Branch chain amino acids: biomarkers of health and disease

PURPOSE OF REVIEW

There is burgeoning evidence that branch chain amino acids (BCAAs) are biomarkers of metabolic, cardiovascular, renal and cerebrovascular disease. The purpose of this review is to summarize the current evidence in this area.

RECENT FINDINGS

Recent evidence demonstrates that BCAAs are associated with insulin resistance, type 2 diabetes, risk of cardiovascular disease, stage I and II chronic kidney disease and ischemic stroke. Further, circulating levels of BCAAs have the potential to predict populations at risk for cardiometabolic disease, type 2 diabetes and mortality from ischemic heart disease. Importantly, the relationship of BCAAs to insulin resistance is affected by the intake of fat in the diet as well as age.

SUMMARY

Current evidence supports the potential use of BCAAs as biomarkers of disease. However, questions regarding the mechanisms underlying the relationship of BCAAs to disease process and severity need to be answered prior to the use of BCAAs as a biomarker in clinical practice.

Association of help-seeking behavior with depression and anxiety disorders among gastroenterological patients in Saudi Arabia

BACKGROUND/AIMS

There is a high prevalence of depression and anxiety disorders among gastroenterological outpatients. Relatively few studies have been done on the help-seeking behavior among those who suffer from gastrointestinal symptoms with or without psychiatric disorders. We aimed to characterize the help-seeking behavior of gastroenterological outpatients and to evaluate if this behavior is linked to the presence of depression and anxiety.

PATIENTS AND METHODS

A cross-sectional study was carried out in gastroenterology clinics in four hospitals in Riyadh between February and September 2013. A self-administrated questionnaire was developed and administered to patients. Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) questionnaires were used to diagnose depression and anxiety, respectively.

RESULTS

A total of 440 patients completed the study questionnaire. The average age was 36.0 ± 12.8 years and 69% of the patients were males. Complaints included abdominal pain (58%), heartburn (29%), diarrhea or constipation (25%), appetite or weight changes (22%), and nausea or vomiting (16%). Depression was diagnosed in 36%, while anxiety was diagnosed in 28% of the patients. The first intervention was use of medications (68%) and undergoing endoscopy (16%), while few patients initially used herbs or Islamic incantation (7.5%). This first intervention was done primarily (59%) in private sector hospitals rather than government sector hospitals (36%). The rates of depression and anxiety in our patients were higher among those who suffered from multiple complaints for longer durations and with less satisfaction with the offered services.

CONCLUSION

Depression and anxiety are common comorbidities in gastroenterological outpatient population, especially those who have a chronic course of multiple gastrointestinal complaints.

Accelerated aging of reproductive capacity in male rat offspring of protein-restricted mothers is associated with increased testicular and sperm oxidative stress

Maternal protein restriction (MPR) in pregnancy causes life course organ dysfunction, but few studies link the developmental origins of disease hypothesis to early aging. Suboptimal developmental nutrition increases oxidative stress (OS) and male infertility, damaging sperm function. We hypothesized that MPR in pregnancy accelerates age-related changes in testicular and sperm function related to both maternal diet and increased testicular OS in rat offspring. We studied male rats whose pregnant mothers ate either control (C, 20 % casein) or restricted (R, 10 % casein) isocaloric diet. After birth, mothers and offspring ate C diet. Testes were retrieved at 19 days gestation and across the life course (postnatal day (PND) 21, 36, 110, and 850) to measure OS markers, antioxidant enzymes, serum FSH, LH, and testosterone, and PND 110 sperm OS and quality. Fertility rate was evaluated at PND 110, 450, and 850. Offspring showed age- and MPR-related changes in testosterone, testicular OS markers and antioxidant enzymes and fertility, and maternal diet-related OS and sperm antioxidant enzyme changes. Developmental programming is considered a key factor in predisposing to chronic disease. Our data show that programming also plays an important role in aging trajectory. This interaction is a little studied area in aging biology that merits more investigation.

Diabetes mellitus may induce cardiovascular disease by decreasing neuroplasticity

Neuroplasticity has been defined "the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections". The nervous system monitors and coordinates internal organ function. Thus neuroplasticity may be associated with the pathogenesis of other diseases besides neuropsychiatric diseases. Decreased neuroplasticity is associated with cardiovascular disease (CVD) and a disease related to decreased neuroplasticity may confer a greater CVD risk. Diabetes mellitus (DM) is related to CVD and DM induces decreased neuroplasticity, which is manifested as depression, Alzheimer's disease and diabetic neuropathy. Therefore we conclude that DM may induce CVD by decreasing neuroplasticity.

Neuropeptides, trophic factors, and other substances providing morphofunctional and metabolic protection in experimental models of diabetic retinopathy

Vision is the most important sensory modality for many species, including humans. Damage to the retina results in vision loss or even blindness. One of the most serious complications of diabetes, a disease that has seen a worldwide increase in prevalence, is diabetic retinopathy. This condition stems from consequences of pathological metabolism and develops in 75% of patients with type 1 and 50% with type 2 diabetes. The development of novel protective drugs is essential. In this review we provide a description of the disease and conclude that type 1 diabetes and type 2 diabetes lead to the same retinopathy. We evaluate existing experimental models and recent developments in finding effective compounds against this disorder. In our opinion, the best models are the long-term streptozotocin-induced diabetes and Otsuka Long-Evans Tokushima Fatty and spontaneously diabetic Torii rats, while the most promising substances are topically administered somatostatin and pigment epithelium-derived factor analogs, antivasculogenic substances, and systemic antioxidants. Future drug development should focus on these.

Kmup-1 Protects Kidney from Streptozotocin-Induced Pro-Inflammation in Early Diabetic Nephropathy by Restoring Enos/Pparγ and Inhibiting MMP-9

KMUP-1 increases nitric oxide (NO) via endothelium nitric-oxide synthase (eNOS). Deficiency of eNOS and peroxisome proliferator-activated receptor-γ (PPARγ) is the pathogenesis of diabetic nephropathy (DN). This study aims to investigate whether KMUP-1 inhibits streptozotocin (STZ)-induced proinflammation in early DN. In experiments, STZ was used to induce diabetes in Wistar rats. Twenty-four male rats were randomly divided into four groups, including control, STZ (65 mg/kg, i.p.), STZ+KMUP-1(1 mg/kg) and STZ+KMUP-1 (2.5 mg/kg). KMUP-1 HCl was dissolved in distilled water for oral administration. The morphology of renal tissues was evaluated by periodic acid-schiff (PAS) staining and immunohistochemistry of eNOS. The expressions of matrix metalloproteinase-2/-9 (MMP-2/-9), eNOS, B-cell lymphoma 2 (Bcl-2), Bcl-2– associated X protein (Bax) and PPARγ of renal tissues were examined by Western blotting technique. NO production was evaluated by Griess reagent. Oxidative stress was evaluated by measuring reactive oxygen species (ROS). Results indicated that STZ-induced diabetic mellitus (DM) and subsequent DN, including excessive deposition of extracellular matrix (ECM) accompanied by enhanced MMP-2/-9, raised ROS production, increased Bcl-2/Bax ratio and decreased eNOS/PPARy over a period of 4 weeks. KMUP-1 inhibited STZ-induced hyperglycemia, BUN, MMP-2/MMP-9, and restored eNOS-PPARγ expression in renal tissues. Immunohistochemistry (IHC) of eNOS in glomeruli of renal cortical tissue sections indicated that KMUP-1 restored the eNOS caused by STZ. PAS staining of glomeruli indicated that KMUP-1 could not significantly reduce STZ-induced ECM expansion. Moreover, KMUP-1 increased Bcl-2/Bax and decreased ROS. In summary, KMUP-1 inhibits STZ-induced proinflammation in early DN by restoring PPARγ/eNOS and inhibiting MMP-9.

Supplementary use of HbA1c as hyperglycemic criterion to detect metabolic syndrome

BACKGROUND

Metabolic syndrome (MetS) refers to a cluster of cardiovascular risk factors including hyperglycemia, dyslipidemia, abdominal obesity and hypertension. An effective detection of MetS not only reflects the prediction risk of diabetes mellitus and cardiovascular diseases but also helps to plan for management strategy which could reduce the healthcare burden of the society. This study aimed to compare the use of hemoglobin A1c (HbA1c) to fasting plasma glucose (FPG) as the hyperglycemic component in MetS diagnosis.

METHODS

Waist circumference, blood pressure, blood triglyceride, high-density lipoprotein (HDL)-cholesterol, FPG, and HbA1c were examined in 120 Hong Kong Chinese adults with MetS and 120 without MetS. After reviewing the subject basal characteristics, 11 of them were found with undiagnosed diabetes (FPG ≧7.0 mmol/L) and were excluded for further analysis.

RESULTS

The most prevalent MetS components among the included subjects were elevated systolic blood pressure and central obesity. Significant correlation relationships existed between FPG and HbA1c in both subject pools diagnosed with and without MetS (p < 0.001). The diagnostic rate of MetS using HbA1c was compared to FPG by the receiver operating characteristics (ROC) analysis which suggested an area under curve of 0.807 (95% CI: 0.727 to 0.887). The agreement was 90.7% in MetS-positive group with increased FPG as one of the criterion co-existed with elevated HbA1c. If including HbA1c as an additional criterion to FPG in the MetS diagnosis, 30 more participants in MetS-negative group would be MetS-positive leading to an increase in detection rate. Furthermore, 47 subjects (38 from MetS-positive group and 9 from MetS-negative group) were found having HbA1c ≧6.5%, who would have been diagnosed with diabetes based on the diagnostic criteria implemented by the Expert Group in 2009.

CONCLUSION

These findings suggest that HbA1c enhances the detection of hyperglycemia for the diagnosis of MetS.

Intrauterine exposure to cigarette smoke is associated with increased ghrelin concentrations in adulthood

BACKGROUND

The appetite-stimulating hormone ghrelin is a fundamental regulator of human energy metabolism. A series of studies support the notion that long-term appetite and weight regulation may be already programmed in early life and it could be demonstrated that the intrauterine environment affects the ghrelin system of the offspring. Animal studies have also shown that intrauterine programming of orexigenic systems persists even until adolescence/adulthood.

METHODS

We hypothesized that plasma ghrelin concentrations in adulthood may be associated with the intrauterine exposure to cigarette smoke. We examined this hypothesis in a sample of 19-year-olds followed up since birth in the framework of the Mannheim Study of Children at Risk, an ongoing epidemiological cohort study of the long-term outcome of early risk factors.

RESULTS

As a main finding, we found that ghrelin plasma concentrations in young adults who had been exposed to cigarette smoke in utero were significantly higher than in those without prenatal smoke exposure. Moreover, individuals with intrauterine nicotine exposure showed a significantly higher prevalence of own smoking habits and lower educational status compared to those in the group without exposure.

CONCLUSION

Smoking during pregnancy may be considered as an adverse intrauterine influence that may alter the endocrine-metabolic status of the offspring even until early adulthood.

Autonomic neuropathy in diabetes mellitus

Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes, often overlooked and misdiagnosed. It is a systemic-wide disorder that may be asymptomatic in the early stages. The most studied and clinically important form of DAN is cardiovascular autonomic neuropathy defined as the impairment of autonomic control of the cardiovascular system in patients with diabetes after exclusion of other causes. The reported prevalence of DAN varies widely depending on inconsistent definition, different diagnostic method, different patient cohorts studied. The pathogenesis is still unclear and probably multifactorial. Once DAN becomes clinically evident, no form of therapy has been identified, which can effectively stop or reverse it. Prevention strategies are based on strict glycemic control with intensive insulin treatment, multifactorial intervention, and lifestyle modification including control of hypertension, dyslipidemia, stop smoking, weight loss, and adequate physical exercise. The present review summarizes the latest knowledge regarding clinical presentation, epidemiology, pathogenesis, and management of DAN, with some mention to childhood and adolescent population.

Metformin rescues the MG63 osteoblasts against the effect of high glucose on proliferation

AIMS. To study the proliferation of osteoblasts and genes expression under normal glucose, high glucose, and metformin (Met). METHODS. MG63 osteoblast-like cells were cultured in osteogenic medium supplemented with normal glucose (glucose 5.5 mmol/L) or high glucose (glucose 16.7 mmol/L) and metformin + high glucose (Met 300  μmol/L + glucose 16.7 mmol/L). Proliferation was detected with CCK-8 assay at days 1, 3, and 7. Real-time PCR and Western blot were performed to compare the expression of collagen I (Col I), osteocalcin (OCN), osteoprotegerin (OPG), receptor activator for NF- κB ligand (RANKL), and metal matrix proteinases 1 and 2 (MMP1, MMP2). Alkaline phosphatase (ALP) activity was also detected at days 6, 12, and 18. RESULTS. Exposure to high glucose inhibited the proliferation of osteoblasts (P < 0.05), with suppressed OCN and OPG. Meanwhile, Col I, RANKL, MMP1, and MMP2 were unaffected. Metformin attenuated the suppression on proliferation with increased expression of Col I, OCN, and OPG, meanwhile suppressing MMP1 and MMP2. High glucose lowered the intracellular ALP, while metformin raised it. Metformin attenuated the downregulation of ALP completely at day 6, partly at day 12, but not at day 18. CONCLUSIONS. Metformin attenuated the suppression effect of high glucose to the osteoblast proliferation and gene expression, more prominently in earlier stage.

Histone lysine methylation in diabetic nephropathy

Diabetic nephropathy (DN) belongs to debilitating microvascular complications of diabetes and is the leading cause of end-stage renal diseases worldwide. Furthermore, outcomes from the DCCT/EDIC study showed that DN often persists and progresses despite intensive glucose control in many diabetes patients, possibly as a result of prior episode of hyperglycemia, which is called "metabolic memory." The underlying mechanisms responsible for the development and progression of DN remain poorly understood. Activation of multiple signaling pathways and key transcription factors can lead to aberrant expression of DN-related pathologic genes in target renal cells. Increasing evidence suggests that epigenetic mechanisms in chromatin such as DNA methylation, histone acetylation, and methylation can influence the pathophysiology of DN and metabolic memory. Exciting researches from cell culture and experimental animals have shown that key histone methylation patterns and the related histone methyltransferases and histone demethylases can play important roles in the regulation of inflammatory and profibrotic genes in renal cells under diabetic conditions. Because histone methylation is dynamic and potentially reversible, it can provide a window of opportunity for the development of much-needed novel therapeutic potential for DN in the future. In this minireview, we discuss recent advances in the field of histone methylation and its roles in the pathogenesis and progression of DN.

Charcot neuroarthropathy of the foot and ankle: diagnosis and management strategies

This article reviews current literature discussing the etiology, pathophysiology, diagnosis and imaging, and conservative and surgical treatment of Charcot osteoarthropathy. The treatment of Charcot osteoarthropathy with concurrent osteomyelitis is also discussed.

General aspects of diabetes mellitus

Diabetes mellitus is a heterogeneous group of disorders characterized by hyperglycemia due to an absolute or relative deficit in insulin production or action. The chronic hyperglycemia of diabetes mellitus is associated with end organ damage, dysfunction, and failure, including the retina, kidney, nervous system, heart, and blood vessels. The International Diabetes Federation (IDF) estimated an overall prevalence of diabetes mellitus to be 366 million in 2011, and predicted a rise to 552 million by 2030. The treatment of diabetes mellitus is determined by the etiopathology and is most commonly subdivided in type 1 and type 2 diabetes mellitus. There is a greater propensity towards hyperglycemia in individuals with coexisting genetic predisposition or concomitant drug therapy such as corticosteroids. The screening for diabetes mellitus may either be in the form of a 2hour oral glucose tolerance test, or via HbA1c testing, as recently recommended by the American Diabetes Association (ADA). Strong associations have been shown in observational studies suggesting poor clinical outcomes both with chronic hyperglycemia and acutely in intensive care settings. However, tight glycemic control in this setting is a contentious issue with an increased incidence of hypoglycemia and possible increase in morbidity and mortality. In a critically ill patient a glucose range of 140-180mg/dL (7.8-10.0mmol/L) should be maintained via continuous intravenous insulin infusion.

Effect of combination therapy with alogliptin and lansoprazole on glycemic control in patients with type 2 diabetes

The main purpose of the current study was to investigate the effect of a combination of alogliptin [a dipeptydil peptidase (DPP)-4 inhibitor] and lansoprazole [a proton pump inhibitor (PPI)] compared with alogliptin mono-therapy on glycemic control in patients with type 2 diabetes. This study was a multicenter randomized open-label study. One hundred type 2 diabetic patients were randomly assigned to either the alogliptin with lansoprazole group or the alogliptin mono-therapy group. After 3 months of treatment, the changes in hemoglobin (Hb)A1c, fasting plasma glucose (FPG), serum gastrin, homeostasis model assessment (HOMA)-β, and HOMA-insulin resistance (IR) were evaluated. A significant decrease in HbA1c and FPG, and a significant increase in HOMA-β were observed in both groups (all with P <0.0001). However, there were no significant differences in changes in HbA1c, FPG, or HOMA-β before and after therapy between the combination and alogliptin mono-therapy group (P =0.2945, P =0.1901, P =0.3042, respectively). There was a significant elevation of serum gastrin in the combination group compared with the alogliptin mono-therapy group (P =0.0004). This study showed that, although combination therapy with alogliptin and lansoprazole more effectively elevated serum gastrin levels compared with alogliptin mono-therapy, the effect of the combination therapy on glycemic control was equal to that of alogliptin mono-therapy during a 3-month study period.

Familial Clustering of Type 2 Diabetes among Omanis

OBJECTIVE

The aim of this study was to screen Omani individuals for the familial aggregation of type 2 diabetes mellitus.

METHODS

A random cohort of 1182 Omani individuals visiting the Family Medicine Clinic at Sultan Qaboos University Hospital (SQUH), Muscat, Oman, for regular medical checkup, aged ≥40 years, were sampled. Patients were categorized into three groups: (1) individuals who claim not to have diabetes and had no family history of diabetes; (2) individuals who claim not to have diabetes but had family history of diabetes; (3) individuals with diabetes. Only 16% of these Omani individuals had no diabetes and no family history of diabetes. Another separate random cohort of 234 Omani type 2 diabetes mellitus patients, from the Diabetes Clinic at SQUH, were interviewed and questioned about their family history of type 2 diabetes mellitus.

RESULTS

Ninety five percent of the patients had a family history of diabetes. Eighty percent had first degree relatives with diabetes and 46% had second degree relatives with diabetes. At least one parent with diabetes was reported among 55% of these diabetics, while maternal diabetes (55%) was found to be higher than paternal diabetes (47%). However, only 15% had both parents with diabetes. Furthermore, almost half of the 234 diabetics were having at least one of the following relatives with diabetes: brother, sister, aunt or an uncle.

CONCLUSION

The findings of this study confirm familial aggregation of diabetes among the Omani population. Compared to other populations, familial aggregation of type 2 diabetes mellitus among Omanis is relatively very high, and is perhaps due to the very high degree of consanguinity among Omanis. Since almost everyone seems to have a genetic predisposition to diabetes, the dramatic lifestyle changes over the past 25 years, could tip the population into an epidemic of type 2 diabetes mellitus.

Increased levels of circulating advanced glycation end-products in menopausal women with osteoporosis

BACKGROUND

Advanced glycation end-products (AGEs) can accumulate in organs and tissues during ageing and diabetes. Increased levels of AGEs are found in the bone tissue of patients with osteoporosis. The purpose of this study was to evaluate circulating AGEs in patients with osteoporosis.

METHODS

We evaluated plasma AGEs, osteoporosis-related biomarkers, and bone mass in 82 menopausal women with osteoporosis or osteopenia, 16 young women with osteopenia, and 43 healthy women without osteoporosis or osteopenia.

RESULTS

Higher levels of serum AGEs were found in the osteoporosis or osteopenia group compared to healthy women (P < 0.0001). A negative correlation was observed between serum AGEs and lumbar spine bone density (BMD of lumbar spine, r = -0.249, P = 0.028; T-score of lumbar spine, r = -0.261, P = 0.021). Women with a increased level of serum AGEs (> 8.12 U/mL) had a 5.34-fold risk of osteopenia regarding lumbar spine T-score and a 3.31-fold risk of osteopenia regarding the hip T-score.

CONCLUSION

Serum AGEs could be used to monitor the severity and progression of osteoporosis. An increased serum level of AGEs was associated with impaired bone formation and was a risk factor for the development of osteoporosis. Targeting AGEs may represent a novel therapeutic approach for primary or secondary osteoporosis.

New insight into the molecular drug target of diabetic nephropathy

Diabetic nephropathy (DN) lowered quality of life and shortened life expectancy amongst those affected. Evidence indicates interaction between advanced glycation end products (AGEs), activated protein kinase C (PKC) and angiotensin II exacerbate the progression of DN. Inhibitors of angiotensin-converting enzyme (ACEIs), renin angiotensin aldosterone system (RAAS), AGEs, and PKC have been tested for slowing down the progression of DN. The exact molecular drug targets that lead to the amelioration of renal injury in DN are not well understood. This review summarizes the potential therapeutic targets, based on putative mechanism in the progression of the disease.

Heart-protective effect of n-3 PUFA demonstrated in a rat model of diabetic cardiomyopathy

This study was designed to examine in vivo functional changes of the heart in the early stages of streptozotocin (STZ)-induced diabetic cardiomyopathy and to evaluate the effects of n-3 PUFA intake. Moreover, we investigated whether modulation of diabetes-related abnormalities of myocardial connexin-43 (Cx43), β-myosin heavy chain (β-MHC), and β1-adrenergic receptors (β1-AR) might be implicated in the cardioprotective mechanism of n-3 PUFA. Our results showed significantly reduced cardiac output and ejection fraction (using the microtip pressure-volume catheter technique) as well as stroke volume and stroke work, 4 weeks after STZ-induced diabetes, with improvement of these parameters due to n-3 PUFA consumption. Myocardial expression of Cx43 mRNA estimated by real-time polymerase chain reaction did not change in diabetic rats regardless of n-3 PUFA consumption (100 mg/100 g b.w./day). In contrast, the total and functional phosphorylated form of Cx43 protein increased significantly, and its cardiomyocyte-related distribution was disordered in the diabetic heart, but these changes normalized because of n-3 PUFA intake. Furthermore, acute diabetes was accompanied by decrease of myocardial β1-AR mRNA expression and mild yet nonsignificant increase of β-MHC mRNA. These alterations were not significantly affected by n-3 PUFA. In conclusion, the results point out that STZ-diabetic rats benefit from n-3 PUFA consumption particularly because of the attenuation of myocardial Cx43 abnormalities that most likely contributes to improvement of cardiac function.

The Association between Type of Work and Insulin Resistance and the Metabolic Syndrome in Middle-Aged Korean Men: Results from the Korean National Health and Nutrition Examination Survey IV (2007~2009)

Purpose

Type of work might be related to insulin resistance and the metabolic syndrome (MetS). However, scant data are available. We performed this study to investigate whether the prevalence of MetS and insulin resistance differed according to occupation in middle-aged men.

Materials and Methods

In all, 2,348 men in their 40s~50s who had participated in the Korean National Health and Nutrition Examination Survey IV were included and were classified into two groups according to the type of work (manual worker vs. non-manual worker). Diagnosis of MetS required satisfying three or more of the National Cholesterol Education Program-Adult Treatment Panel III criteria. Fasting insulin, the glucose/insulin ratio (G/I ratio), and the homeostasis model assessment of insulin resistance (HOMA-IR) were used to estimate the insulin resistance. We used the Mann-Whitney test, χ² tests, multiple linear regression test, and logistic regression analyses to examine the relationships.

Results

Age was significantly higher in the manual worker group. Body mass index was significantly lower in the manual worker group. Rates of current smoking and frequent drinking were higher in the manual worker group. In terms of surrogate markers of insulin resistance, the age-adjusted mean of fasting insulin, G/I ratio, and HOMA-IR indicated that lower insulin resistance was significantly related to manual work. After adjusting for age and other confounding factors, non-manual workers had a higher risk of the MetS than manual workers. The odds ratio in relation to MetS was significantly lower in the manual workers.

Conclusions

MetS and impaired insulin resistance are significantly related to non-manual work in middle-aged Korean men.

Diabetic macular edema: Current management 2013

Diabetic retinopathy (DR) is the leading cause of vision loss of working-age adults, and diabetic macular edema (DME) is the most frequent cause of vision loss related to diabetes. The Wisconsin Epidemiologic Study of Diabetic Retinopathy found the 14-year incidence of DME in type 1 diabetics to be 26%. Similarly the Diabetes Control and Complications Trial reported that 27% of type 1 diabetic patients develop DME within 9 years of onset. The most common type of diabetes, type 2, is strongly associated with obesity and a sedentary lifestyle. An even higher incidence of macular edema has been reported in older patients with type 2 diabetes. Within the last 5 years, the use of intravitreal corticosteroids and intravitreal anti-vascular endothelial growth factor (VEGF) agents have come into clinical practice for the management of DME and several recent randomized clinical trials have shown improved effectiveness of ranibizumab compared to focal/grid laser. In this theme issue, we discuss the classification of DR and the treatment options currently available for the treatment of DME including corticosteroids, anti-VEGF agents, combined therapy, enzymatic vitrectomy (vitreolysis), and new therapies.

Clinical biomarkers in metabolic syndrome

A biomarker can be defined as a measurable variable that may be used as an indicator of a given biological state or condition. Biomarkers have been used in health and disease for diagnostic purposes, as tools to assess effectiveness of nutritional or drug intervention, or as risk markers to predict the development of certain diseases. In nutrition studies, selecting appropriate biomarkers is important to assess compliance, or incidence of a particular dietary component in the biochemistry of the organism, and in the diagnosis and prognosis of nutrition-related diseases. Metabolic syndrome is a cluster of cardiovascular risk factors that occur simultaneously in the same individual, and it is associated with systemic alterations that may involve several organs and tissues. Given its close association with obesity and the increasing prevalence of obesity worldwide, identifying obese individuals at risk for metabolic syndrome is a major clinical priority. Biomarkers for metabolic syndrome are therefore potential important tools to maximize the effectiveness of treatment in subjects who would likely benefit the most. Choice of biomarkers may be challenging due to the complexity of the syndrome, and this article will mainly focus on nutrition biomarkers related to the diagnosis and prognosis of the metabolic syndrome.

Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus

BACKGROUND

The primary objective of this mechanistic open-label, stratified clinical trial was to determine the effect of 8 weeks' sodium glucose cotransporter 2 inhibition with empagliflozin 25 mg QD on renal hyperfiltration in subjects with type 1 diabetes mellitus (T1D).

METHODS AND RESULTS

Inulin (glomerular filtration rate; GFR) and paraaminohippurate (effective renal plasma flow) clearances were measured in individuals stratified based on having hyperfiltration (T1D-H, GFR ≥ 135 mL/min/1.73m(2), n=27) or normal GFR (T1D-N, GFR 90-134 mL/min/1.73m(2), n=13) at baseline. Renal function and circulating levels of renin-angiotensin-aldosterone system mediators and NO were measured under clamped euglycemic (4-6 mmol/L) and hyperglycemic (9-11 mmol/L) conditions at baseline and end of treatment. During clamped euglycemia, hyperfiltration was attenuated by -33 mL/min/1.73m(2) with empagliflozin in T1D-H, (GFR 172±23-139±25 mL/min/1.73 m(2), P<0.01). This effect was accompanied by declines in plasma NO and effective renal plasma flow and an increase in renal vascular resistance (all P<0.01). Similar significant effects on GFR and renal function parameters were observed during clamped hyperglycemia. In T1D-N, GFR, other renal function parameters, and plasma NO were not altered by empagliflozin. Empagliflozin reduced hemoglobin A1c significantly in both groups, despite lower insulin doses in each group (P≤0.04).

CONCLUSIONS

In conclusion, short-term treatment with the sodium glucose cotransporter 2 inhibitor empagliflozin attenuated renal hyperfiltration in subjects with T1D, likely by affecting tubular-glomerular feedback mechanisms.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT01392560.

Heavy metal in the intensive care unit: a review of current literature on trace element supplementation in critically ill patients

Trace elements are essential for many physiologic processes. In recent years, supplementation has been studied for a variety of indications, including glycemic control, wound healing, antioxidant effect, and anemia. Critical illness, especially states such as burns, traumas, and septic shock, is associated with inflammatory and oxidative stress, immune dysfunction, and malnutrition. In these patients, enteral and parenteral nutrition or pharmaceutical supplementation is used to provide essential macronutrients, including trace elements. The purpose of this review is to describe trace element supplementation, including iron, copper, chromium, manganese, selenium, and zinc, and highlight their mechanism, pharmacology, outcome data, and adverse effects.

Creatine supplementation and oxidative stress in rat liver

BACKGROUND

The objective of this study was to determine the effects of creatine supplementation on liver biomarkers of oxidative stress in exercise-trained rats.

METHODS

Forty 90-day-old adult male Wistar rats were assigned to four groups for the eight-week experiment. Control group (C) rats received a balanced control diet; creatine control group (CCr) rats received a balanced diet supplemented with 2% creatine; trained group (T) rats received a balanced diet and intense exercise training equivalent to the maximal lactate steady state phase; and supplemented-trained (TCr) rats were given a balanced diet supplemented with 2% creatine and subjected to intense exercise training equivalent to the maximal lactate steady state phase. At the end of the experimental period, concentrations of creatine, hydrogen peroxide (H2O2) and thiobarbituric acid reactive substances (TBARS) were measured as well as the enzyme activity of superoxide dismutase (SOD), glutathione peroxidase (GSH-GPx) and catalase (CAT). Liver tissue levels of reduced glutathione (GSH), oxidized glutathione (GSSG) and the GSH/GSSG ratio were also determined.

RESULTS

Hepatic creatine levels were highest in the CCr and TCr groups with increased concentration of H2O2 observed in the T and TCr animal groups. SOD activity was decreased in the TCr group. GSH-GPx activity was increased in the T and TCr groups while CAT was elevated in the CCr and TCr groups. GSH, GGS and the GSH/GSSG ratio did not differ between all animal subsets.

CONCLUSIONS

Our results demonstrate that creatine supplementation acts in an additive manner to physical training to raise antioxidant enzymes in rat liver. However, because markers of liver oxidative stress were unchanged, this finding may also indicate that training-induced oxidative stress cannot be ameliorated by creatine supplementation.

Attenuation of hyperlipidemia- and diabetes-induced early-stage apoptosis and late-stage renal dysfunction via administration of fibroblast growth factor-21 is associated with suppression of renal inflammation

Background

Lipotoxicity is a key feature of the pathogenesis of diabetic kidney disease, and is attributed to excessive lipid accumulation (hyperlipidemia). Increasing evidence suggests that fibroblast growth factor (FGF)21 has a crucial role in lipid metabolism under diabetic conditions.

Objective

The present study investigated whether FGF21 can prevent hyperlipidemia- or diabetes-induced renal damage, and if so, the possible mechanism.

Methods

Mice were injected with free fatty acids (FFAs, 10 mg/10 g body weight) or streptozotocin (150 mg/kg) to establish a lipotoxic model or type 1 diabetic model, respectively. Simultaneously the mice were treated with FGF21 (100 µg/kg) for 10 or 80 days. The kidney weight-to-tibia length ratio and renal function were assessed. Systematic and renal lipid levels were detected by ELISA and Oil Red O staining. Renal apoptosis was examined by TUNEL assay. Inflammation, oxidative stress, and fibrosis were assessed by Western blot.

Results

Acute FFA administration and chronic diabetes were associated with lower kidney-to-tibia length ratio, higher lipid levels, severe renal apoptosis and renal dysfunction. Obvious inflammation, oxidative stress and fibrosis also observed in the kidney of both mice models. Deletion of the fgf21 gene further enhanced the above pathological changes, which were significantly prevented by administration of exogenous FGF21.

Conclusion

These results suggest that FFA administration and diabetes induced renal damage, which was further enhanced in FGF21 knock-out mice. Administration of FGF21 significantly prevented both FFA- and diabetes-induced renal damage partially by decreasing renal lipid accumulation and suppressing inflammation, oxidative stress, and fibrosis.

Genetic association analyses of nitric oxide synthase genes and neural tube defects vary by phenotype

Neural tube defects (NTDs) are caused by improper neural tube closure during the early stages of embryonic development. NTDs are hypothesized to have a complex genetic origin and numerous candidate genes have been proposed. The nitric oxide synthase 3 (NOS3) G594T polymorphism has been implicated in risk for spina bifida, and interactions between that single nucleotide polymorphism (SNP) and the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism have also been observed. To evaluate other genetic variation in the NO pathway in the development of NTDs, we examined all three NOS genes: NOS1, NOS2, and NOS3. Using 3109 Caucasian samples in 745 families, we evaluated association in the overall dataset and within specific phenotypic subsets. Haplotype tagging SNPs in the NOS genes were tested for genetic association with NTD subtypes, both for main effects as well as for the presence of interactions with the MTHFR C677T polymorphism. Nominal main effect associations were found with all subtypes, across all three NOS genes, and interactions were observed between SNPs in all three NOS genes and MTHFR C677T. Unlike the previous report, the most significant associations in our dataset were with cranial subtypes and the AG genotype of rs4795067 in NOS2 (p = 0.0014) and the interaction between the rs9658490 G allele in NOS1 and MTHFR 677TT genotype (p = 0.0014). Our data extend the previous findings by implicating a role for all three NOS genes, independently and through interactions with MTHFR, in risk not only for spina bifida, but all NTD subtypes.

Matrix metalloproteinase-10 plays an active role in microvascular complications in type 1 diabetic patients

AIMS/HYPOTHESIS

The role of metalloproteinase-10 (MMP-10) in type 1 diabetes is not known. We hypothesise that it plays a role in the onset and progression of diabetic nephropathy and retinopathy.

METHODS

Serum MMP-10 levels from 269 patients with type 1 diabetes were measured, and their association with microvascular complications was analysed. We also studied whether knocking out the Mmp10 gene influenced the extent of renal injury and retinal damage in a streptozotocin-induced diabetic mouse model.

RESULTS

The risk of nephropathy and proliferative retinopathy associated with the highest vs the lowest MMP-10 tertile was increased three to four times independently of the classical risk factors. Accordingly, renal function and morphology were better preserved in diabetic Mmp10 −⁄− mice than in their Mmp10 +/+ counterparts. There were more kidney-infiltrating macrophages in diabetic Mmp10+/+ mice, suggesting that MMP-10 contributes to the inflammatory response leading to microvascular complications. The loss of neuronal cells in the retinas of diabetic Mmp10 +/+ mice was higher than in Mmp10 −⁄− mice. Retinal inflammation was decreased in Mmp10 −⁄− mice, as indicated by their reduced retinal caspase-1 levels.

CONCLUSIONS/INTERPRETATION

MMP-10 is involved in the development of microvascular complications in type 1 diabetes and emerges as a potential therapeutic target for slowing down the evolution of diabetic nephropathy and retinopathy.

Abundant daily non-sedentary activity is associated with reduced prevalence of metabolic syndrome and insulin resistance

BACKGROUND

Non-exercise activity thermogenesis has recently drawn attention because of its potential to prevent weight gain.

AIM

This study evaluated the relationships between the duration of daily non-sedentary activities and the prevalence of metabolic syndrome and insulin resistance (IR) in the Japanese population.

MATERIAL/SUBJECTS AND METHODS

A total of 518 eligible subjects (380 men and 138 women) who attended the Tokushima Prefectural General Health Checkup Center and participated in the baseline survey of a cohort study conducted in Tokushima Prefecture, Japan were analyzed. Information about lifestyle characteristics including leisure-time exercise and daily non-exercise activities was obtained from a questionnaire. Logistic and multiple linear regression analyses were performed to evaluate the associations between the duration of daily non-exercise non-sedentary activities (beyond sitting) and prevalence of metabolic syndrome (and its components) and IR.

RESULTS

Subjects with longer duration of daily non-sedentary activities had significantly lower adjusted odds ratios for metabolic syndrome (p for trend =0.024), abdominal obesity (p for trend =0.023), and low HDLcholesterol levels (p for trend =0.002), after adjustment for sex, age, and other probable covariates including leisure-time exercise. Longer duration of daily non-sedentary activities was further associated with lower homeostasis model of assessment- IR (HOMA-IR) values (p for trend =0.009).

CONCLUSIONS

Our results suggest that abundant daily non-sedentary activity might be associated with a lower prevalence of metabolic syndrome, especially for the components of central obesity and low HDL-cholesterol levels, and with a lower prevalence of IR, independent of leisure-time exercise.

Efficacy and safety of empagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, as add-on to metformin in type 2 diabetes with mild hyperglycaemia

AIMS

To evaluate the effects of the sodium glucose cotransporter 2 (SGLT2) inhibitor empagliflozin added to metformin for 12 weeks in patients with type 2 diabetes.

METHODS

This dose-ranging, double-blind, placebo-controlled trial randomized 495 participants with type 2 diabetes inadequately controlled on metformin [haemoglobin A1c (HbA1c) >7 to ≤10%] to receive 1, 5, 10, 25, or 50 mg empagliflozin once daily (QD), or placebo, or open-label sitagliptin (100 mg QD), added to metformin for 12 weeks. The primary endpoint was change in HbA1c from baseline to week 12 (empagliflozin groups versus placebo).

RESULTS

Reductions in HbA1c of -0.09 to -0.56% were observed with empagliflozin after 12 weeks, versus an increase of 0.15% with placebo (baseline: 7.8-8.1%). Compared with placebo, empagliflozin doses from 5 to 50 mg resulted in reductions in fasting plasma glucose (-2 to -28 mg/dl vs. 5 mg/dl with placebo; p < 0.0001) and body weight (-2.3 to -2.9 kg vs. -1.2 kg; p < 0.01). Frequency of adverse events was generally similar with empagliflozin (29.6-48.6%), placebo (36.6%) and sitagliptin (35.2%). Hypoglycaemia rates were very low and balanced among groups. Most frequent adverse events with empagliflozin were urinary tract infections (4.0% vs. 2.8% with placebo) and pollakiuria (2.5% vs. 1.4% with placebo). Genital infections were reported only with empagliflozin (4.0%).

CONCLUSIONS

Once daily empagliflozin as add-on therapy to metformin was well tolerated except for increased genital infections and resulted in reductions in HbA1c, fasting plasma glucose and body weight in patients with type 2 diabetes inadequately controlled on metformin monotherapy.

Structure and physiological actions of ghrelin

Ghrelin is a gastric peptide hormone, discovered as being the endogenous ligand of growth hormone secretagogue receptor. Ghrelin is a 28 amino acid peptide presenting a unique n-octanoylation modification on its serine in position 3, catalyzed by ghrelin O-acyl transferase. Ghrelin is mainly produced by a subset of stomach cells and also by the hypothalamus, the pituitary, and other tissues. Transcriptional, translational, and posttranslational processes generate ghrelin and ghrelin-related peptides. Homo- and heterodimers of growth hormone secretagogue receptor, and as yet unidentified receptors, are assumed to mediate the biological effects of acyl ghrelin and desacyl ghrelin, respectively. Ghrelin exerts wide physiological actions throughout the body, including growth hormone secretion, appetite and food intake, gastric secretion and gastrointestinal motility, glucose homeostasis, cardiovascular functions, anti-inflammatory functions, reproductive functions, and bone formation. This review focuses on presenting the current understanding of ghrelin and growth hormone secretagogue receptor biology, as well as the main physiological effects of ghrelin.

Problems and challenges to adaptation of gluten free diet by Indian patients with celiac disease

Celiac disease is emerging in India and has become a public health problem. Almost 6-8 million Indians are estimated to have celiac disease. While there is a large pool of patients with celiac disease in India, until now, only a fraction of them have been diagnosed. With increasing awareness about celiac disease amongst health care providers and the general population, a massive increase in the number of patients with celiac disease is expected now and in the subsequent decade in India. While the number of patients with celiac disease is increasing, the country's preparedness towards the emerging epidemic of this disease is minimal. There are a number of issues, which requires urgent attention. Some of the key issues include increased awareness amongst health care professionals and the general public about the disease and its management, team-based management of patients with celiac disease, proper counseling and supervision of patients, training of dietitians in the management of patients with celiac disease, industrial production of reliable and affordable gluten-free food, and food labeling for gluten contents.

Charcot neuroarthropathy of the foot and ankle

Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.

Curcumin and diabetes: a systematic review

Turmeric (Curcuma longa), a rhizomatous herbaceous perennial plant of the ginger family, has been used for the treatment of diabetes in Ayurvedic and traditional Chinese medicine. The active component of turmeric, curcumin, has caught attention as a potential treatment for diabetes and its complications primarily because it is a relatively safe and inexpensive drug that reduces glycemia and hyperlipidemia in rodent models of diabetes. Here, we review the recent literature on the applications of curcumin for glycemia and diabetes-related liver disorders, adipocyte dysfunction, neuropathy, nephropathy, vascular diseases, pancreatic disorders, and other complications, and we also discuss its antioxidant and anti-inflammatory properties. The applications of additional curcuminoid compounds for diabetes prevention and treatment are also included in this paper. Finally, we mention the approaches that are currently being sought to generate a "super curcumin" through improvement of the bioavailability to bring this promising natural product to the forefront of diabetes therapeutics.

Attenuation of diabetic nephropathy by Chaihuang-Yishen granule through anti-inflammatory mechanism in streptozotocin-induced rat model of diabetics

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medical herbs have been used in China for a long time to treat different diseases. Based on traditional Chinese medicine (TCM) principle, Chaihuang-Yishen granule (CHYS) was developed and has been employed clinically to treat chronic kidney disease including diabetic nephropathy (DN). The present study was designed to investigate its mechanism of action in treatment of DN.

MATERIALS AND METHODS

Diabetic rats were established by having a right uninephrectomy plus a single intraperitoneal injection of STZ. Rats were divided into four groups of sham, diabetes, diabetes with CHYS and diabetes with fosinopril. CHYS and fosinopril were given to rats by gavage for 20 weeks. Samples from blood, urine and kidney were collected for biochemical, histological, immunohistochemical and molecular analyses.

RESULTS

Rats treated with CHYS showed reduced 24h urinary protein excretion, decreased serum TC and TG levels, but CHYS treatment did not affect blood glucose level. Glomerular mesangial expansion and tubulointerstitial fibrosis in diabetic rats were significantly alleviated by CHYS treatment. Moreover, CHYS administration markedly reduced mRNA levels of NF-κB p65 and TGF-β1, as well as decreased protein levels of NF-κB p65, MCP-1, TNF-α and TGF-β1 in the kidney of diabetic rats.

CONCLUSIONS

CHYS ameliorates renal injury in diabetic rats through reduction of inflammatory cytokines and their intracellular signaling.

Charcot foot in diabetes and an update on imaging

Charcot neuroarthropathy (CN) is a serious complication of diabetes mellitus that can cause major morbidity including limb amputation. Since it was first described in 1883, and attributed to diabetes mellitus in 1936, the diagnosis of CN has been very challenging even for the experienced practitioners. Imaging plays a central role in the early and accurate diagnosis of CN, and in distinction of CN from osteomyelitis. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, and positron emission tomography are the imaging techniques currently in use for the evaluation of CN but modalities other than magnetic resonance imaging appeared to be complementary. This study focuses on imaging findings of acute and chronic neuropathic osteoarthropathy in diabetes and discrimination of infected vs. non-infected neuropathic osteoarthropathy.

Role of the General Surgeon in the Early Diagnosis and Treatment of Charcot Foot

INTRODUCTION

The Charcot foot (CF) consists of a progressive deterioration of the bones and joints, most common in diabetic patients with advanced neuropathy. The great problem is that can be confused with other processes, delaying the diagnosis and specific treatment. The aim is to analyze the cases of CF diagnosed in our hospital and especially to highlight the role of the general surgeon.

MATERIAL AND METHODS

Retrospective study of all registered cases diagnosed of CF between the diabetic population of our Department of Health. A review of the literature was performed.

RESULTS

From 2008 to 2012, there 7 cases of CF were diagnosed (prevalence 1:710). Two of the patients were diagnosed erroneously of cellulitis. The average time of delay in the diagnosis was 10 weeks (minimum 1, maximum 24). The initial treatment was immobilization of the extremity. Once the edema was eliminated, an offload orthesis was placed according to Sanders's anatomical classification. Evolution was favorable in 5 patients, 1 patient needed amputation, and other one died of acute cardiac pathology.

CONCLUSIONS

The CF is a more frequent pathology than we believe. The general surgeon is the fundamental prop in the diagnosis and initial treatment. Before the presence of inflammation and edema of the foot in a patient with diabetes and severe neuropathy, once cellulitis, osteomyelitis, and TVP are ruled out, Charcot neuroarthropathy should be considered.

Differences in the topographic profiles of retinal thickening in eyes with and without serous macular detachment associated with diabetic macular oedema

PURPOSE

To investigate if cases of diabetic macular oedema (DMO) associated with serous macular detachment (SMD) have a different topographic profile of retinal thickening compared with DMO cases not associated with SMD.

METHODS

Optical coherence tomography scans of 152 eyes from 152 patients with centre-involving DMO and central subfield thickness >350 µm were identified. Measurements were taken of the neural retina at the highest point of thickening within the central subfield (H) and lateral extent of retina thicker than 350 µm (W). Group means were compared between eyes with SMD and eyes without SMD.

RESULTS

SMD was present in 55 eyes (36%). H was lower in eyes with SMD than in eyes without SMD (396 µm vs 550 µm, p<0.001) while W was higher in eyes with SMD compared with eyes without SMD (4.74 mm vs 4.18 mm, p=0.011).

CONCLUSIONS

There were distinct differences in topographical profiles of retinal thickening between eyes with SMD and eyes without SMD. These findings suggest a possible mechanical basis for the pathogenesis of SMD in DMO.

Ceftaroline plus avibactam demonstrates bactericidal activity against pathogenic anaerobic bacteria in a one-compartment in vitro pharmacokinetic/pharmacodynamic model

Anaerobic pathogens are often associated with polymicrobial infections, such as diabetic foot infections. Patients with these infections are often treated with broad-spectrum, multidrug therapies targeting resistant Gram-positive bacteria, such as methicillin-resistant Staphylococcus aureus, as well as Gram-negative bacteria and anaerobes. The broad-spectrum, non-beta-lactam, beta-lactamase inhibitor avibactam has been combined with ceftaroline and may provide a single-product alternative for complicated polymicrobial infections. We compared the activity of ceftaroline-avibactam (CPA) to that of ertapenem (ERT) against common anaerobic pathogens in an in vitro pharmacokinetic/pharmacodynamic (PK/PD) model. Simulations of doses of ceftaroline-fosamil at 600 mg every 8 h (q8h) (maximum free drug concentration [fCmax], 17.04 mg/liter, and half-life [t1/2], 2.66 h) plus avibactam at 600 mg q8h (fCmax, 11.72 mg/liter, and t1/2, 1.8 h) and of ertapenem at 1 g q24h (fCmax, 13 mg/liter, and t1/2, 4 h) were evaluated against two strains of Bacteroides fragilis, one strain of Prevotella bivia, and one strain of Finegoldia magna in an anaerobic one-compartment in vitro PK/PD model over 72 h with a starting inoculum of ∼8 log10 CFU/ml. Bactericidal activity was defined as a reduction of ≥3 log10 CFU/ml from the starting inoculum. Both CPA and ERT were bactericidal against all four strains. CPA demonstrated improved activity against Bacteroides strains compared to that of ERT but had similar activity against Finegoldia magna and P. bivia, although modest regrowth was observed with CPA against P. bivia. No resistance emerged from any of the models. The pharmacokinetics achieved were 92 to 105% of the targets. CPA has potent in vitro activity against common anaerobic pathogens at clinically relevant drug exposures and may be a suitable single product for the management of complicated polymicrobial infections.

Osteomyelitis or Charcot neuro-osteoarthropathy? Differentiating these disorders in diabetic patients with a foot problem

Both osteomyelitis and Charcot neuro-osteoarthropathy (CN) are potentially limb-threatening complications of diabetic neuropathy, but they require quite different treatments. Almost all bone infections in the diabetic foot originate from an infected foot ulcer while diabetic osteoarthropathy is a non-infectious process in which peripheral neuropathy plays the critical role. Differentiating between diabetic foot osteomyelitis and CN requires careful evaluation of the patient, including the medical history, physical examination, selected laboratory findings, and imaging studies. Based on available studies, we review the approaches to the diagnostic differentiation of osteomyelitis from CN of the foot in diabetic patients.

Prenatal omega 3 fatty acid supplementation to a micronutrient imbalanced diet protects brain neurotrophins in both the cortex and hippocampus in the adult rat offspring

OBJECTIVE

Our earlier studies show that maternal diets imbalanced in micronutrients like folic acid and vitamin B12 reduced brain docosahexaenoic acid (DHA) and brain derived neurotrophic factor (BDNF) and nerve growth factor (NGF) in the offspring at birth and postnatal d21. This study followed the offspring till 3 months to examine the hypothesis that impaired brain neurotrophins at birth and d21 due to altered maternal micronutrients can be reversed by prenatal omega 3 fatty acid but not a postnatal control diet leading to altered cognition in adult life.

MATERIALS AND METHODS

Pregnant rats were divided into control and five treatment groups at two levels of folic acid (normal and excess folate) in the presence and absence of vitamin B12 (NFBD, EFB and EFBD). Omega 3 fatty acid supplementation was given to the vitamin B12 deficient groups (NFBDO and EFBDO). Following delivery, 8 dams from each group were shifted to control and remaining continued on same diet.

RESULTS

Imbalance in maternal micronutrients up to 3months decreased DHA, BDNF and NGF in cortex and only BDNF in the hippocampus and impaired cognitive performance. Postnatal control diet normalized BDNF in the cortex but not the hippocampus and also altered cognitive performance. Prenatal omega 3 fatty acid supplementation normalized DHA, BDNF and NGF while long term supplementation was not beneficial only when micronutrients were imbalanced.

CONCLUSION

Patterns established at birth are not totally reversible by postnatal diets and give clues for planning intervention studies for improving brain functioning and cognitive abilities.

Improvement in albuminuria in patients with type 2 diabetes after laparoscopic adjustable gastric banding

PURPOSE

To determine the effects of laparoscopic adjustable gastric banding (LAGB) on albuminuria in patients with obesity, type 2 diabetes mellitus (T2DM) and established diabetic nephropathy.

METHODS

A retrospective analysis of clinical records from a tertiary diabetes service identified obese patients with T2DM who had micro- or macroalbuminuria prior to LAGB surgery. Clinical data from follow-up appointments including albuminuria were analysed.

RESULTS

A total of 23 T2DM patients were included in the final study. Of 7 patients with macroalbuminuria at baseline, 2 reverted to normoalbuminuria, 2 reverted to microalbuminuria and 3 remained with macroalbuminuria on their final recording in the 36-month period of follow-up. Of 16 patients with microalbuminuria, 9 reverted to normoalbuminuria, while 6 remained with microalbuminuria.

CONCLUSION

This study demonstrates significant improvements in albuminuria in patients with established diabetic nephropathy following LAGB. These results suggest the potential for LAGB to improve or reverse renal damage in patients with T2DM.