Hypoglycemia: The neglected complication

Monitoring individualized glucose levels predicts risk for bradycardia in type 2 diabetes patients with chronic kidney disease: a pilot study

Patients with diabetes mellitus (DM) and chronic kidney disease (CKD) exhibit an elevated risk for cardiac arrhythmias, such as bradycardia, which may potentially lead to sudden cardiac death (SCD). While hypoglycemia, defined as a critical drop in glucose levels below the normal range, has long been associated with adverse cardiovascular events, recent studies have highlighted the need for a comprehensive reevaluation of its direct impact on cardiovascular outcomes, particularly in high-risk populations such as those with DM and CKD. In this study, we investigated the association between glucose levels and bradycardia by simultaneously monitoring interstitial glucose (IG) and ECG for 7 days in insulin-treated patients with DM and CKD. We identified bradycardia episodes in 19 of 85 patients (22%) and associated these episodes with personalized low, medium, and high relative glucose levels. Our analysis revealed a significant increase in bradycardia frequency during periods of lowest relative glucose, particularly between 06:00-09:00 and 12:00-15:00. Furthermore, leveraging a Random Forests classifier, we achieved a promising area under the curve (AUC) of 0.94 for predicting bradyarrhythmias using glucose levels and heart rate variability features. Contrary to previous findings, only 4% of bradycardia episodes in our study population occurred at glucose levels of 70 mg/dL or lower, with 28% observed at levels exceeding 180 mg/dL. Our findings not only highlight the strong correlation between relative glucose levels, heart rate parameters, and bradycardia onset but also emphasize the need for a more personalized definition of hypoglycemia to understand its relationship with bradyarrhythmias in high-risk DM and CKD patient populations.

TRPC5 controls the adrenaline-mediated counter regulation of hypoglycemia

Hypoglycemia triggers autonomic and endocrine counter-regulatory responses to restore glucose homeostasis, a response that is impaired in patients with diabetes and its long-term complication hypoglycemia-associated autonomic failure (HAAF). We show that insulin-evoked hypoglycemia is severely aggravated in mice lacking the cation channel proteins TRPC1, TRPC4, TRPC5, and TRPC6, which cannot be explained by alterations in glucagon or glucocorticoid action. By using various TRPC compound knockout mouse lines, we pinpointed the failure in sympathetic counter-regulation to the lack of the TRPC5 channel subtype in adrenal chromaffin cells, which prevents proper adrenaline rise in blood plasma. Using electrophysiological analyses, we delineate a previously unknown signaling pathway in which stimulation of PAC1 or muscarinic receptors activates TRPC5 channels in a phospholipase-C-dependent manner to induce sustained adrenaline secretion as a crucial step in the sympathetic counter response to insulin-induced hypoglycemia. By comparing metabolites in the plasma, we identified reduced taurine levels after hypoglycemia induction as a commonality in TRPC5-deficient mice and HAAF patients.

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Evaluation of the possible impact of the fear of hypoglycemia on diabetes management in children and adolescents with type 1 diabetes mellitus and their parents: a cross-sectional study

PURPOSE

Hypoglycemia represents a significant source of anxiety for children with type 1 diabetes mellitus (T1DM) and their caretakers. Fear of hypoglycemia (FoH) was measured in children and adolescents with T1DM as well as in their parents using an established research instrument, the Hypoglycemia Fear Survey (HFS).

METHODS

This is a two-center, cross-sectional study involving 100 children and adolescents aged 6-18 years old diagnosed with T1DM. One parent of each child also participated in the study. The participants, who were recruited from two different pediatric endocrine outpatient clinics, were asked to complete the translated Greek version of the HFS, which includes one version for children (C-HFS) and one for parents (P-HFS). The association of the questionnaire responses with subjects' characteristics, such as current age, age at diagnosis, duration of diabetes, HbA1c levels, and mode of diabetes treatment were assessed.

RESULTS

Parents exhibited significantly higher mean HFS scores than their children. No significant correlation was found between the P-HFS or the C-HFS scores and the age of the children, duration of diabetes, HbA1c, or mode of treatment.

CONCLUSION

The finding that parents experience higher levels of FoH compared to their children emphasizes the importance of healthcare providers to screen parental FoH and focus on approaches to support them in order to reduce their psychological burden, thus optimizing children's diabetes management.

Attitudes and practices related to hypoglycemia unawareness in patients with type 1 and type 2 diabetes

Diabetes is considered one of the most prevalent endocrine metabolic diseases. Monitoring hypoglycemia unawareness is an important component of routine diabetes care and can identify patients at increased risk of a severe hypoglycaemic event. This study aimed to evaluate the frequency of hypoglycemia unawareness and identify the factors contributing to its occurrence. A sample of 390 patients diagnosed with type 1 and type 2 diabetes was interviewed in an endocrine and diabetes center in Al-Ahsa city. Sociodemographic data, risk factors, and Clarke scores were used to evaluate the impairment of hypoglycemia awareness. Reduced awareness of hypoglycemia was found in 93 patients (23.8%). There were no statistically significant differences in the age of the patients, mean age of diagnosis, or cumulative glucose level between patients with awareness and those with reduced awareness (P > 0.05). Patients with type 2 diabetes mellitus (T2DM) showed significantly reduced awareness compared to type 1 diabetes (T1DM) (P = 0.038). Additionally, there were no statistically significant differences in hypoglycemia awareness between patients who underwent nephropathy screening and those who did not (P = 0.523). In conclusion, our study revealed reduced hypoglycemia awareness in 93 patients. However, there was no statistically significant difference related to various factors, including age and cumulative glucose levels. Patients with T2DM showed significantly lower hypoglycaemic awareness compared to patients with T1DM. Further research is needed to evaluate other factors of hypoglycemia unawareness.

Expert Opinion on Current Trends in the Use of Insulin in the Management of People with Type 2 Diabetes from the South-Eastern European Region and Israel

Despite the availability of various antihyperglycaemic therapies and comprehensive guidelines, glycaemic control in diabetes management has not improved significantly during the last decade in the real-world clinical setting. Treatment inertia arising from a complex interplay among patient-, clinician- and healthcare-system-related factors is the prime reason for this suboptimal glycaemic control. Also, the key factor leading to inadequate glycaemic levels remains limited communication between healthcare professionals (HCPs) and people with type 2 diabetes (PwT2D). Early insulin administration has several advantages including reduced glucotoxicity, high efficacy and preserved β-cell mass/function, leading to lowering the risk of diabetes complications. The current publication is based on consensus of experts from the South-Eastern European region and Israel who reviewed the existing evidence and guidelines for the treatment of PwT2D. Herein, the experts emphasised the timely use of insulin, preferably second-generation basal insulin (BI) analogues and intensification using basal-plus therapy, as the most-potent glucose-lowering treatment choice in the real-world clinical setting. Despite an increase in the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), the experts urged timely insulin initiation for inadequate glycaemic control in PwT2D. Furthermore, the combination of BI and GLP-1 RA addressing both fasting plasma glucose and post-prandial excursions as a free- or fixed-ratio combination was identified to reduce treatment complexity and burden. To minimise discontinuation and improve adherence, the experts reiterated quality, regular interactions and discussions between HCPs and PwT2D/carers for their involvement in the diabetes management decision-making process. Clinicians and HCPs should consider the opinions of the experts in accordance with the most recent recommendations for diabetes management.

Physiopathology and Treatment of Obesity and Overweight: A Proposal for a New Anorectic

The "new epidemic," as WHO calls obesity, is caused by overeating, which, having exceeded the body's actual needs, accumulates in the form of health-damaging fat deposits. Moving more and eating less is the main remedy, but eating belongs to vital instincts, which are beyond the control of reason. In this sense, eating is different from drinking and breathing because without food it is possible to survive for a few weeks, without water for a few days, without oxygen for a few minutes. The first part of this article provides an overview of obesity and its treatment, focusing on the new anorectic anticipated in the title. The second part focuses on compulsive obesity, typically represented by constitutional obesity and food addiction. The article concludes with a discussion of the pharmacological treatment of compulsive diseases, to which some forms of obesity belong.

Anti-Inflammatory Action of Resveratrol in the Central Nervous System in Relation to Glucose Concentration-An In Vitro Study on a Blood-Brain Barrier Model

Unbalanced blood glucose levels may cause inflammation within the central nervous system (CNS). This effect can be reversed by the action of a natural neuroprotective compound, resveratrol (RSV). The study aimed to investigate the anti-inflammatory effect of RSV on astrocyte cytokine profiles within an in vitro model of the blood-brain barrier (BBB) under varying glucose concentrations (2.2, 5.0, and 25.0 mmol/L), corresponding to hypo-, normo-, and hyperglycemia. The model included co-cultures of astrocytes (brain compartment, BC) and endothelial cells (microvascular compartment, MC), separated by 0.4 µm wide pores. Subsequent exposure to 0.2 μM LPS in the brain compartment (BC) and 50 μM RSV in the microvascular compartment (MC) of each well was carried out. Cytokine levels (IL-1 α, IL-1 β, IL-2, IL-4, IL-6, IL-8) in the BC were assessed using a Multi-Analyte ELISArray Kit before and after the addition of LPS and RSV. Statistical analysis was performed to determine significance levels. The results demonstrated that RSV reduced the concentration of all studied cytokines in the BC, regardless of glucose levels, with the most substantial decrease observed under normoglycemic conditions. Additionally, the concentration of RSV in the BC was highest under normoglycemic conditions compared to hypo- and hyperglycemia. These findings confirm that administration of RSV in the MC exerts anti-inflammatory effects within the BC, particularly under normoglycemia-simulating conditions. Further in vivo studies, including animal and human research, are warranted to elucidate the bioavailability of RSV within the central nervous system (CNS).

Comparative Effect of Glucose-Lowering Drugs for Type 2 Diabetes Mellitus on Stroke Prevention: A Systematic Review and Network Meta-Analysis

BACKGRUOUND

There is still a lack of research on which diabetic drugs are more effective in preventing stroke. Our network metaanalysis aimed to compare cerebrovascular benefits among glucose-lowering treatments.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the ClinicalTrials.gov registry for clinical trials from inception through May 25, 2021. We included both prespecified cerebrovascular outcomes and cerebrovascular events reported as severe adverse events. Subgroup analyses were conducted by stroke subtype, publication type, age of patients, baseline glycosylated hemoglobin (HbA1c), duration of type 2 diabetes mellitus, and cardiovascular risks.

RESULTS

Of 2,861 reports and 1,779 trials screened, 79 randomized controlled trials comprising 206,387 patients fulfilled the inclusion criteria. In the pairwise meta-analysis, the use of glucagon-like peptide-1 (GLP-1) agonist was associated with a lower risk of total stroke compared with placebo (relative risk [RR], -0.17; 95% confidence interval [CI], -0.27 to -0.07). In the network meta- analysis, only the use of sodium-glucose cotransporter-2 (SGLT-2) inhibitor was associated with a reduction of total stroke, compared with placebo (RR, 0.81; 95% CI, 0.67 to 0.98). In the subgroup analyses, the use of SGLT-2 inhibitor and GLP-1 agonist was associated with a lower risk of stroke in those with high HbA1c (≥8.0) and low-risk of cardiovascular disease, respectively.

CONCLUSION

SGLT-2 inhibitors and GLP-1 agonists were shown to be beneficial for stroke prevention in patients with type 2 diabetes mellitus.

Hypoglycemia Unawareness-A Review on Pathophysiology and Clinical Implications

Hypoglycemia is a particular problem in people with diabetes while it can also occur in other clinical circumstances. Hypoglycemia unawareness describes a condition in which autonomic and neuroglycopenic symptoms of hypoglycemia decrease and hence are hardly perceivable. A failure to recognize hypoglycemia in time can lead to unconsciousness, seizure, and even death. The risk factors include intensive glycemic control, prior episodes of severe hypoglycemia, long duration of diabetes, alcohol consumption, exercise, renal failure, and sepsis. The pathophysiological mechanisms are manifold, but mainly concern altered brain glucose sensing, cerebral adaptations, and an impaired hormonal counterregulation with an attenuated release of glucagon, epinephrine, growth hormone, and other hormones, as well as impaired autonomous and neuroglycopenic symptoms. Physiologically, this counterregulatory response causes blood glucose levels to rise. The impaired hormonal counterregulatory response to recurrent hypoglycemia can lead to a vicious cycle of frequent and poorly recognized hypoglycemic episodes. There is a shift in glycemic threshold to trigger hormonal counterregulation, resulting in hypoglycemia-associated autonomic failure and leading to the clinical syndrome of hypoglycemia unawareness. This clinical syndrome represents a particularly great challenge in diabetes treatment and, thus, prevention of hypoglycemia is crucial in diabetes management. This mini-review provides an overview of hypoglycemia and the associated severe complication of impaired hypoglycemia awareness and its symptoms, pathophysiology, risk factors, consequences, as well as therapeutic strategies.

Reactive Hypoglycemia in Patients Prior to Cataract Surgery: A Case Series

Cataract surgery is one of the most frequently performed surgical procedures and is often performed under topical anesthesia in conscious patients. Sweating, palpitations, and anxiety may be seen in patients about to undergo surgery. However, these are typical adrenergic symptoms of hypoglycemia and should be further investigated if occurring before surgery. Here, we report five cases of postprandial or reactive hypoglycemia observed in hospital settings just before conducting cataract surgeries in non-diabetic 52-78-year-old patients from 2019 to 2023.

Role of the Adrenal Medulla in Hypoglycaemia-Associated Autonomic Failure-A Diabetic Perspective

Hypoglycaemia-associated autonomic failure (HAAF) is characterised by an impairment in adrenal medullary and neurogenic symptom responses following episodes of recurrent hypoglycaemia. Here, we review the status quo of research related to the regulatory mechanisms of the adrenal medulla in its response to single and recurrent hypoglycaemia in both diabetic and non-diabetic subjects with particular focus given to catecholamine synthesis, enzymatic activity, and the impact of adrenal medullary peptides. Short-term post-transcriptional modifications, particularly phosphorylation at specific residues of tyrosine hydroxylase (TH), play a key role in the regulation of catecholamine synthesis. While the effects of recurrent hypoglycaemia on catecholamine synthetic enzymes remain inconsistent, long-term changes in TH protein expression suggest species-specific responses. Adrenomedullary peptides such as neuropeptide Y (NPY), galanin, and proenkephalin exhibit altered gene and protein expression in response to hypoglycaemia, suggesting a potential role in the modulation of catecholamine secretion. Of note is NPY, since its antagonism has been shown to prevent reductions in TH protein expression. This review highlights the need for further investigation into the molecular mechanisms involved in the adrenal medullary response to hypoglycaemia. Despite advancements in our understanding of HAAF in non-diabetic rodents, a reliable diabetic rodent model of HAAF remains a challenge.

Validation of the hypoglycemia awareness questionnaire to assess hypoglycemia awareness in patients with type 2 diabetes treated with insulin

AIMS

Given the implications of impaired hypoglycemia awareness in patients with type 2 diabetes (T2D), it is necessary to identify reliable and valid instruments for its measurement. The Hypoglycemia Awareness Questionnaire (HypoA-Q) measures impaired awareness, symptom severity, and symptom frequency. The present study evaluated the HypoA-Q validity for assessing awareness of hypoglycemia in patients with T2D treated with insulin.

METHODS

The questionnaire was administered to 406 patients diagnosed with T2D on insulin treatment at four centers in Bogotá, Colombia. The internal structure of the questionnaire was analyzed using exploratory and confirmatory factor analyses, internal consistency and test-retest reliability were evaluated, and criterion validity was rated by assessing its correlation with the Clarke scale.

RESULTS

Factor analysis identified an empirical structure of four domains that adequately represented the construct. Cronbach's alpha and McDonald's Omega coefficients yielded values between 0.75 and 0.79 for the impaired awareness scale. Lin and intraclass correlation coefficients were 0.86 and 0.85, respectively. The correlation between the impaired awareness subscale and Clarke scale was 0.654, and differences were found between patients with good and poor awareness of hypoglycemia.

CONCLUSIONS

The HypoA-Q is a valid and reliable tool for measuring the awareness of hypoglycemia in patients with T2D who are treated with insulin.

Gammeltoft T, Christian Bygbjerg I, W. Meyrowitsch D, Søndergaard J. Pre-/-post-analyses of a feasibility study of a peer-based club intervention among people living with type 2 diabetes in Vietnam's rural communities

OBJECTIVES

Insufficient self-management is a significant barrier for people with type 2 diabetes (T2D) to achieve glycemic control and consequently reduce the risk of acute and long-term diabetes complications, negatively affecting their quality of life and increasing their risk of diabetes-related death. This pre-post study aimed to evaluate whether a peer-based club intervention might reduce glycated hemoglobin from baseline to post-intervention and enhance self-management among people living with T2D in two rural communities in Vietnam.

METHODS

A pre-post study was implemented with 222 adults with T2D residing in two rural communities in Vietnam. We used a structured questionnaire, clinical examination, and glycated hemoglobin to evaluate the possible effects of a diabetes club intervention by comparing Glycated Hemoglobin (HbA1c), Body Mass Index (BMI), Blood Pressure (BP), and diabetes-related self-management behaviors at baseline and post-intervention. The data were analyzed using SPSS 20, applying two related sample tests (Wilcoxon and McNemar test) and a paired-sample t-test at a significance level of less than 0.05.

RESULTS

The findings indicated that after implementation of the intervention, there were no significant statistical differences when comparing pre-and post-intervention levels of the primary outcome HbA1c, but some components of diabetes self-management showed statistically significant improvement.

CONCLUSIONS

After the peer support intervention in a Vietnamese rural community, there was no significant reduction in the primary outcome proportion of patients having an HbA1c less than 7%, but foot care knowledge and practice had improved.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05602441.

The Role of Glucose Concentration and Resveratrol in Modulating Neuroinflammatory Cytokines: Insights from an In Vitro Blood-Brain Barrier Model

BACKGROUND The prevalence of type 2 diabetes mellitus is rising, presumably because of a coexisting pandemic of obesity. Since diabetic neuropathy and neuroinflammation are frequent and significant complications of both prolonged hyperglycemia and iatrogenic hypoglycemia, the effect of glucose concentration and resveratrol (RSV) supplementation on cytokine profile was assessed in an in vitro model of the blood-brain barrier (BBB). MATERIAL AND METHODS The in vitro model of BBB was formed of endothelial cells and astrocytes, which represented the microvascular and brain compartments (MC and BC, respectively). The BC concentrations of selected cytokines - IL-10, IL-12, IL-17A, TNF-alpha, IFN-γ, GM-CSF in response to different glucose concentrations in the MC were studied. The influence of LPS in the BC and RSV in the MC on the cytokine profile in the BC was examined. RESULTS Low glucose concentration (40 mg/dL) in the MC resulted in increased concentration of all the cytokines in the BC except TNF-alpha, compared to normoglycemia-imitating conditions (90 mg/dL) (P<0.05). High glucose concentration (450 mg/dL) in the MC elevated the concentration of all the cytokines in the BC (P<0.05). RSV decreased the level of all cytokines in the BC after 24 h following its administration for all glucose concentrations in the MC (P<0.02). The greatest decline was observed in normoglycemic conditions (P<0.05). CONCLUSIONS Both hypo- and hyperglycemia-simulating conditions impair the cytokine profile in BC, while RSV can normalize it, despite relatively poor penetration through the BBB. RSV exhibits anti-neuroinflammatory effects, especially in the group with normoglycemia-simulating conditions.

Risk factors of severe hypoglycemia among patients with type 2 diabetes mellitus in outpatient clinic of tertiary hospital in Indonesia

This study aimed to describe risk factors of severe hypoglycemia in type 2 diabetes mellitus (T2DM) patients in a tertiary care hospital in Indonesia. This study was a retrospective cohort study in the Endocrinology Outpatient Clinic of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia. All subjects more than 18 years old who had been visiting the clinic for at least a year were included. Subjects were interviewed whether they had any severe hypoglycemia events within the past year, while data on risk factor variables of severe hypoglycemia was taken from medical records one year before data collection. We recruited 291 subjects, among whom 25.4% suffered at least one episode of severe hypoglycemia within one year. History of severe hypoglycemia (OR 5.864, p ≤ 0.001), eGFR less than 60 mL/min/1.73m2 (OR 1.976, p = 0.028), and insulin use (OR 2.257, p = 0.021) were associated with increased risk of severe hypoglycemia. In conclusion, history of previous severe hypoglycemia, eGFR less than 60 mL/min/1.73m2, and insulin use were associated with severe hypoglycemia.

Real-life 24-week changes in glycemic parameters among European users of flash glucose monitoring with type 1 and 2 diabetes and different levels of glycemic control

AIM

To evaluate real-life changes of glycemic parameters among flash glucose monitoring (FLASH) users who do not meet glycemic targets.

METHODS

De-identified data were obtained between 2014 and 2021 from patients using FLASH uninterrupted for a 24-week period. Glycemic parameters during first and last sensor use were examined in four identifiable groups: type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM) on basal-bolus insulin, T2DM on basal insulin, and T2DM without insulin treatment. Within each group, subgroup analyses were performed in persons with initial suboptimal glycemic regulation (time in range (TIR; 3.9-10 mmol/L) <70%, time above range (TAR; >10 mmol/L) >25%, or time below range (TBR; <3.9 mmol/L) >4%).

RESULTS

Data were obtained from 1,909 persons with T1DM and 1,813 persons with T2DM (1,499 basal-bolus insulin, 189 basal insulin, and 125 non-insulin users). In most of the performed analyses, both overall and in the various subgroups, significant improvements were observed in virtually all predefined primary (TIR) and secondary endpoints (eHbA1c, TAR, TBR and glucose variability).

CONCLUSIONS

24-weeks FLASH use in real life by persons with T1DM and T2DM with suboptimal glycemic regulation is associated with improvement of glycemic parameters, irrespective of pre-use regulation or treatment modality.

Extrahepatic transplantation of 3D cultured stem cell-derived islet organoids on microporous scaffolds

Stem cell differentiation methods have been developed to produce cells capable of insulin secretion which are showing promise in clinical trials for treatment of type-1 diabetes. Nevertheless, opportunities remain to improve cell maturation and function. Three-dimensional (3D) culture has demonstrated improved differentiation and metabolic function in organoid systems, with biomaterial scaffolds employed to direct cell assembly and facilitate cell-cell contacts. Herein, we investigate 3D culture of human stem cell-derived islet organoids, with 3D culture initiated at the pancreatic progenitor, endocrine progenitor, or immature β-cell stage. Clusters formed by reaggregation of immature β-cells could be readily seeded into the microporous poly(lactide-co-glycolide) scaffold, with control over cell number. Culture of islet organoids on scaffolds at the early to mid-stage beta cell progenitors had improved in vitro glucose stimulated insulin secretion relative to organoids formed at the pancreatic progenitor stage. Reaggregated islet organoids were transplanted into the peritoneal fat of streptozotocin-induced diabetic mice, which resulted in reduced blood glucose levels and the presence of systemic human C-peptide. In conclusion, 3D cell culture supports development of islet organoids as indicated by insulin secretion in vitro and supports transplantation to extrahepatic sites that leads to a reduction of hyperglycemia in vivo.

Offline reinforcement learning for safer blood glucose control in people with type 1 diabetes

The widespread adoption of effective hybrid closed loop systems would represent an important milestone of care for people living with type 1 diabetes (T1D). These devices typically utilise simple control algorithms to select the optimal insulin dose for maintaining blood glucose levels within a healthy range. Online reinforcement learning (RL) has been utilised as a method for further enhancing glucose control in these devices. Previous approaches have been shown to reduce patient risk and improve time spent in the target range when compared to classical control algorithms, but are prone to instability in the learning process, often resulting in the selection of unsafe actions. This work presents an evaluation of offline RL for developing effective dosing policies without the need for potentially dangerous patient interaction during training. This paper examines the utility of BCQ, CQL and TD3-BC in managing the blood glucose of the 30 virtual patients available within the FDA-approved UVA/Padova glucose dynamics simulator. When trained on less than a tenth of the total training samples required by online RL to achieve stable performance, this work shows that offline RL can significantly increase time in the healthy blood glucose range from 61.6±0.3% to 65.3±0.5% when compared to the strongest state-of-art baseline (p<0.001). This is achieved without any associated increase in low blood glucose events. Offline RL is also shown to be able to correct for common and challenging control scenarios such as incorrect bolus dosing, irregular meal timings and compression errors. The code for this work is available at: https://github.com/hemerson1/offline-glucose.

Glycemia-Induced miRNA Changes: A Review

Diabetes is a rapidly increasing global health concern that significantly strains the health system due to its downstream complications. Dysregulation in glycemia represents one of the fundamental obstacles to achieving glycemic control in diabetic patients. Frequent hyperglycemia and/or hypoglycemia events contribute to pathologies that disrupt cellular and metabolic processes, which may contribute to the development of macrovascular and microvascular complications, worsening the disease burden and mortality. miRNAs are small single-stranded non-coding RNAs that regulate cellular protein expression and have been linked to various diseases, including diabetes mellitus. miRNAs have proven useful in the diagnosis, treatment, and prognosis of diabetes and its complications. There is a vast body of literature examining the role of miRNA biomarkers in diabetes, aiming for earlier diagnoses and improved treatment for diabetic patients. This article reviews the most recent literature discussing the role of specific miRNAs in glycemic control, platelet activity, and macrovascular and microvascular complications. Our review examines the different miRNAs involved in the pathological processes leading to the development of type 2 diabetes mellitus, such as endothelial dysfunction, pancreatic beta-cell dysfunction, and insulin resistance. Furthermore, we discuss the potential applications of miRNAs as next-generation biomarkers in diabetes with the aim of preventing, treating, and reversing diabetes.

Recurrent hypoglycemia dampens functional regulation mediated via Neurexin-1, Neuroligin-2 and Mint-1 docking proteins: Intensified complications during diabetes

Glycemic regulation is important for maintaining critical physiological functions. Extreme variation in levels of circulating glucose are known to affect insulin secretion. Elevated insulin levels result in lowering of circulating glycemic levels culminating into hypoglycemia. Recurrence of hypoglycemia are often noted owing to fasting conditions, untimely meals, irregular dietary consumption, or as a side-effect of disease pathophysiology. Such events of hypoglycemia threaten to hamper the patterns of insulin secretion in diabetic condition. Insulin vesicle docking is a prerequisite phase which ensures anchoring of the vesicles to the β-cell membrane in order to expel the insulin cargo. Neurexin and Neuroligin are the marker docking proteins which assists in the tethering of the insulin granules to the secretory membrane. However, these cell adhesion molecules indirectly affect the glycemic levels by regulating insulin secretion. The effect of extreme levels of glycemic fluctuations on these molecules, and how it affects the docking machinery remains obscure. Our current study demonstrates down-regulated expression of Neurexin-1, Neuroligin-2 and Mint-1 molecules during hyperglycemia, hypoglycemia and diabetic hypoglycemia in rodents as well as for an in-vitro system using MIN6 cell-line. Studies with fluorescently labelled insulin revealed presence of lessened functional insulin secretory granules, concomitant with the alterations in morphology and as a result of hypoglycemia in control and diabetic condition which was found to be further deteriorating. Our studies indicate towards a feeble vesicular anchorage, which may partly be responsible for dwindled insulin secretion during diabetes. However, hypoglycemia poses as a potent diabetic complication in further deteriorating the docking machinery. To the best of our knowledge this is the first report which demonstrates the effect of hypoglycemic events in affecting insulin secretion by weakening insulin vesicular anchorage in normal and diabetic individuals.

Hydrophobicity Regulation of Energy Acceptors Confined in Mesoporous Silica Enabled Reversible Activation of Optogenetics for Closed-Loop Glycemic Control

Optogenetics-based synthetic biology holds great promise as a cell-based therapy strategy for many clinical incurable diseases; however, precise control over genetic expression strength and timing through disease state-related closed-loop regulation remains a challenge due to the lack of reversible probes to indicate real-time metabolite fluctuations. Here, based on a novel mechanism of analyte-induced hydrophobicity regulation of energy acceptors confined in mesoporous silica, we developed a smart hydrogel platform comprising glucose reversible responsive upconversion nanoprobes and optogenetic engineered cells, in which the upconverted blue light strength was adaptively tuned through blood glucose levels to control optogenetic expressions for insulin secretion. The intelligent hydrogel system enabled convenient maintenance of glycemic homeostasis through simple near-infrared illuminations without any additional glucose concentration monitoring, which efficiently avoided genetic overexpression-induced hypoglycemia. This proof-of-concept strategy efficiently combines diagnostics with optogenetics-based synthetic biology for mellitus therapy, opening up a new avenue for nano-optogenetics.

No Time to Die-How Islets Meet Their Demise in Transplantation

Islet transplantation represents an effective treatment for patients with type 1 diabetes mellitus (T1DM) and severe hypoglycaemia unawareness, capable of circumventing impaired counterregulatory pathways that no longer provide protection against low blood glucose levels. The additional beneficial effect of normalizing metabolic glycaemic control is the minimisation of further complications related to T1DM and insulin administration. However, patients require allogeneic islets from up to three donors, and the long-term insulin independence is inferior to that achieved with solid organ (whole pancreas) transplantation. This is likely due to the fragility of islets caused by the isolation process, innate immune responses following portal infusion, auto- and allo-immune-mediated destruction and β-cell exhaustion following transplantation. This review covers the specific challenges related to islet vulnerability and dysfunction that affect long-term cell survival following transplantation.

Awareness Level of Hypoglycemia Among Diabetes Mellitus Type 2 Patients in Al Qassim Region

Background Hypoglycemia has a major impact on patient health and glycemic management during insulin therapy for both type 1 (T1DM) and type 2 diabetes mellitus (T2DM). It is the rate-limiting complication in diabetes management that prevents stringent glucose control. Objectives To assess the knowledge and awareness about hypoglycemia as a complication of T2D in adults in Al Qassim, Saudi Arabia. Methods This is a cross-sectional study done among type 2 diabetes patients in Al-Qassim, Kingdom of Saudi Arabia, from January to June 2022. A previously validated online questionnaire was disseminated through social media to gather information from respondents. Participants were chosen via a simple random sampling technique. Data analysis was completed using SPSS (version 23; IBM Corp., Armonk, NY). Results Overall, 213 respondents were included in our study. The majority of them were females (70.9%). The participants' average age was 35.9 + 13.0 years. Our results revealed that the average awareness score of the study population was found to be 3.6 ± 1.1 (by using the Clarke method) and 3.7 ± 2.1 (by using the Gold method). Moreover, we found that impaired awareness of hypoglycemia's prevalence by Clarke's questionnaire was 52.1% and 53.5% by using the Gold questionnaire. In addition, almost half of the respondents reported weakness as a symptom of hypoglycemia over the last six months and unconsciousness over the last 12 months. Hypertension was the most commonly reported chronic disease by our participants. Lastly, factors such as age, gender, educational level, geographic distribution, and history of chronic illness did not show any significant association with impaired awareness of the prevalence of hypoglycemia. Conclusion According to our research, we concluded that patients with type 2 diabetes mellitus in the region of Al-Qassim, Saudi Arabia, had insufficient knowledge about hypoglycemia as a complication of T2D. Moreover, the impaired awareness of hypoglycemia in diabetic patients was found to be high. Hence, there is a need for interventional programs to raise public awareness.

The Role of Platelets in Hypoglycemia-Induced Cardiovascular Disease: A Review of the Literature

Cardiovascular diseases (CVDs) are the leading cause of death globally as well as the leading cause of mortality and morbidity in type 2 diabetes (T2D) patients. Results from large interventional studies have suggested hyperglycemia and poor glycemic control to be largely responsible for the development of CVDs. However, the association between hypoglycemia and cardiovascular events is also a key pathophysiological factor in the development of CVDs. Hypoglycemia is especially prevalent in T2D patients treated with oral sulfonylurea agents or exogenous insulin, increasing the susceptibility of this population to cardiovascular events. The adverse cardiovascular risk of hypoglycemia can persist even after the blood glucose levels have been normalized. Hypoglycemia may lead to vascular disease through mechanisms such as enhanced coagulation, oxidative stress, vascular inflammation, endothelial dysfunction, and platelet activation. In the following review, we summarize the evidence for the role of hypoglycemia in platelet activation and the subsequent effects this may have on the development of CVD. In addition, we review current evidence for the effectiveness of therapies in reducing the risk of CVDs.

COVID-19 associated Mucormycosis (CAM): Implications for perioperative physicians - A narrative review

Mucormycosis once considered a rare disease with an incidence of 0.005 to 1.7 per million, has become one of the greatest menaces during the coronavirus disease (COVID-19) pandemic. India alone has contributed to nearly 70% of the global caseload of COVID-associated mucormycosis (CAM) and it had even been declared as a notifiable disease. Second wave of COVID-19 pandemic saw a steep rise in the incidence of mucormycosis and these patients have been presenting to anesthesiologists for various surgical procedures due to its primary or secondary sequelae. Rhino-orbito-cerebral mucormycosis (ROCM) is the commonest manifestation and is caused by Rhizopus arrhizus. Injudicious use of corticosteroids in vulnerable patients could have been a major contributing factor to the sudden rise in ROCM during the pandemic. Concerns related to anesthetic management include COVID-19 infection and post COVID sequalae, common presence of uncontrolled diabetes mellitus, possibility of difficult mask-ventilation and/or intubation, various drug therapy-associated adverse effects, and interaction of these drugs with anesthetic agents. Thorough preoperative optimization, multidisciplinary involvement, perioperative care, and vigilance go a long way in improving overall outcomes in these patients.

Potential of medicinal plants to ameliorate neovascularization activities in diabetes: A systematic review

Hyperglycemia in diabetes mediates the release of angiogenic factors, oxidative stress, hypoxia, and inflammation, which in turn stimulate angiogenesis. Excessive angiogenesis can cause diabetic retinopathy, diabetic neuropathy, and diabetic nephropathy. All of these complications are debilitating, which may lead to an increased susceptibility to lower-limb amputations due to ulcerations and infections. In addition, microvascular alterations, segmental demyelination, and endoneurial microangiopathy may cause progressive deterioration ultimately leading to kidney failure and permanent blindness. Some medicinal plants have potent anti-angiogenic, antioxidant or anti-inflammatory properties that can ameliorate angiogenesis in diabetes. The purpose of this systematic review is to demonstrate the potential of medicinal plants in ameliorating the neovascularization activities in diabetes. Manuscripts were searched from PubMed, Science Direct, and Scopus databases, and Google Scholar was used for searching additional papers. From 1862 manuscripts searched, 1854 were excluded based on inclusion and exclusion criteria and 8 were included into this systematic review, whereas the required information was extracted and summarized. All identified medicinal plants decreased the high blood glucose levels in diabetes, except the aqueous extract of Lonicerae japonicae flos (FJL) and Vasant Kusumakar Ras. They also increased the reduced body weight in diabetes, except the aqueous extract of FL and total lignans from Fructus arctii. However, methanolic extract of Tinospora cordifolia and Vasant Kusumakar Ras were not tested for their ability to affect the body weight. Besides, all medicinal plants identified in this systematic review decreased the vascular endothelial growth factor (VEGF) protein expression and vasculature activity demonstrated by histopathological examination indicating promising anti-angiogenic properties. All medicinal plants identified in this systematic review have a potential to ameliorate neovascularization activities in diabetes by targeting the mechanistic pathways related to oxidative stress, inflammation, and angiogenesis.

Multifaceted Pharmacological Potentials of Curcumin, Genistein, and Tanshinone IIA through Proteomic Approaches: An In-Depth Review

Phytochemicals possess various intriguing pharmacological properties against diverse pathological conditions. Extensive studies are on-going to understand the structural/functional properties of phytochemicals as well as the molecular mechanisms of their therapeutic function against various disease conditions. Phytochemicals such as curcumin (Cur), genistein (Gen), and tanshinone-IIA (Tan IIA) have multifaceted therapeutic potentials and various efforts are in progress to understand the molecular dynamics of their function with different tools and technologies. Cur is an active lipophilic polyphenol with pleiotropic function, and it has been shown to possess various intriguing properties including antioxidant, anti-inflammatory, anti-microbial, anticancer, and anti-genotoxic properties besides others beneficial properties. Similarly, Gen (an isoflavone) exhibits a wide range of vital functions including antioxidant, anti-inflammatory, pro-apoptotic, anti-proliferative, anti-angiogenic activities etc. In addition, Tan IIA, a lipophilic compound, possesses antioxidant, anti-angiogenic, anti-inflammatory, anticancer activities, and so on. Over the last few decades, the field of proteomics has garnered great momentum mainly attributed to the recent advancement in mass spectrometry (MS) techniques. It is envisaged that the proteomics technology has considerably contributed to the biomedical research endeavors lately. Interestingly, they have also been explored as a reliable approach to understand the molecular intricacies related to phytochemical-based therapeutic interventions. The present review provides an overview of the proteomics studies performed to unravel the underlying molecular intricacies of various phytochemicals such as Cur, Gen, and Tan IIA. This in-depth study will help the researchers in better understanding of the pharmacological potential of the phytochemicals at the proteomics level. Certainly, this review will be highly instrumental in catalyzing the translational shift from phytochemical-based biomedical research to clinical practice in the near future.

Fear of hypoglycemia and associated factors in hospitalized patients with type 2 diabetes: a cross‑sectional study

The present cross-sectional survey was performed to assess the prevalence and factors associated with fear of hypoglycemia (FoH) in hospitalized patients with type 2 diabetes (T2D). Between July and December 2020, 494 patients with T2D were evaluated via structured questionnaires containing sociodemographic information, clinical information, and the Fear of Hypoglycemia-15 scale (FH-15). Patients were divided into the FoH and non-FoH groups according to the FH-15 score. Univariate and multivariate logistic regression analyses were performed to determine factors associated with FoH. Variables with P values < 0.1 in the univariate model were included in the multivariate model. In this study, the prevalence of FoH was 17.4% (86/494). 247 (50.0%) patients experienced hypoglycemic episodes in the past year, and 15 (3.0%) patients experienced severe hypoglycemic episodes in the past year. The mean age was 60.04 ± 11.71 years old, and female patients accounted for 39.9% of the sample. The item with the highest average FH-15 scores was: how often are you afraid of having hypoglycemia while alone? Multivariate logistic regression analysis indicated that living alone (OR 2.48; 95% CI 1.20-5.14; P = 0.015), number of hypoglycemic episodes in the past year (OR 1.06; 95% CI 1.03-1.10; P < 0.001), number of severe hypoglycemic episodes in the past year (OR 2.61; 95% CI 1.20-5.69; P = 0.016), and duration of insulin use (OR 1.06; 95% CI 1.02-1.10; P = 0.006) were associated with FoH. The prevalence of FoH in hospitalized patients with T2D was high. FoH was associated with living alone, number of hypoglycemic episodes in the past year, number of severe hypoglycemic episodes in the past year, and duration of insulin use. These findings can contribute to early decision-making for preventing, identifying, and improving FoH in patients with T2D. In the future, interventions aimed at reducing FoH to improve the harmful effects of FoH are necessary, such as increasing diabetes-related knowledge and skills, increasing social support, reducing psychological fear, and minimizing risks for hypoglycemic episodes.

Hypoglycemia prevention practice and associated factors among diabetes mellitus patients in Ethiopia: Systematic review and meta-analyssis

BACKGROUND

Hypoglycemia is an urgent, life-threatening condition that requires prompt recognition and treatment for diabetes mellitus patients to prevent organ and brain damage. Hypoglycemia is one of the most important complications of diabetes mellitus patients around the globe. Hypoglycemia may increase vascular events and even death, in addition to other possible detrimental effects. In spite of the absence of other risk factors, patients receiving intensive insulin therapy are more likely to experience hypoglycemia. To reduce the risk of hypoglycemia and calculate the combined prevalence of hypoglycemia prevention practices among diabetes mellitus patients, recognition of hypoglycemia is critical.

OBJECTIVE

The main aim of this review was to evaluate the available data on Ethiopian diabetes mellitus patients' practices for preventing hypoglycemia and related factors.

METHODS AND MATERIALS

This review was searched using PubMed, the Cochrane Library, Google, Google Scholar, and the Web of Sciences. Microsoft Excel was used to extract the data. All statistical analyses were done using STATA Version 14 software with a random-effects model. The funnel plot and heterogeneity of the studies were checked. Subgroup analysis was done with the study area and authors' names.

RESULTS

In this systematic review, 12 studies totaling 3,639 participants were included. The estimated overall practice for preventing hypoglycemia among diabetic patients in Ethiopia were 48.33% (95% CI (28.21%, 68.46%, I2 = 99.7%, p ≤ 0.001). According to the subgroup analysis based on region, the highest estimated prevalence of the prevention practice of hypoglycemia among diabetes patients in Addis Ababa was 90%, followed by SNNRP at 76.18% and in the Amhara region at 68.31% respectively. The least prevalent was observed in the Oromia region 6.10%. In this meta-analysis, diagnoses with type II diabetes (AOR = 2.53, 95%CI: 1.05, 4.04), duration (AOR = 5.49, 95%CI:3.27,7.70), taking insulin for a long time(AOR = 4.31,95%CI:2.60,6.02), having good prevention knowledge (AOR = 2.89, 95%CI: 1.15,4.23), and occupation (AOR = 4.17, 95%CI: 2.20, 6.15) were significantly associated with hypoglycemia prevention practice.

CONCLUSIONS

This systematic review revealed that diabetic patients in Ethiopia had poor hypoglycemia prevention practices. Being an employee, taking insulin for a long time, having a good prevention practice, and having a type of diabetes mellitus were strongly correlated with practicing hypoglycemia prevention. This review implied the subsequent need for educational interventions for an individualized patient.

Effect of Antidiabetic Therapy on Clinical Outcomes of COVID-19 Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis

Background:

No study has yet systematically evaluated the effect of antidiabetic therapy on clinical outcomes of COVID-19 patients with type 2 diabetes (T2D).

Objective:

We aimed to evaluate the effect of different antidiabetic therapy on clinical outcomes of COVID-19 patients with T2D.

Methods:

We comprehensively retrieved the published research which examined the effect of antidiabetic therapy on clinical outcomes of COVID-19 patients with T2D. The odds ratio (OR) and its 95% confidence interval (95% CI) for clinical outcomes were calculated using the random-effects model, and meta-regression was adopted to evaluate the potential sources of heterogeneity between studies.

Results:

A total of 54 studies were included in this study. We found that the use of metformin (OR = 0.66, 95% CI: 0.58-0.75), SGLT-2i (OR = 0.80, 95% CI: 0.73-0.88), and GLP-1ra (OR = 0.83, 95% CI: 0.70-0.98) were significantly associated with lower mortality risk in COVID-19 patients with T2D, while insulin use might unexpectedly increase the ICU admission rate (OR = 2.32, 95% CI: 1.34-4.01) and risk of death (OR = 1.52, 95% CI: 1.32-1.75). No statistically significant associations were identified for DPP-4i, SUs, AGIs, and TZDs.

Conclusion and Relevance:

We demonstrated that the usage of metformin, SGLT-2i, and GLP-1ra could significantly decrease mortality in COVID-19 patients with T2D. The heterogeneity across the studies, baseline characteristics of the included patients, shortage of dosage and the duration of antidiabetic drugs and autonomy of drug selection might limit the objectivity and accuracy of results. Further adequately powered and high-quality randomized controlled trials are warranted for conclusive findings.

Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts

INTRODUCTION

Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH.

METHOD

The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH.

RESULT

& Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Changes in Treatment Satisfaction Over 3 Years in Patients With Type 2 Diabetes After Initiating Second-line Treatment

CONTEXT

J-DISCOVER is a prospective observational cohort study aiming to understand the current management of patients with early-stage type 2 diabetes mellitus (T2DM) in Japan, enrolling patients initiating second-line treatment.

OBJECTIVE

The current analysis examined the change in treatment satisfaction during the study period and factors affecting this change among patients in J-DISCOVER.

METHODS

We used data from the J-DISCOVER study, in which 1798 patients with T2DM aged ≥ 20 years were enrolled from 142 sites across Japan. Treatment satisfaction was assessed using the Diabetes Treatment Satisfaction Questionnaire (DTSQ).

RESULTS

The mean DTSQ treatment satisfaction score increased from 25.9 points at baseline to 27.3 points at 6 months, which was maintained through 36 months. Among the baseline characteristics examined, higher baseline DTSQ treatment satisfaction scores (P < 0.0001), older age (≥ 75 vs < 65 years, P = 0.0096), living alone (P = 0.0356), and type of facility (clinics vs hospitals, P = 0.0044) had a significantly negative impact on the changes in DTSQ treatment satisfaction scores. Improvement in mean glycated hemoglobin (HbA1c) from baseline (7.7%) to 36 months (7.1%) was associated with positive changes in the DTSQ treatment satisfaction score (P = 0.0003).

CONCLUSION

Changes in DTSQ treatment satisfaction scores were related to HbA1c improvement, suggesting that the management strategy was appropriately planned for each patient. The results also suggest that the availability of social support for patients with T2DM who are elderly or living alone may be an important factor affecting treatment satisfaction, adherence, and clinical outcomes.

Impairment of Mitochondrial Respiration in Metabolic Diseases: An Overview

Mitochondrial dysfunction has emerged as a central pathomechanism in the setting of obesity and diabetes mellitus, linking these intertwined pathologies that share insulin resistance as a common denominator. High-resolution respirometry (HRR) is a state-of-the-art research method currently used to study mitochondrial respiration and its impairment in health and disease. Tissue samples, cells or isolated mitochondria are exposed to various substrate-uncoupler-inhibitor-titration protocols, which allows the measurement and calculation of several parameters of mitochondrial respiration. In this review, we discuss the alterations of mitochondrial bioenergetics in the main dysfunctional organs that contribute to the development of the obese and diabetic phenotypes in both animal models and human subjects. Herein we review data regarding the impairment of oxidative phosphorylation as integrated mitochondrial function assessed by means of HRR. We acknowledge the critical role of this method in determining the alterations in oxidative phosphorylation occurring in the early stages of metabolic pathologies. We conclude that there is a mutual two-way relationship between mitochondrial dysfunction and insulin insensitivity that characterizes these diseases.

High incidence of undetected low sensor glucose events among elderly patients with type 2 diabetes more than a decade on after the ACCORD study

OBJECTIVE

Hypoglycaemia leads to significant morbidity and impacts negatively on quality-of-life, especially in elderly people with increased frailty. The aims of this study were to determine the prevalence of low interstitial fluid glucose (IFG) in patients with tightly controlled type 2 diabetes (T2D), and to evaluate whether there were differences in burden of low IFG between sulphonylurea and insulin treated groups.

METHODS

A Freestyle Libre-Pro sensor was used for sampling of the IFG continuously. Patients were blinded to the IFG levels. The sensor was returned to the investigators after a 2-week period and the data were downloaded for analysis.

RESULTS

There was a total of 69 patients (median age 72 years (IQR = 69-74)) - 40 were sulfonylurea-treated and 29 insulin-treated. In total, 781 low sensor glucose events (<4.0 mmol/L) were detected, of which 254 were very low sensor glucose events (<2.8 mmol/L). Twenty-six out of 29 insulin-treated (89.6%) and 36 out of 40 sulphonylurea-treated patients (90%) contributed to the 781 events of low sensor glucose. Twenty out of 29 insulin-treated (69%) and 26 out of 40 sulphonylurea-treated patients (65.0%) contributed to the 254 very low sensor glucose events. Only 9% of all events were identified by patients. Nocturnal events represented 55.8% of low sensor glucose events and 61.0% of very low sensor glucose events. At a cut-off of <2.8 mmol/L, it was found that the insulin group had a significantly greater number of such events as compared to the sulfonylurea group.

CONCLUSIONS

This study demonstrates that elderly patients with tightly-controlled T2D have a significant number of low sensor glucose events which go by undetected.

Hypoglycemic unawareness: challenges, triggers, and recommendations in patients with hypoglycemic unawareness: a case report

Background

Hypoglycemia is a fairly common complication in diabetic patients, particularly in those on insulin therapy. Hypoglycemia symptoms are classified into two types: autonomic and neuroglycopenic symptoms. If a person develops neuroglycopenic symptoms before the appearance of autonomic symptoms or is asymptomatic until blood sugar levels are very low, the patient will develop hypoglycemic unawareness (HU).

Case presentation

A 25-year-old Iranian woman with HU presented with a severe hypoglycemic episode. This episode was characterized by loss of consciousness and focal neural deficits, which were unusual symptoms in the patient, who was a medical intern with type 1 diabetes and currently being treated with regular and NPH insulin.

Conclusions

Hypoglycemia is a common complication in diabetic patients receiving oral or insulin therapy. A patient who is unaware of their condition may experience severe and potentially fatal episodes. These incidents can negatively affect their daily lives as well as their careers and jobs. Hypoglycemia-associated autonomic failure is a possible cause for patients with multiple episodes of severe hypoglycemia. IThe use of a continuous glucose monitoring device with an alarm, if available, can be an excellent option for these patients.

Pharmacological Properties of 4', 5, 7-Trihydroxyflavone (Apigenin) and Its Impact on Cell Signaling Pathways

Plant bioactive compounds, particularly apigenin, have therapeutic potential and functional activities that aid in the prevention of infectious diseases in many mammalian bodies and promote tumor growth inhibition. Apigenin is a flavonoid with low toxicities and numerous bioactive properties due to which it has been considered as a traditional medicine for decades. Apigenin shows synergistic effects in combined treatment with sorafenib in the HepG2 human cell line (HCC) in less time and statistically reduces the viability of tumor cells, migration, gene expression and apoptosis. The combination of anti-cancerous drugs with apigenin has shown health promoting potential against various cancers. It can prevent cell mobility, maintain the cell cycle and stimulate the immune system. Apigenin also suppresses mTOR activity and raises the UVB-induced phagocytosis and reduces the cancerous cell proliferation and growth. It also has a high safety threshold, and active (anti-cancer) doses can be gained by consuming a vegetable and apigenin rich diet. Apigenin also boosted autophagosome formation, decreased cell proliferation and activated autophagy by preventing the activity of the PI3K pathway, specifically in HepG2 cells. This paper provides an updated overview of apigenin's beneficial anti-inflammatory, antibacterial, antiviral, and anticancer effects, making it a step in the right direction for therapeutics. This study also critically analyzed the effect of apigenin on cancer cell signaling pathways including the PI3K/AKT/MTOR, JAK/STAT, NF-κB and ERK/MAPK pathways.

Alternative analytic and matching approaches for the prevalent new-user design: A simulation study

PURPOSE

To describe the creation of prevalent new user (PNU) cohorts and compare the relative bias and computational efficiency of several alternative analytic and matching approaches in PNU studies.

METHODS

In a simulated cohort, we estimated the effect of a treatment of interest vs a comparator among those who switched to the treatment of interest using the originally proposed time-conditional propensity score (TCPS) matching, standardized morbidity ratio weighting (SMRW), disease risk scores (DRS), and several alternative propensity score matching approaches. For each analytic method, we compared the average RR (across 2000 replicates) to the known risk ratio (RR) of 1.00.

RESULTS

SMRW and DRS yielded unbiased results (RR = 0.998 and 0.997, respectively). TCPS matching with replacement was also unbiased (RR = 0.999). TCPS matching without replacement was unbiased when matches were identified starting with patients with the shortest treatment history as initially proposed (RR = 0.999), but it resulted in very slight bias (RR = 0.983) when starting with patients with the longest treatment history. Similarly, creating a match pool without replacement starting with patients with the shortest treatment history yielded an unbiased estimate (RR = 0.997), but matching with the longest treatment history first resulted in substantial bias (RR = 0.903). The most biased strategy was matching after selecting one random comparator observation per individual that continued on the comparator (RR = 0.802).

CONCLUSIONS

Multiple analytic methods can estimate treatment effects without bias in a PNU cohort. Still, researchers should be wary of introducing bias when selecting controls for complex matching strategies beyond the initially proposed TCPS.

Fear of hypoglycemia-An underestimated problem

INTRODUCTION

Fear of hypoglycemia (FOH) is a phenomenon that affects people with diabetes experiencing hypoglycemia. On the one hand, FOH is an adaptive mechanism that helps to protect patients from hypoglycemia and its consequences. On the other hand, the non-normative level of FOH causes anxiety and tension, disturbs normal functioning, and makes normoglycemia maintenance difficult.

OBJECTIVE

The main objective of this review was to describe factors influencing FOH and methods of measurement of FOH levels. Moreover, we highlighted the impact of the new technologies used in diabetes therapy on FOH and different therapeutic possibilities helping patients cope with excessive levels of FOH. We also presented clinical cases of patients with high FOH levels met in clinical practice and discussed methods to better diagnose and assist people with this kind of problem.

METHODS

We searched for studies and articles via PubMed using the keywords fear of hypoglycemia, diabetes, and hypoglycemia. From screened documents identified from literature search, 67 articles were included in our review.

RESULTS

We divided results from literature screening into five parts: fear of hypoglycemia and hypoglycemia definition, risk factors for the FOH, methods of measuring levels of FOH, therapies for the FOH, and modern technologies. We also described clinical examples of abnormal fear of hypoglycemia in patients.

CONCLUSION

The review highlights the importance of taking into consideration fear of hypoglycemia phenomenon in diabetic patients in everyday clinical practice.

The effect of do-it-yourself real-time continuous glucose monitoring on psychological and glycemic variables in children with type 1 diabetes: A randomized crossover trial

BACKGROUND

Continuous glucose monitoring (CGM) decreases fear of hypoglycemia (FOH) and improves glycemic control among those affected by type 1 diabetes (T1D). No studies to date have examined the impact of using do-it-yourself real-time continuous glucose monitoring (DIY RT-CGM) on psychological and glycemic outcomes.

METHODS

Child-parent dyads were recruited for a multicentre randomized crossover trial. Children with T1D were current intermittently scanned CGM (isCGM) users and aged 2-13 years. Families received either 6 weeks of DIY RT-CGM with parental remote monitoring (intervention) or 6 weeks of isCGM plus usual diabetes care (control), followed by a 4-week washout period, then crossed over. The primary outcome was parental FOH. Secondary outcomes were glycemic control using traditional CGM metrics, as well as a range of other psychosocial measures.

FINDINGS

Fifty five child-parent dyads were recruited. The child mean age was 9.1 ± 2.8 years. Although, there was no effect on parental FOH, -0.1 (95%CI: -0.3, 0.1, p = 0.4), time-in-range (TIR) (%3.9-10 mmol/L) was significantly higher with DIY RT-CGM over isCGM (54.3% ± 13.7 vs. 48.1% ± 13.6), mean difference, 5.7% (95%CI 1.8, 9.6, p <0.004). There was no difference for time spent in hypoglycemia. Parent diabetes treatment satisfaction was significantly higher following DIY RT-CGM compared to isCGM, mean difference 5.3 (95%CI: 2.3, 8.2, p <0.001).

CONCLUSION

The use of DIY RT-CGM versus isCGM did not improve parental FOH; however, TIR and parental satisfaction with diabetes treatment were significantly improved. This suggests in the short term, DIY RT-CGM appears safe and may offer families some clinically important advantages over isCGM.

In vitro generation of transplantable insulin-producing cells from canine adipose-derived mesenchymal stem cells

Canine mesenchymal stem cells (cMSCs) have potential applications for regenerative therapy, including the generation of insulin-producing cells (IPCs) for studying and treating diabetes. In this study, we established a useful protocol for generating IPCs from canine adipose mesenchymal stem cells (cAD-MSCs). Subsequently, in vitro preservation of pluronic F127-coated alginate (ALGPA)-encapsulated cAD-MSC-derived IPCs was performed to verify ready-to-use IPCs. IPCs were induced from cAD-MSCs with the modulated three-stepwise protocol. The first step of definitive endoderm (DE) induction showed that the cooperation of Chir99021 and Activin A created the effective production of Sox17-expressed DE cells. The second step for pancreatic endocrine (PE) progenitor induction from DE indicated that the treatment with taurine, retinoic acid, FGF2, EGF, TGFβ inhibitor, dorsomorphin, nicotinamide, and DAPT showed the significant upregulation of the pancreatic endocrine precursor markers Pdx1 and Ngn3. The last step of IPC production, the combination of taurine, nicotinamide, Glp-1, forskolin, PI3K inhibitor, and TGFβ inhibitor, yielded efficiently functional IPCs from PE precursors. Afterward, the maintenance of ALGPA-encapsulated cAD-MSC-derived IPCs with VSCBIC-1, a specialized medium, enhanced IPC properties. Conclusion, the modulated three-stepwise protocol generates the functional IPCs. Together, the encapsulation of cAD-MSC-derived IPCs and the cultivation with VSCBIC-1 enrich the maturation of generated IPCs.

Comparison of Glycemic Variability and Hypoglycemic Events in Hospitalized Older Adults Treated with Basal Insulin plus Vildagliptin and Basal-Bolus Insulin Regimen: A Prospective Randomized Study

Background: The basal−bolus insulin regimen is recommended in hospitalized patients with diabetes mellitus (DM), but has an increased risk of hypoglycemia. We aimed to compare dipeptidyl peptidase 4 inhibitors (DPP4-i) and basal−bolus insulin glycemic outcomes in hospitalized type 2 DM patients. Methods and patients: Our prospective randomized study included 102 elderly T2DM patients (82 ± 9 years, HbA1c 6.6% ± 1.9). Glycemic control: A variability coefficient assessed by continuous glucose monitoring (Free Style® sensor), mean insulin dose and hypoglycemia rates obtained with the two treatments were analyzed. Results: No differences were found between groups in glycemic control (mean daily glycemia during the first 10 days: 152.6 ± 38.5 vs. 154.2 ± 26.3 mg/dL; p = 0.8). The total doses Kg/day were 0.40 vs. 0.20, respectively (p < 0.001). A lower number of hypoglycemic events (9% vs. 15%; p < 0.04) and lower glycemic coefficient of variation (22% vs. 28%; p < 0.0002) were observed in the basal−DPP4-i compared to the basal−bolus regimen group. Conclusions: Treatment of inpatient hyperglycemia with basal insulin plus DPP4-i is an effective and safe regimen in old subjects with T2DM, with a similar mean daily glucose concentration, but lower glycemic variability and fewer hypoglycemic episodes compared to the basal bolus insulin regimen.

Exogenous Ketones and Lactate as a Potential Therapeutic Intervention for Brain Injury and Neurodegenerative Conditions

Metabolic dysfunction is a ubiquitous underlying feature of many neurological conditions including acute traumatic brain injuries and chronic neurodegenerative conditions. A central problem in neurological patients, in particular those with traumatic brain injuries, is an impairment in the utilization of glucose, which is the predominant metabolic substrate in a normally functioning brain. In such patients, alternative substrates including ketone bodies and lactate become important metabolic candidates for maintaining brain function. While the potential neuroprotective benefits of ketosis have been recognized for up to almost a century, the majority of work has focused on the use of ketogenic diets to induce such a state, which is inappropriate in cases of acute disease due to the prolonged periods of time (i.e., weeks to months) required for the effects of a ketogenic diet to be seen. The following review seeks to explore the neuroprotective effects of exogenous ketone and lactate preparations, which have more recently become commercially available and are able to induce a deep ketogenic response in a fraction of the time. The rapid response of exogenous preparations makes their use as a therapeutic adjunct more feasible from a clinical perspective in both acute and chronic neurological conditions. Potentially, their ability to globally moderate long-term, occult brain dysfunction may also be relevant in reducing lifetime risks of certain neurodegenerative conditions. In particular, this review explores the association between traumatic brain injury and contusion-related dementia, assessing metabolic parallels and highlighting the potential role of exogenous ketone and lactate therapies.

Stimuli-Responsive Microneedles as a Transdermal Drug Delivery System: A Demand-Supply Strategy

Microneedles are one of the most prominent approaches capable of physically disrupting the stratum corneum without devastating the deeper tissues to deliver both small molecules and macromolecules into the viable epidermis/dermis for local/systemic effects. Over the past two decades, microneedles have caught the attention of many researchers because of their outstanding advantages over oral and parenteral drug delivery systems such as self-administration, pain-free, steady-plasma concentration maintenance, avoidance of first-pass hepatic biotransformation, and so on. So far, scientists have reported various types of microneedle patches to deliver the loaded therapeutics as soon as the microneedles are inserted into the skin, regardless of the demand for therapeutics to treat a specific condition. This way of drug delivery can lead to potential risks such as poor therapeutic efficacy or drug overdose. The stimuli-responsive microneedles are the most predominant tool to achieve the on-demand/need-based drug delivery, leading to safe and effective treatment. Various natural and synthetic polymers that can undergo significant transitions such as swelling, shrinking, dissolution, or disintegration play a pivotal role in the development of stimuli-responsive microneedles. The current Review provides brief information about the history, emergence, type, and working principles of microneedles. Furthermore, it selectively discusses various exogenous and endogenous stimuli-responsive microneedles along with their mechanism of action involved in treating different disease conditions. Collaterally, the emergence of "closed-loop" combinatorial stimuli-responsive microneedle patches for precise delivery of therapeutics is meticulously canvassed. Subsequently, it covers the patents of different stimuli-responsive microneedles and further highlights the existing challenges and future perspectives concerning clinical application and large-scale production.

Diving with Diabetes - A Review of Recommendations

Recreational diving is becoming an increasingly popular physical activity around the world. The vast majority of people who practice scuba diving are amateurs, often being treated for a number of chronic diseases and having cardiovascular burdens. Due to the high prevalence of diabetes mellitus in the world population and the potential for dangerous complications during diving, there is a need for unified recommendations for safe diving with this condition. Current guidelines from international diving associations are not entirely consistent. This review presents the positions of international diving associations concerning the requirements for diving with diabetes, the scope of diving and recommended management of life-threatening conditions during the dive.

Efficacy of Flash Glucose Monitoring in Type 1 and Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

Flash glucose monitoring (FlashGM) is a sensor-based technology that displays glucose readings and trends to people with diabetes. In this meta-analysis, we assessed the effect of FlashGM on glycaemic outcomes including HbA1c, time in range, frequency of hypoglycaemic episodes and time in hypo/hyperglycaemia compared to self-monitoring of blood glucose, using data from randomised controlled trials.

Methods

A systematic search was conducted on MEDLINE, EMBASE and CENTRAL for articles published between 2014 and 2021. We selected randomised controlled trials comparing flash glucose monitoring to self-monitoring of blood glucose that reported change in HbA1c and at least one other glycaemic outcome in adults with type 1 or type 2 diabetes. Two independent reviewers extracted data from each study using a piloted form. Meta-analyses using a random-effects model was conducted to obtain a pooled estimate of the treatment effect. Heterogeneity was assessed using forest plots and the I2 statistic.

Results

We identified 5 randomised controlled trials lasting 10 – 24 weeks and involving 719 participants. Flash glucose monitoring did not lead to a significant reduction in HbA1c. However, it resulted in increased time in range (mean difference 1.16 hr, 95% CI 0.13 to 2.19, I2 = 71.7%) and decreased frequency of hypoglycaemic episodes (mean difference -0.28 episodes per 24 hours, 95% CI -0.53 to -0.04, I2 = 71.4%).

Conclusions

Flash glucose monitoring did not lead to a significant reduction in HbA1c compared to self-monitoring of blood glucose, however, it improved glycaemic management through increased time in range and decreased frequency of hypoglycaemic episodes.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42020165688).

A Machine Learning Approach to Minimize Nocturnal Hypoglycemic Events in Type 1 Diabetic Patients under Multiple Doses of Insulin

Nocturnal hypoglycemia (NH) is one of the most challenging events for multiple dose insulin therapy (MDI) in people with type 1 diabetes (T1D). The goal of this study is to design a method to reduce the incidence of NH in people with T1D under MDI therapy, providing a decision-support system and improving confidence toward self-management of the disease considering the dataset used by Bertachi et al. Different machine learning (ML) algorithms, data sources, optimization metrics and mitigation measures to predict and avoid NH events have been studied. In addition, we have designed population and personalized models and studied the generalizability of the models and the influence of physical activity (PA) on them. Obtaining 30 g of rescue carbohydrates (CHO) is the optimal value for preventing NH, so it can be asserted that this is the value with which the time under 70 mg/dL decreases the most, with almost a 35% reduction, while increasing the time in the target range by 1.3%. This study supports the feasibility of using ML techniques to address the prediction of NH in patients with T1D under MDI therapy, using continuous glucose monitoring (CGM) and a PA tracker. The results obtained prove that BG predictions can not only be critical in achieving safer diabetes management, but also assist physicians and patients to make better and safer decisions regarding insulin therapy and their day-to-day lives.

A Pharmacist-Driven Glycemic Control Protocol to Reduce the Rate of Severe Hypoglycemia in High-Risk Patients

Purpose: Hospital pharmacists contribute to patient safety and quality initiatives by overseeing the prescribing of antidiabetic medications. A pharmacist-driven glycemic control protocol was developed to reduce the rate of severe hypoglycemia events (SHE) in high-risk hospitalized patients. Methods: We retrospectively analyzed the rates of SHE (defined as blood glucose ≤40 mg/dL), before and after instituting a pharmacist-driven glycemic control protocol over a 4-year period. A hospital glucose management team that included a lead Certified Diabetes Educator Pharmacist (CDEP), 5 pharmacists trained in diabetes, a lead hospitalist, critical care and hospital providers established a process to first identify patients at risk for severe hypoglycemia and then implement our protocol. Criteria from the American Diabetes Association and the American Association of Clinical Endocrinologists was utilized to identify and treat patients at risk for SHE. We analyzed and compared the rate of SHE and physician acceptance rates before and after protocol initiation. Results: From January 2015 to March 2019, 18 297 patients met criteria for this study; 139 patients experienced a SHE and approximately 80% were considered high risk diabetes patients. Physician acceptance rates for the new protocol ranged from 77% to 81% from the year of initiation (2016) through 2018. The absolute risk reduction of SHE was 9 events per 1000 hospitalized diabetic patients and the relative risk reduction was 74% SHE from the start to the end of the protocol implementation. Linear regression analysis demonstrated that SHE decreased by 1.5 events per 1000 hospitalized diabetic patients (95% confidence interval, -1.54 to -1.48, P < .001) during the 2 years following the introduction of the protocol. This represents a 15% relative reduction of SHE per year. Conclusion: The pharmacist-driven glycemic control protocol was well accepted by our hospitalists and led to a significant reduction in SHE in high-risk diabetes patient groups at our hospital. It was cost effective and strengthened our physician-pharmacist relationship while improving diabetes care.

The Risk Factors of Severe Hypoglycemia in Older Patients with Dementia and Type 2 Diabetes Mellitus

BACKGROUND

The adequate glycemic control and risk factors for hypoglycemia in older patients with dementia and type 2 diabetes mellitus (T2DM) remain unclear. This study aimed to analyze the status of glycemic control and determine the risk of hypoglycemia among these groups.

METHODS

A hospital admission record due to hypoglycemia through an emergency room with glucose supplementation in the Chang Gung Memorial Hospital was identified as a hypoglycemic event. Patients with dementia and T2DM without hypoglycemic events throughout the study period were defined as the control group. We gathered patients aged ≥65 years with a diagnosis of Alzheimer's dementia (AD) and T2DM between 2001 and 2018 in the Chang Gung Research Database (CGRD). We extracted data included medication use, diagnoses, and biochemistry data from hospital records.

RESULTS

A total of 3877 older patients with dementia and T2DM with regular visits to the outpatient department were enrolled in this study. During the two-year follow-up period, 494 participants (12.7%) experienced hypoglycemia. Multivariable logistic multivariable regression models for hypoglycemic events showed that metformin had a protective effect (odds ratio (OR) = 0.75, p = 0.023), insulin had the highest risk (OR = 4.64, p < 0.001). Hemoglobin A1c (HbA1c) levels were not correlated with hypoglycemic events (OR = 0.95, p = 0.140). Patients with hypoglycemic episodes had a significantly higher proportion of ≥2 Charlson Comorbidity Index scores than those without hypoglycemic episodes (83.2% versus 56.4%, p < 0.001).

CONCLUSIONS

Drug regimen affects hypoglycemic episodes but not HbA1c in older patients with dementia and T2DM. In addition, patients with more comorbidities experience an increased risk of hypoglycemia.