Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2018

Impact of chronic kidney disease and end-stage renal disease on the mid-term adverse outcomes in diabetic patients with cardiovascular diseases

The evidence for the impact of renal dysfunction in patients with diabetes mellitus (DM) and first cardiovascular diseases on mid-term adverse outcomes remain scarce. This study included the data of patients with DM having first atherosclerotic cardiovascular disease (ASCVD) or congestive heart failure (CHF) from the Taipei Medical University Clinical Research Database. A Cox proportional hazards regression model was used to assess the impact of chronic kidney disease (CKD) or end-stage renal disease (ESRD) on the 1-year mortality and recurrent ASCVD/CHF outcomes. We enrolled 21,320 patients with DM hospitalized for ASCVD or CHF; of them, 18,185, 2639, and 496 were assigned to the non-CKD, CKD, and ESRD groups, respectively. After propensity score matching, compared with the non-CKD group, the CKD and ESRD groups had higher mid-term all-cause mortality (adjusted hazard ratio 1.72 [95% confidence interval 1.48-1.99] and 2.77 [2.05-3.73], respectively), cardiovascular death (1.84 [1.44-2.35] and 1.87 [1.08-3.24], respectively), and recurrent hospitalization for ASCVD (1.44 [1.24-1.68] and 2.33 [1.69-3.23], respectively) and CHF (2.08 [1.75-2.47] and 1.50 [1.04-2.17], respectively). The advancing age was associated with mortality in CKD/ESRD groups. In CKD group, male sex was associated with all-cause mortality and recurrent ASCVD risk; the diuretics usage was associated with mortality and recurrent CHF risks. Our findings suggest that CKD and ESRD are significant risk factors for mid-term adverse outcomes in patients with DM and established cardiovascular diseases. Additionally, old age, male sex and diuretics usage requires attention. Further good quality studies are needed in the future.

Electrospun skin dressings for diabetic wound treatment: a systematic review

Abstract

Diabetes mellitus is a metabolic disease characterized by persistent hyperglycemia associated with a lack of insulin production or insulin resistance. In diabetic patients, the capacity for healing is generally decreased, leading to chronic wounds. One of the most common treatments for chronic wounds is skin dressings, which serve as protection from infection, reduce pain levels, and stimulate tissue healing. Furthermore, electrospinning is one of the most effective techniques used for manufacturing skin dressings.

Objective

The purpose of this study was to perform a systematic review of the literature to examine the effects of electrospun skin dressings from different sources in the process of healing skin wounds using in vivo experiments in diabetic rats.

Methods

The search was carried out according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and the Medical Subject Headings (MeSH) descriptors were defined as "wound dressing," "diabetes," "in vivo," and "electrospun." A total of 14 articles were retrieved from PubMed and Scopus databases.

Results

The results were based mainly on histological analysis and macroscopic evaluation, demonstrating moderate evidence synthesis for all experimental studies, showing a positive effect of electrospun skin dressings for diabetic wound treatment.

Conclusion

This review confirms the significant benefits of using electrospun skin dressings for skin repair and regeneration. All the inks used were demonstrated to be suitable for dressing manufacturing. Moreover, in vivo findings showed full wound closure in most of the studies, with well-organized dermal and epidermal layers.

Lipidomic studies revealing serological markers associated with the occurrence of retinopathy in type 2 diabetes

PURPOSE

The duration of type 2 diabetes mellitus (T2DM) and blood glucose levels have a significant impact on the development of T2DM complications. However, currently known risk factors are not good predictors of the onset or progression of diabetic retinopathy (DR). Therefore, we aimed to investigate the differences in the serum lipid composition in patients with T2DM, without and with DR, and search for potential serological indicators associated with the development of DR.

METHODS

A total of 622 patients with T2DM hospitalized in the Department of Endocrinology of the First Affiliated Hospital of Xi'an JiaoTong University were selected as the discovery set. One-to-one case-control matching was performed according to the traditional risk factors for DR (i.e., age, duration of diabetes, HbA1c level, and hypertension). All cases with comorbid chronic kidney disease were excluded to eliminate confounding factors. A total of 42 pairs were successfully matched. T2DM patients with DR (DR group) were the case group, and T2DM patients without DR (NDR group) served as control subjects. Ultra-performance liquid chromatography-mass spectrometry (LC-MS/MS) was used for untargeted lipidomics analysis on serum, and a partial least squares discriminant analysis (PLS-DA) model was established to screen differential lipid molecules based on variable importance in the projection (VIP) > 1. An additional 531 T2DM patients were selected as the validation set. Next, 1:1 propensity score matching (PSM) was performed for the traditional risk factors for DR, and a combined 95 pairings in the NDR and DR groups were successfully matched. The screened differential lipid molecules were validated by multiple reaction monitoring (MRM) quantification based on mass spectrometry.

RESULTS

The discovery set showed no differences in traditional risk factors associated with the development of DR (i.e., age, disease duration, HbA1c, blood pressure, and glomerular filtration rate). In the DR group compared with the NDR group, the levels of three ceramides (Cer) and seven sphingomyelins (SM) were significantly lower, and one phosphatidylcholine (PC), two lysophosphatidylcholines (LPC), and two SMs were significantly higher. Furthermore, evaluation of these 15 differential lipid molecules in the validation sample set showed that three Cer and SM(d18:1/24:1) molecules were substantially lower in the DR group. After excluding other confounding factors (e.g., sex, BMI, lipid-lowering drug therapy, and lipid levels), multifactorial logistic regression analysis revealed that a lower abundance of two ceramides, i.e., Cer(d18:0/22:0) and Cer(d18:0/24:0), was an independent risk factor for the occurrence of DR in T2DM patients.

CONCLUSION

Disturbances in lipid metabolism are closely associated with the occurrence of DR in patients with T2DM, especially in ceramides. Our study revealed for the first time that Cer(d18:0/22:0) and Cer(d18:0/24:0) might be potential serological markers for the diagnosis of DR occurrence in T2DM patients, providing new ideas for the early diagnosis of DR.

Association of vitamin D deficiency and subclinical diabetic peripheral neuropathy in type 2 diabetes patients

Background

Diabetic peripheral neuropathy (DPN) contributes to disability and imposes heavy burdens, while subclinical DPN is lack of attention so far. We aimed to investigate the relationship between vitamin D and distinct subtypes of subclinical DPN in type 2 diabetes (T2DM) patients.

Methods

This cross-sectional study included 3629 T2DM inpatients who undertook nerve conduction study to detect subclinical DPN in Zhongshan Hospital between March 2012 and December 2019. Vitamin D deficiency was defined as serum 25-hydroxyvitamin D (25(OH)D) level < 50 nmol/L.

Results

1620 (44.6%) patients had subclinical DPN and they were further divided into subgroups: distal symmetric polyneuropathy (DSPN) (n=685), mononeuropathy (n=679) and radiculopathy (n=256). Compared with non-DPN, DPN group had significantly lower level of 25(OH)D (P < 0.05). In DPN subtypes, only DSPN patients had significantly lower levels of 25(OH)D (36.18 ± 19.47 vs. 41.03 ± 18.47 nmol/L, P < 0.001) and higher proportion of vitamin D deficiency (78.54% vs. 72.18%, P < 0.001) than non-DPN. Vitamin D deficiency was associated with the increased prevalence of subclinical DPN [odds ratio (OR) 1.276, 95% confidence interval (CI) 1.086-1.501, P = 0.003] and DSPN [OR 1. 646, 95% CI 1.31-2.078, P < 0.001], independent of sex, age, weight, blood pressure, glycosylated hemoglobin, T2DM duration, calcium, phosphorus, parathyroid hormone, lipids and renal function. The association between vitamin D deficiency and mononeuropathy or radiculopathy was not statistically significant. A negative linear association was observed between 25(OH)D and subclinical DSPN. Vitamin D deficiency maintained its significant association with subclinical DSPN in all age groups.

Conclusions

Vitamin D deficiency was independently associated with subclinical DSPN, rather than other DPN subtypes.

Continuous intrafemoral artery infusion of urokinase improves diabetic foot ulcers healing and decreases cardiovascular events in a long-term follow-up study

INTRODUCTION

Diabetic foot ulcer (DFU) is a disabling complication of diabetes mellitus. Here, we attempted to assess whether long-term intrafemoral artery infusion of low-dose urokinase therapy improved DFUs and decreased cardiovascular events in patients with DFUs.

RESEARCH DESIGN AND METHODS

This trial was a single-center, randomized, parallel study. A total of 195 patients with DFU were randomized to continuous intrafemoral thrombolysis or conventional therapy groups. The continuous intrafemoral thrombolysis group received continuous intrafemoral urokinase injection for 7 days, and conventional therapy just received wound debridement and dressing change. Then, a follow-up of average 6.5 years was performed.

RESULTS

Compared with conventional therapy, at the first 1 month of intervention stage, the ulcers achieved a significant improvement in continuous intrafemoral thrombolysis group including a complete closure (72.4% vs 17.5%), an improved ulcer (27.6% vs 25.8%), unchanged or impaired ulcer (0% vs 56.7%). During the 6.5-year follow-up, for the primary outcome of ulcer closure rate, continuous intrafemoral thrombolysis therapy obtained a better complete healing rate (HR 3.42 (95% CI 2.35 to 4.98, p<0.0001)). For the secondary outcome of cardiovascular disease events, continuous intrafemoral thrombolysis therapy had a lower incidence of cardiovascular events (HR 0.50 (95% CI 0.34 to 0.74, p<0.0001)). Importantly, intrafemoral thrombolysis therapy decreased the incidence of cardiovascular death (HR 0.42 (95%CI 0.20 to 0.89, p=0.0241)). Additionally, continuous intrafemoral thrombolysis therapy improved local skin oxygenation and peripheral neuropathy as well as glycolipid metabolic profiles when compared with conventional therapy group (p<0.05).

CONCLUSIONS

Continuous intrafemoral thrombolysis therapy has a better therapeutic efficacy to improve DFUs and decrease cardiovascular events.

TRIAL REGISTRATION NUMBER

NCT01108120.

Protective Effects of Sitagliptin on Streptozotocin-Induced Hepatic Injury in Diabetic Rats: A Possible Mechanisms

Diabetes is a ubiquitous disease that causes several complications. It is associated with insulin resistance, which affects the metabolism of proteins, carbohydrates, and fats and triggers liver diseases such as fatty liver disease, steatohepatitis, fibrosis, and cirrhosis. Despite the effectiveness of Sitagliptin (ST) as an antidiabetic drug, its role in diabetes-induced liver injury is yet to be fully investigated. Therefore, this study aims to investigate the effect of ST on hepatic oxidative injury, inflammation, apoptosis, and the mTOR/NF-κB/NLRP3 signaling pathway in streptozotocin (STZ)-induced liver injury. Rats were allocated into four groups: two nondiabetic groups, control rats and ST rats (100 mg/kg), and two diabetic groups induced by STZ, and they received either normal saline or ST for 90 days. Diabetic rats showed significant hyperglycemia, hyperlipidemia, and elevation in liver enzymes. After STZ induction, the results revealed remarkable increases in hepatic oxidative stress, inflammation, and hepatocyte degeneration. In addition, STZ upregulated the immunoreactivity of NF-κB/p65, NLRP3, and mTOR but downregulated IKB-α in liver tissue. The use of ST mitigated metabolic and hepatic changes induced by STZ; it also reduced oxidative stress, inflammation, and hepatocyte degeneration. The normal expression of NF-κB/p65, NLRP3, mTOR, and IKB-α were restored with ST treatment. Based on that, our study revealed for the first time the hepatoprotective effect of ST that is mediated by controlling inflammation, oxidative stress, and mTOR/NF-κB/NLRP3 signaling.

Genomic profile of diabetic retinopathy in a north indian cohort

BACKGROUND

Diabetic Retinopathy (DR) is one of the major microvascular complications of diabetes. Being a complex disease, it is important to delineate the genetic and environmental factors that influence the susceptibility to DR in a population. Therefore, the present study was designed to investigate the role of genetic and lifestyle risk factors associated with DR susceptibility in a North-Indian population.

METHODS

A total of 848 subjects were enrolled, comprising of DR cases (n = 414) and healthy controls (n = 434). The Sequenom MassARRAY technology was used to perform target genome analysis of 111 SNPs across 57 candidate genes and 14 intergenic region SNPs that are involved in the metabolic pathways associated with type 2 diabetes (T2D) and DR. Allele, genotype and haplotype frequencies were determined and compared among cases and controls. Logistic regression models were used to determine genotype-phenotype and phenotype-phenotype correlations.

RESULTS

The strongest association was observed with TCF7L2 rs12255372 T allele [p < 0.0001; odds ratio (OR) = 1.81 (1.44-2.27)] and rs11196205 C allele [p < 0.0008; OR = 1.62 (1.32-1.99)]. Genotype-phenotype and phenotype-phenotype correlations were found in the present study.

CONCLUSION

Our study provides strong evidence of association between the TCF7L2 variants and DR susceptibility.

An evaluation of both serum Klotho/FGF-23 and apelin-13 for detection of diabetic nephropathy

PURPOSE

The aim of our study is to evaluate whether serum Klotho/FGF-23 and apelin-13 can be used as new biomarkers for detection of development of nephropathy.

METHODS

In this cross-sectional study, 88 type 2 diabetes mellitus (T2DM) patients and 38 healthy controls were included. The mean duration of T2DM was 11.4 ± 9.7 years. T2DM individuals were categorized into two groups as group 1 with e-GFR < 60 mL/min/1.73 m2 and group 2 with e-GFR > 60 mL/min/1.73 m2. They were also divided into two groups according to their 24 h urine albumin levels, classifying them as follows: normoalbuminuria if less than 30 mg/day and albuminuria if more than 30 mg/day.

RESULTS

Mean serum Klotho levels in the T2DM group were observed to be significantly higher than in the control group. Serum apelin-13 levels were observed to be significantly lower in the T2DM group compared to the control group (p < 0.001). In the diabetic group, apelin-13 levels were positively correlated with age, waist circumference, and albuminuria while they were negatively correlated with e-GFR. Apelin-13 levels were seen to be significantly higher in group 1 (p < 0.001).

CONCLUSION

Apelin-13 levels were found to be significantly higher in individuals with diabetic nephropathy than in those without diabetic nephropathy. In the diabetic group, a significant relationship was detected between apelin-13 levels and albumin excretion. Based on these findings, we consider that serum Klotho and apelin-13 levels may have a protective effect on diabetic nephropathy and can additionally be used as a biomarker to predict diabetic nephropathy.

Examination of Lower Limb Microcirculation in Diabetic Patients with and without Intermittent Claudication

Intermittent claudication is a frequent complaint in lower extremity artery disease, but approximately two thirds of patients are asymptomatic, most of which are diabetic patients. Non-invasive angiological and microrheological tests on diabetic subjects with and without intermittent claudication were performed in the present study. In total, 98 diabetic patients were included and divided into two groups: 20 patients (63.5 ± 8.8 years, 55% men, 45% women) had intermittent claudication, 78 patients (65.5 ± 9.3 years, 61.5% men, 38.5% women) were asymptomatic. Hand-held Doppler ultrasound examination, transcutaneous tissue partial oxygen pressure (tcpO2) measurement, Rydel-Seiffer tuning fork tests, and 6-min walk tests were performed, and erythrocyte aggregation was investigated. Ankle-brachial index (p < 0.02) and tcpO2, measured during provocation tests (p < 0.003) and the 6-min walk test (p < 0.0001), significantly deteriorated in the symptomatic group. A higher erythrocyte aggregation index and faster aggregate formation was observed in claudication patients (p < 0.02). Despite the statistically better results of the asymptomatic group, 13% of these patients had severe limb ischemia based on the results of tcpO2 measurement. Claudication can be associated with worse hemodynamic and hemorheological conditions in diabetic patients; however, severe ischemia can also develop in asymptomatic subjects. Non-invasive vascular tests can detect ischemia, which highlights the importance of early instrumental screening of the lower limbs.

Performance of artificial intelligence in diabetic retinopathy screening: a systematic review and meta-analysis of prospective studies

Aims

To systematically evaluate the diagnostic value of an artificial intelligence (AI) algorithm model for various types of diabetic retinopathy (DR) in prospective studies over the previous five years, and to explore the factors affecting its diagnostic effectiveness.

Materials and methods

A search was conducted in Cochrane Library, Embase, Web of Science, PubMed, and IEEE databases to collect prospective studies on AI models for the diagnosis of DR from January 2017 to December 2022. We used QUADAS-2 to evaluate the risk of bias in the included studies. Meta-analysis was performed using MetaDiSc and STATA 14.0 software to calculate the combined sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of various types of DR. Diagnostic odds ratios, summary receiver operating characteristic (SROC) plots, coupled forest plots, and subgroup analysis were performed according to the DR categories, patient source, region of study, and quality of literature, image, and algorithm.

Results

Finally, 21 studies were included. Meta-analysis showed that the pooled sensitivity, specificity, pooled positive likelihood ratio, pooled negative likelihood ratio, area under the curve, Cochrane Q index, and pooled diagnostic odds ratio of AI model for the diagnosis of DR were 0.880 (0.875-0.884), 0.912 (0.99-0.913), 13.021 (10.738-15.789), 0.083 (0.061-0.112), 0.9798, 0.9388, and 206.80 (124.82-342.63), respectively. The DR categories, patient source, region of study, sample size, quality of literature, image, and algorithm may affect the diagnostic efficiency of AI for DR.

Conclusion

AI model has a clear diagnostic value for DR, but it is influenced by many factors that deserve further study.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023389687.

Benefit and risk evaluation of quinapril hydrochloride

INTRODUCTION

Angiotensin-converting enzyme (ACE) inhibitors are a mainstay of antihypertensive therapy. Quinapril hydrochloride, a less commonly used, and less-studied ACE inhibitor has been approved for its primary use in hypertension. Studies also indicate its off-label use for congestive heart failure and diabetic nephropathy. The ANDI and TREND trials have been pivotal in demonstrating the effectiveness of quinapril.

AREAS COVERED

The authors conducted a review of the literature analyzing the clinical efficacy and safety profile of quinapril. This review discusses the development of quinapril, provides an updated summary of the indications and contraindications, and presents a comparison with other ACE inhibitors.

EXPERT OPINION

Quinapril is a safe and well-tolerated antihypertensive medication with a favorable safety profile compared to other ACE inhibitors. However, a lack of ample recent clinical trials and post-marketing data investigating the efficacy of quinapril in large cohorts has resulted in limited use in clinical practice. Quinapril may be an effective antihypertensive option for elderly populations as well as those who cannot tolerate the side effects profiles of other ACE inhibitors and as an additional treatment option for patients with heart failure with preserved ejection fraction.

The Role of Noncommunicable Disease Clinics in Improving Control of Hypertension and Diabetes Among Adults Residing in Rural Ballabgarh, Haryana

Introduction High systolic blood pressure (SBP) and raised plasma glucose are major attributable and preventable causes of death worldwide. The objective of this study was to estimate the control rates and identify determinants of control of hypertension and diabetes among adults. Methods A longitudinal follow-up study was conducted among all the adults registered at the noncommunicable disease (NCD) clinics under the national program at two primary health centers in Faridabad, Haryana. Data were collected every month from the individual booklet generated for registered adults. Two monthly visits in three months and four in six months were considered adequate follow-ups at the NCD clinic. Results In the study, 495 (82.2%) adults had hypertension, and 242 (40.2%) had diabetes. The control rates at the third and sixth months were 37.1% (95% confidence interval (CI): 31.4-42.7) and 53.6% (95% CI: 43.4-59.8) among hypertensives and 28.7% (95% CI: 21.7-35.7) and 35.9% (95% CI: 27.5-44.4) among diabetics. Among hypertensives, six-month control status was associated with adequate follow-up at the NCD clinic (adjusted odds ratio (AOR) 2.3; 95% CI: 1.4-4.0; p-value: 0.002), male sex (AOR 0.5; 95% CI: 0.3-0.9; p-value: 0.02) and high SBP (AOR 0.5; 95% CI: 0.3-0.9; p-value: 0.017). Conclusions Control status was achieved in half of the adults with hypertension and one-third of adults with diabetes after six months of regular follow-up. Adequate follow-up at the NCD clinic, male sex, and raised SBP emerged as determinants of control among hypertensives.

Retinal vein changes after treatment with aflibercept and PRP in high-risk proliferative diabetic retinopathy

Objective

The objective of the study was to investigate the effectiveness of aflibercept and panretinal photocoagulation (PRP) in the treatment of proliferative diabetic retinopathy (PDR).

Methods

A retrospective analysis was performed on 59 patients (59 eyes) with high-risk PDR who were treated with aflibercept and PRP between January 2018 and December 2019. The best corrected visual acuity (BCVA), central foveal thickness (CFT), and retinal vein diameter post-treatment were compared to those before the treatment.

Results

The best corrected visual acuity (BCVA) at 6 months (0.49 ± 0.14 logMAR), 12 months (0.54 ± 0.15 logMAR), 18 months (0.48 ± 0.15 logMAR), and 24 months (0.51 ± 0.15 logMAR) post-treatment were superior to the pre-treatment measurement (0.65 ± 0.18 logMAR). The central foveal thickness (CFT) at 6 months (310.67 ± 52.53 μm), 12 months (295.98 ± 45.65 μm), 18 months (282.56 ± 43.57 μm), and 24 months (281.53 ± 51.16 μm) post-treatment were lower than the pre-treatment measurement (456.53 ± 51.49 μm); the retinal vein diameter at 12 months (310.13 ± 24.60 μm), 18 months (309.50 ± 31.58 μm), and 24 months (317.00 ± 27.54 μm) post-treatment were lower than the pre-treatment measurement (361.81 ± 30.26 μm).

Conclusion

Aflibercept intravitreal injection and panretinal photocoagulation may morphologically reverse retinal vein diameter and venous beading in high-risk proliferative diabetic retinopathy.

Peripheral Neuropathy and Vision and Hearing Impairment in US Adults With and Without Diabetes

We aimed to assess the associations of peripheral neuropathy (PN) with vision and hearing impairment among adults aged ≥40 years who attended the lower-extremity disease exam for the National Health and Nutrition Examination Survey (United States, 1999-2004). Overall, 11.8% (standard error (SE), 0.5) of adults had diabetes, 13.2% (SE, 0.5) had PN (26.6% (SE, 1.4) with diabetes, 11.4% (SE, 0.5) without diabetes), 1.6% (SE, 0.1) had vision impairment, and 15.4% (SE, 1.1) had hearing impairment. The prevalence of vision impairment was 3.89% (95% CI: 2.99, 5.05) among adults with PN and 1.29% (95% CI: 1.04, 1.60) among adults without PN (P < 0.001). After adjustment, PN was associated with vision impairment overall (odds ratio (OR) = 1.48, 95% confidence interval (CI): 1.03, 2.13) and among adults without diabetes (OR = 1.80, 95% CI: 1.17, 2.77) but not among adults with diabetes (P for interaction = 0.018). The prevalence of hearing impairment was 26.5% (95% CI: 20.4, 33.7) among adults with PN and 14.2% (95% CI: 12.4, 16.3) among adults without PN (P < 0.001). The association of PN with moderate/severe hearing impairment was significant overall (OR = 2.55, 95% CI: 1.40, 4.64) and among adults without diabetes (OR = 3.26, 95% CI: 1.80, 5.91). Overall, these findings suggest an association between peripheral and audiovisual sensory impairment that is unrelated to diabetes.

Annual Foot Exams are Associated with Reduced Incident Amputation among Older Veterans with Diabetes

We conducted a secondary data analysis to evaluate the association between annual foot exams and incident lower extremity amputations (LEA) among older veterans with diabetes during FY2007-FY2014. Older Veterans with at least one primary care provider visit each year (N = 664,162) and at least one foot exam each year (N = 72,892) and the overlap were identified from the 5 years prior to the study period of interest (FY2002-FY2006 (N = 71,122)). After excluding incident LEA related to cancer and trauma, 71,018 veterans (mean age +/- SD, % male) were included in the final cohort, which was followed from FY2007-FY2014 to evaluate the influence of subsequent annual foot exams and incident LEA. Consistent annual foot exams were protective for incident LEA in older veterans with diabetes, adjusted OR was 0.85 (97% CI: 0.74-0.96). Results indicate that adherence to annual foot exam guidelines can reduce incident LEA in older veterans with diabetes.

Assessment of Diabetic Foot Prevention by Nurses

Diabetic foot is a severe complication of diabetes, with serious consequences such as amputations and high mortality rates as well as elevated economic costs. To evaluate whether or not nursing staff follow the recommendations of national and international organizations regarding diabetic foot prevention, a cross-sectional and observational descriptive study was carried out using an ad hoc self-administered questionnaire validated by seven experts, with a Cronbach's alpha of 0.731. Of the total 164 participants, 157 met the inclusion criteria. Findings showed that 96.58% asked their patients to remove their footwear, 78.34% performed thorough examinations, and 80.25% assessed the risk of developing diabetic foot. Participants educated their patients in self-care and evaluated skills related to diabetic foot control either frequently (84.07%) or very frequently (62.42%), and only 19.11% of them carried out group activity workshops. Significant statistical differences were found in the performance of activities in the groups by participant age intervals, whether working in primary health care or a hospital, having specific training, and the participant's DM patient ratio. We obtained high percentages of compliance in the assessed activities in comparison to other studies. Nevertheless, we believe it is necessary to encourage screening in specialized care, skills testing, and the implementation of educational group activities and workshops.

Protein restriction for diabetic kidney disease

BACKGROUND

Diabetic kidney disease (DKD) continues to be the leading cause of kidney failure across the world. For decades dietary protein restriction has been proposed for patients with DKD with the aim to retard the progression of chronic kidney disease (CKD) towards kidney failure. However, the relative benefits and harms of dietary protein restriction for slowing the progression of DKD have not been addressed.

OBJECTIVES

To determine the efficacy and safety of low protein diets (LPD) (0.6 to 0.8 g/kg/day) in preventing the progression of CKD towards kidney failure and in reducing the incidence of kidney failure and death (any cause) in adult patients with DKD. Moreover, the effect of LPD on adverse events (e.g. malnutrition, hyperglycaemic events, or health-related quality of life (HRQoL)) and compliance were also evaluated.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 17 November 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs in which adults with DKD not on dialysis were randomised to receive either a LPD (0.6 to 0.8 g/kg/day) or a usual or unrestricted protein diet (UPD) (≥ 1.0 g/kg/day) for at least 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies and extracted data. Summary estimates of effect were obtained using a random-effects model. Results were summarised as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised MD (SMD) with 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We identified eight studies involving 486 participants with DKD. The prescribed protein intake in the intervention groups ranged from 0.6 to 0.8 g/kg/day. The prescribed protein intake in the control groups was ≥ 1.0 g/kg/day, or a calculated protein intake ≥ 1.0 g/kg/day if data on prescribed protein intake were not provided. The mean duration of the interventions was two years (ranging from one to five years). Risks of bias in most of the included studies were high or unclear, most notably for allocation concealment, performance and detection bias. All studies were considered to be at high risk for performance bias due to the nature of the interventions. Most studies were not designed to examine death or kidney failure. In low certainty evidence, a LPD may have little or no effect on death (5 studies, 358 participants: RR 0.38, 95% CI 0.10 to 1.44; I² = 0%), and the number of participants who reached kidney failure (4 studies, 287 participants: RR 1.16, 95% CI 0.38 to 3.59; I² = 0%). Compared to a usual or unrestricted protein intake, it remains uncertain whether a LPD slows the decline of glomerular filtration rate over time (7 studies, 367 participants: MD -0.73 mL/min/1.73 m²/year, 95% CI -2.3 to 0.83; I² = 53%; very low certainty evidence). It is also uncertain whether the restriction of dietary protein intake impacts on the annual decline in creatinine clearance (3 studies, 203 participants: MD -2.39 mL/min/year, 95% CI -5.87 to 1.08; I² = 53%). There was only one study reporting 24-hour urinary protein excretion. In very low certainty evidence, a LPD had uncertain effects on the annual change in proteinuria (1 study, 80 participants: MD 0.90 g/24 hours, 95% CI 0.49 to 1.31). There was no evidence of malnutrition in seven studies, while one study noted this condition in the LPD group. Participant compliance with a LPD was unsatisfactory in nearly half of the studies. One study reported LPD had no effect on HRQoL. No studies reported hyperglycaemic events.

AUTHORS' CONCLUSIONS

Dietary protein restriction has uncertain effects on changes in kidney function over time. However, it may make little difference to the risk of death and kidney failure. Questions remain about protein intake levels and compliance with protein-restricted diets. There are limited data on HRQoL and adverse effects such as nutritional measures and hyperglycaemic events. Large-scale pragmatic RCTs with sufficient follow-up are required for different stages of CKD.

Association between the VEGFR-2 -604T/C polymorphism (rs2071559) and type 2 diabetic retinopathy

This retrospective case-control study examined the association between the rs2071559 (-604T/C) single nucleotide polymorphism (SNP) in the vascular endothelial growth factor receptor (VEGFR)-2 gene and the risk of diabetic retinopathy (DR) in Northern Han Chinese. This study included patients diagnosed with diabetes mellitus (DM) in Shijiazhuang between 07/2014 and 07/2016. The healthy controls were unrelated individuals who received routine physical examinations. The diabetic patients were grouped as DM (diabetes but no fundus examination abnormalities), proliferative DR (PDR), and non-proliferative DR (NPDR). Finally, 438 patients were included: 114 controls and 123, 105, and 96 patients in the DM, NPDR, and PDR groups, respectively. In the multivariable analyses and all genetic models, the VEGFR-2 rs2071559 SNP was not associated with DR (among all diabetic patients) or with PDR (among the patients with DR) after adjustment for age, sex, duration of DM, blood glucose, systolic blood pressure, diastolic blood pressure, and body mass index (all P > 0.05). In conclusion, the VEGFR-2- 604T/C rs2071559 SNP is not associated with DR or PDR in the Han Chinese population of Shijiazhuang (China).

[Diabetic neuropathy and diabetic foot syndrome (update 2023)]

These are the guidelines for diagnosis and treatment of diabetic neuropathy and diabetic foot.The position statement summarizes characteristic clinical symptoms and techniques for diagnostic assessment of diabetic neuropathy, including the complex situation of the diabetic foot syndrome. Recommendations for the therapeutic management of diabetic neuropathy, especially for the control of pain in sensorimotor neuropathy, are provided. The needs to prevent and treat diabetic foot syndrome are summarized.

[Diabetic kidney disease (update 2023) : Position paper of the Austrian Diabetes Association and the Austrian Society for Nephrology]

Epidemiological investigations have shown that approximately 2-3% of all Austrians have diabetes mellitus with renal involvement, leaving 250,000 people in Austria affected. The risk of occurrence and progression of this disease can be attenuated by lifestyle interventions as well as optimization of blood pressure, blood glucose control and special drug classes. The present article represents the joint recommendations of the Austrian Diabetes Association and the Austrian Society of Nephrology for the diagnostic and treatment strategies of diabetic kidney disease.

Relationship Between Estimated Glucose Disposal Rate and Type 2 Diabetic Retinopathy

PURPOSE

To investigate the association between diabetic retinopathy (DR), DR intensity, and estimated glucose disposal rate (eGDR) in individuals with type 2 diabetes mellitus (T2DM).

PATIENTS AND METHODS

This study comprised 1762 T2DM patients who were admitted between January and December, 2021. Overall, the DR was identified in 430 patients. Based on the eGDR, the participants were divided into four study groups. One-way analysis of variance was used to compare the groups. The correlations between eGDR and DR risk, eGDR, and DR severity were analyzed using regression analysis. Furthermore, these relationships were analyzed in different sex groups.

RESULTS

Patients with T2DM had a 19.75% (348/1762) DR detection rate, whereas those with DR had a 22.41% (78/348) proliferative DR detection rate. The DR group had substantially reduced levels of eGDR compared with the non-DR group. Multivariate logistic regression analysis demonstrated that reduced eGDR was an independent risk factor for DR, after adjusting for confounding variables. eGDR correlated significantly with proliferative DR in women but not in men.

CONCLUSION

In Chinese individuals with T2DM, lower eGDR was independently associated with a higher risk of DR.

Optimal Frequency of Urinary Albumin Screening in Type 1 Diabetes

OBJECTIVE

Kidney disease screening recommendations include annual urine testing for albuminuria after 5 years' duration of type 1 diabetes. We aimed to determine a simple, risk factor-based screening schedule that optimizes early detection and testing frequency.

RESEARCH DESIGN AND METHODS

Urinary albumin excretion measurements from 1,343 participants in the Diabetes Control and Complications Trial and its long-term follow-up were used to create piecewise-exponential incidence models assuming 6-month constant hazards. Likelihood of the onset of moderately or severely elevated albuminuria (confirmed albumin excretion rate AER ≥30 or ≥300 mg/24 h, respectively) and its risk factors were used to identify individualized screening schedules. Time with undetected albuminuria and number of tests were compared with annual screening.

RESULTS

The 3-year cumulative incidence of elevated albuminuria following normoalbuminuria at any time during the study was 3.2%, which was strongly associated with higher glycated hemoglobin (HbA1c) and AER. Personalized screening in 2 years for those with current AER ≤10 mg/24 h and HbA1c ≤8% (low risk [0.6% three-year cumulative incidence]), in 6 months for those with AER 21-30 mg/24 h or HbA1c ≥9% (high risk [8.9% three-year cumulative incidence]), and in 1 year for all others (average risk [2.4% three-year cumulative incidence]) was associated with 34.9% reduction in time with undetected albuminuria and 20.4% reduction in testing frequency as compared with annual screening. Stratification by categories of HbA1c or AER alone was associated with reductions of lesser magnitude.

CONCLUSIONS

A personalized alternative to annual screening in type 1 diabetes can substantially reduce both the time with undetected kidney disease and the frequency of urine testing.

ARTICLE HIGHLIGHTS

Kidney disease screening recommendations include annual urine testing for albuminuria after 5 years' duration of type 1 diabetes. We investigated simple screening schedules that optimize early detection and testing frequency. Personalized screening in 2 years for those with current AER ≤10 mg/24 h and HbA1c ≤8%, in 6 months for those with AER 21-30 mg/24 h or HbA1c ≥9%, and in 1 year for all others yielded 34.9% reduction in time with undetected albuminuria and 20.4% fewer evaluations compared with annual screening. A personalized alternative to annual screening in type 1 diabetes can substantially reduce both the time with undetected kidney disease and the frequency of urine testing.

Access and Use of Health Services by People with Diabetes from the Item Response Theory

The objective of this study was to analyze the indicators of access and use of health services in people with diabetes mellitus. This study used data from the National Health Survey, conducted in Brazil in 2013. The National Health Survey was carried out with adults aged 18 years or older residing in permanent private households in Brazil. Indicators from 492 individuals with self-reported diabetes mellitus living in the Central-West region of the country were analyzed. Item response theory was used to estimate the score for access to and use of health services. Multiple linear regression was used to analyze factors associated with scores of access and use of health services by people with diabetes mellitus. The mean score of access estimated by the item response theory and use estimated was 51.4, with the lowest score of zero (lowest access and use) and the highest 100 (highest access and use). Among the indicators analyzed, 74.6% reported having received medical care in the last 12 months and 46.4% reported that the last visit occurred in primary care. Only 18.9% had their feet examined and 29.3% underwent eye examinations. Individuals of mixed-race/skin color and those residing outside capital and metropolitan regions had lower access and use scores when compared to white individuals and residents of state capitals, respectively. The study shows several gaps in the indicators of access and use of health services by people with diabetes. People of mixed race/skin color and residents outside the capitals and metropolitan regions had lower scores for access and use, suggesting the need to increase health care in these groups.

Epidemiological-clinical and paraclinical particularities of acute coronary syndrome without persistent ST-segment elevation in type 2 diabetes mellitus: Retrospective comparative study in a Malagasy population

INTRODUCTION

This study aimed at determining the epidemiological-clinical and paraclinical particularities of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in Malagasy with type 2 diabetes mellitus (T2DM).

METHODS

This was a retrospective, descriptive and comparative study between patients with and without T2DM, carried out over a period of 38 months. The diagnosis of NSTE-ACS was retained in front of the association of chest discomfort, electrical abnormalities and elevations beyond fivefold the upper reference limit of high-sensitivity cardiac troponin.

RESULT

With 130 patients included, the overall prevalence of NSTE-ACS was 4.1%, of which 68 patients (52.3%) had T2DM. Compared to without T2DM, NSTE-ACS in T2DM was characterized by young age (p = .0002), high-frequency hypertension (OR 2.92 [1.23-7.25]; p = .0041), overweight/obesity (OR 4.39 [1.72-12.4]; p = .0002) and microalbuminuria (p < .0001), accelerated heart rate (p = .0104), atypical chest discomfort (OR 5.57 [2.21-15.7]; p < .0001), pulmonary crepitations (OR 2.25 [1.02-5.14]; p = .0224), high GRACE score (p = .0016), damage of extensive anterior leads (OR 2.11 [1.02-4.98]; p = .0402) and septal lead (OR 3.64 [1.41-10.3]; p = .0015), significant increase in cardiac troponin (p < .0001), high left ventricular filling pressure (OR 3.39 [1.51-7.90]; p = .001).

CONCLUSION

NSTE-ACS in T2DM is frequent, with an atypical clinical and severe paraclinical presentations. Adequate and multidisciplinary management of cardiovascular risk factors, including T2DM, could thus minimize the occurrence of NSTE-ACS and improve this profile.

The effect of berberine and fenugreek seed co-supplementation on inflammatory factor, lipid and glycemic profile in patients with type 2 diabetes mellitus: a double-blind controlled randomized clinical trial

BACKGROUND

Type 2 Diabetes mellitus is one of the most common chronic diseases in the world and has many complications. Due to the importance of using alternative therapies in managing symptoms of this disease, the present study was designed and conducted to investigate the effect of co-supplementation of berberine and fenugreek in patients with type 2 diabetes mellitus.

METHODS

A randomized controlled clinical trial was conducted on 50 patients with type 2 diabetes mellitus. Participants were randomized in the intervention group, which received 3 capsules/day of 500 mg (300 mg of berberine + 200 mg of fenugreek seed powder) or placebo for 12 weeks. Biochemical and anthropometric variables were measured at the beginning and end of the study.

RESULTS

We observed that fasting insulin, HbA1C, and hs-CRP significantly decreased in the intervention group compared to the baseline. The mean difference in insulin resistance (-0.32 vs. 0.15), fasting blood sugar (-14.40 vs. 1.68), and fasting insulin (- 2.18 vs. 1.34) were clinically significant in comparison to the control group. Almost all domains of SF-12 scores were significantly higher in the intervention group than in the placebo group.

CONCLUSIONS

The combination of berberine and fenugreek seed can improve cardio-metabolic status in patients with diabetes and support the anti-diabetic and anti-inflammatory role of herb in the improvement of quality of life.

A qualitative study of barriers to care-seeking for diabetic foot ulceration across multiple levels of the healthcare system

Introduction

The mechanisms for the observed disparities in diabetes-related amputation are poorly understood and could be related to access for diabetic foot ulceration (DFU) care. This qualitative study aimed to understand patients’ personal experiences navigating the healthcare system and the barriers they faced.

Methods

Fifteen semi-structured interviews were conducted over the phone between June 2020 to February 2021. Participants with DFUs were recruited from a tertiary referral center in Southern Arizona. The interviews were audio-recorded and analyzed according to the NIMHD Research Framework, focusing on the health care system domain.

Results

Among the 15 participants included in the study, the mean age was 52.4 years (66.7% male), 66.7% was from minority racial groups, and 73.3% was Medicaid or Indian Health Service beneficiaries. Participants frequently reported barriers at various levels of the healthcare system.

On the individual level, themes that arose included health literacy and inadequate insurance coverage resulting in financial strain. On the interpersonal level, participants complained of fragmented relationships with providers and experienced challenges in making follow-up appointments. On the community level, participants reported struggles with medical equipment.

On the societal level, participants also noted insufficient preventative foot care and education before DFU onset, and many respondents experienced initial misdiagnoses and delays in receiving care.

Conclusions

Patients with DFUs face significant barriers in accessing medical care at many levels in the healthcare system and beyond. These data highlight opportunities to address the effects of diabetic foot complications and the inequitable burden of inadequately managed diabetic foot care.

Administration of mesenchymal stem cells in diabetic kidney disease: mechanisms, signaling pathways, and preclinical evidence

Diabetic kidney disease (DKD) is a serious microvascular complication of diabetes. Currently, the prevalence and mortality of DKD are increasing annually. However, with no effective drugs to prevent its occurrence and development, the primary therapeutic option is to control blood sugar and blood pressure. Therefore, new and effective drugs/methods are imperative to prevent the development of DKD in patients with diabetes. Mesenchymal stem cells (MSCs) with multi-differentiation potential and paracrine function have received extensive attention as a new treatment option for DKD. However, their role and mechanism in the treatment of DKD remain unclear, and clinical applications are still being explored. Given this, we here provide an unbiased review of recent advances in MSCs for the treatment of DKD in the last decade from the perspectives of the pathogenesis of DKD, biological characteristics of MSCs, and different molecular and signaling pathways. Furthermore, we summarize information on combination therapy strategies using MSCs. Finally, we discuss the challenges and prospects for clinical application.

Tolerability of duloxetine in elderly and in non-elderly adults: a protocol of a systematic review and individual participant data meta-analysis of randomized placebo-controlled trials

BACKGROUND

Duloxetine is an antidepressant that benefits from a wide range of approval in the elderly population, while its safety for use compared to non-elderly is not clearly assessed. This protocol outlines a systematic review and individual participant data meta-analysis comparing the tolerability of duloxetine between elderly and non-elderly.

METHODS

Searches will be conducted in PubMed, ClinicalTrials.gov , Clinicaltrialsregister.eu, data sharing platforms, FDA drug approval packages, European public assessment reports and withdrawn applications from the EMA website. The review will be performed on studies available in electronic databases from their date of inception to the 31 March 2022. Only randomized controlled clinical trials, comparing duloxetine to placebo, will be included in this meta-analysis. The studies will be selected if they comprise both elderly and non-elderly adults, in conditions of use of duloxetine approved by the European Medical Agency (EMA) and the Food and Drug Administration (FDA). The primary outcome will be the rate ratio of serious adverse events under duloxetine compared to placebo, between participants at least 65 years old and non-elderly. Second, the number of any adverse events, clinical efficacy and quality of life will be compared between elderly and non-elderly under both interventions. The quality of evidence in the tolerability of duloxetine will be assessed using the GRADE system. A one or two-stage individual participant data random effect meta-analysis will be conducted depending on the availability of the data.

DISCUSSION

This meta-analysis will investigate the tolerability safety of duloxetine in the elderly population across all conditions approved by European and American regulatory authorities. The results from this meta-analysis are intended to help prescribers to provide better care for the elderly population.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019130488 ).

An Optimization-Based Diabetes Prediction Model Using CNN and Bi-Directional LSTM in Real-Time Environment

Diabetes is a long-term illness caused by the inefficient use of insulin generated by the pancreas. If diabetes is detected at an early stage, patients can live their lives healthier. Unlike previously used analytical approaches, deep learning does not need feature extraction. In order to support this viewpoint, we developed a real-time monitoring hybrid deep learning-based model to detect and predict Type 2 diabetes mellitus using the publicly available PIMA Indian diabetes database. This study contributes in four ways. First, we perform a comparative study of different deep learning models. Based on experimental findings, we next suggested merging two models, CNN-Bi-LSTM, to detect (and predict) Type 2 diabetes. These findings demonstrate that CNN-Bi-LSTM surpasses the other deep learning methods in terms of accuracy (98%), sensitivity (97%), and specificity (98%), and it is 1.1% better compared to other existing state-of-the-art algorithms. Hence, our proposed model helps clinicians obtain complete information about their patients using real-time monitoring and can check real-time statistics about their vitals.

Clinical Characteristics of Peripheral Neuropathy in Kenyan Patients with HIV Infection Compared with Patients with Concurrent HIV Infection and Diabetes Mellitus

INTRODUCTION

Persons living with human immunodeficiency virus (HIV) are living longer and at risk of non-communicable diseases, including diabetes mellitus (DM). Both HIV and DM place patients at risk of peripheral neuropathy (PN). Our aim was to demonstrate the prevalence and characteristics of PN in our population of patients with HIV infection compared with concomitant HIV and DM.

METHODS

A prospective cross-sectional study was performed at the Aga Khan Hospital in Nairobi, Kenya. Data were collected on demographics and characteristics of DM and HIV. Symptoms and signs of PN were evaluated by Neuropathy Symptom Score, Neuropathy Disability Score, and 10 g monofilament testing.

RESULTS

Two groups were recruited, each consisting of 68 patients: (1) HIV only, (2) HIV and DM. The median age of patients was 51 years (IQR 42.8-58.6) and 55% were male. Median duration for HIV was 10 years (IQR 5-12) with a median CD4 count of 524 cells/mm³ (IQR 369-731). Median duration for DM was 1 year with a median glycosylated hemoglobin of 6.7% (IQR 6.6-7.6). Sixty-nine percent of patients with HIV had suppressed viral loads, and 9 patients (6.6%) had a history neurotoxic antiretroviral therapy use. PN was detected in 11 (16%) HIV-only patients, and in 17 (25%) participants who had both HIV and DM (Fisher exact test chi-square = 0.4). Univariate analysis demonstrated older age, high body mass index, and long duration of HIV were associated with an OR of 1.07 (95% CI 1.02-1.11), 1.21 (95% CI 0.46-3.11), and 1.07 (95% CI 0.99-1.15) in the overall group, respectively.

CONCLUSION

Our study demonstrates a higher but non-significant prevalence of PN in patients with both HIV and DM when compared to HIV alone. HIV disease control had no association with PN presence.

Ginsenoside Rb1 alleviates diabetic kidney podocyte injury by inhibiting aldose reductase activity

Panax notoginseng, a traditional Chinese medicine, exerts beneficial effect on diabetic kidney disease (DKD), but its mechanism is not well clarified. In this study we investigated the effects of ginsenoside Rb1 (Rb1), the main active ingredients of Panax notoginseng, in alleviating podocyte injury in diabetic nephropathy and the underlying mechanisms. In cultured mouse podocyte cells, Rb1 (10 μM) significantly inhibited high glucose-induced cell apoptosis and mitochondrial injury. Furthermore, Rb1 treatment reversed high glucose-induced increases in Cyto c, Caspase 9 and mitochondrial regulatory protein NOX4, but did not affect the upregulated expression of aldose reductase (AR). Molecular docking analysis revealed that Rb1 could combine with AR and inhibited its activity. We compared the effects of Rb1 with eparestat, a known aldose reductase inhibitor, in high glucose-treated podocytes, and found that both alleviated high glucose-induced cell apoptosis and mitochondrial damage, and Rb1 was more effective in inhibiting apoptosis. In AR-overexpressing podocytes, Rb1 (10 μM) inhibited AR-mediated ROS overproduction and protected against high glucose-induced mitochondrial injury. In streptozotocin-induced DKD mice, administration of Rb1 (40 mg·kg^-1·d^-1, ig, for 7 weeks) significantly mitigated diabetic-induced glomerular injuries, such as glomerular hypertrophy and mesangial matrix expansion, and reduced the expression of apoptotic proteins. Collectively, Rb1 combines with AR to alleviate high glucose-induced podocyte apoptosis and mitochondrial damage, and effectively mitigates the progression of diabetic kidney disease.

Evaluation of Achilles Tendon in Patients with Diabetic Foot Ulcer by High-Frequency Ultrasound Combined with Real-Time Shear-Wave Elastography

To our best knowledge, no study investigated the utility of the combination of high-frequency US and real-time shear wave elastography (RTSWE) in the evaluation of Achilles tendon (AT). Our study aimed to evaluate AT in patients with diabetic foot ulcers using high-frequency US and RTSWE. We retrospectively reviewed 100 patients who visited our hospital due to diabetes. Patients were divided into the study group (those with diabetic foot ulcers) and the control group (those without diabetic foot ulcers). Patients' demographics, basic medical records, and laboratory tests were reviewed. High-frequency ultrasound and RTSWE were performed in both AT for all 100 patients. Young's modulus was measured at the upper, middle, and lower parts of each AT by RTSWE. There were 50 patients with diabetic foot ulcers. Patients in the study group had older age, a higher incidence of insulin use, and a higher level of cholesterol than those in the control group. However, thickness and Young's modulus of AT were comparable in two groups, when evaluated by the combination of high-frequency ultrasound and RTSWE. There was no significant difference in thickness and elastic modulus of AT in patients with and without diabetic foot ulcers when evaluated by the combination of high-frequency ultrasound and RTSWE.

Development of a Measure to Assess Attitudes Towards Nasal versus Autoinjector Glucagon Delivery Devices for Treatment of Severe Hypoglycemia

BACKGROUND

For individuals managing diabetes, the administration of glucagon for severe hypoglycemia can be lifesaving, yet, until recently, there were no easy-to-use devices for these stressful emergencies. New products have emerged to meet this need, including nasal glucagon (NG) and auto-injector glucagon (AI). This study evaluated the psychometric properties of a new measure, the Glucagon Device Attitudes Questionnaire (GDAQ), in assessing attitudes toward NG and AI from the perspectives of persons with diabetes on insulin (PWDs), caregivers, and acquaintances.

METHODS

Developed based on qualitative research, the GDAQ consists of 38 rating items for each device and 16 direct-elicitation of attitudes of device relative to each other. It was administered to participants via a cross-sectional online survey. Twenty-six rating items were included in principal component analysis and confirmatory factor analysis. Items comprising each factor were averaged to form scales. Additionally, 12 direct elicitation items were averaged to form an overall "Attitudes" scale. Reliability and validity analyses were conducted. Descriptive statistics were provided for the rating items not included in the factor analysis.

RESULTS

A total of 405 PWDs, 313 caregivers, and 305 acquaintances participated. Three factors were identified: "Prepared and Protected" (7 items), "Hesitation" (12 items), and "Device Perceptions by Others" (7 items); factor loadings ranged from 0.13 to 0.92, 0.50 to 0.89, and 0.16 to 0.92, respectively. Cronbach's alpha for the four scales ranged from 0.76 to 0.96. Correlations of the scales with their global item ranged from 0.30 to 0.90. The items outside of the factor analysis showed good distribution in responses and differentiation between the two devices.

DISCUSSION

This study supports the validity and reliability of the GDAQ, which successfully conceptualizes attitudes towards devices for administering glucagon among different respondent groups. Use of the GDAQ can help guide the development and testing of new glucagon drug/device combinations.

High-Normal Protein Intake Is Not Associated With Faster Renal Function Deterioration in Patients With Type 2 Diabetes: A Prospective Analysis in the DIALECT Cohort

OBJECTIVE

To study the prospective association between dietary protein intake and renal function deterioration in patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Prospective analyses were performed in data of 382 patients of the Diabetes and Lifestyle Cohort Twente (DIALECT) study. Dietary protein intake was determined by the Maroni equation from 24-h urinary urea excretion. Renal function deterioration was defined as need for renal replacement therapy or a persistent increase of ≥50% in serum creatinine. Cox proportional hazards models were used to calculate hazard ratios (HRs) for the association between dietary protein intake and renal function deterioration. Threshold levels represent the dietary protein intake at which there was a significantly increased and reduced hazard of renal function deterioration.

RESULTS

Renal function deterioration occurred in 53 patients (14%), with a median follow-up duration of 6 (interquartile range 5-9) years. Mean dietary protein intake was 91 ± 27 g/day (1.22 ± 0.33 g/kg ideal body weight/day). Dietary protein intake was inversely associated with renal function deterioration (HR 0.62 [95% CI 0.44-0.90]). Patients with an intake <92 g/day had an increased hazard for renal function deterioration (HR 1.44 [95% CI 1.00-2.06]), while patients with an intake >163 g/day had a decreased hazard for renal function deterioration (HR 0.42 [95% CI 0.18-1.00]). Regarding dietary protein intake per kilogram body weight, patients with an intake <1.08 g/kg/day had an increased hazard for renal function deterioration (HR 1.63 [95% CI 1.00-2.65]).

CONCLUSIONS

In patients with T2D, unrestricted dietary protein intake was not associated with an increased hazard of renal function deterioration. Therefore, substituting carbohydrates with dietary protein is not contraindicated as a part of T2D management, although it may have a positive effect on body weight while minimizing loss of muscle mass.

Internal Medicine Resident Adherence to Evidence-Based Practices in Management of Diabetes Mellitus

OBJECTIVE

Diabetic preventative health maintenance involves (1) adherence to guidelines and (2) appropriate documentation. This study evaluates the frequency with which internal medicine (IM) residents met these two outcomes. We also evaluated if there were differences in outcomes between resident classes.

METHODS

In this retrospective analysis, 234 diabetic outpatient visits were analyzed. Guidelines were derived from the American Diabetes Association (ADA). The outcomes for each guideline were averaged and stratified by resident class. Averages within and between classes were compared using the student's paired t-test and one-way ANOVA respectively.

RESULTS

Classes were most adherent to A1c testing guidelines (PGY-1 96.1%, PGY-2 97.6%, and PGY-3 95.9%). PGY-1 and PGY-2 classes were least adherent to podiatry (27.5% and 17.6% respectively), whereas PGY-3 had equal least adherence rates to podiatry and lifestyle modification guidelines (36.7%). All classes had highest rates in documenting A1c findings (PGY-1 92.2%, PGY-2 97.6%, and PGY-3 85.7%) and lowest rates in documenting relevant podiatry information (PGY-1 5.9%, PGY-2 5.9%, and PGY-3 11.2%). Comparing sequential resident classes, there was a decline in lifestyle counselling and documentation from PGY-1 to PGY-2. From PGY-2 to PGY-3, there was improvement in adherence to statin, podiatry, microalbuminuria, and monofilament guidelines. There was also improvement in documenting statin and monofilament usage, however, A1c reporting declined.

CONCLUSION

The findings of the study suggest disproportionate levels of care in diabetes preventative management. Additionally, program directors should take caution in assuming linear improvement with sequential resident classes.

Impacts of statin and metformin on neuropathy in patients with type 2 diabetes mellitus: Korean Health Insurance data

BACKGROUND

Neuropathy is a common chronic complication in type 2 diabetes mellitus (T2DM). Statin and metformin are commonly used medications in T2DM patients, and some studies showed statin- or metformin-induced neuropathy.

AIM

To evaluate the incidence of neuropathy among patients with T2DM associated with statin and metformin therapies.

METHODS

Korean Health Insurance Review and Assessment national patient sample data from 2016 and 2017 were used. Patients with T2DM and no complications were divided into statin/metformin/statin + metformin users and non-users. Neuropathy incidence was defined by International Statistical Classification of Diseases and Related Health Problems, 10^th revision codes and concomitant prescriptions for anticonvulsants or antidepressants. Logistic regression analyses were conducted to examine the associations between statin/metformin/statin + metformin therapies and the incidence of neuropathy. Propensity score (PS) matching was performed on the basis of age, sex and comorbidities.

RESULTS

Overall, 34964 and 35887 patients with T2DM and no complications were included in the Korean Health Insurance Review and Assessment national patient sample datasets from 2016 and 2017, respectively. Statin therapy was associated with increased risks of neuropathy in 2016 and 2017 [PS-matched odds ratio (OR) = 1.22, 95% confidence interval (CI): 1.08-1.38; PS-matched OR = 1.17, 95%CI: 1.03-1.33, respectively]. Metformin therapy was associated with reduced risks of neuropathy in 2016 and 2017 (PS-matched OR = 0.30, 95%CI: 0.21-0.42; PS-matched OR = 0.44, 95%CI: 0.32-0.60, respectively). Combined statin + metformin therapy was not significantly associated with neuropathy in 2016 or 2017 (PS-matched OR = 0.85, 95%CI: 0.61-1.19; PS-matched OR = 0.95, 95%CI: 0.66-1.38, respectively).

CONCLUSION

Statin therapy was associated with enhanced risk of new-onset neuropathy in patients with T2DM, but metformin therapy showed the opposite association.

Mineralocorticoid Receptor Antagonists-Use in Chronic Kidney Disease

Mineralocorticoid receptor antagonists (MRA) are drugs with a potentially broad spectrum of action. They have been reported to have healing effects in many diseases, such as chronic heart failure, hypertension, or nephrotic syndrome. Numerous studies suggest that mineralocorticoid receptor activation is pathogenic and a progression factor of chronic kidney disease (CKD); however, results of studies on the use of MRA in the treatment of CKD are inconclusive. Current guidelines recommend against the use of MRA in patients with advanced CKD. Although, there is growing interest on their use in this population due to treatment benefits. In this review, we summarize studies which were purposed to evaluate the impact of MRA therapy on CKD patients. Despite many benefits of this treatment e.g., reducing cardiovascular mortality or alleviating proteinuria, steroidal MRA (such as spironolactone or eplerenone) have a low safety profile. They often lead to hyperkalemia complications which are dangerous in patients with CKD, and diabetic nephropathy, especially in hemodialysis patients. Studies on recently developed nonsteroidal MRA showed that they have fewer side effects. In our review, we discuss steroidal and nonsteroidal MRA treatment effects on the estimated glomerular filtration rate (eGFR), proteinuria, the cardiovascular system, and hyperkalemia in CKD patients. We present new content and recent publications in this field.

Quantitative vibration perception threshold in assessing diabetic polyneuropathy: Should the cut-off value be adjusted for Chinese individuals with type 2 diabetes?

AIMS/INTRODUCTION

To examine the performance and identify the optimal threshold of vibration perception threshold (VPT) for diagnosing diabetic polyneuropathy (DPN) in a Chinese population according to multiple definitions of DPN as gold standards.

MATERIALS AND METHODS

VPT was determined in 421 Chinese individuals with type 2 diabetes, who simultaneously completed a questionnaire of neuropathic symptoms, and underwent the assessment of signs of peripheral neuropathy and electromyography tests. Three definitions of DPN (i.e., clinician-diagnosed DPN, abnormal nerve conduction and confirmed DPN) were taken as reference gold standards.

RESULTS

Vibration perception threshold was a specific measure for all three groups of DPN outcomes, with the highest specificity noted for clinician-diagnosed DPN (85.1%). The specificity for abnormal nerve conduction and confirmed DPN was 77.0 and 76.6%, respectively. The sensitivity of VPT was 67.0% for clinician-diagnosed DPN, 66.5% for abnormal nerve conduction and 67.2% for confirmed DPN. The optimal cut-off threshold for abnormal nerve conduction, as well as confirmed DPN, was VPT >14.9 V. The specificity and sensitivity of VPT >14.9 V as the cut-off value for clinician-diagnosed DPN were 85.6 and 66.2%, respectively. When taking clinician-diagnosed DPN as the gold standard, the performance of VPT for diagnosing DPN was best with an area under the curve value of 0.804.

CONCLUSIONS

VPT measured using the neurothesiometer had relatively high specificity and best performance for diagnosing DPN when clinician-diagnosed DPN rather than abnormal nerve conduction was taken as the gold standard in a Chinese population. A VPT value of ≥15 V might be equally applicable for diagnosing DPN in a Chinese population.

Chronic Kidney Disease Testing Among At-Risk Adults in the U.S. Remains Low: Real-World Evidence From a National Laboratory Database

OBJECTIVE

An estimated 37 million Americans have chronic kidney disease (CKD). Nearly 90% do not know about their condition because of low awareness about the importance of CKD testing and diagnosis among practitioners and people at risk for CKD. This study uses data from a national clinical laboratory to identify guideline-recommended CKD testing rates across the U.S.

RESEARCH DESIGN AND METHODS

Patients with Laboratory Corporation of America Holdings (Labcorp) testing between 2013 and 2019 were defined as at risk for CKD if they had any testing ordered with diagnosis codes for diabetes and/or hypertension. Guideline-concordant CKD assessment was defined by estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR) testing within the study year.

RESULTS

We identified 28,295,982 at-risk patients (mean age 60.6 ± 14.8 years; 53.6% women): 16.2% had diabetes, 63.8% had hypertension, and 20.1% had both comorbidities. Of these, 80.3% did not receive guideline-concordant assessment during the study period. Furthermore, only 21.0% had uACR testing versus 89.6% with eGFR. CKD assessment occurred at least once in 28.7% of patients with diabetes, 10.5% of patients with hypertension, and 41.4% of patients with both conditions. In a state-by-state comparison, annual testing rates ranged from 5 to 30%. The nationwide rate increased modestly each year between 2013 and 2018 (from 10.7% to 15.2%).

CONCLUSIONS

Despite guideline recommendations, testing for CKD with uACR and eGFR in U.S. adults with diabetes and hypertension is low in routine clinical care. These data highlight the need for strategies to improve routine CKD assessment nationwide.

Efficacy, Pharmacokinetics, Biodistribution and Excretion of a Novel Acylated Long-Acting Insulin Analogue INS061 in Rats

Purpose

Long-acting insulin analogues are known to be a major player in the management of glucose levels in type I diabetic patients. However, highly frequent hypo- and hyperglycemic incidences of current long-acting insulins are the important factor to limit stable management of glucose level for clinical benefits. To further optimize the properties for steadily controlling glucose level, a novel long-acting insulin INS061 was designed and its efficacy, pharmacokinetics, biodistribution and excretion profiles were investigated in rats.

Methods

The glucose-lowering effects were evaluated in a streptozocin-induced diabetic rats compared to commercial insulins via subcutaneous administration. The pharmacokinetics, biodistribution, and excretion were examined by validated analytical methods including radioactivity assay and radioactivity assay after the precipitation with TCA and the separation by HPLC.

Results

INS061 exhibited favorable blood glucose lowering effects up to 24 h compared to Degludec. Pharmacokinetic study revealed that the concentration-time curves of INS061 between two administration routes were remarkably different. Following intravenous administration, INS061 was quickly distributed to various organs and tissues and slowly eliminated over time with urinary excretion being the major route for elimination, and the maximum plasma concentrations (Cmax) and systemic exposures (AUC) increased in a linear manner.

Conclusion

The present structural modifications of human insulin possessed a long-acting profile and glucose-lowering function along with favorable in vivo properties in rats, which establish a foundation for further preclinical and clinical evaluation.

Testing a Deep Learning Algorithm for Detection of Diabetic Retinopathy in a Spanish Diabetic Population and with MESSIDOR Database

Background: The aim of the present study was to test our deep learning algorithm (DLA) by reading the retinographies. Methods: We tested our DLA built on convolutional neural networks in 14,186 retinographies from our population and 1200 images extracted from MESSIDOR. The retinal images were graded both by the DLA and independently by four retina specialists. Results of the DLA were compared according to accuracy (ACC), sensitivity (S), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC), distinguishing between identification of any type of DR (any DR) and referable DR (RDR). Results: The results of testing the DLA for identifying any DR in our population were: ACC = 99.75, S = 97.92, SP = 99.91, PPV = 98.92, NPV = 99.82, and AUC = 0.983. When detecting RDR, the results were: ACC = 99.66, S = 96.7, SP = 99.92, PPV = 99.07, NPV = 99.71, and AUC = 0.988. The results of testing the DLA for identifying any DR with MESSIDOR were: ACC = 94.79, S = 97.32, SP = 94.57, PPV = 60.93, NPV = 99.75, and AUC = 0.959. When detecting RDR, the results were: ACC = 98.78, S = 94.64, SP = 99.14, PPV = 90.54, NPV = 99.53, and AUC = 0.968. Conclusions: Our DLA performed well, both in detecting any DR and in classifying those eyes with RDR in a sample of retinographies of type 2 DM patients in our population and the MESSIDOR database.

Prognostic models for predicting the risk of foot ulcer or amputation in people with type 2 diabetes: a systematic review and external validation study

AIMS/HYPOTHESIS

Approximately 25% of people with type 2 diabetes experience a foot ulcer and their risk of amputation is 10-20 times higher than that of people without type 2 diabetes. Prognostic models can aid in targeted monitoring but an overview of their performance is lacking. This study aimed to systematically review prognostic models for the risk of foot ulcer or amputation and quantify their predictive performance in an independent cohort.

METHODS

A systematic review identified studies developing prognostic models for foot ulcer or amputation over minimal 1 year follow-up applicable to people with type 2 diabetes. After data extraction and risk of bias assessment (both in duplicate), selected models were externally validated in a prospective cohort with a 5 year follow-up in terms of discrimination (C statistics) and calibration (calibration plots).

RESULTS

We identified 21 studies with 34 models predicting polyneuropathy, foot ulcer or amputation. Eleven models were validated in 7624 participants, of whom 485 developed an ulcer and 70 underwent amputation. The models for foot ulcer showed C statistics (95% CI) ranging from 0.54 (0.54, 0.54) to 0.81 (0.75, 0.86) and models for amputation showed C statistics (95% CI) ranging from 0.63 (0.55, 0.71) to 0.86 (0.78, 0.94). Most models underestimated the ulcer or amputation risk in the highest risk quintiles. Three models performed well to predict a combined endpoint of amputation and foot ulcer (C statistics >0.75).

CONCLUSIONS/INTERPRETATION

Thirty-four prognostic models for the risk of foot ulcer or amputation were identified. Although the performance of the models varied considerably, three models performed well to predict foot ulcer or amputation and may be applicable to clinical practice.

Self-care activities among patients with type 2 diabetes mellitus: A cross-sectional study

AIMS

This study investigated self-care activities and identified their related factors in Chinese patients with type 2 diabetes mellitus.

METHODS

A cross-sectional study was conducted in Guangzhou, China, between September 2016 and February 2017, involving 202 Chinese patients with type 2 diabetes mellitus. Measures included the Summary of Diabetes Self-Care Activities Questionnaire and Revised Illness Perception Questionnaire.

RESULTS

Self-care activities in Chinese patients with type 2 diabetes mellitus were suboptimal overall. Foot care and blood sugar testing were the self-care activities that were performed the least. One fifth of patients smoked. Some subscales of illness perceptions, receiving health education on diabetes, employment status, education level, body mass index, age and time since type 2 diabetes mellitus diagnosis, were related to self-care activities in patients with type 2 diabetes mellitus.

CONCLUSION

Health-care providers and nurses should encourage greater engagement in self-care activities in patients with type 2 diabetes mellitus, especially foot care and blood sugar testing. Illness perceptions may be used as a framework to guide interventions.

Management of patients with chronic heart failure and type 2 diabetes mellitus: the SCODIAC-II study

SCODIAC was a pilot study which revealed an increasing use of SGLT2i in 123 outpatients affected with Heart Failure (HF) and Type 2 Diabetes Mellitus. SCODIAC-II study, the second phase of the program, has been carried out to determine diagnostic and therapeutic pathways in a larger group of patients and to verify whether the use of innovative antidiabetic therapies could modify echocardiographic parameters and cardiovascular therapies. 406 HF-diabetic patients, referred to Cardiologists and Diabetologists of pertaining healthcare districts in Campania, were enrolled in this retrospective study and divided in Group A, composed of 136 patients with preserved Ejection Fraction (HF-pEF)(> 45%) and Group B, formed of 270 patients with reduced EF (HF-rEF)(≤ 45%). All patients had performed periodic clinical and echocardiographic evaluations. The antidiabetic therapies resulted modified after 1 year with a greater use of GLP1-AR, gliptins and SGLT2i. Cardiovascular therapies resulted also modified with a greater use of sacubitril/valsartan and a reduction of ACEi and ARBs in HF-rEF patients. Echocardiography E velocity, A velocity and E/e' ratio resulted markedly reduced in 25 HF-pEF and in 60 HF-rEF patients treated with SGLT2i, in respect to both the whole sample of subjects at beginning and the other diabetic patients. LAVi resulted reduced only in HF-pEF patients and EF increased only in HF-rEF patients. The approach to the patients with HF and diabetes must necessarily take place in the healthcare districts, be multidisciplinary and integrated. SGLT2i could improve left ventricular function in HF-rEF patients and modify cardiovascular therapies, almost in this setting of patients.Trial registration The protocol was approved by the University of Naples Federico II Ethics Committee and registered at ClinicalTrial.gov (CT04375943). The principles outlined in the Declaration of Helsinki were followed.

Evaluating The Effect of Establishing Protocol for Self- Care Practice of Diabetic Foot Patients Regarding Their Needs, Concerns and Medication Use: A quasi-experimental study

The practice of diabetic self-care plays a significant role in maintaining and preventing diabetic foot complications, but low commitment to self-care practices is common. This study evaluates the effect of establishing protocol for self-care practice of diabetic foot patients according to their needs, concerns, and medication use. A quasi-experimental research (pre-test and post-test) design was used in outpatient clinics at Benha University Hospital, Egypt. The study included 100 adult patients diagnosed with diabetes (types I and II) for at least six months. The findings revealed that 79% suffered from burning or tingling in legs or feet; 74% complained of presence of redness of lower limb, legs or foot pain with activity, and loss of lower extremity sensation; and 80% had changes in skin colour or skin lesions. A comparison between the group pre- and post-intervention (protocol) showed that post-intervention patient foot care knowledge and self-care practice scores were higher. Also, 72% of the participants obtained good knowledge related to foot care post- protocol intervention compared to 37% pre- intervention. Based on the findings, the establishing intervention protocol fosters self-care practice and knowledge regarding needs, concerns, and medication use among diabetic foot patients. Therefore, this protocol can be applied in health practice and research in order to prevent diabetic foot ulcer, and thereby foot amputation.

Evaluation of Clinical Factors Predictive of Diabetes Remission Following Bariatric Surgery

Bariatric surgery is an effective treatment for achieving significant weight loss and improving metabolic comorbidities such as type 2 diabetes mellitus (T2DM). The aim of our study was to investigate clinical factors related to T2DM remission in obese patients who had undergone bariatric surgery.

METHODS

A cohort of patients with T2DM and a minimum of class II obesity undergoing bariatric surgery had their clinical and anthropometric variables assessed. The statistical evaluation included multivariate analyses of clinical factors predicting a T2DM remission two years post-surgery.

RESULTS

83 patients were included (mean age 44.13 ± 10.38 years). Two years post-surgery, the percentage of excess weight lost was 63.43 ± 18.59%, and T2DM was resolved in 79.5% of the patients. T2DM remission was directly related to a high body mass index (BMI) (OR: 1.886; p = 0.022) and the absence of macro-vascular complications (OR: 34.667; p = 0.002), while it was inversely associated with T2DM with a duration longer than 5 years (OR: 0.022; p = 0.040) and baseline insulin treatment (OR: 0.001; p = 0.009). 15.6% of the patients presented early complications and 20.5% developed late complications.

CONCLUSION

In our study sample, bariatric surgery proved to be an effective and safe technique for sustained medium-term weight loss and the resolution of T2DM. A higher baseline BMI, a shorter T2DM duration, non-insulin treatment, and the absence of macro-vascular complications are factors predictive of T2DM remission.

Blood lead, vitamin D status, and albuminuria in patients with type 2 diabetes

Environmental lead exposure has been linked with reduced kidney function. However, evidence about its role in diabetic kidney damage, especially when considering the nutritional status of vitamin D, is sparse. In this observational study, we investigated the association between low-level lead exposure and urinary albumin-to-creatinine ratio (UACR) and assessed potential impact of vitamin D among 4033 diabetic patients in Shanghai, China. Whole blood lead was measured by graphite furnace atomic absorption spectrometry. Serum 25-hydroxyvitamin D [25(OH)D] was tested using a chemiluminescence immunoassay. The associations of blood lead with UACR and albuminuria, defined as UACR ≥30 mg/g, according to 25(OH)D levels were analyzed using linear and Poisson regression models. A doubling of blood lead level was associated with a 10.7% higher UACR (95% CI, 6.19%-15.5%) in diabetic patients with 25(OH)D < 50 nmol/L, whereas the association was attenuated toward null (2.03%; 95% CI, -5.18% to 9.78%) in those with 25(OH)D ≥ 50 nmol/L. Similarly, the risk ratios of prevalent albuminuria per doubling of blood lead level between the two groups were 1.09 (95% CI, 1.03-1.15) and 0.99 (95% CI, 0.86-1.14), respectively. Joint analysis demonstrated that a combination of high blood lead and low 25(OH)D corresponded to significantly higher UACR. Among diabetic patients with 25(OH)D < 50 nmol/L, the increment of UACR relative to blood lead was more remarkable in those with reduced estimated glomerular filtration rate (<60 mL/min/1.73 m²). These results suggested that higher blood lead levels were associated with increased urinary albumin excretion in diabetic patients with vitamin D deficiency. Further prospective studies are needed to validate our findings and to determine whether vitamin D supplementation yields a benefit.