By causing endothelial dysfunction, oxidative stress, and chronic inflammation, chronic hyperglycemia worsens already existing cardiometabolic risk factors. Vasoconstriction, inflammation, and platelet aggregation are caused by endothelial dysfunction, which is characterized by decreased nitric oxide production, increased release of vasoconstrictors, proinflammatory cytokines, and adhesion molecules. The loop of IR and endothelial dysfunction is sustained by chronic inflammation fueled by inflammatory mediators produced in adipose tissue. Infiltrating inflammatory cells exacerbate inflammation and the development of plaque in the artery wall. In addition, the combination of chronic inflammation, dyslipidemia, and IR contributes to the emergence of hypertension, a prevalent comorbidity in T2DM. The ability to target therapies and management techniques is made possible by improvements in our knowledge of these mechanistic insights. Aim of present review is to enhance our current understanding of the mechanistic insights into the cardiometabolic risk factors related to T2DM provides important details into the interaction of pathophysiological processes resulting in cardiovascular problems. Understanding these pathways will enable us to create efficient plans for the prevention, detection, and treatment of cardiovascular problems in T2DM patients, ultimately leading to better overall health outcomes.

Body composition and sexual hormones for the glucose control of autoimmune diabetes in males: are they necessary to predict diabetes-related complications?

Background

Glucose control in diabetes is essential for avoiding diabetes-related complications.

Aim

To determine the impact of body composition and sexual hormones in glucose control and diabetes-related complications, in males with autoimmune diabetes.

Patients and methods

Thirty-nine patients with autoimmune diabetes and flash glucose monitoring were included. A morphofunctional nutritional evaluation with bioelectrical impedance vector analysis (BIVA), abdominal adipose tissue ultrasound, rectus femoris ultrasound and biochemical parameters, was performed.

Results

Strong, positive correlations were observed between body composition parameters, biochemical variables and sexual hormones (p<0.05). Adipose tissue measured by BIVA and ultrasound was more significantly associated with glucose control (including time in range >70%, glucose variability <36% determined by flash glucose monitoring; p<0.05) and the presence of microvascular/macrovascular complications (p<0.05) than lean mass. After adjusting by the duration of diabetes, BMI, abdominal circumference, fat mass and phase angle increased the risk for microvascular complications (OR 1.32(1.00 - 1.73), OR 1.06(1.00 - 1.12), OR 1.14(1.01 - 1.20), 0R 0.3(0.10 - 0.91) respectively; for macrovascular complications: BMI OR 1.38(1.04 - 1.84) and fat mass OR 1.26(1.00 - 1.58)]. Sexual hormone levels did not influence on glucose control or the development of diabetes-related complications.

Conclusion

Anthrpometric parameters, especially adipose tissue, were associated with glucose control and variability determined by flash glucose monitoring. Furthermore, changes in fat and lean mass were associated with the presence of microvascular and macrovascular complications. Thus, a comprehensive nutritional evaluation might be useful for the evaluation of males with autoimmune diabetes, in order to identify patients with increased risk of complications.

The effect of neighborhood social cohesion on life satisfaction in type 2 diabetes mellitus patients: the chain mediating role of depressive symptoms and sleep quality

Objective

Although most studies have shown that neighborhood social cohesion (NSC) is associated with life satisfaction among patients with type 2 diabetes mellitus (T2DM), it remains unclear how NSC is linked to life satisfaction. The present study aims to examine the potential mediation effect of depressive symptoms and sleep quality on the relationship between NSC and life satisfaction among Chinese individuals with T2DM.

Methods

A cross-sectional survey was conducted from August 2019 to November 2020 involving 1747 T2DM patients. The main information was obtained using the Center for Epidemiological Survey Depression Scale (CES-D), self-report sleep quality and life satisfaction questionnaire and NSC scales. Mediation analyses were performed using the PROCESS macro in SPSS.

Results

The results manifested that the NSC was positively associated with sleep quality (r = 0.219) and life satisfaction (r = 0.214), while negatively correlated with depressive symptoms (r = -0.232). Depressive symptoms were found to be negatively associated with life satisfaction (r = -0.263). NSC influenced life satisfaction through three mediating pathways: (a) depressive symptoms (effect = 0.0081); (b) depressive symptoms and sleep quality (effect = 0.0019); and (c) sleep quality (effect = 0.0015). The total mediating effect accounted for 28.1% of the overall effect.

Conclusion

Our findings support the hypothesis that depressive symptoms and sleep quality mediated the relationship between NSC and life satisfaction in patients with T2DM. It is important to encourage T2DM patients to participate in social interactions and enhance their level of NSC. Additionally, efforts should be made to actively reduce depressive symptoms and improve sleep quality, so as to improve their life satisfaction.

The role of Caenorhabditis elegans in the discovery of natural products for healthy aging

Covering: 2012 to 2023The human population is aging. Thus, the greatest risk factor for numerous diseases, such as diabetes, cancer and neurodegenerative disorders, is increasing worldwide. Age-related diseases do not typically occur in isolation, but as a result of multi-factorial causes, which in turn require holistic approaches to identify and decipher the mode of action of potential remedies. With the advent of C. elegans as the primary model organism for aging, researchers now have a powerful in vivo tool for identifying and studying agents that effect lifespan and health span. Natural products have been focal research subjects in this respect. This review article covers key developments of the last decade (2012-2023) that have led to the discovery of natural products with healthy aging properties in C. elegans. We (i) discuss the state of knowledge on the effects of natural products on worm aging including methods, assays and involved pathways; (ii) analyze the literature on natural compounds in terms of their molecular properties and the translatability of effects on mammals; (iii) examine the literature on multi-component mixtures with special attention to the studied organisms, extraction methods and efforts regarding the characterization of their chemical composition and their bioactive components. (iv) We further propose to combine small in vivo model organisms such as C. elegans and sophisticated analytical approaches ("wormomics") to guide the way to dissect complex natural products with anti-aging properties.

Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association

Cardiovascular-kidney-metabolic (CKM) syndrome is a novel construct recently defined by the American Heart Association in response to the high prevalence of metabolic and kidney disease. Epidemiological data demonstrate higher absolute risk of both atherosclerotic cardiovascular disease (CVD) and heart failure as an individual progresses from CKM stage 0 to stage 3, but optimal strategies for risk assessment need to be refined. Absolute risk assessment with the goal to match type and intensity of interventions with predicted risk and expected treatment benefit remains the cornerstone of primary prevention. Given the growing number of therapies in our armamentarium that simultaneously address all 3 CKM axes, novel risk prediction equations are needed that incorporate predictors and outcomes relevant to the CKM context. This should also include social determinants of health, which are key upstream drivers of CVD, to more equitably estimate and address risk. This scientific statement summarizes the background, rationale, and clinical implications for the newly developed sex-specific, race-free risk equations: PREVENT (AHA Predicting Risk of CVD Events). The PREVENT equations enable 10- and 30-year risk estimates for total CVD (composite of atherosclerotic CVD and heart failure), include estimated glomerular filtration rate as a predictor, and adjust for competing risk of non-CVD death among adults 30 to 79 years of age. Additional models accommodate enhanced predictive utility with the addition of CKM factors when clinically indicated for measurement (urine albumin-to-creatinine ratio and hemoglobin A1c) or social determinants of health (social deprivation index) when available. Approaches to implement risk-based prevention using PREVENT across various settings are discussed.

Pea protein hydrolysate reduces blood glucose in high-fat diet and streptozotocin-induced diabetic mice

Introduction

Food proteins have been recognized as an ideal source to release bioactive peptides with the potential to intervene nutrition related chronic diseases, such as cardiovascular diseases, obesity and diabetes. Our previous studies showed that pea protein hydrolysate (PPH) could suppress hepatic glucose production in hepatic cells via inhibiting the gluconeogenic signaling. Thus, we hypothesized that PPH could play the hypoglycemic role in vivo.

Methods

In the present study, the mice model with type 2 diabetic mellitus (T2DM) was developed by high-fat diet and low dose of streptozotocin injections. PPH was administered orally with a dosage of 1000 mg/kg body weight for 9 weeks, followed by the downstream biomedical analyses.

Results

The results showed that the 9-week treatment of PPH could reduce fasting blood glucose by 29.6% and improve glucose tolerance in the T2DM mice. The associated mechanisms included suppression of the gluconeogenic pathway, activation of the insulin signaling and modulation of the renin angiotensin system in the liver of the diabetic mice. In addition, the levels of pro-inflammatory markers in both liver and serum were reduced by the PPH treatment.

Conclusion

The hypoglycemic effect of PPH in T2DM mice was demonstrated in the present study. Findings from this study could provide rationale to incorporate PPH into functional foods or nutraceuticals for glycemic control.

Adult Male Hypogonadism: A Laboratory Medicine Perspective on Its Diagnosis and Management

Testosterone (T), the principal androgen secreted by the testes, plays an essential role in male health. Male hypogonadism is diagnosed based on a combination of associated clinical signs and symptoms and laboratory confirmation of low circulating T levels. In this review, we have highlighted factors, both biological and analytical, that introduce variation into the measurement of serum T concentrations in men; these need to be considered when requesting T levels and interpreting results. There is an ongoing need for analytical standardisation of T assays and harmonisation of pre- and post-analytical laboratory practices, particularly in relation to the laboratory reference intervals provided to clinicians. Further, there is a need to share with service users the most up-to-date and evidence-based action thresholds for serum T as recommended in the literature. Estimation of free testosterone may be helpful. Causes of secondary hypogonadism should be considered. A comprehensive approach is required in the management of male hypogonadism, including lifestyle modification as well as medication where appropriate. The goal of treatment is the resolution of symptoms as well as the optimisation of metabolic, cardiovascular, and bone health. The advice of an endocrinologist should be sought when there is doubt about the cause and appropriate management of the hypogonadism.

Effect of camel milk on lipid profile among patients with diabetes: a systematic review, meta-analysis, and meta-regression of randomized controlled trials

The effects of camel milk (CM) intake on lipid profile among patients with diabetes remain controversial. This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to calculate the effect size of CM intake on blood lipids among patients with type 1 (T1D) and type 2 (T2D) diabetes. We searched nine databases from inception until December 31, 2022, to identify relevant RCTs. Effect sizes for total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), and high-density lipoprotein (HDL) were calculated and expressed using mean differences (MD) and confidence intervals (CI). Of 4,054 retrieved articles, 10 RCTs (a total of 347 participants aged 8-70 years, 60.5% male) were eligible for inclusion. The pooled results from a random-effects model showed statistically significant decreases in TC (MD - 21.69, 95% CI: 41.05, - 2.33; p = 0.03; I2=99%), TG (MD - 19.79, 95% CI: -36.16, - 3.42; p=0.02, I2=99%), and LDL (MD -11.92, CI: -20.57, -3.26; p = 0.007, I2=88%), and a significant increase in HDL (MD 10.37, 95% CI, 1.90, 18.84; p=0.02, I2=95%) in patients with diabetes supplemented with CM compared with usual care alone. Subgroup analysis revealed that only long-term interventions (> 6 months) elicited a significant reduction in TC levels and TG levels. Consumption of fresh CM by patients with diabetes resulted in significant reductions in TC, TG, and LDL levels, while showing a significant increase in HDL levels. Patients with T1D elicited a more beneficial effect in lowering TC, LDL, and TG levels and in increasing HDL levels than their corresponding partners with T2D. In conclusion, long-term consumption of CM for patients with diabetes, especially those with T1D, could be a useful adjuvant therapy to improve lipid profile alongside prescribed medications. However, the high heterogeneity in the included studies suggests that more RCTs with larger sample sizes and longer intervention durations are required to improve the robustness of the available evidence.

Enhanced external counterpulsation increases coronary flow reserve in coronary microvascular disease

OBJECTIVES

To investigates the outcomes of enhanced external counterpulsation (EECP) among coronary microvascular disease (CMD) patients.

METHODS

Coronary microvascular disease patients were separated into the EECP (n=41) and control cohorts (n=42). Prior to and following the 4-week EECP program, coronary flow reserve (CFR) was recorded using transthoracic Doppler echocardiography. The serum endothelial nitric oxide synthase (eNOS) and endothelin-1 (ET-1) contents were analyzed by ELISA. Quality of life (QoL) was assessed by the Seattle Angina Questionnaire (SAQ) and the Canadian Cardiovascular Society (CCS) angina class.

RESULTS

After four weeks, CFR was substantially enhanced in the EECP versus control cohort (p<0.05). Endothelin-1 was strongly diminished whereas eNOS was considerably upregulated in the EECP cohort. EECP also enhanced patients' SAQ scores and decreased the CCS angina class.

CONCLUSION

Enhanced external counterpulsation may improve CFR and enhance the CMD patient QoL.

Number of CAG repeats and mortality in middle aged and older men

DESIGN

The androgen receptor (AR) mediates peripheral effects of testosterone. Previous data suggests an association between the number of CAG repeats in exon-1 of the AR gene and AR transcriptional activity. The aim of this analysis was to determine the association between the number of AR CAG repeats and all-cause mortality in men and the influence of testosterone level on the association.

PATIENTS AND MEASUREMENTS

Follow-up data to 27 January 2018 were available for men aged 40-79 years recruited across six countries of the European Male Aging Study between 2003 and 2005. Cox proportional hazards modelling was used to determine the association between CAG repeat number/mortality. Results were expressed as hazard ratios (HR)/95% confidence intervals (CI).

RESULTS

One thousand nine hundred and seventy-seven men were followed up. Mean baseline age was 60 ± 11.1 years. Mean duration of follow-up was 12.2 years. At follow up 25.1% of men had died. CAG repeat length ranged from 6 to 39, with the highest proportion of CAG repeat number at 21 repeats (16.4%). In a multivariable model, compared to men with 22-23 AR CAG repeats: for men with <22 and >23 AR CAG HR, 95% CI for mortality were, <22 CAG repeats 1.17 (0.93-1.49) and >23 CAG repeats 1.14 (0.88-1.47). In a post-hoc analysis, the association was significant for men in the lowest tertile of baseline testosterone (<14.2 nmol/L) with >23 CAG repeats: in the adjusted model for <22 and >23 CAG repeats, respectively, 1.49 (0.97-2.27) and 1.68 (1.06-2.67) versus 22-23 repeats.

CONCLUSIONS

Our European-wide cohort data overall found no association of androgen receptor CAG repeat number and mortality in men. However, post hoc analysis suggested that an association might be present in men with lower baseline testosterone concentrations, which merits further investigation.

Association of Vitamin D with Risk Factors for Coronary Artery Disease

Introduction:Vitamin D safeguards cardiovascular health by reducing inflammation and susceptibility to atheroma. This study aimed to evaluate the association of coronary artery disease (CAD) and its risk factors like body mass index (BMI), glycated hemoglobin (HbA1c), and lipid profile with vitamin D. Methods:Patients of both genders aged over 18 years, who underwent coronary angiogram for cardiac symptoms such as chest pain, breathlessness, palpitation, or syncope, were enrolled in the present study. Demographic and anthropometric data were collected. Glycated hemoglobin, lipid profile and 25-hydroxyvitamin D were measured. The severity of CAD was analyzed along with the SYNTAX scoring. Results:The study population was divided into three groups based on vitamin D levels: Group I (vitamin D level <20 ng/mL), Group II (20-30 ng/mL) and Group III (>30 ng/mL). There was a significantly higher number of patients with diabetes mellitus and triple vessel disease in Group I. On multivariable suplogistic regression, vitamin D had a significant odds ratio (OR) of 1.21 (1.03-1.43) for single vessel disease and 0.92 (1.13-1.43) for triple vessel disease. SYNTAX score had a significant OR of 0.697 (0.557-0.873) for single vessel disease and 1.27 (1.13-1.43) for triple vessel disease. There was a significant negative correlation between HbA1c and vitamin D (r =-0.269, p= 0.008). Vitamin D levels negatively correlated with triple vessel disease (r =-0.252, p= 0.013). Conclusions:Incidence of diabetes mellitus and levels of HbA1c were both higher among patients with vitamin D deficiency. Vitamin D deficiency was a risk factor for single and triple vessel disease.

A fat- and sucrose-enriched diet causes metabolic alterations in mdx mice

Duchenne muscular dystrophy (DMD), a progressive muscle disease caused by the absence of functional dystrophin protein, is associated with multiple cellular, physiological, and metabolic dysfunctions. As an added complication to the primary insult, obesity/insulin resistance (O/IR) is frequently reported in patients with DMD; however, how IR impacts disease severity is unknown. We hypothesized a high-fat, high-sucrose diet (HFHSD) would induce O/IR, exacerbate disease severity, and cause metabolic alterations in dystrophic mice. To test this hypothesis, we treated 7-wk-old mdx (disease model) and C57 mice with a control diet (CD) or an HFHSD for 15 wk. The HFHSD induced insulin resistance, glucose intolerance, and hyperglycemia in C57 and mdx mice. Of note, mdx mice on CD were also insulin resistant. In addition, visceral adipose tissue weights were increased with HFHSD in C57 and mdx mice though differed by genotype. Serum creatine kinase activity and histopathological analyses using Masson's trichrome staining in the diaphragm indicated muscle damage was driven by dystrophin deficiency but was not augmented by diet. In addition, markers of inflammatory signaling, mitochondrial abundance, and autophagy were impacted by disease but not diet. Despite this, in addition to disease signatures in CD-fed mice, metabolomic and lipidomic analyses demonstrated a HFHSD caused some common changes in C57 and mdx mice and some unique signatures of O/IR within the context of dystrophin deficiency. In total, these data revealed that in mdx mice, 15 wk of HFHSD did not overtly exacerbate muscle injury but further impaired the metabolic status of dystrophic muscle.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) as a marker of coronary lesion severity in stable coronary artery disease (CAD) patients

Coronary artery disease (CAD) remains a significant global health concern with considerable high morbidity and mortality and its development is influenced by various genetic and environmental factors. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a vital regulator of low-density lipoprotein receptor (LDLR) metabolism, directly impacting serum cholesterol levels. However, its role in development of CAD is not fully understood. The aim of this study was to assess the association between the level of PCSK9 and coronary lesion severity in patients with CAD. A case-control study using consecutive sampling was conducted among CAD patients at H. Adam Malik General Hospital and Murni Teguh Memorial Hospital, Medan, Indonesia. A total of 200 CAD patients were divided into two groups based on the SYNTAX score: control (score ≤22, n=100) and case (score >22, n=100). Plasma PCSK9 levels were measured from venous blood using quantitative sandwich enzyme immunoassay. The Chi-squared test was used to analyze the data. Our data suggested that PCSK9 level was associated with coronary lesion severity (p<0.001) of which high PCSK9 level was associated with severe coronary lesion. We also found that hypertension (p<0.001), smoking (p=0.072), diabetes (p<0.001), dyslipidemia (p<0.001), obesity (p=0.023), and family history (p=0.001) were associated with lesion severity. Using the receiver operating characteristic (ROC) curve analysis, the cut-off 70.35 ng/mL of PCSK9 had sensitivity 75% and specificity 78% to predict severe coronary lesion. This study highlights that PCSK9 level has moderate sensitivity and specificity to predict the coronary lesion severity among CAD patients.

A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The "beyond diabetes" initiative

Objective

Despite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability.

Methods

We designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach.

Results

Among grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18-1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties.

Conclusions

Our "Beyond Diabetes" initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

Decrypting the circular RNAs does a favor for us: Understanding, diagnosing and treating diabetes mellitus and its complications

Circular RNAs (circRNAs), a novel type of single-stranded noncoding RNAs with a covalently closed loop structure, are generated in a circular conformation via non-canonical splicing or back-splicing events. Functionally, circRNAs have been elucidated to soak up microRNAs (miRNAs) and RNA binding proteins (RBPs), serve as protein scaffolds, maintain mRNA stability, and regulate gene transcription and translation. Notably, circRNAs are strongly implicated in the regulation of β-cell functions, insulin resistance, adipocyte functions, inflammation as well as oxidative stress via acting as miRNA sponges and RBP sponges. Basic and clinical studies have demonstrated that aberrant alterations of circRNAs expressions are strongly associated with the initiation and progression of diabetes mellitus (DM) and its complications. Here in this review, we present a summary of the biogenesis, transportation, degradation and functions of circRNAs, and highlight the recent findings on circRNAs and their action mechanisms in DM and its complications. Overall, this review should contribute greatly to our understanding of circRNAs in DM pathogenesis, offering insights into the further perspectives of circRNAs for DM diagnosis and therapy.

Repurposing nucleoside reverse transcriptase inhibitors (NRTIs) to slow aging

Repurposing drugs already approved in the clinic to be used off-label as geroprotectors, compounds that combat mechanisms of aging, are a promising way to rapidly reduce age-related disease incidence in society. Several recent studies have found that a class of drugs-nucleoside reverse transcriptase inhibitors (NRTIs)-originally developed as treatments for cancers and human immunodeficiency virus (HIV) infection, could be repurposed to slow the aging process. Interestingly, these studies propose complementary mechanisms that target multiple hallmarks of aging. At the molecular level, NRTIs repress LINE-1 elements, reducing DNA damage, benefiting the hallmark of aging of 'Genomic Instability'. At the organellar level, NRTIs inhibit mitochondrial translation, activate ATF-4, suppress cytosolic translation, and extend lifespan in worms in a manner related to the 'Loss of Proteostasis' hallmark of aging. Meanwhile, at the cellular level, NRTIs inhibit the P2X7-mediated activation of the inflammasome, reducing inflammation and improving the hallmark of aging of 'Altered Intercellular Communication'. Future development of NRTIs for human aging health will need to balance out toxic side effects with the beneficial effects, which may occur in part through hormesis.

Sodium-Glucose Cotransporter 2 Inhibitors and Risk of Retinopathy in Patients With Type 2 Diabetes

Importance

Diabetic nephropathy and diabetic retinopathy share many similarities in pathophysiological processes. Preclinical studies have shown that sodium-glucose cotransporter 2 inhibitors (SGLT2is) have a protective role in the risk of diabetic retinopathy.

Objective

To compare the risk of sight-threatening retinopathy associated with SGLT2is and other second-line glucose-lowering medications (including pioglitazone, sulfonylureas, and dipeptidyl peptidase-4 inhibitors [DPP-4is]) in patients with type 2 diabetes (T2D).

Design, Setting, and Participants

This cohort study in Taiwan applied a new-user and active-comparator design. Patient demographic and clinical data were obtained from the National Health Insurance Research Database. Adult patients with newly diagnosed T2D from January 1, 2009, to December 31, 2019, were recruited and followed up until December 31, 2020. Propensity score matching was used to identify pairs of patients treated with SGLT2i vs DPP-4i, SGLT2i vs pioglitazone, and SGLT2i vs sulfonylurea from January 1, 2016, to December 31, 2019. Data were analyzed between August 18, 2022, and May 5, 2023.

Exposures

Treatment with SGLT2i, DPP-4i, pioglitazone, and sulfonylureas starting on January 1, 2016.

Main Outcomes and Measures

The main outcome was sight-threatening retinopathy in participants. Cox proportional hazards regression models were used to assess relative hazards of sight-threatening retinopathy between the matched case and control groups.

Results

A total of 3 544 383 patients with newly diagnosed T2D were identified. After 1:1 propensity score matching, 65 930 pairs of patients treated with SGLT2i vs DPP-4i, 93 760 pairs treated with SGLT2i vs pioglitazone, and 42 121 pairs treated with SGLT2i vs sulfonylurea were identified. These matched patients included 236 574 males (58.6%), with a mean (SD) age of 56.9 (11.8) years. In the matched cohorts, SGLT2i had a significantly lower risk of sight-threatening retinopathy than DPP-4i (adjusted hazard ratio [AHR], 0.57; 95% CI, 0.51-0.63), pioglitazone (AHR, 0.75; 95% CI, 0.69-0.81), and sulfonylureas (AHR, 0.62; 95% CI, 0.53-0.71). The Kaplan-Meier curves showed that SGLT2i was associated with a significantly lower cumulative incidence of sight-threatening retinopathy than DPP-4i (3.52 vs 6.13; P < .001), pioglitazone (4.32 vs 5.76; P < .001), and sulfonylureas (2.94 vs 4.67; P < .001).

Conclusions and Relevance

This cohort study found that SGLT2i was associated with a lower risk of sight-threatening retinopathy compared with DPP-4i, pioglitazone, and sulfonylureas. This finding suggests that SGLT2i may play a role not only in reduced risk of diabetic nephropathy but also in the slow progression of diabetic retinopathy in patients with T2D.