Glycaemic management in diabetes: old and new approaches

Efficient and Effective Diabetes Care in the Era of Digitalization and Hypercompetitive Research Culture: A Focused Review in the Western Pacific Region with Malaysia as a Case Study

There are approximately 220 million (about 12% regional prevalence) adults living with diabetes mellitus (DM) with its related complications, and morbidity knowingly or unconsciously in the Western Pacific Region (WP). The estimated healthcare cost in the WP and Malaysia was 240 billion USD and 1.0 billion USD in 2021 and 2017, respectively, with unmeasurable suffering and loss of health quality and economic productivity. This urgently calls for nothing less than concerted and preventive efforts from all stakeholders to invest in transforming healthcare professionals and reforming the healthcare system that prioritizes primary medical care setting, empowering allied health professionals, improvising health organization for the healthcare providers, improving health facilities and non-medical support for the people with DM. This article alludes to challenges in optimal diabetes care and proposes evidence-based initiatives over a 5-year period in a detailed roadmap to bring about dynamic and efficient healthcare services that are effective in managing people with DM using Malaysia as a case study for reference of other countries with similar backgrounds and issues. This includes a scanning on the landscape of clinical research in DM, dimensions and spectrum of research misconducts, possible common biases along the whole research process, key preventive strategies, implementation and limitations toward high-quality research. Lastly, digital medicine and how artificial intelligence could contribute to diabetes care and open science practices in research are also discussed.

Glucose-fueled cationic nanomotors for promoting the healing of infected diabetic wounds

Hyperglycemia-promoted bacterial infection will seriously exacerbate diabetic wounds, and its current clinical treatments are suffering from the adverse effects associated with off-target, bacterial resistance, and glycemic fluctuation. Herein, we present a kind of glucose-fueled cationic nanomotors capable of remarkably enhancing antibacterial efficacy, and thus expediting diabetic wound healing. The nanomotors have positively charged surfaces, and consist of mesoporous bowl-shaped polydopamine nanoparticles grafted with quaternized polymer brushes and coupled with glucose oxidase (GOx) and catalase (CAT). Stemming from the GOx-CAT cascade reaction in diabetic wound microenvironment, they can perform robust chemotactic motion towards both high glucose regions, where bacteria proliferation predominantly occurs, and elevated H2O2 levels, which bacterial metabolism produced. This enables the nanomotors to facilitate targeted migration towards bacteria-rich regions and simultaneous downregulation of glycemic levels, as well as to significantly enhance the electrostatic interaction between antibacterial components and bacteria. Consequently, the nanomotors exhibit amplified contact-killing effects of their attached cationic molecules, leading to an almost 10-fold enhancement in antibacterial efficacy compared to previous counterparts. The in vivo experiments approved that the nanomotors demonstrated the accelerated healing of infected diabetic wounds by S. aureus and biosafety. The results herein provide an insight into the clinical treatment of infected diabetic wounds.

Meta-Analysis of the Association Between VEGF-2578C/A Polymorphism and Susceptibility to Type 2 Diabetic Retinopathy

PURPOSE

to investigate the association between vascular endothelial growth factor (VEGF)-2578C/A polymorphism and susceptibility to type 2 diabetic retinopathy (T2DR) by meta-analysis.

METHODS

According to the search strategy, Four databases were retrieved to identify the literature on the relationship between VEGF polymorphism and the risk of T2DR from inception to July 2024. Stata 15.0 was used for data processing.

RESULTS

Ten articles were involved in this review, covering 1390 cases and 1306 controls. The pooled results exhibited that the risk of T2DR was associated with VEGF-2578C/A polymorphism under the allele model (A/C: OR= 1.33, 95%CI: 1.04-1.72, p = 0.025) and dominant models (AA+CA/CC: OR= 1.38, 95%CI: 1.00-1.91, p = 0.047). However, in recessive, homozygous, and heterozygous models, no significant difference was observed (all p > 0.05).

CONCLUSIONS

The VEGF-2578C/A polymorphism is associated with susceptibility to T2DR. In particular, allele A and genotype AA+CA at the VEGF-2578C/A locus were significantly associated with an increased risk of T2DR.

Pharmacokinetic and Pharmacodynamic Equivalence of Biosimilar and Reference Ultra-Rapid Lispro: A Comparative Clamp Study in Healthy Volunteers

Ultra-rapid insulin lispro is an innovative insulin analogue designed to achieve rapid onset and short duration of action, aimed at optimizing glycemic control in patients with diabetes. This was a double-blind, randomized, 2-period, crossover clamp study to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD), along with safety profiles, of a potential biosimilar ultra-rapid insulin lispro compared to the reference product in healthy White men. A total of 35 healthy volunteers completed hyperinsulinemic euglycemic clamp procedures across both study periods. Blood samples were collected at predefined intervals up to 8 hours to assess PK parameters. Plasma glucose levels were monitored every 5 minutes during the 8-hour clamps, with adjustments to the glucose infusion rate to maintain the target range. Insulin quantification in plasma was conducted using a validated enzyme-linked immunosorbent assay method. PD assessment was based on glucose infusion rate profiles during both clamps. Geometric mean ratios for maximum plasma concentration and area under the concentration-time curve from insulin administration to the last measurable concentration for the test and reference drugs fell within the bioequivalence range of 80%-125%. Furthermore, the investigational drugs demonstrated comparable PK/PD profiles of insulin lispro. Both formulations exhibited similar safety profiles primarily characterized by mild injection site reactions.

Association between time in tight range and incident diabetic retinopathy in adults with type 2 diabetes

AIMS

Time spent in the glucose range of 70-180 mg/dL (TIR) has become entrenched as a key measure of glycaemic control, which was linked to diabetes-related outcomes in previous studies. However, there has been a recent debate about whether to instead emphasize time in the target range of 70-140 mg/dL (time in tight range, TITR). We aimed to assess the association between TITR and incident diabetic retinopathy in adults with type 2 diabetes.

MATERIALS AND METHODS

This is a dynamic cohort study conducted at a tertiary hospital. 2518 adults with type 2 diabetes and without diabetic retinopathy at baseline were finally included. TITR was obtained from continuous glucose monitoring data at baseline. Cox proportional hazard regression analysis was performed to assess the relationships of TITR with the risk of incident diabetic retinopathy.

RESULTS

During a mean follow-up period of 5.43 years, 646 patients developed retinopathy. The multivariable-adjusted hazard ratios (HRs) for incident retinopathy across descending TITR quartiles (Q4: >58% [reference], Q3: 38% ~ 57%, Q2: 19% ~ 37%, and Q1: <19%) were 1.00, 1.47 (95%CI 1.16, 1.87), 1.52 (95%CI 1.20, 1.93) and 1.93 (95%CI 1.53, 2.43), respectively. For per 10% decrease in TITR, the risk of diabetic retinopathy was increased by 9% (HR = 1.09, 95%CI 1.06, 1.13) after full adjustment for covariates. In the TIR >70% subgroup, the significant association between TIR, as a continuous variable and the risk of incident retinopathy disappeared, whereas TITR remained significantly associated with the outcome. Similar results were observed in the TIR >80% and TIR >90% subgroups.

CONCLUSIONS

TITR is inversely associated with the incidence of diabetic retinopathy in adults with type 2 diabetes. Among adults with well-controlled TIR (70% or higher), TITR may provide added value regarding glucose control.

Impact of co-administration of apricot kernels and caffeine on adult male diabetic albino rats

The purpose of this study is to evaluate the impacts of apricot kernels and caffeine on blood glucose, lipid profile, insulin secretion, and antioxidant effect in diabetic rats. Forty adult male albino rats were divided into five groups: normal control, diabetic control, diabetic rats treated with apricot kernels, diabetic rats treated with caffeine, and diabetic rats treated with apricot kernels plus caffeine. Fasting samples were collected at the end of the study for analysis, and pieces of liver and pancreatic tissues were removed for histological analysis. There was a significant decrease in blood glucose, glycated hemoglobin, body weight, total cholesterol, triglyceride, and low-density lipoprotein cholesterol (LDL-C) levels and a significant increase in insulin and high-density lipoprotein cholesterol (HDL-C) levels in the kernel and caffeine-treated groups. However, there was little histological alteration in the liver or pancreas, and no significant differences were observed in the histological findings between groups. Overall, it can be concluded that apricot kernel and caffeine had a positive effect in decreasing blood glucose and harmful lipid profile and that caffeine had a synergistic effect on the apricot kernel.

Enzyme Inhibitory Activities and RP-HPLC Analysis of Geranium and Erodium Species

The genera Geranium and Erodium (Geraniaceae) have been documented to possess diverse ethnopharmacological uses, including diabetes mellitus. Relevant to their ethnopharmacological use, the current study aimed to evaluate the α-glucosidase, α-amylase, acetylcholinesterase (AChE), and butyrylcholinesterase (BChE) enzyme inhibitory activity of ethanol extracts from 46 samples belonging to thirty-one species of Geranium (20) and Erodium (11) collected throughout Türkiye. The majority of the extracts displayed a marked α-glucosidase and α-amylase inhibitory activity. Besides, 23 extracts out of 46 exhibited a concentration-dependent inhibitory effect over 50 % towards AChE. The highest AChE inhibition was found in G. subcaulescens collected from Konya with an IC50 value of 4.73±2.96 μg/mL. E. somanum, E. leucanthum, and E. sipthorpianum exhibited the most potent α-glucosidase inhibitory activity, while E. birandianum and E. pelargoniiflorum were the most active extracts against AChE and BChE, respectively. Three extracts that had inhibitory activity over 50 % against four of the enzymes were selected and proceeded to RP-HPLC analysis. Geraniin and ellagic acid were identified as major compounds in the active extracts. Most species screened in the current study were examined for the first time against α-glucosidase, α-amylase, AChE, and BChE.

Theaflavins mitigate diabetic symptoms in GK rats by modulating the INSR/PI3K-Akt/GSK-3 pathway and intestinal microbiota

Dietary management and interventions are crucial in the clinical management of diabetes. Numerous active dietary components in black tea have demonstrated positive effects on blood glucose levels and metabolic functions. However, limited research has explored the potential of theaflavins (TF), polyphenols in black tea, for diabetes management. In this study, high-purity TF was administered to Goto-Kakizaki (GK) diabetic model rats for four weeks to investigate its impact on diabetic pathology and analyze the underlying mechanisms through liver transcriptomics, hepatocyte metabolomics, and gut microbiome analysis. The findings indicated that continuous administration of TF (100 mg/kg) significantly suppressed blood glucose levels, reduced insulin resistance, and decreased the expression of oxidative stress indicators and inflammatory factors in GK rats. Further analysis revealed that TF might alleviate insulin resistance by improving hepatic glycogen conversion and reducing hepatic lipid deposition through modulation of key pathways, such as peroxisome proliferator-activated receptors and PI3K/AKT/GSK-3 pathways within the liver, thereby ameliorating diabetic symptoms. Additionally, TF intake facilitated the restoration of the intestinal microbial community structure by reducing the abundance of harmful bacteria and increasing the abundance of beneficial bacteria. It also reduced endotoxin lipopolysaccharide production, thereby lowering the chances of insulin resistance development and enhancing its efficacy in regulating blood glucose levels. These findings offer a novel perspective on the potential of black tea and its active constituents to prevent and treat diabetes and other metabolic disorders, providing valuable references for identifying and applying active dietary components from tea.

Intermittent hyperglycaemia induces macrophage dysfunction by extracellular regulated protein kinase-dependent PKM2 translocation in periodontitis

Early fluctuations in blood glucose levels increased susceptibility to macrophage dysfunction. However, the underlying pathological mechanisms linking glucose variations and macrophage dysregulation remains elusive. In current study, we established an animal model of transient intermittent hyperglycaemia (TIH) to simulate early fluctuations in blood glucose levels. Our findings revealed that both TIH and diabetic group exhibited more severe periodontal lesions and increased secretion of pro-inflammatory cytokines compared to healthy controls. In immortalized bone marrow-derived macrophages (iBMDMs), phagocytosis and chemotaxis were impaired with transient and lasting hyperglycaemia, accompanied by enhanced glycolysis. We also found that TIH activated pyruvate kinase M2 (PKM2) through the phosphorylation of extracellular regulated protein kinase (ERK) in vivo, particularly at dimeric levels. In macrophage cultured with TIH, PKM2 translocated into the nucleus and involved in the regulating inflammatory genes, including TNF-α, IL-6 and IL-1β. PKM2 translocation and secretion of inflammatory cytokines were attenuated by PD98059, while PKM2 tetramer activator TEPP-46 prevented the formation of dimeric PKM2 in macrophages. Moreover, inhibition of glycolysis alleviated the TIH-induced pro-inflammatory cytokines. In conclusion, our manuscript provides a rationale for understanding how TIH modulates metabolic rewiring and dysfunction in macrophages via ERK-dependent PKM2 nuclear translocation.

Impact of different hormones on the regulation of nitric oxide in diabetes

Polymetabolic syndrome achieved pandemic proportions and dramatically influenced public health systems functioning worldwide. Chronic vascular complications are the major contributors to increased morbidity, disability, and mortality rates in diabetes patients. Nitric oxide (NO) is among the most important vascular bed function regulators. However, NO homeostasis is significantly deranged in pathological conditions. Additionally, different hormones directly or indirectly affect NO production and activity and subsequently act on vascular physiology. In this paper, we summarize the recent literature data related to the effects of insulin, estradiol, insulin-like growth factor-1, ghrelin, angiotensin II and irisin on the NO regulation in physiological and diabetes circumstances.

Body composition in a pediatric population with type-1 diabetes - The importance of planned physical exercise

OBJECTIVE AND METHODS

This study aimed to assess the body composition of pediatric patients with type-1 diabetes (T1D) in a Portuguese pediatric endocrinology/diabetic clinic, using the InBody 570 bioimpedance system. Preschool children (<6 years) and those recently diagnosed (<6 months) were excluded.

RESULTS

The study included 78 patients (53% female). Median age at assessment was 14 years, with 81% pubertal children. Eighty-seven percent were using continuous subcutaneous insulin infusion (CSII), 25% with an automated closed-loop model. Median HbA1c was 7.3%. Most had an adequate body mass index (BMI) standard deviation score (62%) and 48% engaged in regular physical exercise (PE) outside of school. Median percentage body fat (PBF) was 21.5% and was abnormal in 48%, with median visceral adiposity of 4. Despite adequate BMI, 11% had excessive PBF. PBF was significantly associated with visceral fat (r=0.79; P<0.001), female gender (P<0.001) and PE performed out of school (P=0.005). PE was associated with lower PBF (P=0.005), lower visceral fat (P=0.002), and higher muscle-to-fat ratio (P=0.006).

CONCLUSION

Engaging in physical exercise out of school correlated significantly with improved body composition, characterized by reduced PBF and diminished visceral adiposity. Considering the known benefits of physical exercise for metabolic and glycemic control, this study highlights the importance of promoting regular physical exercise in T1D patients.

Impact of diverse aerobic exercise plans on glycemic control, lipid levels, and functional activity in stroke patients with type 2 diabetes mellitus

Aims

This study aimed to assess the effects of Low-to-Moderate Intensity Continuous Training (LMICT), Moderate-Intensity Interval Training (MIIT), and Reduced-Exertion High-Intensity Training (REHIT) on blood glucose regulation, functional recovery, and lipid levels in individuals who have experienced a stroke and are diagnosed with Type 2 Diabetes Mellitus (T2DM).

Methods

Forty-two T2DM stroke patients were randomly allocated to four groups: LMICT, MIIT, REHIT, and a control group (CON). Participants continuously monitored their blood glucose levels throughout the intervention using continuous glucose monitoring (CGM) devices. The study comprised two exercise intervention cycles: the first lasting from Day 3 to Day 14 and the second from Day 15 to Day 28, with the initial two days serving as contrasting periods. Primary outcomes encompassed CGM-derived blood glucose measurements, the Barthel Index (BI), Fugl-Meyer Assessment lower-extremity subscale (FMA-LE), and alterations in triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c).

Results

Compared with the CON, the MIIT group showed significant improvements in mean glucose (MG), glucose standard deviation (SD), time above range (TAR), and time in range (TIR). The REHIT group exhibited significantly reduced time below range (TBR), glucose SD, and coefficient of variation (CV). Regarding lipid levels, although the REHIT group achieved a significant reduction in TG levels compared with the CON, the overall effects of LMICT, MIIT, and REHIT on lipid profiles were relatively modest. Concerning functional recovery, the REHIT group significantly improved the BI and FMA-LE.

Conclusion

Although the short-term quantitative impact of exercise on lipid levels may be limited, both REHIT and MIIT significantly improved glycemic management and reduced glucose variability in post-stroke patients with Type 2 Diabetes Mellitus. Additionally, REHIT notably enhanced functional recovery.

Use of GLP-1 Receptor Agonists for the Management of Type 1 Diabetes: A Pediatric Perspective

BACKGROUND

Despite all the technological advances in treatment of patients with type 1 diabetes (T1D), glucose control remains suboptimal in most patients. In addition, a relatively high percentage of patients with T1D, including children, have obesity. Therefore, new interventions are required that focus their effects on weight loss, in order to help with associated insulin resistance and improve glycemic control.

SUMMARY

GLP-1 receptor agonists (GLP-1 RAs) have proven to be effective and safe in adults with T1D, showing improvement in glycemic control, body weight and cardiorenal protection. GLP-1 RAs are also approved for children with obesity (above the age of 12 years) or type 2 diabetes (above the age of 10 years). However, currently these medications are not approved for use in children with T1D. Only a few published studies have evaluated their efficacy and safety for this indication.

KEY MESSAGE

This review presents the rationale and experience of add-on GLP-1 RA therapy to pediatric and adolescent patients with T1D, otherwise treated, from RCTs and real-world data. Results of studies of GLP-1 RA in children with T1D are still pending, while large multicenter randomized controlled trials (RCTs) in this population are lacking.

Enhancing the Capabilities of Continuous Glucose Monitoring With a Predictive App

BACKGROUND

Despite abundant evidence demonstrating the benefits of continuous glucose monitoring (CGM) in diabetes management, a significant proportion of people using this technology still struggle to achieve glycemic targets. To address this challenge, we propose the Accu-Chek® SmartGuide Predict app, an innovative CGM digital companion that incorporates a suite of advanced glucose predictive functionalities aiming to inform users earlier about acute glycemic situations.

METHODS

The app's functionalities, powered by three machine learning models, include a two-hour glucose forecast, a 30-minute low glucose detection, and a nighttime low glucose prediction for bedtime interventions. Evaluation of the models' performance included three data sets, comprising subjects with T1D on MDI (n = 21), subjects with type 2 diabetes (T2D) on MDI (n = 59), and subjects with T1D on insulin pump therapy (n = 226).

RESULTS

On an aggregated data set, the two-hour glucose prediction model, at a forecasting horizon of 30, 45, 60, and 120 minutes, achieved a percentage of data points in zones A and B of Consensus Error Grid of: 99.8%, 99.3%, 98.7%, and 96.3%, respectively. The 30-minute low glucose prediction model achieved an accuracy, sensitivity, specificity, mean lead time, and area under the receiver operating characteristic curve (ROC AUC) of: 98.9%, 95.2%, 98.9%, 16.2 minutes, and 0.958, respectively. The nighttime low glucose prediction model achieved an accuracy, sensitivity, specificity, and ROC AUC of: 86.5%, 55.3%, 91.6%, and 0.859, respectively.

CONCLUSIONS

The consistency of the performance of the three predictive models when evaluated on different cohorts of subjects with T1D and T2D on different insulin therapies, including real-world data, offers reassurance for real-world efficacy.

Is it time to revise the fighting strategy toward type 2 diabetes? Sex and pollution as new risk factors

Diabetes mellitus, a metabolic condition affecting around 537 million individuals worldwide, poses significant challenges, particularly among the elderly population. The etiopathogenesis of type 2 diabetes (T2D) depends on a combination of the effects driven by advancing age, genetic background, and lifestyle habits, e.g. overnutrition. These factors influence the development of T2D differently in men and women, with an obvious sexual dimorphism possibly underlying the diverse clinical features of the disease in different sexes. More recently, environmental pollution, estimated to cause 9 million deaths every year, is emerging as a novel risk factor for the development of T2D. Indeed, exposure to atmospheric pollutants such as PM2.5, O3, NO2, and Persistent Organic Pollutants (POP)s, along with their combination and bioaccumulation, is associated with the development of T2D and obesity, with a 15 % excess risk in case of exposure to very high levels of PM2.5. Similar data are available for plasticizer molecules, e.g. bisphenol A and phthalates, emerging endocrine-disrupting chemicals. Even though causality is still debated at this stage, preclinical evidence sustains the ability of multiple pollutants to affect pancreatic function, promote insulin resistance, and alter lipid metabolism, possibly contributing to T2D onset and progression. In addition, preclinical findings suggest a possible role also for plastic itself in the development of T2D. Indeed, pioneeristic studies evidenced that micro- or nanoplastics (MNP)s, particles in the micro- or nano- range, promote cellular damage, senescence, inflammation, and metabolic disturbances, leading to insulin resistance and impaired glucose metabolism in animal and/or in vitro models. Here we synthesize recent knowledge relative to the association between air-related or plastic-derived pollutants and the incidence of T2D, discussing also the possible mechanistic links suggested by the available literature. We then anticipate the need for future studies in the field of candidate therapeutic strategies limiting pollution-induced damage in preclinical models, such as SGLT-2 inhibitors. We finally postulate that future guidelines for T2D prevention should consider pollution and sex an additional risk factors to limit the diabetes pandemic.

Continuous Glucose Monitoring-Derived Glucometrics in Adults with Type 1 Diabetes When Switching Basal Insulins

Context: Limited evidence is available on the real-world effect of insulin degludec (IDeg) in type 1 diabetes (T1D), using continuous glucose monitoring (CGM)-derived metrics. Objective: To assess the real-world effect of switching to IDeg from other long-acting insulins on time in ranges (TIRs) measured by CGM, metabolic control, and insulin dose for people with T1D. Design: This retrospective multicenter study encompassed five time points during a 12-month pre-switch of IDeg and a 12-month follow-up period. For each visit, clinical and CGM data were collected to evaluate temporal trends in glycemic outcomes. Participants: Of 753 persons with T1D who were assessed for eligibility, 486 persons were included, mostly men (61.5%), 47.4 (16.9) years old and diabetes duration of 23.8 (14.2) years at IDeg-initiation. Main Outcome Measure: Primary outcome was the evolution of percent TIR (70-180 mg/dL or 3.9-10.0 mmol/L, TIR) before versus after switch to IDeg. Results: TIR over 24 h increased at 12 months versus baseline (56.7% vs. 52.3%, P < 0.001), mostly during daytime. Time <54 mg/dL (<3.0 mmol/L) over 24 h decreased at 12 months versus baseline (2.02% vs. 2.86%, P < 0.001), mostly during nighttime. Glycated hemoglobin (7.9% vs. 8.1%, P < 0.001) and coefficient of variation (40.0% vs. 41.5%, P < 0.001) improved at 12 months versus baseline. Mean daily basal, bolus and total insulin doses decreased at 12 months (P < 0.001 for all vs. baseline). Conclusions: This retrospective real-world study reports that switching basal insulin significantly improved time spent in glucometric ranges and glycemic variability in the studied population of people with T1D. Clinical Trial Registration number: NCT05434559.

Tibial cortex transverse transport surgery improves wound healing in patients with severe type 2 DFUs by activating a systemic immune response: a cross-sectional study

BACKGROUND

Tibial cortex transverse transport (TTT) surgery has become an ideal treatment for patients with type 2 severe diabetic foot ulcerations (DFUs) while conventional treatments are ineffective. Based on our clinical practice experience, the protective immune response from TTT surgery may play a role against infections to promote wound healing in patients with DFUs. Therefore, this research aimed to systematically study the specific clinical efficacy and the mechanism of TTT surgery.

MATERIALS AND METHODS

Between June 2022 and September 2023, 68 patients with type 2 severe DFUs were enrolled and therapized by TTT surgery in this cross-sectional and experimental study. Major clinical outcomes including limb salvage rate and antibiotics usage rate were investigated. Ten clinical characteristics and laboratory features of glucose metabolism and kidney function were statistically analyzed. Blood samples from 6 key time points of TTT surgery were collected for label-free proteomics and clinical immune biomarker analysis. Besides, tissue samples from 3 key time points were for spatially resolved metabolomics and transcriptomics analysis, as well as applied to validate the key TTT-regulated molecules by RT-qPCR.

RESULTS

Notably, 64.7% of patients did not use antibiotics during the entire TTT surgery. TTT surgery can achieve a high limb salvage rate of 92.6% in patients with unilateral or bilateral DFUs. Pathway analysis of a total of 252 differentially expressed proteins (DEPs) from the proteomic revealed that the immune response induced by TTT surgery at different stages was first comprehensively verified through multi-omics combined with immune biomarker analysis. The function of upward transport was activating the systemic immune response, and wound healing occurs with downward transport. The spatial metabolic characteristics of skin tissue from patients with DFUs indicated downregulated levels of stearoylcarnitine and the glycerophospholipid metabolism pathway in skin tissue from patients with severe DFUs. Finally, the expressions of PRNP (prion protein) to activate the immune response, PLCB3 (PLCB3, phospholipase C beta 3) and VE-cadherin to play roles in neovascularization, and PPDPF (pancreatic progenitor cell differentiation and proliferation factor), LAMC2 (laminin subunit gamma 2) and SPRR2G (small proline rich protein 2G) to facilitate the developmental process mainly keratinocyte differentiation were statistically significant in skin tissues through transcriptomic and RT-qPCR analysis.

CONCLUSION

Tibial cortex transverse transport (TTT) surgery demonstrates favorable outcomes for patients with severe type 2 DFUs by activating a systemic immune response, contributing to anti-infection, ulcer recurrence, and the limb salvage rate for unilateral or bilateral DFUs. The specific clinical immune responses, candidate proteins, genes, and metabolic characteristics provide directions for in-depth mechanistic research on TTT surgery. Further research and public awareness are needed to optimize TTT surgery in patients with severe type 2 DFUs.

Global burden of type 1 diabetes in adults aged 65 years and older, 1990-2019: population based study

OBJECTIVES

To estimate the burden, trends, and inequalities of type 1 diabetes mellitus (T1DM) among older adults at global, regional, and national level from 1990 to 2019.

DESIGN

Population based study.

POPULATION

Adults aged ≥65 years from 21 regions and 204 countries and territories (Global Burden of Disease and Risk Factors Study 2019)from 1990 to 2019.

MAIN OUTCOME MEASURES

Primary outcomes were T1DM related age standardised prevalence, mortality, disability adjusted life years (DALYs), and average annual percentage change.

RESULTS

The global age standardised prevalence of T1DM among adults aged ≥65 years increased from 400 (95% uncertainty interval (UI) 332 to 476) per 100 000 population in 1990 to 514 (417 to 624) per 100 000 population in 2019, with an average annual trend of 0.86% (95% confidence interval (CI) 0.79% to 0.93%); while mortality decreased from 4.74 (95% UI 3.44 to 5.9) per 100 000 population to 3.54 (2.91 to 4.59) per 100 000 population, with an average annual trend of -1.00% (95% CI -1.09% to -0.91%), and age standardised DALYs decreased from 113 (95% UI 89 to 137) per 100 000 population to 103 (85 to 127) per 100 000 population, with an average annual trend of -0.33% (95% CI -0.41% to -0.25%). The most significant decrease in DALYs was observed among those aged <79 years: 65-69 (-0.44% per year (95% CI -0.53% to -0.34%)), 70-74 (-0.34% per year (-0.41% to -0.27%)), and 75-79 years (-0.42% per year (-0.58% to -0.26%)). Mortality fell 13 times faster in countries with a high sociodemographic index versus countries with a low-middle sociodemographic index (-2.17% per year (95% CI -2.31% to -2.02%) v -0.16% per year (-0.45% to 0.12%)). While the highest prevalence remained in high income North America, Australasia, and western Europe, the highest DALY rates were found in southern sub-Saharan Africa, Oceania, and the Caribbean. A high fasting plasma glucose level remained the highest risk factor for DALYs among older adults during 1990-2019.

CONCLUSIONS

The life expectancy of older people with T1DM has increased since the 1990s along with a considerable decrease in associated mortality and DALYs. T1DM related mortality and DALYs were lower in women aged ≥65 years, those living in regions with a high sociodemographic index, and those aged <79 years. Management of high fasting plasma glucose remains a major challenge for older people with T1DM, and targeted clinical guidelines are needed.

Advances in fecal microbiota transplantation for the treatment of diabetes mellitus

Diabetes mellitus (DM) refers to a group of chronic diseases with global prevalence, characterized by persistent hyperglycemia resulting from various etiologies. DM can harm various organ systems and lead to acute or chronic complications, which severely endanger human well-being. Traditional treatment mainly involves controlling blood sugar levels through replacement therapy with drugs and insulin; however, some patients still find a satisfactory curative effect difficult to achieve. Extensive research has demonstrated a close correlation between enteric dysbacteriosis and the pathogenesis of various types of DM, paving the way for novel therapeutic approaches targeting the gut microbiota to manage DM. Fecal microbiota transplantation (FMT), a method for re-establishing the intestinal microbiome balance, offers new possibilities for treating diabetes. This article provides a comprehensive review of the correlation between DM and the gut microbiota, as well as the current advancements in FMT treatment for DM, using FMT as an illustrative example. This study aims to offer novel perspectives and establish a theoretical foundation for the clinical diagnosis and management of DM.

Probiotics and synbiotics for glycemic control in diabetes: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND & AIMS

The escalating prevalence of diabetes mellitus may benefit from add-on therapeutic approaches. Given the recognized need for an updated synthesis of the literature, this systematic review and meta-analysis aimed to synthesize and critically assess the available randomized controlled trials (RCTs) that investigate the efficacy of probiotics and synbiotics on glycemic control in patients with Type 1 (T1DM) and Type 2 (T2DM) diabetes mellitus.

METHODS

Comprehensive searches were conducted on PubMed, Embase, CINAHL, Scopus, and Web of Science, focusing on adults with T1DM or T2DM. All comparators were deemed eligible. Primary outcomes included changes in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and insulin levels. Only RCTs were included, and the Cochrane RoB2 tool assessed the risk of bias. Random-effect models facilitated data analysis, supplemented by sensitivity, subgroup analyses, and meta-regressions.

RESULTS

A total of 537 records were screened, resulting in 41 RCTs for analysis, which comprises 2991 (54% females) patients with diabetes. The meta-analysis revealed statistically significant improvements in HbA1c (standardized mean difference (SMD) = -0.282, 95% CI: [-0.37, -0.19], p < 0.001), FPG (SMD = -0.175, 95% CI: [-0.26, -0.09], p < 0.001), and insulin levels (SMD = -0.273, 95% CI: [-0.35, -0.20], p < 0.001). A medium degree of heterogeneity between studies was found in HbA1c (I2 = 62.5%), FPG (I2 = 71.5%), and insulin levels (I2 = 66.4%) analyses. Subgroup analyses indicated that the efficacy varied based on the type of strains used and the country. Multispecies strains were particularly effective in improving HbA1c levels.

CONCLUSION

The study findings suggest that probiotics and synbiotics may be effective as complementary therapies for managing diabetes. Additionally, the study underscores the need for further tailored research that considers variables such as strain types and geographical factors to deepen the understanding of the role of these interventions in diabetes care.

REVIEW REGISTRATION NUMBER

PROSPERO (CRD42023396348).

Advances in secondary prevention mechanisms of macrovascular complications in type 2 diabetes mellitus patients: a comprehensive review

Type 2 diabetes mellitus (T2DM) poses a significant global health burden. This is particularly due to its macrovascular complications, such as coronary artery disease, peripheral vascular disease, and cerebrovascular disease, which have emerged as leading contributors to morbidity and mortality. This review comprehensively explores the pathophysiological mechanisms underlying these complications, protective strategies, and both existing and emerging secondary preventive measures. Furthermore, we delve into the applications of experimental models and methodologies in foundational research while also highlighting current research limitations and future directions. Specifically, we focus on the literature published post-2020 concerning the secondary prevention of macrovascular complications in patients with T2DM by conducting a targeted review of studies supported by robust evidence to offer a holistic perspective.

Short-term glucose variability as a determinant of the healing rate of diabetic foot ulcer: A retrospective study

BACKGROUND

The aim of this study was to describe the clinical characteristics of people with diabetic foot ulcer (DFU) according to glucose variability (GV) and to investigate the relationship between GV and DFU outcome in a population with type 2 diabetes (T2D) and DFU.

METHODS

This is a retrospective study of 300 individuals aged 64.3 years (181 males) treated for DFU in a tertiary-care center with a regular follow-up for 6 months. Laboratory measurements and clinical assessments were collected at baseline. According to the coefficient of variation (CV) cut-off (≥36%), people were divided into two groups (low and high GV).

RESULTS

Compared with low GV group (n = 245), high GV group (n = 55) had significant longer duration of diabetes [low vs high GV, mean ± Standard Deviation (SD), 17.8 ± 11.8 vs 22.4 ± 10.8, P = 0.012], higher levels of glycated haemoglobin [median (IQR), 7.4 (6.6, 8.8) vs 8.2 (7.0, 9.6), P = 0.010] and urinary albumin excretion [25.2 (11.9, 77.0) vs 48.0 (23.2, 106.0), P = 0.031]. Moreover, 10 days self-monitoring of blood glucose-derived glycemic metrics were significantly different between groups. No differences among clinical features were found. The multiple logistic regression analysis identified CV and SD as negative predictors of healing.

CONCLUSIONS

In a population of people with T2D and DFU treated in a tertiary-care center, individuals with high GV had a 3-fold higher risk of healing failure, as compared with those with low GV. CV and SD were related to poor healing within 6 months follow-up.

One-hour post-load glucose levels are associated with hepatic steatosis assessed by transient elastography

AIM

To examine the association between 1-hour plasma glucose (PG) concentration and markers of non-alcoholic fatty liver disease (NAFLD) assessed by transient elastography (TE).

METHODS

We performed TE in 107 metabolically well-characterized non-diabetic White individuals. Controlled attenuation parameter (CAP) was used to quantify liver steatosis, while liver stiffness marker (LS) was used to evaluate fibrosis.

RESULTS

Controlled attenuation parameter correlated significantly with 1-hour PG (r = 0.301, P < 0.01), fasting insulin (r = 0.285, P < 0.01), 2-hour insulin (r = 0.257, P < 0.02), homeostasis model assessment index of insulin resistance (r = 0.252, P < 0.01), high-density lipoprotein cholesterol (r = -0.252, P < 0.02), body mass index (BMI; r = 0.248, P < 0.02) and age (r = 0.212, P < 0.03), after correction for age, sex and BMI. In a multivariable linear regression analysis, 1-hour PG (β = 0.274, P = 0.008) and fasting insulin levels (β = 0.225, P = 0.029) were found to be independent predictors of CAP. After excluding subjects with prediabetes, 1-hour PG was the sole predictor of CAP variation (β = 0.442, P < 0.001). In a logistic regression model, we observed that the group with 1-hour PG ≥  8.6 mmol/L (155 mg/dL) had a significantly higher risk of steatosis (odds ratio 3.98, 95% confidence interval 1.43-11.13; P = 0.008) than individuals with 1-hour PG <  8.6 mmol/L, after correction for potential confounders. No association was observed between 1-hour PG and LS.

CONCLUSION

Our data confirm that 1-hour PG ≥  8.6 mmol/L is associated with higher signs of NAFLD, even among individuals with normal glucose tolerance, categorized as low risk by canonical diagnostic standards. TE is a safe low-impact approach that could be employed for stratifying the risk profile in these patients, with a high level of accuracy.

Diabetes Mellitus to Accelerated Atherosclerosis: Shared Cellular and Molecular Mechanisms in Glucose and Lipid Metabolism

Diabetes is one of the critical independent risk factors for the progression of cardiovascular disease, and the underlying mechanism regarding this association remains poorly understood. Hence, it is urgent to decipher the fundamental pathophysiology and consequently provide new insights into the identification of innovative therapeutic targets for diabetic atherosclerosis. It is now appreciated that different cell types are heavily involved in the progress of diabetic atherosclerosis, including endothelial cells, macrophages, vascular smooth muscle cells, dependence on altered metabolic pathways, intracellular lipids, and high glucose. Additionally, extensive studies have elucidated that diabetes accelerates the odds of atherosclerosis with the explanation that these two chronic disorders share some common mechanisms, such as endothelial dysfunction and inflammation. In this review, we initially summarize the current research and proposed mechanisms and then highlight the role of these three cell types in diabetes-accelerated atherosclerosis and finally establish the mechanism pinpointing the relationship between diabetes and atherosclerosis.

Adoption of Wearable Insulin Biosensors for Diabetes Management: A Cross-Sectional Study

BACKGROUND

Wearable insulin biosensors represent a novel approach that combines the benefits of real-time glucose monitoring and automated insulin delivery, potentially revolutionizing how individuals with diabetes manage their condition.

STUDY PURPOSE

To analyze the behavioral intentions of wearable insulin biosensors among diabetes patients, the factors that drive or hinder their usage, and the implications for diabetes management and healthcare outcomes.

METHODS

A cross-sectional survey design was adopted in this study. The validated questionnaire included 10 factors (Performance expectancy, effort expectancy, social influence, facilitating conditions, behavioral intention, trust, perceived privacy risk, and personal innovativeness) affecting the acceptance of wearable insulin sensors. A total of 248 diabetic patients who had used wearable sensors participated in the study.

RESULTS

Performance expectancy was rated the highest (Mean = 3.84 out of 5), followed by effort expectancy (Mean = 3.78 out of 5), and trust (Mean = 3.53 out of 5). Statistically significant differences (p < 0.05) were observed with respect to socio-demographic variables including age and gender on various influencing factors and adoption intentions. PE, EE, and trust were positively associated with adoption intentions.

CONCLUSION

While wearable insulin sensors are positively perceived with respect to diabetes management, issues like privacy and security may affect their adoption.

Guideline Development for Medical Device Technology: Issues for Consideration

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Interaction between haptoglobin genotype and glycemic variability on diabetic macroangiopathy: a population-based cross-sectional study

PURPOSE

Haptoglobin (Hp) is a hemoglobin-binding protein that functions as an antioxidant in human plasma. It is reported that glycemic variability (GV) plays a key role in diabetes-related complications associated with impaired glucose metabolism and oxidative stress. Here we aim to investigate whether the effect of GV on diabetic macroangiopathy depends on Hp genotype in type 2 diabetes.

METHODS

A number of 860 Chinese patients with type 2 diabetes was genotyped and assigned to two Hp subgroups (Hp 2-2 and Hp 1 carriers). Glycemic variability (GV) was assessed by using a retrospective continuous glucose monitoring system for three consecutive days, and it was measured using the glucose coefficient of variation (%CV), which is calculated as the ratio of glucose standard deviation to glucose mean. Clinical features, history of cardiac surgery, and vascular imaging tests were utilized to diagnose macroangiopathy. We evaluated the interaction between Hp genotypes and %CV on diabetic macroangiopathy. Furthermore, serum concentration of 8-hydroxy-2'-deoxyguanosine (8-OHdG) was measured using an enzyme-linked immunosorbent assay as a biomarker of oxidative stress.

RESULTS

Serum 8-OHdG levels were positively correlated with %CV in Hp 1 carriers (r = 0.117; p = 0.021). Patients in the highest %CV tertile were associated with a higher prevalence of diabetic macroangiopathy than those in the lowest %CV tertile in Hp 1 carriers (OR = 2.461 [95% CI, 1.183-5.121], p = 0.016), but not in those with Hp 2-2 genotype (OR = 0.540 [95% CI, 0.245-1.191], p = 0.127). A significant interactive effect of Hp genotypes and %CV on diabetic macroangiopathy was found (p interaction = 0.008).

CONCLUSION

Hp genotype modifies the effect of GV on diabetic macroangiopathy among Chinese patients with type 2 diabetes.

Key indices of glycaemic variability for application in diabetes clinical practice

Near normal glycaemic control in diabetes consists to target daily glucose fluctuations and quarterly HbA1c oscillations in addition to overall glucose exposure. Consequently, the prerequisite is to define simple, and mathematically undisputable key metrics for the short- and long-term variability in glucose homeostasis. As the standard deviations (SD) of either glucose or HbA1c are dependent on their means, the coefficient of variation (CV = SD/mean) should be applied instead as it that avoids the correlation between the SD and mean values. A CV glucose of 36% is the most appropriate threshold between those with stable versus labile glucose homeostasis. However, when near normal mean glucose concentrations are achieved a lower CV threshold of <27 % is necessary for reducing the risk for hypoglycaemia to a minimal rate. For the long-term variability in glucose homeostasis, a CVHbA1c < 5 % seems to be a relevant recommendation for preventing adverse clinical outcomes.

Glucose fluctuations aggravate myocardial fibrosis via activating the CaMKII/Stat3 signaling in type 2 diabtetes

BACKGROUND

Glucose fluctuations (GF) are a risk factor for cardiovascular complications associated with type 2 diabetes. However, there is a lack of adequate research on the effect of GF on myocardial fibrosis and the underlying mechanisms in type 2 diabetes. This study aimed to investigate the impact of glucose fluctuations on myocardial fibrosis and explore the potential mechanisms in type 2 diabetes.

METHODS

Sprague Dawley (SD) rats were randomly divided into three groups: the control (Con) group, the type 2 diabetic (DM) group and the glucose fluctuations (GF) group. The type 2 diabetic rat model was established using a high-fat diet combined with low-dose streptozotocin injection and the GF model was induced by using staggered glucose and insulin injections daily. After eight weeks, echocardiography was used to assess the cardiac function of the three groups. Hematoxylin-eosin and Masson staining were utilized to evaluate the degree of pathological damage and fibrosis. Meanwhile, a neonatal rat cardiac fibroblast model with GF was established. Western and immunofluorescence were used to find the specific mechanism of myocardial fibrosis caused by GF.

RESULTS

Compared with rats in the Con and the DM group, cardiac function in the GF group showed significant impairments. Additionally, the results showed that GF aggravated myocardial fibrosis in vitro and in vivo. Moreover, Ca2+/calmodulin‑dependent protein kinase II (CaMKII) was activated by phosphorylation, prompting an increase in phosphorylation of signal transducer and activator of transcription 3 (Stat3) and induced nuclear translocation. Pretreatment with KN-93 (a CaMKII inhibitor) blocked GF-induced Stat3 activation and significantly suppressed myocardial fibrosis.

CONCLUSIONS

Glucose fluctuations exacerbate myocardial fibrosis by triggering the CaMKII/Stat3 pathway in type 2 diabetes.

Effects of pharmacist-led interventions on glycaemic control, adherence, disease management and health-related quality of life in patients with type 2 diabetes: a protocol for a network meta-analysis

INTRODUCTION

The increase in the number of patients with uncontrolled type 2 diabetes mellitus (T2DM) is in need of effective management interventions. However, research to date has been limited to the evaluation of the outcomes of community pharmacists alone. Therefore, the aim of the study protocol is to compare the effects of clinical pharmacist-led intervention strategies for the management of T2DM in the outpatient settings.

METHOD AND ANALYSIS

The study will collect and analyse data applying standard Cochrane methodological procedures. A search for eligible studies and ongoing trials will be conducted using PubMed, Embase, Medline (via Ovid), EBSCO (via Ovid), Lippincott Williams & Wilkins (LWW) Journals (via Ovid), ProQuest Health and Medical Complete, and ClinicalTrials.gov (clinicaltrials.gov) from database inception to December 2023. Clinical and health outcomes will be measured using both glycaemic control related indicators (eg, glycated haemoglobin, fasting blood glucose, postprandial glucose) and general indicators (eg, adherence, disease management and health-related quality of life). The meta-analysis will conduct pairwise meta-analysis using random effects models and network meta-analysis (NMA) employing the Bayesian hierarchical model. The visualisation and statistical analysis will be carried out using RevMan, R Studio and ADDIS. Additionally, we will evaluate the certainty of the evidence by using Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

There will be no primary data collection from NMA participants, and there is no requirement for formal ethical review. Our aim is to present the results of this NMA in a peer-reviewed scientific journal, at conferences, and in the mainstream media.

PROSPERO REGISTRATION NUMBER

CRD42022355368.

The Effect of Insulin Degludec Versus Insulin Glargine U100 on Glucose Metrics Recorded During Continuous Glucose Monitoring in People With Type 1 Diabetes and Recurrent Nocturnal Severe Hypoglycemia

AIM

Comparing continuous glucose monitoring (CGM)-recorded metrics during treatment with insulin degludec (IDeg) versus insulin glargine U100 (IGlar-100) in people with type 1 diabetes (T1D) and recurrent nocturnal severe hypoglycemia.

MATERIALS AND METHODS

This is a multicenter, two-year, randomized, crossover trial, including 149 adults with T1D and minimum one episode of nocturnal severe hypoglycemia within the last two years. Participants were randomized 1:1 to treatment with IDeg or IGlar-100 and given the option of six days of blinded CGM twice during each treatment. CGM traces were reviewed for the percentage of time-within-target glucose range (TIR), time-below-range (TBR), time-above-range (TAR), and coefficient of variation (CV).

RESULTS

Seventy-four participants were included in the analysis. Differences between treatments were greatest during the night (23:00-06:59). Treatment with IGlar-100 resulted in 54.0% vs 49.0% with IDeg TIR (70-180 mg/dL) (estimated treatment difference [ETD]: -4.6%, 95% confidence interval [CI]: -9.1, -0.0, P = .049). TBR was lower with IDeg at level 1 (54-69 mg/dL) (ETD: -1.7% [95% CI: -2.9, -0.5], P < .05) and level 2 (<54 mg/dL) (ETD: -1.3% [95% CI: -2.1, -0.5], P = .001). TAR was higher with IDeg compared with IGlar-100 at level 1 (181-250 mg/dL) (ETD: 4.0% [95% CI: 0.8, 7.3], P < .05) and level 2 (> 250 mg/dL) (ETD: 4.0% [95% CI: 0.8, 7.2], P < .05). The mean CV was lower with IDeg than that with IGlar-100 (ETD: -3.4% [95% CI: -5.6, -1.2], P < .05).

CONCLUSION

For people with T1D suffering from recurrent nocturnal severe hypoglycemia, treatment with IDeg, compared with IGlar-100, results in a lower TBR and CV during the night at the expense of more TAR.

Efficacy and safety of closed-loop control system for type one diabetes in adolescents a meta analysis

This meta-analysis compares the efficacy and safety of Closed-Loop Control (CLC) to Sensor-Augmented Insulin Pump (SAP) for adolescent patients with Type 1 Diabetes Mellitus (T1DM). Eleven randomized-controlled trials were included with a total of 570 patients, from a total of 869 articles found adhering to PRISMA guidelines. The efficacy of the therapies were evaluated from the day, night and during physical activities monitoring of the of the mean blood glucose (BG), Time In Range (TIR), and Standard Deviation (SD) of the glucose variability. The safety measure of the therapies, was assessed from the day and night recording of the hypoglycemic and hyperglycemic events occurred. Pooled results of comparison of mean BG values for day, night and physical activities, - 4.33 [- 6.70, - 1.96] (P = 0.0003), - 16.61 [- 31.68, - 1.54] (P = 0.03) and - 8.27 [- 19.52, 2.99] (P = 0.15). The monitoring for day, night and physical activities for TIR - 13.18 [- 19.18, - 7.17] (P < 0.0001), - 15.36 [- 26.81, - 3.92] (P = 0.009) and - 7.39 [- 17.65, 2.87] (P = 0.16). The day and night results of SD of glucose variability was - 0.40 [- 0.79, - 0.00] (P = 0.05) and - 0.86 [- 2.67, 0.95] (P = 0.35). These values shows the superiority of CLC system in terms of efficacy. The safety evaluation, of the day, night and physical activities observations of average blood glucose goal hypoglycemic events - 0.54 [- 1.86, 0.79] (P = 0.43), 0.04 [- 0.20, 0.27] (P = 0.77) and 0.00 [- 0.25, 0.25] (P = 1.00) and hyperglycemic events - 0.04 [- 0.20, 0.27] (P = 0.77), - 7.11 [- 12.77, - 1.45] (P = 0.01) and - 0.00 [- 0.10, 0.10] (P = 0.97), highlights the commendable safety factor of CLC. The CLC systems can be considered as an ideal preference in the management of adolescents with type 1 diabetes to be used during a 24 h basis.

Patent analysis of digital sensors for continuous glucose monitoring

The high need for optimal diabetes management among an ever-increasing number of patients dictates the development and implementation of new digital sensors for continuous glucose monitoring. The purpose of this work is to systematize the global patenting trends of digital sensors for continuous glucose monitoring and analyze their effectiveness in controlling the treatment of diabetes patients of different ages and risk groups. The Lens database was used to build the patent landscape of sensors for continuous glucose monitoring. Retrospective analysis showed that the patenting of sensors for continuous glucose monitoring had positive trend over the analyzed period (2000-2022). Leading development companies are Dexcom Inc., Abbott Diabetes Care Inc., Medtronic Minimed Inc., Roche Diabetes Care Inc., Roche Diagnostics Operations Inc., Roche Diabetes Care Gmbh, and Ascensia Diabetes Care Holdings Ag, among others. Since 2006, a new approach has emerged where digital sensors are used for continuous glucose monitoring, and smartphones act as receivers for the data. Additionally, telemedicine communication is employed to facilitate this process. This opens up new opportunities for assessing the glycemic profile (glycemic curve information, quantitative assessment of the duration and amplitude of glucose fluctuations, and so on), which may contribute to improved diabetes management. A number of digital sensors for minimally invasive glucose monitoring are patented, have received FDA approval, and have been on the market for over 10 years. Their effectiveness in the clinic has been proven, and advantages and disadvantages have been clarified. Digital sensors offer a non-invasive option for monitoring blood glucose levels, providing an alternative to traditional invasive methods. This is particularly useful for patients with diabetes who require frequent monitoring, including before and after meals, during and after exercise, and in other scenarios where glucose levels can fluctuate. However, non-invasive glucose measurements can also benefit patients without diabetes, such as those following a dietary treatment plan, pregnant women, and individuals during fasting periods like Ramadan. The availability of non-invasive monitoring is especially valuable for patients in high-risk groups and across different age ranges. New world trends have been identified in the patenting of digital sensors for non-invasive glucose monitoring in interstitial skin fluid, saliva, sweat, tear fluid, and exhaled air. A number of non-invasive devices have received the CE mark approval, which confirms that the items meet European health, safety, and environmental protection standards (TensorTip Combo-Glucometer, Cnoga Medical Ltd.; SugarBEAT, Nemaura Medical; GlucoTrack, GlucoTrack Inc.), but are not FDA-approved yet. The above-mentioned sensors have characteristics that make them popular in the treatment of diabetes: they do not require implantation, do not cause an organism reaction to a foreign body, and are convenient to use. In the EU, in order to increase clinical safety and the level of transparency about medical devices, manufacturers must obtain certificates in accordance with Regulation (EU) 2017/745, taking into account the transition period. The development of systems, which include digital sensors for continuous glucose monitoring, mobile applications, and web platforms for professional analysis of glycemic control and implementation of unified glycemic assessment principles in mobile healthcare, represent promising approaches for controlling glycaemia in patients.

Perspectives on weight control in diabetes - Tirzepatide

Tirzepatide, a once-weekly glucose-dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonist (GIP/GLP-1 RA) improves glycemic control. Besides improvement of glycemic control, tirzepatide treatment is associated with significantly more weight loss as compared to potent selective GLP-1 receptor agonists as well as other beneficial changes in cardio-metabolic parameters, such as reduced fat mass, blood pressure, improved insulin sensitivity, lipoprotein concentrations, and circulating metabolic profile in individuals with type 2 diabetes (T2D). Some of these changes are partially associated with weight reduction. We review here the putative mechanisms of GIP receptor agonism contributing to GLP-1 receptor agonism-induced weight loss and respective findings with GIP/GLP-1 RAs, including tirzepatide in T2D preclinical models and clinical studies. Subsequently, we summarize the clinical data on weight loss and related non-glycemic metabolic changes of tirzepatide in T2D. These findings suggest that the robust weight loss and associated changes are important contributors to the clinical profile of tirzepatide for the treatment of T2D diabetes and serve as the basis for further investigations including clinical outcomes.

Continuous glucose monitoring versus blood glucose monitoring for risk of severe hypoglycaemia and diabetic ketoacidosis in children, adolescents, and young adults with type 1 diabetes: a population-based study

BACKGROUND

The effect of continuous glucose monitoring on the risk of severe hypoglycaemia and ketoacidosis in patients with diabetes is unclear. We investigated whether rates of acute diabetes complications are lower with continuous glucose monitoring, compared with blood glucose monitoring, and which metrics predict its risk in young patients with type 1 diabetes.

METHODS

In this population-based cohort study, patients were identified from 511 diabetes centres across Austria, Germany, Luxembourg, and Switzerland participating in the Diabetes Prospective Follow-up initiative. We included people with type 1 diabetes aged 1·5-25·0 years, with a diabetes duration of more than 1 year, who had been treated between Jan 1, 2014, and June 30, 2021, and had an observation time of longer than 120 days in the most recent treatment year. Severe hypoglycaemia and ketoacidosis rates during the most recent treatment year were examined in people using continuous glucose monitoring and in those using blood glucose monitoring. Adjustments of statistical models included age, sex, diabetes duration, migration background, insulin therapy (pump or injections), and treatment period. Rates of severe hypoglycaemia and diabetic ketoacidosis were evaluated by several continuous glucose monitoring metrics, including percentage of time below target glucose range (<3·9 mmol/L), glycaemic variability (measured as the coefficient of variation), and mean sensor glucose.

FINDINGS

Of 32 117 people with type 1 diabetes (median age 16·8 years [IQR 13·3-18·1], 17 056 [53·1%] males), 10 883 used continuous glucose monitoring (median 289 days per year), and 21 234 used blood glucose monitoring. People using continuous glucose monitoring had lower rates of severe hypoglycaemia than those using blood glucose monitoring (6·74 [95% CI 5·90-7·69] per 100 patient-years vs 8·84 [8·09-9·66] per 100 patient-years; incidence rate ratio 0·76 [95% CI 0·64-0·91]; p=0·0017) and diabetic ketoacidosis (3·72 [3·32-4·18] per 100 patient-years vs 7·29 [6·83-7·78] per 100 patient-years; 0·51 [0·44-0·59]; p<0·0001). Severe hypoglycaemia rates increased with percentage of time below target glucose range (incidence rate ratio 1·69 [95% CI 1·18-2·43]; p=0·0024, for 4·0-7·9% vs <4·0% and 2·38 [1·51-3·76]; p<0·0001, for ≥8·0% vs <4·0%) and glycaemic variability (coefficient of variation ≥36% vs <36%; incidence rate ratio 1·52 [95% CI 1·06-2·17]; p=0·022). Diabetic ketoacidosis rates increased with mean sensor glucose (incidence rate ratio 1·77 [95% CI 0·89-3·51], p=0·13, for 8·3-9·9 mmol/L vs <8·3 mmol/L; 3·56 [1·83-6·93], p<0·0001, for 10·0-11·6 mmol/L vs <8·3 mmol/L; and 8·66 [4·48-16·75], p<0·0001, for ≥11·7 mmol/L vs <8·3 mmol/L).

INTERPRETATION

These findings provide evidence that continuous glucose monitoring can reduce severe hypoglycaemia and ketoacidosis risk in young people with type 1 diabetes on insulin therapy. Continuous glucose monitoring metrics might help to identify those at risk for acute diabetes complications.

FUNDING

German Center for Diabetes Research, German Federal Ministry of Education and Research, German Diabetes Association, and Robert Koch Institute.

Weight variability and diabetes complications

Body weight is a recognized risk factor for cardiovascular diseases (CVD). More recently, weight variability, i.e. the oscillation of body weight over time, has also been suggested to be independently associated with development of CVD and mortality in subjects without diabetes and in people with both type 1 and type 2 diabetes (T2D). In T2D, weight variability emerged as one of the most relevant risk factors for CVD and it was suggested to interact with the variability of other risk factors to identify people at high cardiovascular risk. In addition, weight variability seems also to confer a higher risk for microvascular complications in people with T2D. While the exact mechanism linking weight variability to CVD is unknown, evidence from experimental models suggests that weight cycling promote an enduring pro-inflammatory program in the adipose tissue. Here we review the clinical evidence relative to the association of weight variability with CVD and microvascular complications of diabetes. We then briefly summarize the alterations proposed to explain this association. Finally, we synthesize the possible strategies, e.g. specific dietetic regimens and available glucose-lowering drugs, to minimize weight fluctuations.

Multimorbidity in nephrotic syndrome

Nephrotic syndrome (NS) is characterized by high proteinuria (over 3,5g/24 hrs), hypalbuminaemia, general edemas and hypercoagulation. Beside of primary glomerulonephritides this is found in secundary glomerulopaties eg. diabetes, systemic inflammatory diseases, oncology, damage by drugs and poisoning, by alergy, serious infections and in children from hereditary reasons. The most frequent reason for NS in adults patiens is diabetes and diabetes with nephropathy represents almost 40% of dialysed patiens. From this point of view, there is great interest focusing on gliflozins (SGLT2 inhibitors) with positive nephroprotecive effect. It leads do increasing of glycosuria with concomitant natriuresis and osmotic diuresis. The effect is proportional to glomerulal filtration, but the effect on natriuresis stay in all stages of renal insufficiency.

Precision Medicine in Diabetes

Tailoring treatment or management to groups of individuals based on specific clinical, molecular, and genomic features is the concept of precision medicine. Diabetes is highly heterogenous with respect to clinical manifestations, disease progression, development of complications, and drug response. The current practice for drug treatment is largely based on evidence from clinical trials that report average effects. However, around half of patients with type 2 diabetes do not achieve glycaemic targets despite having a high level of adherence and there are substantial differences in the incidence of adverse outcomes. Therefore, there is a need to identify predictive markers that can inform differential drug responses at the point of prescribing. Recent advances in molecular genetics and increased availability of real-world and randomised trial data have started to increase our understanding of disease heterogeneity and its impact on potential treatments for specific groups. Leveraging information from simple clinical features (age, sex, BMI, ethnicity, and co-prescribed medications) and genomic markers has a potential to identify sub-groups who are likely to benefit from a given drug with minimal adverse effects. In this chapter, we will discuss the state of current evidence in the discovery of clinical and genetic markers that have the potential to optimise drug treatment in type 2 diabetes.

Continuous glucose monitoring and metrics for clinical trials: an international consensus statement

Randomised controlled trials and other prospective clinical studies for novel medical interventions in people with diabetes have traditionally reported HbA1c as the measure of average blood glucose levels for the 3 months preceding the HbA1c test date. The use of this measure highlights the long-established correlation between HbA1c and relative risk of diabetes complications; the change in the measure, before and after the therapeutic intervention, is used by regulators for the approval of medications for diabetes. However, with the increasing use of continuous glucose monitoring (CGM) in clinical practice, prospective clinical studies are also increasingly using CGM devices to collect data and evaluate glucose profiles among study participants, complementing HbA1c findings, and further assess the effects of therapeutic interventions on HbA1c. Data is collected by CGM devices at 1-5 min intervals, which obtains data on glycaemic excursions and periods of asymptomatic hypoglycaemia or hyperglycaemia (ie, details of glycaemic control that are not provided by HbA1c concentrations alone that are measured continuously and can be analysed in daily, weekly, or monthly timeframes). These CGM-derived metrics are the subject of standardised, internationally agreed reporting formats and should, therefore, be considered for use in all clinical studies in diabetes. The purpose of this consensus statement is to recommend the ways CGM data might be used in prospective clinical studies, either as a specified study endpoint or as supportive complementary glucose metrics, to provide clinical information that can be considered by investigators, regulators, companies, clinicians, and individuals with diabetes who are stakeholders in trial outcomes. In this consensus statement, we provide recommendations on how to optimise CGM-derived glucose data collection in clinical studies, including the specific glucose metrics and specific glucose metrics that should be evaluated. These recommendations have been endorsed by the American Association of Clinical Endocrinologists, the American Diabetes Association, the Association of Diabetes Care and Education Specialists, DiabetesIndia, the European Association for the Study of Diabetes, the International Society for Pediatric and Adolescent Diabetes, the Japanese Diabetes Society, and the Juvenile Diabetes Research Foundation. A standardised approach to CGM data collection and reporting in clinical trials will encourage the use of these metrics and enhance the interpretability of CGM data, which could provide useful information other than HbA1c for informing therapeutic and treatment decisions, particularly related to hypoglycaemia, postprandial hyperglycaemia, and glucose variability.

Correlations between parameters of glycaemic variability and foetal growth, neonatal hypoglycaemia and hyperbilirubinemia in women with gestational diabetes

The diagnosis of gestational diabetes mellitus (GDM) is important to prevent maternal and neonatal complications. This study aimed to investigate the feasibility of parameters of glycaemic variability to predict neonatal complications in women with GDM. A retrospective study was conducted on pregnant women tested positive at the oral glucose tolerance test (OGTT) during 16-18 or 24-28 weeks of gestation. Glycaemic measures were extracted from patients' glucometers and expanded to obtain parameters of glycaemic variability. Data on pregnancy outcomes were obtained from clinical folders. Descriptive group-level analysis was used to assess trends in glycaemic measures and foetal outcomes. Twelve patients were included and analysed, accounting for 111 weeks of observations. The analysis of trends in parameters of glycaemic variability showed spikes of glycaemic mean, high blood glucose index and J-index at 30-31 weeks of gestation for cases with foetal macrosomia, defined as foetal growth >90° percentile, neonatal hypoglycaemia and hyperbilirubinemia. Specific trends in parameters of glycaemic variability observed at third trimester correlate with foetal outcomes. Further research is awaited to provide evidence that monitoring of glycaemic variability trends could be more clinically informative and useful than standard glycaemic checks to manage women with GDM at delivery.

The Role of NLRP3 Inflammasome Signaling on Arrhythmias in Diabetes

Diabetes is a significant risk factor for arrhythmias. However, the pathophysiology of diabetes-related arrhythmias still needs to be elucidated, presumably associated with structural and electrical remodeling. There is growing evidence that inflammation and arrhythmias are intimately associated, which has spurred significant interest in exploring the regulatory links in diabetes. Recent research findings have revealed a vital role for the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome signaling, and facilitated the occurrence of arrhythmias in diabetes, including NLRP3 inflammasome activation by multiple stressors and its downstream cytokines, interleukin-1β (IL-1β) and interleukin-18 (IL-18). This narrative review aims to summarize the complex interaction between NLRP3 inflammasomes signaling and diabetes-related arrhythmias. Articles regarding the role of NLRP3 inflammasome in diabetes-related arrhythmias and relevant mechanisms were selected. Relevant articles were selected from PubMed. The search terms were "NLRP3 inflammasome" and "diabetes" and "arrhythmia". Important references from selected articles were also retrieved. The role of NLRP3 inflammasome signaling in diabetes-induced arrhythmias may provide a new option for the prevention and treatment diabetes-related arrhythmias.

Time-varying parameters of glycemic control and glycation in relation to arterial stiffness in patients with type 1 diabetes

BACKGROUND

A substantial proportion of type 1 diabetes (T1D) patients free from known cardiovascular disease (CVD) show premature arterial stiffening, with age, blood pressure, and HbA1c-as gold standard of glycemic control-as main predictors. However, the relationship of arterial stiffness with other time-varying parameters of glycemic control and glycation has been far less explored. This study investigated the relationship of arterial stiffness with several short- and long-term parameters of glycemic control and glycation in patients with T1D, such as advanced glycation end-products (AGEs) and continuous glucose monitoring (CGM)-derived parameters.

METHODS

Cross-sectional study at a tertiary care centre including 54 patients with T1D free from known CVD. Arterial stiffness was assessed with carotid-femoral pulse wave velocity (cf-PWV). Current level and 10-year history of HbA1c were evaluated, and skin AGEs, urinary AGEs, and serum soluble AGE-receptor (sRAGE) concentrations. CGM for 7 days was used to determine time in range, time in hyper- and hypoglycemia, and glycemic variability.

RESULTS

Cf-PWV was associated with current HbA1c (r_s = + 0.28), mean 10-years HbA1c (r_s = + 0.36), skin AGEs (r_s = + 0.40) and the skin AGEs-to-sRAGE ratio (r_s = + 0.40), but not with urinary AGE or serum sRAGE concentrations; and not with any of the CGM-parameters. Multiple linear regression for cf-PWV showed that the model with the best fit included age, T1D duration, 24-h mean arterial pressure and mean 10-years HbA1c (adjusted R² = 0.645, p < 0.001).

CONCLUSIONS

Longer-term glycemic exposure as reflected by current and mean 10-years HbA1c is a key predictor of arterial stiffness in patients with T1D, while no relationship was found with any of the short-term CGM parameters. Our findings stress the importance of early and sustained good glycemic control to prevent premature CVD in patients with T1D and suggest that HbA1c should continue to be used in the risk assessment for diabetic complications. The role of skin glycation, as a biomarker for vascular aging, in the risk assessment for CVD is an interesting avenue for further research.

Reconsidering the role of glycaemic control in cardiovascular disease risk in type 2 diabetes: A 21st century assessment

It is well known that the multiple factors contributing to the pathogenesis of type 2 diabetes (T2D) confer an increased risk of developing cardiovascular disease (CVD). Although the relationship between hyperglycaemia and increased microvascular risk is well established, the relative contribution of hyperglycaemia to macrovascular events has been strongly debated, particularly owing to the failure of attempts to reduce CVD risk through normalizing glycaemia with traditional therapies in high-risk populations. The debate has been further fuelled by the relatively recent discovery of the cardioprotective properties of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors. Further, as guidelines now recommend individualizing glycaemic targets, highlighting the importance of achieving glycated haemoglobin (HbA1c) goals safely, the previously observed negative influences of intensive therapy on CVD risk might not present if trials were repeated using current-day treatments and individualized HbA1c goals. Emerging longitudinal data illuminate the overall effect of excess glucose, the impacts of magnitude and duration of hyperglycaemia on disease progression and risk of CVD complications, and the importance of glycaemic control at or early after diagnosis of T2D for prevention of complications. Herein, we review the role of glucose as a modifiable cardiovascular (CV) risk factor, the role of microvascular disease in predicting macrovascular risk, and the deleterious impact of therapeutic inertia on CVD risk. We reconcile new and old data to offer a current perspective, highlighting the importance of effective, early treatment in reducing latent CV risk, and the timely use of appropriate therapy individualized to each patient's needs.

To do one and to get more: Part II. Diabetes and metabolic dysfunction-associated fatty liver diseases

Type 2 diabetes mellitus (DM) is characterized by inability of faulty pancreatic β-cells to secret a normal amount of insulin to maintain normal body consumption, and/or peripheral tissue has a decreased susceptibility to insulin, resulting in hyperglycemia and insulin resistance. Similar to other chronic systemic inflammatory diseases, DM is a result from dysregulated interactions between ethnic, genetic, epigenetic, immunoregulatory, hormonal, and environmental factors. Therefore, it is rational to suppose the concept as "To do one and to get more", while using antidiabetic agents (ADA), a main pharmacologic agent for the treatment of DM, can provide an extraglycemia effect on comorbidities or concomittent comorbidities to DM. In this review, based on the much strong correlation between DM and metabolic dysfunction-associated fatty liver diseases (MAFLD) shown by similar pathophysiological mechanisms and a high prevalence of DM in MAFLD and its vice versa (a high prevalence of MAFLD in DM), it is possible to use the strategy to target both diseases simultaneously. We focus on a new classification of ADA, such as glucagon-like peptide-1 receptor (GLP1R) agonist and sodium-glucose cotransporter-2 (SGLT-2) inhibitors to show the potential benefits of extraglycemic effect on MAFLD. We conclude that the management of DM patients, especially for those who need ADA as adjuvant therapy should include healthy lifestyle modification to overcome the metabolic syndrome, contributing to the urgent need of an effective weight-reduction strategy. GLP1R agonist is one of effective body weight-lowering medications, which may be a better choice for DM complicated with MAFLD or its-associated severe form as metabolic associated steatohepatitis (MASH), although the role of SGLT-2 inhibitors is also impressive. The prescription of these two classes of ADA may satisfy the concept "To do one and to get more", based on successful sugar-lowering effect for controlling DM and extraglycemia benefits of hepatoprotective activity in DM patients.

Association of visit-to-visit HbA1c variability with cardiovascular diseases in type 2 diabetes within or outside the target range of HbA1c

Background

Although a growing attention has been recently paid to the role of HbA1c variability in the risk of diabetic complications, the impact of HbA1c variability on cardiovascular diseases (CVD) in type 2 diabetes is still debated. The aim of the study is to investigate the association of HbA1c variability with CVD in individuals within or outside the target range of HbA1c.

Methods

Using data from Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE), we enrolled 855 patients with type 2 diabetes in China. The primary outcomes included major macrovascular events and major microvascular events. Visit-to-visit HbA1c variability was expressed as the coefficient of variation (CV) of five measurements of HbA1c taken 3-24 months after treatment. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR).

Results

Among 855 patients in the intensive glucose treatment group, 563 and 292 patients were assigned to the group of "within the target range of HbA1c" (WTH) (updated mean HbA1c ≤ 7.0%) and "outside the target range of HbA1c" (OTH) (updated mean HbA1c > 7.0%), respectively. HbA1c variability was positively associated with the risk of major microvascular events in all patients and both the subgroups during a median follow-up period of 4.8 years. Particularly, the risk related to HbA1c variability was higher in patients in WTH group for the new or worsening nephropathy [aHR: 3.35; 95% confidence interval (CI): 1.05-10.74; P = 0.042].

Conclusions

This retrospective cohort study confirmed the positive correlation between HbA1c variability and major microvascular events, especially in subjects in WTH or OTH.

Pilot study in human healthy volunteers on the use of magnetohydrodynamics in needle-free continuous glucose monitoring

The benefits of continuous glucose monitoring (CGM) in diabetes management are extensively documented. Yet, the broader adoption of CGM systems is limited by their cost and invasiveness. Current CGM devices, requiring implantation or the use of hypodermic needles, fail to offer a convenient solution. We have demonstrated that magnetohydrodynamics (MHD) is effective at extracting dermal interstitial fluid (ISF) containing glucose, without the use of needles. Here we present the first study of ISF sampling with MHD for glucose monitoring in humans. We conducted 10 glucose tolerance tests on 5 healthy volunteers and obtained a significant correlation between the concentration of glucose in ISF samples extracted with MHD and capillary blood glucose samples. Upon calibration and time lag removal, the data indicate a Mean Absolute Relative Difference (MARD) of 12.9% and Precision Absolute Relative Difference of 13.1%. In view of these results, we discuss the potential value and limitations of MHD in needle-free glucose monitoring.