Glycemic variability in diagnosis of gestational diabetes as predictor of pharmacological treatment

INTRODUCTION

To establish whether glycemic variability (GV) parameters used when gestational diabetes mellitus (GDM) has been diagnosed could help predict the probability that a patient will need pharmacological treatment, and to analyze the link of these parameters to the development of maternal-fetal complications.

MATERIALS AND METHODS

A prospective study of 87 women with GDM who underwent retrospective continuous glucose monitoring (CGM) for six days between weeks 26 and 32 of gestation, following diagnosis. The mean glycemia levels and GV variables were analyzed together with their link to maternal-fetal complications, and the need for pharmacological treatment. ROC (receiver operating characteristic) curves were developed to determine validity to detect the need for pharmacological treatment.

RESULTS

Patients with higher mean glycemia (p < 0.001) and continuous overlapping of net glycemic action in a period of n-hours (CONGAn) (p = 0.001) required pharmacological treatment. The ROC curves showed cut-off points of 98.81 mg/dL for mean glycemia, and 86.70 mg/dL for CONGAn, with 83.3% sensitivity and 67.8% specificity for both parameters. No relation between the GV parameters and development of maternal-fetal complications was observed.

CONCLUSIONS

The use of CGM, once GDM is diagnosed, enables us to identify those patients who would benefit from closer monitoring during gestation, and facilitate a speedier take-up of pharmacological treatment. However, prospective studies involving a higher number of patients are needed, as well as a cost assessment for recommending the use of CGM following GDM diagnosis.

Cardiovascular Risk Factors in Transgender People after Gender-Affirming Hormone Therapy

INTRODUCTION

In the last decade, healthcare for the transgender population has increased considerably in many countries thanks to depathologization movements and the easier accessibility of medical assistance. The age at which they request to start gender-affirming hormones (GAHs) is increasingly younger. The cardiovascular risk associated with hormonal treatment is a novel research field, and the published studies are heterogeneous and inconclusive. Our objective is to determine the metabolic impact of GAHs in the transgender people treated in our Gender Identity Treatment Unit.

METHODS

We designed a pre-post study to analyze changes in anthropometric parameters (weight and body mass index), analytical determinations (fasting blood glucose, glycated hemoglobin, and lipoproteins), and blood pressure control in the transgender population treated with GAHs in Puerta del Mar University Hospital. These variables were collected before and one year after hormonal therapy.

RESULTS

A total of 227 transgender people were recruited between 2017 and 2020, 97 (40.09%) transwomen and 136 (59.91%) transmen. The average age at which GAHs began was 18 years. Weight, body mass index, and blood pressure increased significantly in both genders. Transmen showed a more atherogenic lipid profile, with a decrease in cholesterol LDL (p < 0.001) and an increase in triglycerides (p < 0.001). The risk of developing prediabetes or diabetes did not increase one year after treatment, although non-specific alterations in carbohydrate metabolism were detected, such as an increase in glycated hemoglobin in transmen (p = 0.040) and fasting blood glucose in transwomen (p = 0.008). No thromboembolic processes or cardiovascular events were reported during the first year of treatment.

CONCLUSION

In our setting, transgender people developed changes in their metabolic profiles in the first year after hormonal treatment. Both transmen and transwomen showed early alterations in lipid and carbohydrate metabolism, slight elevations in blood pressure, and a tendency to gain weight. This makes lifestyle interventions necessary from the beginning of GAHs.

Significance of Umbilical Cord Leptin Profile during Pregnancy in Gestational Diabetes Mellitus-A Systematic Review and Meta-Analysis

BACKGROUND

The literature provides limited evidence of cord blood leptin levels in gestational diabetes mellitus (GDM), with contradictory and inconsistent results with respect to their possible implications for maternal, perinatal, and future complications.

METHODS

MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched in order to investigate the state of evidence on the association of leptin profile in cord blood during perinatal complications in GDM. We critically assessed the risk of bias using the Newcastle-Ottawa scale. Meta-analyses were performed, and heterogeneity and publication bias were analyzed.

RESULTS

sixteen primary-level studies were included, recruiting 573 GDM and 1118 control pregnant women. Cord blood leptin levels were significantly higher in GDM participants compared to controls (standardized mean difference [SMD] = 0.59, 95% confidence intervals (CI) = 0.37 to 0.80, p < 0.001). All subgroups also maintained significant differences stratified by continents (Asia: SMD = 0.91, 95% CI = 0.45 to 1.37, p < 0.001; Europe: SMD = 0.38, 95% CI = 0.20 to 0.56, p < 0.001), analysis technique (ELISA: SMD = 0.70, 95% CI = 0.44 to 0.97, p < 0.001; RIA: SMD = 0.30, 95% CI = 0.11 to 0.49, p = 0.002), and sample source (plasma: SMD = 0.71, 95% CI = 0.33 to 1.09, p < 0.001; serum: SMD = 0.55, 95% CI = 0.34 to 0.77, p < 0.001).

CONCLUSION

Cord blood leptin levels were significantly higher in GDM compared to controls. Further research is needed to clarify its role as a predictive biomarker of subsequent metabolic diseases in mothers with GDM and offspring.

Significance of cell adhesion molecules profile during pregnancy in gestational diabetes mellitus. A systematic review and meta-analysis

Endothelial dysfunction has been considered as a key etiological factor contributed to the development of vascular disease in diabetes mellitus. Serum level of endothelial cell adhesion molecules (AMs) were reported to be increased in GDM and pregnant women with normal glucose tolerance when compared with nonpregnant women. The literature provides limited evidence of endothelial dysfunction in GDM with heterogeneous and contradictory results respect to their possible involvement in maternal, perinatal and future complications. Our objective is to evaluate current evidence on the role of AMs in maternal and perinatal complications in women with GDM. PubMed, Embase, Web of Science, and Scopus databases were searched. We evaluated the studies' quality using the Newcastle-Ottawa scale. Meta-analyses were conducted, and heterogeneity and publication bias were examined. Nineteen relevant studies were finally included, recruiting 765 GDM and 2368 control pregnant women. AMs levels were generally higher in GDM participants showing statistical significance maternal ICAM-1 levels (SMD=0.58, 95% CI= 0.25 to 0.91; p=0.001). Our meta-analysis did not detect significant differences in subgroups or in meta-regression analyses. Future studies are needed to establish the potential role of these biomarkers in GDM and its complications.

Higher daytime systolic BP, prepregnancy BMI and an elevated sFlt-1/PlGF ratio predict the development of hypertension in normotensive pregnant women

BACKGROUND

The risk of hypertensive disorders of pregnancy (HDP) varies in women with gestational diabetes mellitus (GDM), depending on the degree of insulin resistance and is also influenced by obesity. The aim of this study was to evaluate clinical features, blood pressure (BP) profiles and inflammatory markers, to identify patients with an elevated risk of developing HDP.

METHODS

A total of 146 normotensive pregnant women were studied. We analysed the relationships of BP profiles detected by ambulatory blood pressure monitoring (ABPM) with serum biomarkers and angiogenic factors and their association with the development of HDP.

RESULTS

Fourteen (9.6%) women developed HDP, of which 11 had GDM and 8 had obesity. Women with HDP had higher values of 24-h and daytime systolic/diastolic BP (113/69 vs. 104/64; 115/72 vs. 106/66 mmHg, respectively; p <  0.05). Higher levels of leptin (10.97 ± 0.82 vs. 10.2 ± 1.11; p = 0.018) andmonocyte chemoattractant protein-1 (MCP-1) (5.24 ± 0.60 vs. 4.9 ± 0.55; p = 0.044) and a higher soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio (4.37 ± 2.2 vs. 2.2 ± 1.43; p = 0.003) were also observed in the HDP patients. Multivariate analysis showed that a higher sFlt-1/PlGF ratio was associated with an increased risk of developing HDP [OR = 2.02; IC 95%: 1.35-3.05]. Furthermore, higher daytime systolic BP [OR = 1.27; IC 95% 1.00-1.26] and prepregnancy body mass index (BMI) [OR = 1.14; IC 95%: 1.01-1.30] significantly increased the risk of developing HDP.

CONCLUSIONS

Higher daytime systolic BP values, prepregnancy BMI and the sFlt-1/PlGF ratio are useful for identifying normotensive pregnant women with an increased risk of developing HDP.

Proinflammatory Polyphosphate Increases in Plasma of Obese Children with Insulin Resistance and Adults with Severe Type 2 Diabetes

Obesity increases the risk of insulin resistance and type 2 diabetes through increased inflammation at cellular and tissue levels. Therefore, study of the molecular elements involved in obesity-related inflammation may contribute to preventing and controlling it. Inorganic polyphosphate is a natural phosphate polymer that has recently been attracting more attention for its role in inflammation and hemostasis processes. Polyphosphates are one of the main constituents of human platelets, which are secreted after platelet activation. Among other roles, they interact with multiple proteins of the coagulation cascade, trigger bradykinin release, and inhibit the complement system. Despite its importance, determinations of polyphosphate levels in blood plasma had been elusive until recently, when we developed a method to detect these levels precisely. Here, we perform cross sectional studies to evaluate plasma polyphosphate in: 25 children, most of them with obesity and overweight, and 20 adults, half of them with severe type 2 diabetes. Our results show that polyphosphate increases, in a significant manner, in children with insulin resistance and in type 2 diabetes patients. As we demonstrated before that polyphosphate decreases in healthy overweight individuals, these results suggest that this polymer could be an inflammation biomarker in the metabolic disease onset before diabetes.

Significance of Serum-Plasma Leptin Profile during Pregnancy in Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

Gestational diabetes mellitus (GDM) represents a stage of subclinical inflammation and a risk factor for subsequent future type 2 diabetes and cardiovascular disease development. Leptin has been related with vascular and metabolic changes in GDM with heterogeneous and contradictory results with respect to their possible involvement in maternal, perinatal, and future complications. Our objective is to evaluate current evidence on the role of leptin in maternal and perinatal complications in women with GDM. PubMed, Embase, Web of Science, and Scopus databases were searched. We evaluated the studies’ quality using the Newcastle-Ottawa scale. Meta-analyses were conducted, and heterogeneity and publication bias were examined. Thirty-nine relevant studies were finally included, recruiting 2255 GDM and 3846 control pregnant women. Leptin levels were significantly higher in GDM participants than in controls (SMD = 0.57, 95%CI = 0.19 to 0.94; p < 0.001). Subgroup meta-analysis did not evidence significant differences in leptin in the different trimesters of pregnancy. Meta-regression showed a positive significant relationship for HOMA in the GDM group (p = 0.05). According to these results, it seems that high levels of leptin can be used as predictive markers in GDM.

Adult kidney explants is a physiologic model for studying diabetic nephropathy

Inflammatory processes play a central role in the pathogenesis of diabetic nephropathy (DN) in the early stages of the disease. In vitro approach using cell lines help to understand the mechanisms involves and allow the molecular and biochemical processes. Adult kidney (AK) explants remain an essential instrument for advancing our understanding of the molecular and cellular regulation of signalling pathways from an organotipic view with physiological system interaction integrated. AK explants from T1DM animal model (BB rat) are obtained by slicing central kidney area preserving the organ's cytoarchitecture and reproduce the classical events detected during the DN in an in vivo model such as inflammation, epithelial-mesenchymal transition (EMT) processes by the modulation of a-SMA and e-Cadherin among others which have been determined by qRT-PCR, western-blot and immunohistochemistry. In this regard, AK explants reproduce the signalling pathways involve in DN progression (proinflammatory NFkB and inflammasome complex). This work demonstrates AK explants is a physiological experimental approach for studying the development and progression of DN. Furthermore, the inflammatory processes in AK explants under a diabetic environment and/or BB rats could be modulated by potential treatments for DN.

IL-1β Implications in Type 1 Diabetes Mellitus Progression: Systematic Review and Meta-Analysis

During Type 1 Diabetes Mellitus (T1DM) progression, there is chronic and low-grade inflammation that could be related to the evolution of the disease. We carried out a systematic review and meta-analysis to evaluate whether peripheral levels of pro-inflammatory markers such as interleukin-1 beta (IL-1β) is significantly different among patients with or without T1DM, in gender, management of the T1DM, detection in several biological fluids, study design, age range, and glycated hemoglobin. We searched PubMed, Embase, Web of Science, and Scopus databases, and 26 relevant studies (2186 with T1DM, 2047 controls) were included. We evaluated the studies’ quality using the Newcastle−Ottawa scale. Meta-analyses were conducted, and heterogeneity and publication bias were examined. Compared with controls, IL-1β determined by immunoassays (pooled standardized mean difference (SMD): 2.45, 95% CI = 1.73 to 3.17; p < 0.001) was significantly elevated in T1DM. The compared IL-1β levels in patients <18 years (SMD = 2.81, 95% CI = 1.88−3.74) was significantly elevated. The hemoglobin-glycated (Hbg) levels in patients <18 years were compared (Hbg > 7: SMD = 5.43, 95% CI = 3.31−7.56; p = 0.001). Compared with the study design, IL-1β evaluated by ELISA (pooled SMD = 3.29, 95% CI = 2.27 to 4.30, p < 0.001) was significantly elevated in T1DM patients. IL-1β remained significantly higher in patients with a worse management of T1DM and in the early stage of T1DM. IL-1β levels determine the inflammatory environment during T1DM.

Autoimmune disorders in oral lichen planus: systematic review and meta-analysis

OBJECTIVES

The association of OLP with other autoimmune processes points to the possibility that OLP-affected patients are actually developing an autoimmune status that predisposes them to autoaggression against different targets. This systematic review and meta-analysis aims to evaluate the current evidence on the prevalence of autoimmune disorders in patients with OLP and their magnitude of association.

METHODS

We searched PubMed, Embase, Web of Science, Scopus databases for studies published before May 2021, with no limitation in regards to their publication date or language. We evaluated the quality of studies, carried out meta-analyses and performed heterogeneity, subgroups, meta-regression and small-study effects analyses.

RESULTS

Inclusion criteria were met by 153 studies (23,327 patients). Our results indicate the existence of high prevalences and a frequent association between OLP and some autoimmune disorders, especially in regards to thyroid disease (PP=7.96%,95%CI=6.32-9.75; OR=1.99, 95%=1.60-2.49,p<0.001) and diabetes mellitus (PP=9.41%,95%CI=8.16-10.74; OR=1.64, 95%CI=1.34-2.00,p<0.001).

CONCLUSIONS

Our study demonstrates the existence of a comorbidity between autoimmune thyroid diseases an as well as between diabetes mellitus and OLP, respectively. Quality of evidence should be upgraded on other autoimmune diseases (fibromyalgia, gastrointestinal disorders, rheumatic diseases, Sjögren's syndrome, lupus erythematosus and dermatological diseases) for which the current data do not allow us to know whether they are really associated with OLP.

Validation of an Automated Screening System for Diabetic Retinopathy Operating under Real Clinical Conditions

Background. Retinopathy is the most common microvascular complication of diabetes mellitus. It is the leading cause of blindness among working-aged people in developed countries. The use of telemedicine in the screening system has enabled the application of large-scale population-based programs for early retinopathy detection in diabetic patients. However, the need to support ophthalmologists with other trained personnel remains a barrier to broadening its implementation. Methods. Automatic diagnosis of diabetic retinopathy was carried out through the analysis of retinal photographs using the 2iRetinex software. We compared the categorical diagnoses of absence/presence of retinopathy issued by family physicians (PCP) with the same categories provided by the algorithm (ALG). The agreed diagnosis of three specialist ophthalmologists is used as the reference standard (OPH). Results. There were 653 of 3520 patients diagnosed with diabetic retinopathy (DR). Diabetic retinopathy threatening to vision (STDR) was found in 82 patients (2.3%). Diagnostic sensitivity for STDR was 94% (ALG) and 95% (PCP). No patient with proliferating or severe DR was misdiagnosed in both strategies. The k-value of the agreement between the ALG and OPH was 0.5462, while between PCP and OPH was 0.5251 (p = 0.4291). Conclusions. The diagnostic capacity of 2iRetinex operating under normal clinical conditions is comparable to screening physicians.

Synthesis of sp2-Iminosugar Selenoglycolipids as Multitarget Drug Candidates with Antiproliferative, Leishmanicidal and Anti-Inflammatory Properties

sp²-Iminosugar glycolipids (sp²-IGLs) represent a consolidated family of glycoconjugate mimetics encompassing a monosaccharide-like glycone moiety with a pseudoamide-type nitrogen replacing the endocyclic oxygen atom of carbohydrates and an axially-oriented lipid chain anchored at the pseudoanomeric position. The combination of these structural features makes them promising candidates for the treatment of a variety of conditions, spanning from cancer and inflammatory disorders to parasite infections. The exacerbated anomeric effect associated to the putative sp²-hybridized N-atom imparts chemical and enzymatic stability to sp²-IGLs and warrants total α-anomeric stereoselectivity in the key glycoconjugation step. A variety of O-, N-, C- and S-pseudoglycosides, differing in glycone configurational patterns and lipid nature, have been previously prepared and evaluated. Here we expand the chemical space of sp²-IGLs by reporting the synthesis of α-d-gluco-configured analogs with a bicyclic (5N,6O-oxomethylidene)nojirimycin (ONJ) core incorporating selenium at the glycosidic position. Structure-activity relationship studies in three different scenarios, namely cancer, Leishmaniasis and inflammation, convey that the therapeutic potential of the sp²-IGLs is highly dependent, not only on the length of the lipid chain (linear aliphatic C₁₂ vs. C₈), but also on the nature of the glycosidic atom (nitrogen vs. sulfur vs. selenium). The ensemble of results highlights the α-dodecylseleno-ONJ-glycoside as a promising multitarget drug candidate.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017)

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent chronicdiseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease (VD) reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.

OBJECTIVE

To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).

PATIENTS AND METHODS

A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.

RESULTS

During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level < 8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction (AMI) and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (P = .001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14 ± 1.73%; 95% CI: 0.73-1.55; P = .0001) and cholesterol (11.28 ± 40 mg/dL; 95% CI: 2.07-20.48; P = .012).

CONCLUSIONS

This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

The metabesity factor HMG20A potentiates astrocyte survival and reactive astrogliosis preserving neuronal integrity

Rationale: We recently demonstrated that the 'Metabesity' factor HMG20A regulates islet beta-cell functional maturity and adaptation to physiological stress such as pregnancy and pre-diabetes. HMG20A also dictates central nervous system (CNS) development via inhibition of the LSD1-CoREST complex but its expression pattern and function in adult brain remains unknown. Herein we sought to determine whether HMG20A is expressed in the adult CNS, specifically in hypothalamic astrocytes that are key in glucose homeostasis and whether similar to islets, HMG20A potentiates astrocyte function in response to environmental cues. Methods: HMG20A expression profile was assessed by quantitative PCR (QT-PCR), Western blotting and/or immunofluorescence in: 1) the hypothalamus of mice exposed or not to either a high-fat diet or a high-fat high-sucrose regimen, 2) human blood leukocytes and adipose tissue obtained from healthy or diabetic individuals and 3) primary mouse hypothalamic astrocytes exposed to either high glucose or palmitate. RNA-seq and cell metabolic parameters were performed on astrocytes treated or not with a siHMG20A. Astrocyte-mediated neuronal survival was evaluated using conditioned media from siHMG20A-treated astrocytes. The impact of ORY1001, an inhibitor of the LSD1-CoREST complex, on HMG20A expression, reactive astrogliosis and glucose metabolism was evaluated in vitro and in vivo in high-fat high-sucrose fed mice. Results: We show that Hmg20a is predominantly expressed in hypothalamic astrocytes, the main nutrient-sensing cell type of the brain. HMG20A expression was upregulated in diet-induced obesity and glucose intolerant mice, correlating with increased transcript levels of Gfap and Il1b indicative of inflammation and reactive astrogliosis. Hmg20a transcript levels were also increased in adipose tissue of obese non-diabetic individuals as compared to obese diabetic patients. HMG20A silencing in astrocytes resulted in repression of inflammatory, cholesterol biogenesis and epithelial-to-mesenchymal transition pathways which are hallmarks of reactive astrogliosis. Accordingly, HMG20A depleted astrocytes exhibited reduced mitochondrial bioenergetics and increased susceptibility to apoptosis. Neuron viability was also hindered in HMG20A-depleted astrocyte-derived conditioned media. ORY1001 treatment rescued expression of reactive astrogliosis-linked genes in HMG20A ablated astrocytes while enhancing cell surface area, GFAP intensity and STAT3 expression in healthy astrocytes, mimicking the effect of HMG20A. Furthermore, ORY1001 treatment protected against obesity-associated glucose intolerance in mice correlating with a regression of hypothalamic HMG20A expression, indicative of reactive astrogliosis attenuation with improved health status. Conclusion: HMG20A coordinates the astrocyte polarization state. Under physiological pressure such as obesity and insulin resistance that induces low grade inflammation, HMG20A expression is increased to induce reactive astrogliosis in an attempt to preserve the neuronal network and re-establish glucose homeostasis. Nonetheless, a chronic metabesity state or functional mutations will result in lower levels of HMG20A, failure to promote reactive astrogliosis and increase susceptibility of neurons to stress-induced apoptosis. Such effects could be reversed by ORY1001 treatment both in vitro and in vivo, paving the way for a new therapeutic approach for Type 2 Diabetes Mellitus.

Anti-Inflammatory (M2) Response Is Induced by a sp2-Iminosugar Glycolipid Sulfoxide in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the most common complications of Diabetes Mellitus (DM) and is directly associated with inflammatory processes. Currently, neuro-inflammation is considered an early event in DR and proceeds via microglia polarization. A hallmark of DR is the presence of retinal reactive gliosis. Here we report the beneficial effect of (S_S,1R)-1-docecylsulfiny-5N,6O-oxomethylidenenojirimycin ((Ss)-DS-ONJ), a member of the sp²-iminosugar glycolipid (sp²-IGL) family, by decreasing iNOS and inflammasome activation in Bv.2 microglial cells exposed to pro-inflammatory stimuli. Moreover, pretreatment with (Ss)-DS-ONJ increased Heme-oxygenase (HO)-1 as well as interleukin 10 (IL10) expression in LPS-stimulated microglial cells, thereby promoting M2 (anti-inflammatory) response by the induction of Arginase-1. The results strongly suggest that this is the likely molecular mechanism involved in the anti-inflammatory effects of (S_S)-DS-ONJ in microglia. (S_S)-DS-ONJ further reduced gliosis in retinal explants from type 1 diabetic BB rats, which is consistent with the enhanced M2 response. In conclusion, targeting microglia polarization dynamics in M2 status by compounds with anti-inflammatory activities offers promising therapeutic interventions at early stages of DR.

Socioeconomic deprivation and development of diabetic retinopathy in patients with type 1 diabetes mellitus

INTRODUCTION

Very little is known about the influence of socioeconomic status on type 1 diabetes mellitus (T1DM) complications. Our aim was to determine whether socioeconomic level is a risk factor for the development of diabetic retinopathy (DR) in patients with T1DM.

RESEARCH DESIGN AND METHODS

A cohort of 150 patients with T1DM were studied prospectively over 9 years. Socioeconomic status was assessed using a neighborhood-level measure based on an index of deprivation. The contribution of other variables such as hypertension, dyslipidemia, diabetic nephropathy and smoking habit was evaluated. Cox proportional hazards models were used to quantify the associations.

RESULTS

The incidence of DR was 21.6 cases per 1000 patient-years. Multivariable analyses showed that for each percentage point increase in glycated hemoglobin (HbA1c), the risk of developing DR increased by 58% (HR 1.58, 95% CI 1.19 to 2.10).Patients with T1DM onset >18 years of age and resident in areas of lower socioeconomic levels presented with almost triple the risk of developing DR (HR 2.95, 95% CI 1.08 to 8.00) compared with those with onset <18 years of age and resident in less deprived areas. We did not find significant relationships with other variables studied such as hypertension, dyslipidemia, diabetic nephropathy and smoking habit.

CONCLUSIONS

Low socioeconomic level is a risk factor, independent of glycemic control, in the development of DR in patients with T1DM when the onset of diabetes is in adulthood. This finding indicates that socioeconomic status and age of onset need to be considered in population screening for DR in patients with T1DM.

Andalusian program for early detection of diabetic retinopathy: implementation and 15-year follow-up of a population-based screening program in Andalusia, Southern Spain

INTRODUCTION

Diabetic retinopathy (DR) is a preventable cause of vision loss and blindness worldwide. We aim at analyzing the impact of a population-based screening program of DR using retinal photography with remote reading in terms of population coverage, diagnosis of asymptomatic DR and impact on visual disability, in the region of Andalusia, Spain, in the period 2005-2019.

RESEARCH DESIGN AND METHODS

Descriptive study. Sociodemographic and clinical features included in the Andalusian program for early detection of diabetic retinopathy (APDR) were analyzed. Population coverage, annual incidence of DR, and DR severity gradation were analyzed. Estimated data on prevalence and incidence of legal blindness due to DR were included.

RESULTS

407 762 patients with at least one successful DR examination during the study period were included. Most of the performed retinographies (784 584, 84.3%) were 'non-pathological.' Asymptomatic DR was detected in 52 748 (5.9%) retinographies, most of them (94.2%) being classified as 'mild to moderate non-proliferative DR.' DR was detected in 44 815 patients, while sight-threatening DR (STDR) in 6256 patients; cumulative incidence of DR was 11.0% and STDR was 1.5%, as DR and STDR was detected in 44 815 and 6256 patients, respectively. Annual incidence risk per patient recruitment year progressively decreased from 22.0% by January 2005 to 3.2% by June 2019.

CONCLUSIONS

Implementation of a long-term population-based screening program for early detection of DR is technically feasible and clinically viable. Thus, after 15 years of existence, the program has enabled the screening of the vast majority of the target population allowing the optimization of healthcare resources and the identification of asymptomatic DR.

Specific model for the coordination of primary and hospital care for patients with diabetes mellitus. Evaluation of two-year results (2015-2017)

INTRODUCTION

Diabetes mellitus (DM) is one of the most prevalent chronic diseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.

OBJECTIVE

To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).

PATIENTS AND METHODS

A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.

RESULTS

During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level<8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (p=0.001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14±1.73%; 95% CI: 0.73-1.55; p=0.0001) and cholesterol (11.28±40mg/dL; 95% CI: 2.07-20.48; p=0.012).

CONCLUSIONS

This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.

Continuous Glucose Monitoring and Glycemic Patterns in Pregnant Women with Gestational Diabetes Mellitus

Background: Continuous glucose monitoring (CGM) could detect certain patterns of hyperglycemia at different times of the day that may help predict the development of maternal-fetal complications and the probability of needing pharmacological treatment. Methods: This study prospectively examined 77 women with gestational diabetes mellitus (GDM) who were placed on a CGM system for 6 days after diagnosis between 26 and 32 weeks of gestation. Patterns of hyperglycemia before meals (period of time of an hour just before meal) (>95 mg/dL), after meals (time interval of 2 h and half just after meal) (>140 mg/dL), and overnight (0-7 am) (>120 mg/dL) and their association with maternal-fetal complications and pharmacological treatment were analyzed. Receiver operating characteristic curves were developed to estimate the validity of the various patterns in detecting the need for pharmacological treatment. Results: A statistically significant relationship was observed between time in hyperglycemia after lunch and macrosomia (P = 0.035) and large for gestational age infants (P = 0.010). Pharmacological treatment was required for patients with time above range (TAR; P = 0.006) and those with hyperglycemia patterns before breakfast (P < 0.001), after breakfast (P = 0.006), before dinner (P = 0.012), and overnight (P = 0.001). Every additional percentage point of TAR was associated with a 24% increase in the probability of pharmacological treatment. Conclusions: The use of CGM for the diagnosis of GDM allows the identification of those patients who would benefit from closer monitoring during pregnancy, including self-monitoring of both pre- and postprandial blood glucose levels, facilitating the initiation of early pharmacological treatment.

Diabetes mellitus and oral cancer/oral potentially malignant disorders: A systematic review and meta-analysis

The objective was to evaluate current evidence on the prevalence and risk of oral cancer and potentially malignant oral disorders among patients with diabetes mellitus. We searched PubMed, Embase, Web of Science, and Scopus for observational studies published before November 2019. We evaluated the study quality using GRADE, QUIPS, and a specific method for systematic reviews addressing prevalence questions. Meta-analyses were conducted, and heterogeneity and publication bias were examined. A total of 1,489 studies were found, 116 analyzed in full text, 52 included in qualitative synthesis and 49 meta-analyzed. Pooled prevalence (PP) of oral cancer in patients with diabetic was 0.25% (95% CI = 0.15-0.39)-250 per 100,000 patients with diabetes mellitus -with a greater chance of oral cancer among patients with diabetes mellitus (OR = 1.41 [95% CI = 1.10-1.81], p = .007). Patients with oral cancer and diabetes mellitus had a higher mortality than controls (HR = 2.09 [95%CI = 1.36-3.22], p = .001). Leukoplakia had a PP = 2.49% (95% CI = 1.14-4.29)-2,490 per 100,000 patients with diabetes mellitus -(OR = 4.34 [95% CI = 1.14-16.55], p = .03). A PP of 2.72 (95% CI = 1.64-4.02) was obtained for oral lichen planus among patients with diabetic -2,720 per 100,000 patients with diabetes mellitus (OR = 1.87 [95% CI = 1.37-2.57], p < .001). A low PP was estimated for erythroplakia (0.02%[95%CI = 0.00-0.12]-20 per 100,000 patients with diabetes mellitus. In conclusion, patients with diabetes mellitus have a higher prevalence and greater chance of oral cancer and OPMD development in comparison with non-diabetic patients. In addition, patients with oral cancer suffering from diabetes mellitus have a higher mortality compared to non-diabetic patients with oral cancer.

Randomized Study to Evaluate the Impact of Telemedicine Care in Patients With Type 1 Diabetes With Multiple Doses of Insulin and Suboptimal HbA1c in Andalusia (Spain): PLATEDIAN Study

OBJECTIVE

To assess the impact of a telemedicine visit using the platform Diabetic compared with a face-to-face visit on clinical outcomes, patients' health-related quality of life (HRQoL), and physicians' satisfaction in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

PLATEDIAN (Telemedicine on Metabolic Control in Type 1 Diabetes Mellitus Andalusian Patients) (NCT03332472) was a multicenter, randomized, 6-month follow-up, open-label, parallel-group controlled study performed in patients with type 1 diabetes with suboptimal metabolic control (HbA_1c <8% [<64 mmol/mol]), treated with multiple daily injections. A total of 388 patients were assessed for eligibility; 379 of them were randomized 1:1 to three face-to-face visits (control cohort [CC]) (n = 167) or the replacement of an intermediate face-to-face visit by a telemedicine visit using Diabetic (intervention cohort [IC]) (n = 163). The primary efficacy end point was the mean change of HbA_1c levels from baseline to month 6. Other efficacy and safety end points were mean blood glucose, glucose variability, episodes of hypoglycemia and hyperglycemia, patient-reported outcomes, and physicians' satisfaction.

RESULTS

At month 6, the mean change in HbA_1c levels was -0.04 ± 0.5% (-0.5 ± 5.8 mmol/mol) in the CC and 0.01 ± 0.6% (0.1 ± 6.0 mmol/mol) in the IC (P = 0.4941). The number of patients who achieved HbA_1c <7% (<53 mmol/mol) was 73 and 78 in the CC and IC, respectively. Significant differences were not found regarding safety end points at 6 months. Changes in HRQoL between the first visit and final visit did not differ between cohorts, and, regarding fear of hypoglycemia (FH-15 score ≥28), statistically significant differences observed at baseline remained unchanged at 6 months (P < 0.05).

CONCLUSIONS

The use of telemedicine in patients with type 1 diabetes with HbA_1c <8% (<64 mmol/mol) provides similar efficacy and safety outcomes as face-to-face visits.

Effect of Different Insulin Therapies on Obstetric-Fetal Outcomes

To evaluate the effectiveness of the different insulin therapies on obstetrics-fetal outcomes in women with pregestational diabetes mellitus. We enrolled 147 pregnant women with pre-existing type 1 or 2 diabetes mellitus. Clinical and biochemical parameters were analysed in relation to obstetric and fetal outcomes. 14.2% received treatment with Neutral Protamine Hagedorn insulin and short-acting insulin analogues; 19% with premixed human insulin; 40.1% with insulin glargine and lispro, 6.2% with detemir and aspart and 20% with continuous subcutaneous insulin infusion. All 5 types of treatment achieved a reduction of the mean HbA1c during pregnancy (p = 0.01). Pre-pregnancy care was carried out for 48% of patients. We found no statistically significant differences between the different insulin therapies and the obstetric-fetal outcomes. In conclusión, the different insulin therapies used in patients with pregestational diabetes mellitus does not seem to affect obstetric-fetal outcomes.

Synthesis of polyfluoroalkyl sp2-iminosugar glycolipids and evaluation of their immunomodulatory properties towards anti-tumor, anti-leishmanial and anti-inflammatory therapies

Immunomodulatory glycolipids, among which α-galactosylceramide (KRN7000) is an iconic example, have shown strong therapeutic potential in a variety of conditions ranging from cancer and infection to autoimmune or neurodegenerative diseases. A main difficulty for those channels is that they often provoke a cytokine storm comprising both pro- and anti-inflammatory mediators that antagonize each other and negatively affect the immune response. The synthesis of analogues with narrower cytokine secretion-inducing capabilities is hampered by the intrinsic difficulty at controlling the stereochemical outcome in glycosidation reactions, particularly if targeting the α-anomer, which seriously hampers drug optimization strategies. Here we show that replacing the monosaccharide glycone by a sp²-iminosugar glycomimetic moiety allows accessing N-linked sp²-iminosugar glycolipids (sp²-IGLs) with total α-stereocontrol in a single step with no need of protecting groups or glycosidation promotors. The lipid tail has been then readily tailored by incorporating polyfluoroalkyl segments of varied lengths in view of favouring binding to the lipid binding site of the master p38 mitogen activated protein kinase (p38 MAPK), thereby polarizing the immune response in a cell-context dependent manner. The compounds have been evaluated for their antiproliferative, anti-leishmanial and anti-inflammatory activities in different cell assays. The size of the fluorous segment was found to be critical for the biological activity, probably by regulating the aggregation and membrane-crossing properties, whereas the hydroxylation profile (gluco or galacto-like) was less relevant. Biochemical and computational data further support a mechanism of action implying binding to the allosteric lipid binding site of p38 MAPK and subsequent activation of the noncanonical autophosphorylation route. The ensemble of results provide a proof of concept of the potential of sp²-IGLs as immunoregulators.

IGF-1, Inflammation and Retinal Degeneration: A Close Network

Retinal degenerative diseases are a group of heterogeneous diseases that include age-related macular degeneration (AMD), retinitis pigmentosa (RP), and diabetic retinopathy (DR). The progressive degeneration of the retinal neurons results in a severe deterioration of the visual function. Neuroinflammation is an early hallmark of many neurodegenerative disorders of the retina including AMD, RP and DR. Microglial cells, key components of the retinal immune defense system, are activated in retinal degenerative diseases. In the microglia the interplay between the proinflammatory/classically activated or antiinflammatory/alternatively activated phenotypes is a complex dynamic process that occurs during the course of disease due to the different environmental signals related to pathophysiological conditions. In this regard, an adequate transition from the proinflammatory to the anti-inflammatory response is necessary to counteract retinal neurodegeneration and its subsequent damage that leads to the loss of visual function. Insulin like-growth factor-1 (IGF-1) has been considered as a pleiotropic factor in the retina under health or disease conditions and several effects of IGF-1 in retinal immune modulation have been described. In this review, we provide recent insights of inflammation as a common feature of retinal diseases (AMD, RP and RD) highlighting the role of microglia, exosomes and IGF-1 in this process.

Usefulness of blood pressure monitoring in patients with gestational diabetes mellitus

BACKGROUND AND OBJECTIVE

Gestational diabetes mellitus (GDM) is associated to an increased risk of pregnancy-induced hypertension (PIH). Ambulatory blood pressure monitoring (ABPM) has been used to detect PIH and preeclampsia, but few data are currently available on its use in women with GDM. The aim of this study was to achieve early identification in women with GDM of BP profiles (detected by ABPM) that could define a population at greater risk of developing PIH and preeclampsia.

MATERIAL AND METHODS

A prospective study of 93 normotensive women with GDM in whom 24-h ABPM was performed (using a Spacelabs 90207 monitor) at 28-32 weeks of pregnancy. Clinical and laboratory variable and obstetric and perinatal outcomes were analyzed.

RESULTS

Mean age was 34.8±4.39years, and 5.4% of patients developed PIH. Higher levels of HbA1c (P=.005) and microalbumin (P=.001) were seen in patients with PIH. Patients with non-dipper patterns (50.5%) had higher values of night-time systolic BP (106.7 vs 98.4mmHg) and night-time diastolic BP (64.8 vs 57.2mmHg) (P<.001). Lower birth weights (3,084.57 vs 3,323.7) (P=.021) and shorter gestational age at delivery (38.67 vs 39.27 weeks) (P=.04) were found in women with non-dipper pattern. High night-time systolic BP significantly increased the chance of developing PIH (OR: 1.18; 95%CI: 1.00-1.39; P=.043).

CONCLUSIONS

Patients with GDM have BP changes, with predominance of the non-dipper pattern and higher night-time systolic and diastolic BP, changes that could be useful predictors of PIH. High night-time systolic BP values increase the risk of developing PIH. Further studies are needed to ascertain the relationships between BP changes and obstetric and perinatal complications.

The type 2 diabetes-associated HMG20A gene is mandatory for islet beta cell functional maturity

HMG20A (also known as iBRAF) is a chromatin factor involved in neuronal differentiation and maturation. Recently small nucleotide polymorphisms (SNPs) in the HMG20A gene have been linked to type 2 diabetes mellitus (T2DM) yet neither expression nor function of this T2DM candidate gene in islets is known. Herein we demonstrate that HMG20A is expressed in both human and mouse islets and that levels are decreased in islets of T2DM donors as compared to islets from non-diabetic donors. In vitro studies in mouse and human islets demonstrated that glucose transiently increased HMG20A transcript levels, a result also observed in islets of gestating mice. In contrast, HMG20A expression was not altered in islets from diet-induced obese and pre-diabetic mice. The T2DM-associated rs7119 SNP, located in the 3' UTR of the HMG20A transcript reduced the luciferase activity of a reporter construct in the human beta 1.1E7 cell line. Depletion of Hmg20a in the rat INS-1E cell line resulted in decreased expression levels of its neuronal target gene NeuroD whereas Rest and Pax4 were increased. Chromatin immunoprecipitation confirmed the interaction of HMG20A with the Pax4 gene promoter. Expression levels of Mafa, Glucokinase, and Insulin were also inhibited. Furthermore, glucose-induced insulin secretion was blunted in HMG20A-depleted islets. In summary, our data demonstrate that HMG20A expression in islet is essential for metabolism-insulin secretion coupling via the coordinated regulation of key islet-enriched genes such as NeuroD and Mafa and that depletion induces expression of genes such as Pax4 and Rest implicated in beta cell de-differentiation. More importantly we assign to the T2DM-linked rs7119 SNP the functional consequence of reducing HMG20A expression likely translating to impaired beta cell mature function.

Impact of positive thyroid autoimmunity on pregnant women with subclinical hypothyroidism

BACKGROUND

The impact of subclinical hypothyroidism (SH) and thyroid autoimmunity on obstetric and perinatal complications continues to be a matter of interest and highly controversial.

AIM

To assess the impact of SH and autoimmunity in early pregnancy on the obstetric and perinatal complications in our population.

MATERIAL AND METHOD

A retrospective cohort study in 435 women with SH (TSH ranging from 3.86 and 10 μIU/mL and normal FT4 values) in the first trimester of pregnancy. Epidemiological and clinical parameters were analyzed and were related to obstetric and perinatal complications based on the presence of autoimmunity (thyroid peroxidase antibodies [TPO] > 34 IU/mL).

RESULTS

Mean age was 31.3 years (SD 5.2). Seventeen percent of patients had positive TPO antibodies. Presence of positive autoimmunity was associated to a family history of hypothyroidism (P=.04) and a higher chance of miscarriage (P=.009). In the multivariate analysis, positive TPO antibodies were associated to a 10.25-fold higher risk of miscarriage. No statistically significant associations were found with all other obstetric and perinatal complications.

CONCLUSIONS

In our region, pregnant women with SH and thyroid autoimmunity had a higher risk of miscarriage but not of other obstetric and perinatal complications.

Bariatric surgery influences β-cell turnover in non obese rats

BACKGROUND

The aim of this study was to investigate the relation between the different bariatric surgeries and pancreatic β-cell turnover.

MATERIAL AND METHODS

We used healthy adult male Wistar rats to undergo the different techniques. Three surgical techniques were developed (malabsorptive, Sleeve gastrectomy and Roux-Y Gastric Bypass-), together with two control groups (Sham and fasting control). Pancreatic β-cell mass was measured, as well as apoptosis, proliferation and neogenesis related to cellular turnover. Otherwise, we measured the functional issues to elucidate the physiological role that these surgical techniques trigger in the carbohydrate metabolism (e.g. food intake, weight gain, intraperitoneal glucose tolerance test, and basal glycaemia). Results included the differences in phenotypes of the rat after the surgery. The rats did not show important differences in glycaemic parameters between the surgical groups. The β-cell mass presented modifications related with proliferation processes. A significant increase of β-cell mass in the malabsorptive technique was reported. On the other hand, the peripheral resistance to insulin tended to be reduced in rats which underwent malabsorptive and mixed techniques.

CONCLUSION

This work showed an increase in β-cell mass after the resection of an important portion of small bowel. The Roux-Y Gastric Bypass produced a non-significant increase in β-cell mass. We considered that these implications of surgery over the endocrine pancreas must be one of the mechanisms related to the improvement of type 2 Diabetes mellitus following bariatric surgery.

Ghrelin mitigates β-cell mass loss during insulitis in an animal model of autoimmune diabetes mellitus, the BioBreeding/Worcester rat

BACKGROUND

Ghrelin is a peptide hormone with pleiotropic effects. It stimulates cell proliferation and inhibits apoptosis-mediated cell death. It prevents diabetes mellitus in several models of chemical, surgical and biological toxic insults to pancreas in both in vivo and in vitro models and promotes glucose-stimulated insulin secretion under cytotoxic conditions. It has not yet been tested in vivo in an autoimmune model of diabetes with a persistent insult to the β-cell. Given the immunomodulating effects of ghrelin and its trophic effects on β-cells, we hypothesized that ghrelin treatment during the early stages of insulitis would delay diabetes onset.

METHODS

BioBreeding/Worcester male rats received ghrelin (10 ng/kg/day) before insulitis development. Glucose metabolism was characterized by glucose and insulin tolerance tests. β-cell mass, islet area, islet number, β-cell clusters, proliferation and apoptosis and degree of insulitis were analysed by histomorphometry. A Kaplan-Meier survival curve was plotted and analysed applying the log-rank (Mantel-Cox) test.

RESULTS

Ghrelin treatment significantly reduced the probability of developing diabetes in our model (p < 0.0001). It decreased islet infiltration and partially prevented β-cell mass loss, enabling the maintenance of β-cell neogenesis and proliferation rates. Furthermore, ghrelin treatment did not induce any metabolic perturbations.

CONCLUSIONS

These findings support the hypothesis that ghrelin delays the development of autoimmune diabetes by attenuating insulitis and supporting β-cell mass.

GENERAL SIGNIFICANCE

Ghrelin promotes β-cell viability and function through diverse mechanisms that may have significant implications for diabetes prevention, therapy and also transplant success of both islets and complete pancreas. Copyright © 2016 John Wiley & Sons, Ltd.

Concomitant Agranulocytosis and Hepatotoxicity After Treatment with Carbimazole

Objective:

To describe a case of agranulocytosis and severe hepatotoxicity associated with Carbimazole treatment.

Case Summary:

A 37-year-old woman was diagnosed with severe hyperthyroidism resulting from Graves' disease. Treatment with Carbimazole 30 mg/day was initiated. Within 15 days following the start of therapy, both minor (eg, pruritus, rash, urticaria, fever, arthralgias) and potentially life-threatening (eg, agranulocytosis, severe mixed hepatotoxicity with severe cholestatic jaundice) adverse effects developed. The patient's symptoms and laboratory abnormalities resolved following withdrawal of Carbimazole. Treatment with other antithyroid drugs was not attempted, and 131I ablation of the thyroid was successfully performed. Thyroid function was maintained with standard follow-up care. Agranulocytosis, identified following bone marrow biopsy, was treated with granulocyte colony-stimulating factor.

Discussion:

Agranulocytosis and hepatotoxicity are rare adverse effects associated with Carbimazole treatment and are usually dose- and age-related. The likelihood that Carbimazole induced these undesirable events in our patient is rated as probable based on the Naranjo probability scale. We believe this case to be the first to describe minor and major adverse effects related to Carbimazole therapy in a patient with Graves' disease.

Conclusions:

Major adverse effects associated with Carbimazole are infrequent. However, clinicians need to be aware that the effects described here, including severe liver failure and bone marrow toxicity, may occur in patients receiving this drug.

Nocturnal blood pressure is associated with the progression of microvascular complications and hypertension in patients with type 1 diabetes mellitus

AIMS

To evaluate relationships between early alterations in blood pressure and the progression of microvascular complications of diabetes in clinically-normotensive patients with type 1 diabetes (T1DM).

METHODS

In a prospective observational study of 85 normotensive T1DM patients without microalbuminuria, blood pressure (BP) was monitored over 24h using the ambulatory blood pressure monitoring (ABPM) system at baseline and 7years later. Development or progression of microalbuminuria, retinopathy and hypertension was evaluated.

RESULTS

Initially, 20 patients (24%) were diagnosed with masked hypertension and 31 (37%) with non-dipper pattern as the only pathological findings. At 7years: 1) twenty-seven patients (32%) had progression of retinopathy related to the nocturnal diastolic blood pressure (BPD) (OR:1.122; p=0.034) and final non-dipper pattern (OR:5.857; p=0.005); 2) seven patients (10%) developed microalbuminuria for which nocturnal systolic blood pressure (BPS) was a risk factor (OR:1.129; p=0.007); 3) five of the normotensive patients (9%) progressed to hypertension; historic HbA1c (OR:2.767; p=0.046) and nocturnal BPD (OR:1.243; p=0.046) being the related risk factors. BPD level ≥65mmHg was associated with an increase in progression of retinopathy and hypertension.

CONCLUSIONS

In T1DM patients there is an elevated prevalence of BP alterations, detected using ABPM. Alterations in nocturnal BP predispose to development/progression of microvascular complications and overt hypertension.

A surgical model of short bowel syndrome induces a long-lasting increase in pancreatic beta-cell mass

Several surgical techniques are used nowadays as a severe treatment for obesity and diabetes mellitus type 2. These techniques are aggressive due to drastic changes in the nutrient flow and non-reversible modifications on the digestive tube. In this paper we present the effects of a massive intestinal resection on the pancreas. Results have shown that short bowel technique is less aggressive to normal anatomy and physiology of the intestinal tract than Gastric bypass or biliopancreatic diversion (e.g.). In this paper we reproduce a model of short bowel syndrome (SIC), with similar surgical conditions and clinical complications as seen in human cases. This work was conducted on normal Wistar rats, with no other concurrent factors, in order to determine the effects on normal pancreas islets. We measured pancreatic implications by histomorphometric studies, which included beta-cell mass by immunocytochemistry, and apoptosis/proliferation test with TUNEL technique and Ki-67. Briefly, we reported on an increased relative area of the islets of the pancreas, as well as an increase in the average size of islets in the SIC versus the control group. Furthermore we stated that this increase in size of the pancreatic islets is due to the mechanisms of proliferation of beta cells in animals undergoing SIC. These goals could reveal a direct influence of surgical modification of the digestive tract over the pancreatic beta cell homeostasis. In this sense, there are many potential stimulators of intestinal adaptation, including peptide hormones and growth components which are associated or involved as effectors of the endocrine pancreas.

Should the diagnostic and therapeutic protocols for adrenal incidentalomas be changed?

BACKGROUND

The prevalence of adrenal incidentalomas is increasing with the aging of the population and the use of high resolution imaging technics. Current protocols propose a comprehensive monitoring of their functional and morphological state, but with no conclusive clinical evidence that endorses it.

METHOD

Retrospective study of 96 patients diagnosed with adrenal incidentaloma between 2008 and 2012. We evaluated clinical, functional and imaging at baseline and during follow-up.

RESULTS

Initially, 9 cases were surgically removed: 4 due to hyperfunction (2 Cushing syndromes and 2 pheochromocytomas) and 5 due to size larger than 4cm. During follow-up one case of pheochromocytoma was diagnosed and another grew more than 1cm, needing surgery. In 98.86% of nonfunctional and benign lesions, there was no functional and/or morphological changes in the final evaluation.

CONCLUSIONS

The results of our study challenge the validity of current diagnostic-therapeutic protocols of incidentalomas, which should be reassessed in prospective studies taking into account efficiency characteristics.

Postpartum development of endothelial dysfunction and oxidative stress markers in women with previous gestational diabetes mellitus

BACKGROUND

Relationships between adhesion molecules (AM), oxidative stress, gestational diabetes mellitus (GDM) and future development of type 2 diabetes mellitus are unclear.

AIM

We investigated AM and oxidant/antioxidant markers in women with previous history of GDM.

SUBJECTS AND METHODS

Postpartum women with GDM (cases; n = 41) and healthy women (controls; n = 21) had clinical and laboratory variables measured, including indicators of vascular damage (ICAM-1, VCAM-1 and E-selectin), oxidative stress (LPO, GSH and GST) and antioxidant markers (catalase, SOD, GPX and TAC).

RESULTS

Previous GDM versus control women presented higher body mass index: 27.4 ± 5.6 versus 23.9 ± 3.6 (p = 0.013); waist circumference: 85.2 ± 12.9 versus 77.5 ± 9.0 (p = 0.017); MetS (WHO definition): 14.6 versus 0 % (p = 0.012); MetS (NCEP-ATPIII definition): 22 versus 0 % (p = 0.002); low HDL: 36.6 versus 9.5 % (p = 0.024); fasting glucose (mmol/L): 5.4 ± 0.6 versus 4.9 ± 0.2 (p < 0.001); glucose 120 min (mg/dL): 105.0 ± 30.2 versus 85.1 ± 14.2 (p = 0.007); fasting insulin (μU/mL): 13.4 ± 8.1 versus 8.4 ± 4.3 (p = 0.004); HOMA index: 3.3 ± 2.3 versus 1.8 ± 1.0 (p = 0.002); HbA1c (%/mmol/mol): 5.4 ± 0.2 versus 5.2 ± 0.2/36 ± 1.4 versus 33 ± 1.4 (p = 0.021); uric acid (mg/dL): 4.1 ± 1 versus 3.5 ± 0.6 (p = 0.009); catalase (nmol/min/mL): 38.7 ± 15.6 versus 28.9 ± 11.1 (p = 0.013). There were no significant differences in hypertension prevalence, lipid fractions, albumin/creatinine ratio and AM.

CONCLUSIONS

Women with previous GDM have high catalase levels which correlate positively with glucose intolerance, indicating the potential effect of oxidative stress on postpartum dysglycemic status.

Oxidative stress and antioxidant status in patients with late-onset gestational diabetes mellitus

The relationship between late-onset gestational diabetes mellitus [GDM] and oxidative stress is not well known, and the importance of the oxidant/antioxidant equilibrium in the clinical evolution and its complications require elucidation. The aim of the study was to evaluate the relationships between maternal levels of markers of oxidative stress in women with late-onset GDM that, potentially, may have considerable clinical implications in the pathogenesis and/or the evolution of GDM. Pregnant women (n = 78; 53 with GDM, 25 controls), between the 24th and 29th week of gestation, were enrolled. Both groups were analysed for demographic data, perinatal and obstetrics outcomes together with the levels of the marker's oxidative stress and antioxidant status. Control versus patient results in the univariate analysis were the following: pre-gestational body mass index [BMI] 23.31 ± 4.2 vs. 27.13 ± 4.6 kg/m(2) (P = 0.001); weeks at delivery 39.2 ± 3.05 vs. 38.9 ± 1.8 (P = 0.09); Caesarean delivery 12.5 vs. 43% (P = 0.004); macrosomia 4 vs. 9.4% (P = 0.6); lipoperoxides [LPO] 2.06 ± 1.00 vs. 3.14 ± 1.55 μmol/mg (P = 0.001); catalase 3.23 ± 1.41 vs. 2.52 ± 1.3 nmol/min/ml (P = 0.03); superoxide dismutase [SOD] 0.11 ± 0.04 vs. 0.08 ± 0.01 U/ml (P = 0.0003); glutathione peroxidase [GPX] 0.03 ± 0.006 vs. 0.025 ± 0.006 nmol/min/ml (P = 0.01); glutathione reductase [GSH] 0.004 ± 0.002 vs. 0.004 ± 0.004 nmol/min/ml (P = 0.9)]; and glutathione transferase [GST] 0.0025 ± 0.0012 vs. 0.0027 ± 0.00017 nmol/min/ml (P = 0.7). Multivariate analysis showed catalase might have a protective effect against GDM development and LPO seems to be a risk factor for the disease. These data suggest an increase in oxidative stress and a decrease in antioxidative defence in women with late-onset GDM and, as such, may have considerable clinical implications in the pathogenesis and/or the course of the pregnancy in these patients.

Adipokines and metabolic syndrome risk factors in women with previous gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has been recognized as a significant risk factor for metabolic syndrome and CVD. The aim of the study was to evaluate the relationships between levels of cytokines, components of metabolic syndrome and cardiovascular risk markers in women with previous gestational diabetes.

METHODS

Women (n = 41) with gestational diabetes background (cases) and 21 healthy women (controls) in the postpartum period were enrolled. Demographic and clinical data, lipid and carbohydrate metabolism and uric acid and adipokine levels (TNF-α, IL-6, leptin and adiponectin) were compared and their relationships analysed. Metabolic syndrome prevalence was calculated by WHO and NCEP-ATPIII definitions.

RESULTS

There were significant differences between cases and controls: body mass index (kg/m(2) ) 27.4 ± 5.6 vs 23.9 ± 3.6 (p = 0.013), waist circumference (cm) 85.2 ± 12.9 vs 77.5 ± 9.0 (p = 0.017), metabolic syndrome (WHO definition) 14.6% vs 0% (p = 0.012), metabolic syndrome (NCEP-ATPIII definition) 22% vs 0% (p = 0.002), low HDL 36.6% vs 9.5% (p = 0.024), fasting glucose (mmol/L) 5.4 ± 0.6 vs 4.9 ± 0.2 (p < 0.001), glucose 120' oral glucose tolerance test (mmol/L) 5.8 ± 1.7vs 4.7 ± 0.8 (p = 0.007), fasting insulin (μU/mL) 13.4 ± 8.1 vs 8.4 ± 4.3 (p = 0.004), HOMA index 3.3 ± 2.3 vs 1.8 ± 1.0 (p = 0.002), HbA(1c) (%) 5.4 ± 0.2 vs 5.2 ± 0.2 (p = 0.021), uric acid (mg/dL) 4.1 ± 1 vs 3.5 ± 0.6 (p = 0.009), leptin (ng/mL) 32 025.5 ± 19 917.3 vs 20 258.9 ± 16 359.9 (p = 0.023), respectively.

CONCLUSIONS

Women with previous gestational diabetes have central adiposity, atherogenic lipid profile, carbohydrate intolerance and adverse adipokine profile, all of which are risk factors for the future development of metabolic disease and CVD.

Alterations in arterial pressure in patients with Type 1 diabetes are associated with long-term poor metabolic control and a more atherogenic lipid profile

AIM

To determine the prevalence of alterations in blood pressure (BP) in patients with Type 1 diabetes who are normoalbuminuric and normotensive; and to evaluate the association with genetic, clinical and metabolic factors. MATERIAL/ METHODS: Normoalbuminuric, normotensive Type 1 diabetic patients (no.=85) had their ambulatory blood pressure monitoring (ABPM) performed over 24 h, together with measurement of HbA1c and lipid profile, polymorphisms of the ACE gene, non-midriatic retinography, and the "historical HbA1c" calculated (mean of all the determinations available on the patient).

RESULTS

Of the 85 patients, a mean of 18.8% had pathologic values of BP over the 24 h, 31.8% during active periods and 22.4% during rest periods; in 42% there was a non-dipper pattern in BP. The patients with alterations of BP had higher body mass index (BMI), higher levels of glycemia and of triglycerides, and decreased levels of HDL cholesterol. The "historical HbA1c" was significantly higher in the patients with the non-dipper pattern (8.6 ± 1.4% vs 7.9 ± 1.4%; p=0.046). Pulse pressure was directly associated with male gender (p=0.006) and with BMI (p=0.001). No differences were detected in the distribution of the polymorphisms of the ACE gene as a function of the BP alterations.

CONCLUSIONS

An elevated number normoalbuminuric, normotensive, Type 1 diabetic patients have alterations in BP detected with ABPM over 24 h, and these are associated with a greater BMI, poor long-term metabolic control and a more atherogenic lipid profile.

Use of sensors in the treatment and follow-up of patients with diabetes mellitus

Glucose control is the cornerstone of Diabetes Mellitus (DM) treatment. Although self-regulation using capillary glycemia (SRCG) still remains the best procedure in clinical practice, continuous glucose monitoring systems (CGM) offer the possibility of continuous and dynamic assessment of interstitial glucose concentration. CGM systems have the potential to improve glycemic control while decreasing the incidence of hypoglycemia but the efficiency, compared with SRCG, is still debated. CGM systems have the greatest potential value in patients with hypoglycemic unawareness and in controlling daily fluctuations in blood glucose. The implementation of continuous monitoring in the standard clinical setting has not yet been established but a new generation of open and close loop subcutaneous insulin infusion devices are emerging making insulin treatment and glycemic control more reliable.

Decrease in {beta}-cell proliferation precedes apoptosis during diabetes development in bio-breeding/worcester rat: beneficial role of Exendin-4

In autoimmune type 1 diabetes mellitus, proinflammatory cytokine-mediated apoptosis of beta-cells has been considered to be the first event directly responsible for beta-cell mass reduction. In the Bio-Breeding (BB) rat, an in vivo model used in the study of autoimmune diabetes, beta-cell apoptosis is observed from 9 wk of age and takes place after an insulitis period that begins at an earlier age. Previous studies by our group have shown an antiproliferative effect of proinflammatory cytokines on cultured beta-cells in Wistar rats, an effect that was partially reversed by Exendin-4, an analogue of glucagon-like peptide-1. In the current study, the changes in beta-cell apoptosis and proliferation during insulitis stage were also determined in pancreatic tissue sections in normal and thymectomized BB rats, as well as in Wistar rats of 5, 7, 9, and 11 wk of age. Although stable beta-cell proliferation in Wistar and thymectomized BB rats was observed along the course of the study, a decrease in beta-cell proliferation and beta-cell mass from the age of 5 wk, and prior to the commencement of apoptosis, was noted in BB rats. Exendin-4, in combination with anti-interferon-gamma antibody, induced a near-total recovery of beta-cell proliferation during the initial stages of insulitis. This highlights the importance of early intervention and, as well, the possibilities of new therapeutic approaches in preventing autoimmune diabetes by acting, initially, in the insulitis stage and, subsequently, on beta-cell regeneration and on beta-cell apoptosis.

Benefits of continuous subcutaneous insulin infusion in type 1 diabetes previously treated with multiple daily injections with once-daily glargine and pre-meal analogues

BACKGROUND/AIMS

There is insufficient information about the use of continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) using long-acting insulin analogs in relation to possible metabolic consequences and, as well, on the grade of patient satisfaction. The aim of the study was to evaluate the usefulness of CSII treatment in patients with type 1 diabetes in achieving glycemic objectives using continuous glucose monitoring system (CGMS) and in improving patient's satisfaction with treatment.

METHODS

We have studied 45 type 1 diabetic patients treated with MDI with once-daily glargine and pre-meal rapid-acting insulin analogues, and 20 patients who commenced CSII because they had not achieved a good glycemic control.

RESULTS

With CSII, there were significant reductions in insulin requirements (0.75+/-0.21 vs. 0.64+/-0.21 UI/kg/day; p=0.001), HbA (1c) (7.99+/-0.76 vs. 7.19+/-0.51%; p=0.001) and hypoglycemic episodes (4.60+/-1.82 vs. 3.05+/-1.88 events/patient/week; p=0.031) and improved patient satisfaction with treatment. CSII reduced hyperglycemic episodes in 04:00-08 h period (131.65+/-113.49 vs. 69.70+/-101.52 min; p=0.049), 24 h period area-under-the-curve (AUC) (4521.60+/-3689.23 vs. 3000.36+/-493.96 mmol/L x min; p=0.025) and AUC before dinner (217.36+/-181.46 vs. 136.22+/-202.88 mmol/L x min; p=0.048).

CONCLUSIONS

In selected patients with poor metabolic control with once-daily glargine and pre-meal rapid-acting insulin analogues, CSII is a good alternative since it reduces hypoglycemic episodes and insulin requirement and improves glycemic control and patient's satisfaction.

Can the metabolic control targets established for patients with type 1 diabetes be achieved in clinical practice?

OBJECTIVE

To evaluate the quality of healthcare in patients with type 1 diabetes attended in the Endocrinology and Clinical Nutrition Unit of the Hospital Puerta del Mar in Cadiz (Spain).

METHODOLOGY

: The database included in the computer application HP-Doctor used for all patients attended in our unit (admissions, consultations and peripheral centers) was analyzed. All patients with a principal or secondary diagnosis of type 1 diabetes were included. The quality indicators analyzed were selected from the main clinical practice guidelines for these patients.

RESULTS

A large cohort of patients with type 1 diabetes (n=489) followed-up from 2005 to 2007 was analyzed. During the study period, the mean glycated hemoglobin level (HbA(1c)) decreased from 7.78% to 7.36%, the percentage of patients with HbA(1c) lower than 7% increased from 24.6% to 27.1% and the percentage patients with a mean HbA(1c) of more than 8% decreased from 42.6% to 38.7%. In 2007, only 35.5% of patients maintained low-density lipoprotein concentrations of less than 100 mg/dl.

CONCLUSIONS

Despite the improvement obtained in metabolic control parameters, most of the patients with type 1 diabetes studied showed inadequate glycemic and lipid control.

Anti-proliferative effect of pro-inflammatory cytokines in cultured beta cells is associated with extracellular signal-regulated kinase 1/2 pathway inhibition: protective role of glucagon-like peptide -1

Pancreatic beta-cell homeostasis is a balance between programmed cell death (apoptosis) and regeneration. Although autoimmune diabetes mellitus type 1 (DM1) is the most-studied cause of beta-cell mass loss by pro-inflammatory cytokine-induced apoptosis, influences of a pro-inflammatory environment on beta-cell regenerative response have been poorly studied. In this study, we assess the anti-proliferative effect of pro-inflammatory cytokines and glucose concentration on rat pancreatic beta cells and the potential protective role of glucagon-like peptide (GLP-1). Apoptotic and proliferating islet cells were stained using the DeadEnd Fluorimetric TUNEL System and 5-bromo-2'-deoxyuridine label respectively, in the presence-absence of varying concentrations of glucose, pro-inflammatory cytokines, and GLP-1. The potential signaling pathways involved were evaluated by western blot. Considerable anti-proliferative effects of pro-inflammatory cytokines interleukin (IL)-1beta, interferon (IFN)-gamma, and tumour necrosis factor-alpha (TNF-alpha) were observed. The effects were synergistic and independent of glucose concentration, and appeared to be mediated by the inhibition of extracellular signal-regulated kinase 1/2 (ERK1/2) activation, the signaling pathway involved in beta-cell replication. GLP-1 completely reversed the cytokine-induced inhibition of ERK phosphorylation and increased beta-cell proliferation threefold in cytokine-treated cultures. While pro-inflammatory cytokines reduced islet cell ERK1/2 activation and beta-cell proliferation in pancreatic islet culture, GLP-1 was capable of reversing this effect. These data suggest a possible pharmacological application of GLP-1 in the treatment of early stage DM1, to prevent the loss of pancreatic beta cells as well as to delay the development of overt diabetes.

Ultrasound evaluation of visceral fat and metabolic risk factors during early pregnancy

OBJECTIVE

The objective was to study the relationships between ultrasound estimated visceral fat and metabolic risk factors during early pregnancy.

RESEARCH METHODS AND PROCEDURES

Thirty consecutive healthy pregnant women at 11 to 14 weeks of gestation were studied. Maximum subcutaneous fat thickness (SFT) and visceral fat thickness (VFT) were successfully measured by ultrasound. Fasting plasma glucose, insulin, triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and blood pressure were measured. Insulin resistance was calculated by using the homeostasis model assessment (HOMA).

RESULTS

VFT significantly correlated with diastolic blood pressure (r = 0.37, p = 0.04), glycemia (r = 0.37, p = 0.04), insulinemia (r = 0.59, p = 0.001) insulin sensitivity (HOMA; r = 0.59, p = 0.001), triglycerides (r = 0.58, p = 0.03), HDL-C (r = -0.39, p = 0.03), and total cholesterol/HDL-C ratio (p = 0.002), whereas SFT was significantly correlated with only diastolic blood pressure (p = 0.03). VFT better significantly correlated with the metabolic risk factors than pre-gestational BMI [r = 0.39, p = 0.03 for insulinemia, r = 0.42, p = 0.02 for insulin sensitivity (HOMA), and r = 0.49, p = 0.01 for triglycerides and not significant for the rest].

DISCUSSION

Visceral fat thickness can be easily measured by ultrasound at early pregnancy and correlates better than BMI with metabolic risk factors.

Cardiovascular disease risk in subjects with type 2 diabetes mellitus in a population in southern Spain

To calculate overall 10-year cardiovascular disease (CVD) risk for patients with type 2 diabetes we applied the UKPDS and SCORE prediction models to data derived from clinical notes of 1846 patients (mean age 65.5 years; 55.8% women) with type 2 diabetes attending eight Primary-Care Centres serving a catchment population of 200,000 citizens in Andalusia. The results showed obesity and high blood pressure present in >50%, established CVD in 24%, retinopathy in 30%, and nephropathy in 17%. Mean HbAlc level was 7.3%. Compliance with therapeutic goals was 54% for systolic blood pressure <130 mmHg, 39% for HbA1c <7% and 9% for LDL cholesterol <2.58 mmol/L. Approximately 33% were receiving treatment with metformin, statins, renin-angiotensin system inhibitors and anti-aggregation agents. UKPDS risk for coronary heart disease (CHD) was 23% and 16% for stroke. The SCORE 10-year mortality risk was 5%. Correlation coefficient between the two models predicting CVD risk was 0.68 (p<0.001). We conclude that, despite the European consensus that CVD is low in Mediterranean countries, the CVD risk factors in the type 2 diabetes sub-population in southern Spain is relatively high. Specific measures of health-care intervention are needed if CVD-associated morbido-mortality rates in these diabetic patients are to be reduced.

Assay for high glucose-mediated islet cell sensitization to apoptosis induced by streptozotocin and cytokines

Pancreatic beta-cell apoptosis is known to participate in the beta-cell destruction process that occurs in diabetes. It has been described that high glucose level induces a hyperfunctional status which could provoke apoptosis. This phenomenon is known as glucotoxicity and has been proposed that it can play a role in type 1 diabetes mellitus pathogenesis. In this study we develop an experimental design to sensitize pancreatic islet cells by high glucose to streptozotocin (STZ) and proinflammatory cytokines [interleukin (IL)-1beta, tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma]-induced apoptosis. This method is appropriate for subsequent quantification of apoptotic islet cells stained with Tdt-mediated dUTP Nick-End Labeling (TUNEL) and protein expression assays by Western Blotting (WB).