Diabetic Disease of the Eye in Canada: Consensus Statements from a Retina Specialist Working Group

Despite advances in systemic care, diabetic disease of the eye (DDE) remains the leading cause of blindness worldwide. There is a critical gap of up-to-date, evidence-based guidance for ophthalmologists in Canada that includes evidence from recent randomized controlled trials. Previous guidance has not always given special consideration to applying treatments and managing DDE in the context of the healthcare system. This consensus statement aims to assist practitioners in the field by providing a spectrum of acceptable opinions on DDE treatment and management from recognized experts in the field. In compiling evidence and generating consensus, a working group of retinal specialists in Canada addressed clinical questions surrounding the four themes of disease, patient, management, and collaboration. The working group reviewed literature representing the highest level of evidence on DDE and shared their opinions on topics surrounding the epidemiology and pathophysiology of diabetic retinopathy and diabetic macular edema; diagnosis and monitoring; considerations around diabetes medication use; strategic considerations for management given systemic comorbidities, ocular comorbidities, and pregnancy; treatment goals and modalities for diabetic macular edema, non-proliferative and proliferative diabetic retinopathy, and retinal detachment; and interdisciplinary collaboration. Ultimately, this work highlighted that the retinal examination in DDE not only informs the treating ophthalmologist but can serve as a global index for disease progression across many tissues of the body. It highlighted further that DDE can be treated regardless of diabetic control, that a systemic approach to patient care will result in the best health outcomes, and prevention of visual complications requires a multidisciplinary management approach. Ophthalmologists must tailor their clinical approach to the needs and circumstances of individual patients and work within the realities of their healthcare setting.

Role of nutritional therapy on dietary habits and glycemic control in insulin-treated kidney transplant patients with diabetes

AIMS

To evaluate the effect of nutritional therapy on glycemic compensation and key cardio-renal risk markers in patients with diabetes and kidney transplant, on insulin treatment by Multiple Daily Injection (MDI) or Continuous Subcutaneous Insulin Infusion (CSII).

METHODS

34 patients with diabetes on insulin treatment and kidney transplant recipients were enrolled;12 participated in the structured nutritional program (intervention group), 22 patients (control group) did not receive nutritional protocol. Both groups were then divided into subgroups according to the method of insulin administration (MDI and CSII).

RESULTS

Statistically significant reduction in fasting blood glucose values, glycosylated hemoglobin (HbA1c) and glycosuria were observed in both groups at the end of the study. The intervention group, significantly reduced total cholesterolemia and the glycemic index, together with reduced dietary intake of lipids, cholesterol, soluble carbohydrates and increased consumption of carbohydrates and fiber. These improvements were even more pronounced in patients treated with CSII.

CONCLUSIONS

A proper nutritional approach optimize glycometabolic outcomes and contribute significantly to the reduction of the major cardiovascular risk factors in renal transplant patients.

Trends in Diabetes Medication Taking and Incidence of Depression in Patients with Type 2 Diabetes: A Retrospective Cohort Study from 2010 to 2018

BACKGROUND

This study examined the trends in diabetes medication taking and its association with the incidence of depression in patients with type 2 diabetes (T2D).

METHOD

A retrospective cohort of Medicare enrollees with regular care in 2010 was defined from 100% Texas Medicare claims. The impact of medication taking on incident depression was evaluated from 2010 to 2018. Cox proportional hazards regressions were used to estimate the association between medication taking and depression.

RESULTS

A total of 72,461 patients with T2D and with regular care were analyzed. Among 60,216 treated patients, the regular medication taking rate slightly increased from 60.8 to 63.2% during the study period. Patients with regular medication taking at baseline had a 9% lower risk of developing depression (hazard ratio [HR]: 0.91, 95% confidence interval [CI]: 0.89-0.94), and the magnitude of the association increased after adjustment of the model for time-varied medication taking (HR: 0.82, 95% CI: 0.79-0.85). The presence of nephropathy had the greatest mediating effect (23.2%) on the association of medication taking and depression.

CONCLUSION

We demonstrated a steady but modest increase in regular diabetes medication taking over a 9-year period and a significant relationship between medication taking and incident depression in patients with T2D.

Efficacy of a phone reminder to improve adherence to post-partum glucose tolerance testing after gestational diabetes and clinical predictors of post-partum follow-up compliance

AIM

To assess the effectiveness of a phone reminder to improve adherence to post-partum glucose tolerance testing in women with gestational diabetes mellitus (GDM) and to identify clinical predictors of adherence to post-partum follow-up.

METHODS

Retrospective study including 543 women with GDM. We assessed the adherence rate to post-partum glucose tolerance testing in women who received a phone reminder (n = 297) compared to women not alerted (n = 246). Demographic and clinical variables were collected to identify the predictors of adherence to the post-partum oral glucose tolerance test (OGTT).

RESULTS

The adherence to post-partum OGTT was higher in women who received the phone reminder compared to those not alerted (60.6 % vs. 35.4 %, p < 0.001). Women less compliant compared to those more compliant, had a higher pre-pregnancy body mass index (BMI) (29.3 ± 7.9 vs. 27.0 ± 6.1 Kg/m2, p = 0.03). The adherence was lower in pre-pregnant obese compared to non-obese women (42.7 % vs. 52.0 %, p < 0.05), in women with only one, compared to multiple OGTT alterations during pregnancy (44.5 % vs. 57.8 %, p < 0.05), and in women non-insulin treated compared to those insulin-treated (40.0 % vs. 57.1 % vs, p < 0.001).

CONCLUSIONS

The phone reminder improved post-partum follow-up adherence. Pre-pregnancy BMI, number of OGTT alterations and type of therapy could identify poorly adherent women.

Hospitalisation for herpes zoster in people with and without diabetes: A 10-year-observational study

AIMS

This study explores the association between Herpes Zoster (HZ) hospitalizations and diabetes in Piedmont, Italy from 2010 to 2019. Focusing on the burden of HZ hospitalizations in diabetic and non-diabetic groups, it aims to identify risk factors in diabetics to enhance prevention strategies.

METHODS

In a two-phase study, we first compared age-standardized HZ hospitalization rates between diabetic and non-diabetic individuals from 2010 to 2019. We then examined hospitalization risk factors for HZ within a diabetic patient cohort managed by regional diabetes clinics.

RESULTS

Of 3,423 HZ hospitalizations in 2010-2019, 17.9 % (613 cases) were diabetic patients, who exhibited higher hospitalization rates (15.9 to 6.0 per 100,000) compared to non-diabetese individuals. Among diabetics subjects risk factors for HZ hospitalization included age over 65, obesity (BMI > 30), and poor glycemic control (HbA1c > 8.0 %). These patients had a 40 % increased rehospitalization risk and a 25 % higher risk of severe complications, such as stroke and myocardial infarction, post-HZ.

CONCLUSIONS

Diabetes markedly increases HZ hospitalization rates, rehospitalization, and complication risks. These findings underscore the need for preventive strategies, especially improved glycemic control among high-risk diabetic patients, to inform public health policies and clinical practices aimed at mitigating HZ's impact on this population.

Effect of post-transplant diabetes mellitus on cardiovascular events and mortality: a single-center retrospective cohort study

PURPOSE

This study aims to investigate the impact of post-transplant diabetes mellitus (PTDM) on cardiovascular events, graft survival, and mortality and to determine the risk factors involved in developing PTDM.

METHODS

A total of 703 patients who underwent kidney transplantation were included in the study. The total sample was subdivided into three groups: (i) patients with PTDM; (ii) patients who had diabetes before the transplantation (DM); and (iii) patients without diabetes (NoDM). The data on graft failure, cardiovascular events, all-cause mortality, and the potential risk factors that play a role in developing PTDM were recorded and analyzed.

RESULTS

The patients were followed for a median of 80 (6-300) months after transplantation. Out of all patients, 41 (5.8%) had DM before transplantation, and 101 (14.4%) developed PTDM. Recipient BMI, post-transplant fasting plasma glucose, and hepatitis C seropositivity were independent risk factors for PTDM development. The incidence of cardiovascular events was 6.1% in the NoDM group, 14.9% in the PTDM group, and 29.3% in the DM group (p < 0.001). In PTDM patients, hepatitis C seropositivity and the recipient's age at transplant were independent predictors of a cardiovascular event. There were no significant differences between the groups regarding the risk of graft loss. PTDM had no significant effect on all-cause mortality. However, the survival rates of DM patients were significantly reduced compared to those with NoDM or PTDM.

CONCLUSIONS

PTDM had no impact on patient survival. Hepatitis C seropositivity and recipient age at transplant predicted cardiovascular events in PTDM patients.

Effects of vitamin family members on insulin resistance and diabetes complications

The following letter to the editor highlights the article "Effects of vitamin D supplementation on glucose and lipid metabolism in patients with type 2 diabetes mellitus and risk factors for insulin resistance" in World J Diabetes 2023 Oct 15; 14 (10): 1514-1523. It is necessary to explore the role of vitamin family members in insulin resistance and diabetes complications.

Suppression of SOCS3 expression in macrophage cells: Potential application in diabetic wound healing

Impaired polarization of M1 to M2 macrophages has been reported in diabetic wounds. We aimed to improve this polarization by down-regulation of expression of the "Suppressor of Cytokine Signaling 3" (SOCS3) gene in macrophages. Two oligodeoxynucleotide (ASO) sequences were designed against SOC3 mRNA and were loaded to mannosylated-polyethyleneimine (Man-PEI). The optimum N/P ratio for Man-PEI-ASO was determined to be 8 based on loading efficiency, particle size, zeta potential, cellular uptake and cytotoxicity assay. pH stability of ASO in Man-PEI-ASO and its protection from DNase I was confirmed. After in vitro treatment of macrophages with Man-PEI-ASO, SOCS3 was downregulated, SOCS1 upregulated, and SOCS1/SOCS3 ratio increased. Also, expressions of macrophage markers of M2 (IL-10, Arg1, CD206) increased and those of M1 (IL-1β, NOS2, CD68) decreased, and secretion of pro-inflammatory cytokines (TNF-α and IL-1β) decreased while that of anti-inflammatory cytokine IL-4 increased. All suggested a polarization into M2 phenotype. Finally, the Man-PEI-ASO was loaded in hydrogel and applied to a diabetic wound model in mice. It improved the healing to the level observed in non-diabetic wounds. We show that using antisense sequences against SOC3 mRNA, macrophage polarization could be directed into the M2 phenotype and healing of diabetic wound could be highly improved.

Excessive generalized and visceral adiposity is associated with a higher prevalence of diabetic retinopathy in Caucasian patients with type 2 diabetes

BACKGROUND AND AIMS

Type 2 Diabetes Mellitus (T2D) has heterogeneous clinical phenotypes related to different risk of developing diabetes complications. We investigated the correlation between generalized and abdominal adiposity and the prevalence of both micro- and macrovascular complications in Caucasian patients with T2D.

METHODS AND RESULTS

We evaluated 769 individuals with T2D consecutively referred to our diabetes center. Body mass index (BMI), waist circumference (WC), waist to hip (W/H) ratio, glycated hemoglobin (HbA1c), systolic and diastolic blood pressure, lipid profile, smoking habit, diabetes therapy, and micro- and macrovascular complications were recorded. Patients were divided into three groups based on BMI and WC: non-obese with normal WC (nWC, n = 220), non-obese with excess of abdominal fat (AF, n = 260) and obese (Ob, n = 289). We found that nWC, compared with AF and Ob individuals, were predominantly males (p<0.01), had lower HbA1c (p<0.01), diastolic blood pressure (p<0.01), triglycerides (p<0.01), and showed a significantly lower prevalence of diabetic retinopathy (DR) (p = 0.01). The rate of proliferative DR was significantly higher in Ob (13.2 %) compared to the other groups (p = 0.03). Multivariate analyses showed a significantly decreased prevalence of DR in nWC compared to both AF (OR 0.58, 95 CI 0.34-0.96; p = 0.03) and Ob (OR 0.57, 95 CI 0.33-0.98; p = 0.04) individuals. Conversely, DR was associated, mainly in women, to higher WC and W/H ratio. The prevalence of the other diabetes-related complications was similar among the studied groups.

CONCLUSIONS

In our population, nWC subjects showed a lower prevalence of DR. An increased generalized and abdominal adiposity was associated to a higher prevalence of DR, especially among females.

Interpretable prediction model for assessing diabetes complication risks in Chinese sufferers

AIMS

With growing concerns over complications in diabetes sufferers, this study sought to develop an interpretable machine learning model to offer enhanced diagnostic and treatment recommendations.

METHODS

We assessed coronary heart disease, diabetic nephropathy, diabetic retinopathy, and fatty liver disease using logistic regression, decision tree, random forest, and CatBoost algorithms. The SHAP algorithm was employed to elucidate the model's predictions, offering a more in-depth understanding of influential features.

RESULTS

The CatBoost model notably outperformed other algorithms in AUC, achieving an average AUC of 90.47 % for the four complications. Through SHAP analysis and visualization, we provided clear and actionable insights into risk factors, enabling better complication risk assessment.

CONCLUSIONS

We introduced an innovative, interpretable complication risk model for people with diabetes. This not only offers a potent tool for healthcare professionals but also empowers sufferers with clearer self-assessment capabilities, encouraging earlier preventive actions. Further studies will underscore the model's clinical applicability.

Ambient heat and diabetes hospitalizations: Does the timing of heat exposure matter?

BACKGROUND

Although ambient heat exposure is linked with diabetes mortality, the impacts of heat exposure on diabetes-related hospitalizations remain controversial. Previous research did not examine the timing of heat-diabetes associations and relation with comorbidities/risk factors.

OBJECTIVE

We examined the association between heat exposure and diabetes-related hospitalizations in the transitional and summer months and identified populations vulnerable to heat.

METHODS

We conducted a time-stratified case-crossover study. Data on diabetes hospital admissions (primary diagnosis of type 1 and type 2 diabetes, 2013-2020) were collected by the New York State (NYS) Department of Health under the state legislative mandate. We treated temperature and air pollutants as continuous variables and defined the heat exposure as per interquartile range (IQR, a measure between the 25th and 75th percentiles) increase of daily mean temperature. Conditional logistic regressions were performed to quantify the heat-diabetes associations after controlling for air pollutants and time variant variables. Multiplicative-scale interactions between heat and demographics/comorbidities/risk factors on diabetes hospitalizations were investigated.

RESULTS

Each IQR increase in temperature was associated with significantly increased risks for diabetes admissions that occurred immediately and lasted for an entire week during multi-day lags in the transitional month of May (ranges of excess risk: 3.1 %-4.8 %) but not in the summer (June-August) (ranges of excess risk: -0.3 %-1.3 %). The significant increases in the excess risk of diabetes were also found among diabetes patients with complications of neuronopathy (excess risk: 27.7 %) and hypoglycemia (excess risk: 19.1 %). Furthermore, the modification effects on the heat-diabetes association were significantly stronger in females, Medicaid enrollees, non-compliant patients, and individuals with comorbidities of atherosclerotic heart disease and old myocardial infarction.

CONCLUSIONS

Ambient heat exposure significantly increased the burden of hospital admissions for diabetes in transitional rather than summer months indicating the importance of exposure timing. Vulnerability to heat varied by demographics and heart comorbidity.

To swab or not to swab? A qualitative study of pathology testing, interpretation, and value in diabetes-related foot ulceration

BACKGROUND

Diagnostic testing has been proposed as a key strategy to tackle escalating antimicrobial resistance (AMR). However, effectiveness of testing is limited by the complexities of the hospital environment, including human factors.

OBJECTIVES

To examine swab-testing in diabetes-related foot infections as a case study of the factors impacting microbiology testing use, efficacy, and antimicrobial resistance.

METHODS

Seventeen clinicians involved in the management of diabetes-related foot infections, including podiatrists, nurses, and doctors, participated in in-depth individual interviews conducted by a qualitative researcher on the investigation and management of diabetes-related foot infections. Thematic analysis was performed.

RESULTS

The multilayered and evolving features of the human-diagnostic interface were described by participants as potential barriers to effective swab-testing in clinical care, including diagnostic training and interpretation deficits; communication difficulties; interpretation deficits and diagnostic assumptions; the influence of inter-professional dynamics; and flow-on consequences for patient decisions and care.

CONCLUSIONS

Swab-testing has been used for over 100 years, and yet there remain substantial factors that limit their effective use in clinical practice as demonstrated by this study. A focus on upscaling diagnostic testing, particularly with escalating AMR, without considering complex implementation and human factors is likely to have limited impact on practice improvement. This study identified vulnerability points in the human-diagnostic interaction which should be considered in the implementation of other microbiological tests. This study on the simple wound swab has implications for future diagnostic upscaling and investment, including its role in address antimicrobial resistance.

Relationship between elevated circulating thrombospondin-1 levels and vascular complications in diabetes mellitus

AIMS/INTRODUCTION

Thrombospondin-1 (TSP-1) participates in a series of physiological and pathological processes by binding to various receptors regulating cell proliferation, adhesion and apoptosis. Elevated circulating TSP-1 is linked with diabetic vascular complications (DVC). This study aimed to determine the relationship between circulating TSP-1 levels and DVC.

MATERIALS AND METHODS

A comprehensive search of PubMed, Embase, Web of Science and CNKI databases was carried out. A meta-analysis was carried out to compare circulating TSP-1 levels between diabetes patients without vascular complications (DNVC), diabetes patients with DVC and non-diabetes patients. The correlation between TSP-1 and metabolic parameters was also analyzed. Subgroup analysis was carried out according to complication type, defined as diabetic retinopathy, diabetic nephropathy and diabetic cardiovascular disease (DCVD).

RESULTS

A total of eight studies were included. Compared with non-diabetes patients, diabetic patients, including DNVC and DVC, had significantly higher circulating TSP-1 levels (standardized mean difference [SMD] 2.660, 95% CI 1.17-4.145, P = 0.000). DNVC had significantly higher circulating TSP-1 levels than non-diabetes patients (SMD 3.613, 95% CI 1.607-5.619, P = 0.000). DVC had significantly higher TSP-1 levels than DNVC (SMD 0.568, 95% CI 0.100-1.036, P = 0.017). TSP-1 was significantly positively correlated with fasting plasma glucose (overall Fisher's z = 0.696, 95% CI 0.559-0.833) and HbA1c (overall Fisher's z = 0.849, 95% CI 0.776-0.923).

CONCLUSIONS

Elevated circulating TSP-1 levels are closely related to DVC, especially in diabetic nephropathy and diabetic cardiovascular disease. Circulating TSP-1 detection might be helpful in the timely diagnosis and treatment of DVC.

Stem Cells Reprogramming in Diabetes Mellitus and Diabetic Complications: Recent Advances

BACKGROUND

The incidence of diabetes mellitus (DM) is dramatically increasing worldwide, and it is expected to affect 700 million cases by 2045. Diabetes influences health care economics, human quality of life, morbidity, and mortality, which were primarily seen extensively in developing countries. Uncontrolled DM, which results in consistent hyperglycemia, may lead to severe life-threatening complications such as nephropathy, retinopathy, neuropathy, and cardiovascular complications.

METHODOLOGY

In addition to traditional therapies with insulin and oral anti-diabetics, researchers have developed new approaches for treatment, including stem cell (SC) therapy, which exhibits promising outcomes. Besides its significant role in treating type one DM (T1DM) and type two DM (T2DM), it can also attenuate diabetic complications. Furthermore, the development of insulin-producing cells can be achieved by using the different types of SCs, such as embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs), and multiple types of adult stem cells, such as pancreatic, hepatic, and mesenchymal stem cells (MSC). All these types have been extensively studied and proved their ability to develop insulin-producing cells, but every type has limitations.

CONCLUSION

This review aims to enlighten researchers about recent advances in stem cell research and their potential benefits in DM and diabetic complications.

Optimizing Diabetes Management Using a Low-Calorie Diet in Saudi Arabia: A Cost-Benefit Analysis

BACKGROUND

Low-calorie diets, high in protein and low in carbohydrates, are commonly recommended for patients with pre-diabetes and type 2 diabetes. The objective of this study was to carry out a cost-benefit analysis (CBA) of a low-calorie versus a standard diet from the perspective of the Saudi Arabian health system.

METHODS

The CBA compares costs and benefits of the two diet strategies over a 1-year time horizon. Costs included diet and diabetes treatment-related resources while benefits were measured in terms of the costs of diabetes complications avoided. Data on costs and benefits were collected from published literature and subject matter experts. Incremental costs were estimated as the cost difference between low-calorie and standard diet. Incremental benefits were estimated as cost difference from medical complications when following a low-calorie or standard diet. The incremental absolute cost-benefit ratio was calculated to show the difference between the costs and benefits of the low-calorie diet. Incremental relative cost-benefit ratio was calculated to show the cost per dollar of benefit obtained. Monte Carlo simulation modeled variability in outcomes due to variation in costs and uncertainty of diabetes complications.

RESULTS

The 1 year cost of standard diet was US$2515 ± 156 compared to US$2469 ± 107 per patient for a low-calorie diet. Incremental benefit is estimated at US$21,438 ± 7367 per patient. The estimated incremental absolute cost-benefit ratio was US$ - 21,360 establishing that benefits are greater than costs, while the estimated incremental relative cost-benefit ratio is 0.0037, establishing that benefits are 270 times greater than costs.

CONCLUSION

The low-calorie diet was the dominant strategy compared to the standard diet in modeled scenarios. These findings highlight the importance of a low-calorie diet as part of diabetes management programs for outpatients with type 2 diabetes.

Estimation of the onset time of diabetic complications in type 2 diabetes patients in Thailand: a survival analysis

BACKGROUND

This study aimed to identify factors associated with the onset time of diabetic complications in patients with type 2 diabetes mellitus (T2DM) and determine the best-fitted survival model.

METHODS

A retrospective cohort study was conducted among T2DM patients enrolled from October 1, 2016 to July 15, 2020 at the National Health Security Office (NHSO). In total, 388 T2DM patients were included. Cox proportional-hazard and parametric models were used to identify factors related to the onset time of diabetic complications. The Akaike information criterion, Bayesian information criterion, and Cox-Snell residual were compared to determine the best-fitted survival model.

RESULTS

Thirty diabetic complication events were detected among the 388 patients (7.7%). A 90% survival rate for the onset time of diabetic complications was found at 33 months after the first T2DM diagnosis. According to multivariate analysis, a duration of T2DM ≥42 months (time ratio [TR], 0.56; 95% confidence interval [CI], 0.33-0.96; p=0.034), comorbid hypertension (TR, 0.30; 95% CI, 0.15-0.60; p=0.001), mildly to moderately reduced levels of the estimated glomerular filtration rate (eGFR) (TR, 0.43; 95% CI, 0.24-0.75; p=0.003) and an eGFR that was severely reduced or indicative of kidney failure (TR, 0.38; 95% CI, 0.16-0.88; p=0.025) were significantly associated with the onset time of diabetic complications (p<0.05).

CONCLUSION

Patients with T2DM durations of more than 42 months, comorbid hypertension, and decreased eGFR were at risk of developing diabetic complications. The NHSO should be aware of these factors to establish a policy to prevent diabetic complications after the diagnosis of T2DM.

Tu-Xian Decoction ameliorates diabetic cognitive impairment by inhibiting DAPK-1

Tu-Xian decoction (TXD), a traditional Chinese medicine (TCM) formula, has been frequently administered to manage diabetic cognitive impairment (DCI). Despite its widespread use, the mechanisms underlying TXD's protective effects on DCI have yet to be fully elucidated. As a significant regulator in neurodegenerative conditions, death-associated protein kinase-1 (DAPK-1) serves as a focus for understanding the action of TXD. This study was designed to whether TXD mediates its beneficial outcomes by inhibiting DAPK-1. To this end, a diabetic model was established using Sprague-Dawley (SD) rats through a high-fat, high-sugar (HFHS) diet regimen, followed by streptozotocin (STZ) injection. The experimental cohort was stratified into six groups: Control, Diabetic, TC-DAPK6, high-dose TXD, medium-dose TXD, and low-dose TXD groups. Following a 12-week treatment period, various assessments-including blood glucose levels, body weight measurements, Morris water maze (MWM) testing for cognitive function, brain magnetic resonance imaging (MRI), and histological analyses using hematoxylin-eosin (H&E), and Nissl staining-were conducted. Protein expression in the hippocampus was quantified through Western blotting analysis. The results revealed that TXD significantly improved spatial learning and memory abilities, and preserved hippocampal structure in diabetic rats. Importantly, TXD administration led to a down-regulation of proteins indicative of neurological damage and suppressed DAPK-1 activity within the hippocampal region. These results underscore TXD's potential in mitigating DCIvia DAPK-1 inhibition, positioning it as a viable therapeutic candidate for addressing this condition. Further investigation into TXD's molecular mechanisms may elucidate new pathways for the treatment of DCI.

Decrypting the circular RNAs does a favor for us: Understanding, diagnosing and treating diabetes mellitus and its complications

Circular RNAs (circRNAs), a novel type of single-stranded noncoding RNAs with a covalently closed loop structure, are generated in a circular conformation via non-canonical splicing or back-splicing events. Functionally, circRNAs have been elucidated to soak up microRNAs (miRNAs) and RNA binding proteins (RBPs), serve as protein scaffolds, maintain mRNA stability, and regulate gene transcription and translation. Notably, circRNAs are strongly implicated in the regulation of β-cell functions, insulin resistance, adipocyte functions, inflammation as well as oxidative stress via acting as miRNA sponges and RBP sponges. Basic and clinical studies have demonstrated that aberrant alterations of circRNAs expressions are strongly associated with the initiation and progression of diabetes mellitus (DM) and its complications. Here in this review, we present a summary of the biogenesis, transportation, degradation and functions of circRNAs, and highlight the recent findings on circRNAs and their action mechanisms in DM and its complications. Overall, this review should contribute greatly to our understanding of circRNAs in DM pathogenesis, offering insights into the further perspectives of circRNAs for DM diagnosis and therapy.

Evaluation of the health-related quality of life of patients with type 2 diabetes in relation to macrovascular and microvascular complications

PURPOSE

The complications of type 2 diabetes (T2DM) have a negative impact on health-related quality of life (HRQoL) and could lead to increased healthcare costs. However, there is a lack of evidence regarding how and to what extent T2DM complications, particularly macrovascular and microvascular complications, affect the patients' HRQoL. This study aimed to evaluate the HRQoL in relation to diabetes complications and identify associated factors among patients with T2DM.

METHODS

A cross-sectional study was conducted over six months on T2DM patients at a National University Hospital, Malaysia. Since Malaysia is a multiethnic country with majority Malay-speaking and English widely used, the Malay and English versions of the revised version Diabetes Quality of life (DQoL) questionnaire was used to measure HRQoL. Multiple Linear Regression was applied to estimate association of individual DQoL domains with T2DM-related complications, sociodemographic and clinical characteristics.

RESULTS

A total of 513 patients were recruited in the study. Sociodemographic (age, gender, ethnicity, employment, education) and body mass index affected satisfaction, impact and worry domains while complications affected the impact domain. Poorer HRQoL were demonstrated for severe stages heart failure (p = 0.001), nephropathy (p = 0.029), retinopathy (p < 0.001). The presence of neuropathy (p = 0.004) and foot ulcer (p = 0.039) showed poor HRQoL regardless of severity stage. Increase frequencies of hypoglycaemia (p < 0.001) showed poorer HRQoL compared to those with lesser frequencies.

CONCLUSION

The complications, sociodemographic and clinical characteristics of patients with T2DM affect the HRQoL domains differently. Understanding the point of which complication types and stages impact HRQoL the most can provide insights to clinicians to prioritise on effective interventions. The study findings may assist researchers and policymakers in selecting appropriate health state values when conducting cost-effectiveness studies to aid decision making.

Time in range and complications of diabetes: a cross-sectional analysis of patients with Type 1 diabetes

BACKGROUND/ OBJECTIVE

To evaluate the association of CGM parameters and HbA1c with diabetes complications in patients with Type 1 Diabetes (T1D).

METHODS

Patients with T1D using the CGM system Freestyle Libre were included in this analysis. The association of CGM-metrics and HbA1c with diabetes complications (any complication, microvascular complications, or macrovascular complications) was assessed using logistic regression unadjusted and adjusted for age, sex, and diabetes duration (model 1), and further adjusted for hypertension and dyslipidemia (model 2).

RESULTS

One hundred and sixty-one patients with T1D were included. The mean (± SD) age was 37.4 ± 13.4 years old and the median T1D duration was 17.7 ± 10.6 years. Time in range (TIR) was associated with any complication and microvascular complications in the unadjusted model and in the adjusted models. TIR was associated with retinopathy in the unadjusted model as well as in model 1, and was associated with macrovascular complications only in the unadjusted model. HbA1c was associated with any complications, microvascular complications, and retinopathy in the unadjusted model but not in the adjusted models. HbA1c was associated with macrovascular complications in the unadjusted model and in the adjusted model 1.

CONCLUSIONS

In this cross-sectional analysis of patients with T1D using intermittent scanned CGM, TIR, and HbA1c were associated with complications of diabetes. TIR may be a better predictor than HbA1c of any complication and microvascular complications, while HbA1c may be a better predictor of macrovascular complications.

Australian evidence-based guidelines for the prevention and management of diabetes-related foot disease: a guideline summary

INTRODUCTION

Diabetes-related foot disease (DFD) - foot ulcers, infection, ischaemia - is a leading cause of hospitalisation, disability, and health care costs in Australia. The previous 2011 Australian guideline for DFD was outdated. We developed new Australian evidence-based guidelines for DFD by systematically adapting suitable international guidelines to the Australian context using the ADAPTE and GRADE approaches recommended by the NHMRC.

MAIN RECOMMENDATIONS

This article summarises the most relevant of the 98 recommendations made across six new guidelines for the general medical audience, including: prevention - screening, education, self-care, footwear, and treatments to prevent DFD; classification - classifications systems for ulcers, infection, ischaemia and auditing; peripheral artery disease (PAD) - examinations and imaging for diagnosis, severity classification, and treatments; infection - examinations, cultures, imaging and inflammatory markers for diagnosis, severity classification, and treatments; offloading - pressure offloading treatments for different ulcer types and locations; and wound healing - debridement, wound dressing selection principles and wound treatments for non-healing ulcers.

CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE

For people without DFD, key changes include using a new risk stratification system for screening, categorising risk and managing people at increased risk of DFD. For those categorised at increased risk of DFD, more specific self-monitoring, footwear prescription, surgical treatments, and activity management practices to prevent DFD have been recommended. For people with DFD, key changes include using new ulcer, infection and PAD classification systems for assessing, documenting and communicating DFD severity. These systems also inform more specific PAD, infection, pressure offloading, and wound healing management recommendations to resolve DFD.

Diabetic microvascular disease in non-classical beds: the hidden impact beyond the retina, the kidney, and the peripheral nerves

Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.

Association of eGFR slope with all-cause mortality, macrovascular and microvascular outcomes in people with type 2 diabetes and early-stage chronic kidney disease

AIMS

The association of estimated glomerular filtration rate (eGFR) slope with progression of complications in people with type 2 diabetes (T2D) and early-stage chronic kidney disease (CKD) is less clear.

METHODS

We identified 115,139 T2D participants without decreased eGFR (>60 mL/min/1.73 m2) between 2008 and 2015 from the electronic database of the Hong Kong Hospital Authority. eGFR slope calculated by linear-mixed effects model using 3-year eGFR measurements was categorized into quintiles. With Quintile 3 of eGFR slope as the reference group, we used Cox proportional or cause-specific models to investigate the association between eGFR slope and all-cause mortality, macrovascular and microvascular complications, as appropriate.

RESULTS

Over a median follow-up of 7.8 years, fastest eGFR declines (Quintile 1 with median eGFR slope: -4.32 mL/min/1.73 m2/year) were associated with increased risk of all adverse outcomes (adjusted hazard ratio [aHR] 1.36 to 2.97, all P < 0.0001), compared with less steep eGFR declines (Quintile 3: -1.08 mL/min/1.73 m2/year). Substantial eGFR increases (Quintile 5: 1.34 mL/min/1.73 m2/year) were associated with decreased risk of CKD and ≥ 40 % decline in eGFR (aHR [95 % CI] 0.65 [0.63, 0.67] and 0.85 [0.82, 0.89], respectively) and higher risk of death, CVD, DR and DN (aHR [95 % CI] 1.48 [1.40, 1.56], 1.19 [1.14, 1.25], 1.07 [1.004, 1.15] and 1.62 [1.37, 1.91], respectively).

CONCLUSIONS

In a cohort of T2D people without decreased eGFR, accelerated declines and increases in eGFR were associated with all-cause mortality, macrovascular and microvascular complications, supporting the potential prognostic utility of eGFR slope in T2D people with early-stage CKD.

Does nutritional guidance reduce cardiovascular events in patients with type 2 diabetes mellitus? A retrospective cohort study using a nationwide claims database

AIM

To examine the effect of nutritional guidance (NG) provided by a registered dietitian under the direction of a physician on the development of subsequent cardiovascular events in patients with early-stage type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

This retrospective cohort study used the JMDC claims database to explore patients aged 18 years or older who first met the diagnostic criteria for T2DM at a health checkup between January 2011 and January 2019. The last day of the observation period was set for 28 February, 2021. Exposure was defined as receiving NG within 180 days of diagnosis of T2DM. The primary outcome was a composite endpoint of coronary artery disease (CAD) and cerebrovascular disease, and the secondary outcomes were each event, and time to event was compared. The propensity score weighting method was used for adjusting the distribution of confounding variables. Cox regression was conducted to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Overall, 31,378 patients met the eligibility criteria at an annual health checkup. 9.6% received NG (n = 3013). Patients who attended ≥ 1 NG after diagnosis had significantly reduced risk of cardiovascular composite (adjusted HR 0.75, 95% CI 0.58-0.97) and cerebrovascular disease (adjusted HR 0.65, 95% CI 0.47-0.90) during approximately 3.3 years of follow-up. In contrast, no difference was observed for CAD.

CONCLUSIONS

Receiving NG in early-stage diabetes may reduce the incidence of cardiovascular events, especially cerebrovascular events.

Shifts in KDIGO CKD risk groups with empagliflozin: Kidney-protection from SGLT2 inhibition across the spectrum of risk

T2D is a well-established risk factor for development and progression of CKD. KDIGO recommends categorization of risk by likelihood of progression to ESKD. Compared to placebo, empagliflozin decreases likelihood of worsening (OR 0.70, 95 % CI 0.62-0.78) and increases likelihood of improvement (OR 1.56, 95 % CI 1.30-1.86) in KDIGO risk category.

Crosstalk between autophagy and insulin resistance: evidence from different tissues

Insulin is a critical hormone that promotes energy storage in various tissues, as well as anabolic functions. Insulin resistance significantly reduces these responses, resulting in pathological conditions, such as obesity and type 2 diabetes mellitus (T2DM). The management of insulin resistance requires better knowledge of its pathophysiological mechanisms to prevent secondary complications, such as cardiovascular diseases (CVDs). Recent evidence regarding the etiological mechanisms behind insulin resistance emphasizes the role of energy imbalance and neurohormonal dysregulation, both of which are closely regulated by autophagy. Autophagy is a conserved process that maintains homeostasis in cells. Accordingly, autophagy abnormalities have been linked to a variety of metabolic disorders, including insulin resistance, T2DM, obesity, and CVDs. Thus, there may be a link between autophagy and insulin resistance. Therefore, the interaction between autophagy and insulin function will be examined in this review, particularly in insulin-responsive tissues, such as adipose tissue, liver, and skeletal muscle.

Fluocinolone Acetonide Implant Injected 1 Month after Dexamethasone Implant for Diabetic Macular Oedema: the ILUVI1MOIS Study

INTRODUCTION

The aim of this study was to assess the efficacy and safety of fluocinolone acetonide implant (FAci) injected 1 month after the last dexamethasone intravitreal implant (DEXi) in chronic diabetic macular oedema (DME) patients.

METHODS

Retrospective multicentric study conducted in pseudophakic patients with chronic DME frequently treated with dexamethasone intravitreal implant (DEXi; time to DME recurrence ≤ 6 months), receiving FAci 1 month after the last DEXi, with at least a 6-month follow-up. Best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography, intraocular pressure (IOP) and additional treatments were assessed on the day of FAci injection (M0), 1 (M1) and 3 months (M3) later and then every 3 months.

RESULTS

A total of 41 eyes from 34 patients were included. At M0, patients' mean age was 68.7 ± 9.8 years, the mean DME duration was 63.9 ± 22.9 months, the mean interval between two DEXi was 14.2 ± 3.3 weeks. M12 data were available for 71% of patients. At baseline, the mean BCVA, CMT and IOP were 63.2 ± 16.6 letters, 299.4 ± 103.3 µm, and 16.2 ± 4.5 mmHg, respectively, and remained stable during the follow-up. At M12, 14% of patients required additional intravitreal treatments.

CONCLUSION

In pseudophakic patients with chronic DME showing good response to DEXi but requiring repeated injections every < 6 months, switching to FAci 1 month after the last DEXi was effective and safe. Further prospective randomized controlled studies are needed to confirm these findings, and to determine the best interval between the last DEXi and the first FAci.

How to evaluate over 60 million blood glucose data - The design of the MÉRY Diabetes Database

AIMS

The aim of the article is to describe the method for creating a close to ideal diabetes database. The MÉRY Diabetes Database (MDD) consists of a large quantity of reliable, well-maintained, precise and up-to-date data suited for clinical research with the intention to improve diabetes care in terms of maintaining targeted blood glucose levels, avoiding hypoglycemic episodes and complications and improving patient compliance and quality of life.

METHODS

Based on the analysis of the databases found in the literature and the experience of our research team, nine important characteristics were identified as critical to an ideal diabetes database. The data for our database is collected using MÉRYkék glucometers, a device that meets all requirements of international regulations and measures blood glucose levels within the normal range with appropriate precision (10 %).

RESULTS

Using the key characteristics defined, we were able to create a database suitable for the analysis of a large amount of data regarding diabetes care and outcomes.

CONCLUSIONS

The MDD is a reliable and ever growing database which provides stable and expansive foundation for extensive clinical investigations that hold the potential to significantly influence the trajectory of diabetes care and enhance patient outcomes.

Abnormal tryptophan catabolism in diabetes mellitus and its complications: Opportunities and challenges

In recent years, the incidence rate of diabetes mellitus (DM), including type 1 diabetes mellitus(T1DM), type 2 diabetes mellitus(T2DM), and gestational diabetes mellitus (GDM), has increased year by year and has become a major global health problem. DM can lead to serious complications of macrovascular and microvascular. Tryptophan (Trp) is an essential amino acid for the human body. Trp is metabolized in the body through the indole pathway, kynurenine (Kyn) pathway and serotonin (5-HT) pathway, and is regulated by intestinal microorganisms to varying degrees. These three metabolic pathways have extensive regulatory effects on the immune, endocrine, neural, and energy metabolism systems of the body, and are related to the physiological and pathological processes of various diseases. The key enzymes and metabolites in the Trp metabolic pathway are also deeply involved in the pathogenesis of DM, playing an important role in pancreatic function, insulin resistance (IR), intestinal barrier, and angiogenesis. In DM and its complications, there is a disruption of Trp metabolic balance. Several therapy approaches for DM and complications have been proven to modify tryptophan metabolism. The metabolism of Trp is becoming a new area of focus for DM prevention and care. This paper reviews the impact of the three metabolic pathways of Trp on the pathogenesis of DM and the alterations in Trp metabolism in these diseases, expecting to provide entry points for the treatment of DM and its complications.

The Impact of Taurine on Obesity-Induced Diabetes Mellitus: Mechanisms Underlying Its Effect

This review explores the potential benefits of taurine in ameliorating the metabolic disorders of obesity and type 2 diabetes (T2D), highlighting the factors that bridge these associations. Relevant articles and studies were reviewed to conduct a comprehensive analysis of the relationship between obesity and the development of T2D and the effect of taurine on those conditions. The loss of normal β-cell function and development of T2D are associated with obesity-derived insulin resistance. The occurrence of diabetes has been linked to the low bioavailability of taurine, which plays critical roles in normal β-cell function, anti-oxidation, and anti-inflammation. The relationships among obesity, insulin resistance, β-cell dysfunction, and T2D are complex and intertwined. Taurine may play a role in ameliorating these metabolic disorders through different pathways, but further research is needed to fully understand its effects and potential as a therapeutic intervention.

Reliability of F-Scan® in-shoe plantar pressure measurements in people with diabetes at risk of developing foot ulcers

BACKGROUND

The provision of therapeutic footwear, to prevent the development of diabetic foot ulcers by re-distributing high peak plantar pressure is frequently prescribed for patients with diabetes. Areas of interest (ROI) are identified by placing boxes on the visualised pressure movie. The aims were to evaluate the inter-reliability of the placements of seven ROI boxes and to explore how the box placement affected peak pressure in the seven ROIs.

METHODS

Plantar pressure movies from 20 of a total of 40 movies were selected for the analysis. Boxes were placed at ROIs, the heel, the lateral midfoot, the metatarsal phalangeal heads (5, 3-4, 2 and 1) and the hallux. The box placements were registered for the left vertical position (L) and the top horizontal position (T) for each of the ROIs, based on registrations by two certified prosthetists and orthotists.

FINDINGS

The inter correlation coefficient of the placement of the boxes ranged from 1.00 to 0.12 (heel_L and metatarsal phalangeal head 2_L respectively). Of the 14 positions of the boxes; four were excellent, four were good, two were moderate and four were poor. No significant differences in the mean peak pressure corresponding to the box placements were found between the CPOs.

INTERPRETATION

The inter-reliability of eight of the 14 registered placements, made by prosthetists and orthotists, of the boxes in Scan® was good to excellent. A variation of 1.00-0.12 was present. Despite the variation, no significant differences in the corresponding mean peak pressure between prosthetists and orthotists was found.

Hospital stays and costs of telemedical monitoring versus standard follow-up for diabetic foot ulcer: an open-label randomised controlled study

Background

Two randomised controlled trials (RCTs) have previously shown that telemedical monitoring of diabetic foot ulcer (DFU) reduces the number of visits to the outpatient clinic, without losing treatment efficacy or increasing costs. Here we present the results of an open-label, randomised controlled trial designed to investigate whether telemonitoring, provided by an expert nurse (with extensive experience in DFU and trained in remote monitoring), reduces the hospital stay and the associated costs for a patient with DFU (TELEPIED trial).

Methods

Eligible patients (n = 180) were randomly allocated to: (i) a control group, in which they received standard care, and (ii) an intervention group, in which they received asynchronous telemedicine follow-up by the expert nurse. The primary outcome was the cumulative hospital days over 12 months. The main secondary outcomes were (i) direct healthcare costs (estimated in a collective perspective), (ii) wound healing and (iii) amputation rates. ITT (intention-to-treat) population was analysed.

Findings

In the ITT population, cumulative hospital days were significantly higher in the control group (13.4 days [95% CI 9.0-17.8]) than in the intervention group (7.1 days [2.8-11.5]) (p = 0.0458, ANCOVA model). Cumulative direct costs over 12 months were 7185 € (95% CI 5144-9226) in the control group and 3471 € (95% CI 1430-5512) in the intervention group (p = 0.0120). The percentage of wounds healed and amputation rate were not significantly different between groups. Similar results were found with the PP population.

Interpretation

The implementation of a telemedical intervention with an expert nurse could lead to a length of hospitalization and direct costs that were two times lower compared to conventional follow-up. This lower medical and economic burden was obtained without losing effectiveness on the rate of healing, nor increasing the amputation rate. Additional studies are required to confirm these findings.

Funding

This study was designed, funded and conducted by CERITD (Study and Research Centre for Intensification of Diabetes Treatment, Evry, France), Genopole GIP, 20 rue Henri Desbruères, 91030 EVRY Cedex and Laboratoires URGO, 15 Avenue d'Iéna, 75116 Paris Cedex, France. The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the sponsor. The corresponding author (DD) certify that authors were not precluded from accessing data in the study, and they accept responsibility to submit for publication.

Association of oral health with risk of incident micro and macrovascular complications: A prospective cohort study of 24,862 people with diabetes

AIMS

To investigate the association between self-reported oral health and incident micro and macrovascular diabetes complications.

METHODS

This prospective cohort study linked data from the 45 and Up Study, Australia, to administrative health records. The participants were 24,862 men and women, aged ≥45 years, with diabetes at baseline (2006-2009). The oral health of participants was assessed by questionnaire. Incident diabetes complications were determined using hospitalisation data and claims for medical services up until 2019. Hazard ratios for the association between oral health and incident complications were calculated using multivariable cox proportional hazards models.

RESULTS

Almost 60 % of participants had <20 teeth, and 38 % rated their teeth and gums as fair or poor. Compared with those with ≥20 teeth, those with 0 teeth had an increased risk of cardiovascular disease (aHR 1.24, 95 % CI: 1.15, 1.35), lower limb (aHR 1.22, 95 % CI: 1.11, 1.33) and kidney (aHR 1.19, 95 % CI: 1.11, 1.29) complications. Individuals with 1-9 teeth had an increased risk of eye complications (aHR 1.14, 95 % CI: 1.07, 1.22). The associations were generally consistent for poor self-rated teeth and gums.

CONCLUSIONS

Self-reported oral health measures may be a marker of elevated risk of complications in people with diabetes.

Macrovascular and renal microvascular complications in West Africans with intermediate hyperglycemia living in West Africa and Europe: The RODAM study

Background

Metabolic conditions, including intermediate hyperglycemia (IH), affect migrants to a greater extent than the populations of origin. Evidence suggests that IH increases the risk of vascular complications, but it is unclear whether the differences in IH between the non-migrant and migrant populations translate to differences in vascular complications between the two populations. We compared the prevalence of macrovascular and renal microvascular complications among West Africans with IH living in West Africa and their migrant compatriots in Europe.

Methods

Data from the multicenter Research on Obesity and Diabetes among African Migrants(RODAM) study were analyzed. Ghanaians with IH(524 non-migrant and 1439 migrants) were included. Logistic regression analyses were used to determine the associations between migrant status and macrovascular [coronary artery disease(CAD) and peripheral artery disease(PAD)] and renal microvascular[nephropathy] complications with adjustment for age, sex, socioeconomic status, smoking, systolic blood pressure, BMI, total cholesterol, HbA1c, C-reactive protein, and serum uric acid.

Findings

The prevalence of microvascular/macrovascular complications was higher in non-migrants than in migrants(nephropathy 15.3vs.9.7%; PAD 3.1%vs.1.3%; and CAD 15.8% vs. 5.0%). The differences persisted in the fully adjusted model: nephropathy [odds ratio, 2.12; 95% CI(1.46-3.08); PAD, 4.44(1.87-10.51); CAD 2.35(1.64-3.37)]. Non-migrant females had higher odds of nephropathy[2.14(1.34-3.43)], PAD[7.47(2.38-23.40)] and CAD [2.10(1.34-3.27)] compared to migrant females. Non-migrant males had higher odds of nephropathy[2.54(1.30-4.97)] and CAD[2.85(1.48-5.50)], but not PAD[1.81(0.32-10.29)],than their migrant peers.

Interpretation

Macrovascular and renal microvascular complications were more prevalent in non-migrants than in migrant West Africans with IH. Further studies are needed to identify factors that increase the risk to aid preventive/treatment strategies.

Epigenetic changes underlie the association between diabetes mellitus and oral diseases

Patients with diabetes mellitus (DM) suffer from oral complications related to oral infections, periodontal diseases, and endodontic lesions. Emerging evidence has revealed the contribution of the epigenetic process as the underlying mechanism of DM complications. DNA methylation, histone modifications, and non-coding RNAs are epigenetic regulators that directly affect gene expression. The present review elaborated on the role of epigenetic dysregulation in the etiology of diabetes-related periodontal and endodontic diseases. The narrative review study was prepared using databases such as PubMed, Google Scholar, Science Direct, and Scopus. The formation of glycation products as a result of hyperglycemic condition increases oxidative stress, and elevates chronic inflammatory mediators that could in turn adversely change the cellular environment and alter the epigenetic status. This process contributes to the alteration of regulatory genes expression, leading to the development of diabetes-induced bone complications and impaired odontogenic capacity of pulp. Indeed, epigenetic mechanisms mediate the interaction between gene expression and DM cellular environment. Further investigations on epigenetic factors involved in DM oral complications may provide novel therapeutic targets.

The effect of surgical weight loss on diabetes complications in individuals with class II/III obesity

AIMS/HYPOTHESIS

The aim of this study was to determine the effect of bariatric surgery on diabetes complications in individuals with class II/III obesity (BMI > 35 kg/m2).

METHODS

We performed a prospective cohort study of participants with obesity who underwent bariatric surgery. At baseline and 2 years following surgery, participants underwent metabolic phenotyping and diabetes complication assessments. The primary outcomes for peripheral neuropathy (PN) were a change in intra-epidermal nerve fibre density (IENFD, units = fibres/mm) at the distal leg and proximal thigh, the primary outcome for cardiovascular autonomic neuropathy (CAN) was a change in the expiration/inspiration (E/I) ratio, and the primary outcome for retinopathy was a change in the mean deviation on frequency doubling technology testing.

RESULTS

Among 127 baseline participants, 79 completed in-person follow-up (age 46.0 ± 11.3 years [mean ± SD], 73.4% female). Participants lost a mean of 31.0 kg (SD 18.4), and all metabolic risk factors improved except for BP and total cholesterol. Following bariatric surgery, one of the primary PN outcomes improved (IENFD proximal thigh, +3.4 ± 7.8, p<0.01), and CAN (E/I ratio -0.01 ± 0.1, p=0.89) and retinopathy (deviation -0.2 ± 3.0, p=0.52) were stable. Linear regression revealed that a greater reduction in fasting glucose was associated with improvements in retinopathy (mean deviation point estimate -0.7, 95% CI -1.3, -0.1).

CONCLUSIONS/INTERPRETATION

Bariatric surgery may be an effective approach to reverse PN in individuals with obesity. The observed stability of CAN and retinopathy may be an improvement compared with the natural progression of these conditions; however, controlled trials are needed.

Assessing the Burden of Kidney Disease among Type 2 Diabetic Subjects Attending a Semi-Urban Tertiary Health Facility in South-West Nigeria

BACKGROUND AND OBJECTIVES

Diabetes Mellitus (DM) remains an important public health issue and its complications are important causes of morbidity and mortality. Diabetic nephropathy (DN) is one of these complications and could be prevented/delayed by early detection. This study determined the burden of DN among patients with type 2 diabetes (T2DM).

METHODS

This cross-sectional, hospital-based study was conducted among 100 T2DM patients attending the medical outpatient clinics of a tertiary hospital in Nigeria and 100 age- and sex-matched healthy controls. The procedure included collection of sociodemographic parameters, urine for microalbuminuria and blood samples for estimation of fasting plasma glucose, glycated haemoglobin (HbA1c), and creatinine. Estimated creatinine clearance (eGFR) was derived from two formulae - Cockroft Gault formula, and Modification of Diet in Renal Disease study (MDRD) for staging chronic kidney disease. Data were analysed using the IBM SPSS version 23 software.

RESULTS

Participants' ages ranged from 28 years to 73 years [mean 53.0 (±10.7) years] with males accounting for 56% of the population and females 44%. Mean HbA1c was 7.6 (±1.8) % among the subjects; 59% had poor glycaemic control with HbA1c >7% (p-value <0.001). Overt proteinuria was present in 13% of T2DM participants while 48% had microalbuminuria compared to the non-diabetic group where 2% had overt proteinuria and 17% had microalbuminuria. Using the eGFR, chronic kidney disease was present in 14% of T2DM group and in 6% of the non-diabetic population. Increased age [OR= 1.09; 95%CI (1.03-1.14)], male sex [OR = 3.50; 95%CI (1.13 10.88)], and duration of diabetes [OR =1.01; 95%CI (1.00-1.01)] were associated with DN.

CONCLUSION

The burden of diabetic nephropathy is high in the T2DM patients attending our clinic and this is linked with advancing age.

Research progress on the role of PDGF/PDGFR in type 2 diabetes

Platelet-derived growth factors (PDGFs) are basic proteins stored in the α granules of platelets. PDGFs and their receptors (PDGFRs) are widely expressed in platelets, fibroblasts, vascular endothelial cells, platelets, pericytes, smooth muscle cells and tumor cells. The activation of PDGFR plays a number of critical roles in physiological functions and diseases, including normal embryonic development, cellular differentiation, and responses to tissue damage. In recent years, emerging experimental evidence has shown that activation of the PDGF/PDGFR pathway is involved in the development of diabetes and its complications, such as atherosclerosis, diabetic foot ulcers, diabetic nephropathy, and retinopathy. Research on targeting PDGF/PDGFR as a treatment has also made great progress. In this mini-review, we summarized the role of PDGF in diabetes, as well as the research progress on targeted diabetes therapy, which provides a new strategy for the treatment of type 2 diabetes.

Circulating soluble CD163 as a potential biomarker of diabetes complications

AIMS

To investigate whether soluble CD163 (sCD163) is altered in those with diabetes and various subtypes of complications and non-alcoholic fatty liver disease (NAFLD), and whether it can assess disease complications and severity in people with diabetes.

METHODS

Adults with diabetes (n = 101) were recruited and assessed for the presence of any complications (D^+Comps). Liver steatosis presence was determined by ultrasound and liver stiffness measurement (LSM) by transient elastography. Liver pathology other than non-alcoholic steatohepatitis (NASH) was excluded. Plasma sCD163 was measured by ELISA.

RESULTS

sCD163 was higher in D^+Comps (n = 59) compared to D^-comps (n = 42) in those with microvascular complications (n = 56; 1.3-fold), including a 1.4-fold increase in chronic kidney disease (CKD) (n = 42). sCD163 correlated positively with HbA_1c and urinary albumin-creatinine ratio and negatively with HDL-c in D^+Comps. sCD163 was increased 1.7-fold in those with advanced NASH fibrosis (LSM ≥ 10.3 kPa, n = 19) compared to those without (LSM < 10.3 kPa, n = 80). The AUC-ROC-curve was 0.64 for sCD163 to detect CKD and 0.74 to detect advanced NASH fibrosis.

CONCLUSIONS

In this study, the elevated circulating sCD163 occurred in people with diabetes who had microvascular complications or advanced NASH fibrosis, suggesting sCD163 may have clinical utility as a biomarker in certain diabetes complications and disease severity in NAFLD.

A multi-centre investigation of macrovascular and non-ocular microvascular complications in children and adolescents with diabetes mellitus in southern Ghana

Objectives

To investigate the prevalence of macrovascular and non-ocular microvascular complications and the associated factors among children and adolescents with diabetes mellitus in selected hospitals in southern Ghana.

Design

A cross-sectional study.

Setting

The out-patient clinics of the Departments of Child Health, Medicine and Therapeutics, Family Medicine, Ophthalmology, and the National Diabetes Management and Research Centre, all at the Korle Bu Teaching Hospital, Accra, as well as from Cape-Coast Teaching Hospital in the Central Region of Ghana.

Participants

Fifty-eight children and adolescents aged 4-19 years who had been diagnosed with diabetes mellitus.

Main outcome measures

Macrovascular (peripheral artery disease and coronary heart disease) and non-ocular microvascular complications (neuropathy and nephropathy).

Results

Data from 58 children and adolescents with diabetes were analysed. The mean age of participants was 14.6±2.6 years, and a female preponderance was observed (45, 77.6%). The prevalence of macrovascular and non-ocular microvascular complications was 27.6% and 8.6%, respectively. Long duration of diabetes diagnosis (p=0.044) and low triglycerides (p=0.009) were associated with microvascular complications, while high triglycerides (p=0.032), lower HDL cholesterol (p=0.046), and abnormal body mass index (p=0.020) were associated with macrovascular complications.

Conclusions

Macrovascular and non-ocular microvascular complications are common among children and adolescents with diabetes in southern Ghana and are associated with a long duration of diabetes diagnosis, abnormal body mass index, low HDL cholesterol, and triglyceride levels. Therefore, the early institution of regular screening for diabetes-related complications to allow early detection and appropriate management is recommended.

Funding

University of Ghana Research Fund.

Diagnostic values of ischemia modified albumin in diabetes-related complications: a narrative review

Purpose

Oxidative stress (OS) plays a critical role in the onset and progression of macro and microvascular complications of diabetes mellitus (DM). Ischemia-modified albumin (IMA) is a novel and simple test for evaluating OS. In the present study, we reviewed the available information on the alteration of circulating IMA in DM and its possible prognostic and diagnostic value in DM-related complications.

Methods

Relevant studies regarding IMA alteration in DM published until May 30, 2022 were extracted from Google Scholar, PubMed, Scopus, and Science Direct databases. The following key words were used: IMA, DM, diabetes complications, retinopathy, nephropathy, diabetic foot, and vascular complications.

Results

This review revealed increased circulating IMA levels in the patients with type 1, type 2, and gestational DM. Furthermore, IMA showed a close relationship with the severity of DM complications including hyperglycemia, dyslipidemia, diabetic retinopathy, diabetic nephropathy, peripheral arterial disease, and diabetic foot ulcer. However, lack of assay standardization and low specificity are major obstacles to the use of IMA as a promising biomarker.

Conclusion

IMA levels are associated with DM complications and can be applied as a practical test for evaluating the risk and predicting the severity of DM complications.

Outcomes of a multidisciplinary Diabetic Foot Day Unit

OBJECTIVE

To analyse the main characteristics of patients and the health outcomes obtained and to evaluate the impact of peripheral artery disease (PAD) in patients treated in our multidisciplinary Diabetic Foot Unit.

RESEARCH DESIGN AND METHODS

Observational prospective study. 273 patients from two different populations (with and without PAD - classified according to the presence of distal pulses) treated over a 14-month period in the multidisciplinary Diabetic Foot Unit were included. The data on patient characteristics and outcomes were analysed for the purpose of comparison. For the inference study, a comparison of medians with the non-parametric test for independent samples for the quantitative variables and a χ² test for the comparison of proportions in qualitative variables were performed.

RESULTS

Patients with PAD ulcers were older (60 (54-67) vs. 64 (75-81), p=0.000) and had a higher macrovascular burden (8.1% vs. 29% for ischaemic heart disease history, p=0.000; 6.7% vs. 18.1% for cerebrovascular disease history, p=0.004). Their Texas Score was higher (p=0.000) and their major amputation rate was higher (1.4% vs. 12.3%, p=0.001). They had less background of previous ulcers (52.6% vs. 26.8%, p=0.000), their episode duration was shorter (4 (0-10) vs. 0 (0-3) weeks, p=0.000), and their proportional need for antibiotic therapy was lower (64.4% vs. 51.4%, p=0.03).

CONCLUSIONS

The differences found between ulcers with and without vascular involvement support the need for a different approach and for the inclusion of vascular surgeons on the team. The multidisciplinary care model for diabetic foot patients could be effective and improve health outcomes.

Chronic disease management program applied to type 2 diabetes patients and prevention of diabetic complications: a retrospective cohort study using nationwide data

BACKGROUND

The outcomes of education and counseling by medical professionals for patients with type 2 diabetes mellitus (T2DM) are unclear. This study examined the effects of the Chronic Disease Management Program (CDMP), a health insurance fee-for-service benefit, on the incidence of diabetic complications in patients newly diagnosed with T2DM using the National Health Insurance data.

METHODS

Patients newly diagnosed with T2DM aged ≥ 20 years from 2010 to 2014 were followed up until 2015. Selection bias was minimized using propensity score matching. A stratified Cox proportional hazards model was used to analyze the association between the CDMP and the risk of incident diabetic complications. Subgroup analysis was performed for patients with high medication adherence, which was indicated by a medication possession ratio (MPR) ≥ 80.

RESULTS

Among the 11,915 patients with T2DM in the cohort, 4,617 were assigned to the CDMP and non-CDMP group each. The CDMP helped reduce the overall and microvascular risks of complications compared to the non-CDMP group; however, the protective effect against macrovascular complications was only observed in those aged ≥ 40 years. Subgroup analysis of the group aged ≥ 40 years with high adherence (an MPR ≥ 80) showed that the CDMP effectively reduced the incidence of micro- and macrovascular complications.

CONCLUSIONS

Effective management of T2DM is crucial in preventing complications in patients with the condition, and includes regular monitoring and adjustment of treatment by qualified physicians. Nevertheless, long-term prospective studies on the effects of CDMP are required to confirm this finding.

Exercise facility availability and incidence of type 2 diabetes and complications in Spain: A population-based retrospective cohort 2015-2018

BACKGROUND

To study the association between exercise facility availability and type 2 diabetes incidence and its complications, and to explore effect modification by socioeconomic status (SES) and sex in the Madrid adult population.

METHODS

A multilevel longitudinal design, based on a population-based retrospective cohort including 1,214,281 residents of Madrid (Spain) aged 40-75 years from 2015 to 2018. Outcomes were type 2 diabetes incidence and macrovascular (cardiac ischemia and/or stroke) and microvascular (chronic kidney disease, retinopathy, and/or peripheral vascular disease) complications in those with diabetes at baseline. Exercise facility availability was defined as the count of exercise facilities in a 1000 m street network buffer around each participant's residence. Poisson regression models with robust standard errors were used to estimate the risk ratios (RR). Interactions were explored with SES tertiles and by sex.

RESULTS

Residents living in areas with lower exercise facility availability showed higher risk of type 2 diabetes (RR_tertile3vs1 = 1.25, CI95% 1.21-1.30) as well as macrovascular (RR_Tertile3vs1 = 1.09 CI95% 1.00-1.19), and microvascular (RR_Tertile3vs1 = 1.10 CI95% 1.01-1.19) complications. Associations were strongest in low SES areas for type 2 diabetes (RR_{tertile3vs1-LOW-SES} = 1.22, CI95% 1.12-1.32; RR_{tertile3vs1-HIGH-SES} = 0.91, CI95% 0.85-0.98) and microvascular complications (RR_{tertile3vs1-LOW-SES} = 1.12, CI95% 0,94-1,33; RR_{tertile3vs1-HIGH-SES} = 0.88, CI95% 0.73-1.05).

CONCLUSIONS

Living in areas with lower availability of exercise facilities was associated with a greater risk of type 2 diabetes and its complications. Increasing exercise opportunities, particularly in low SES areas, could help reduce the social gradient of diabetes and its complications.

Amino acid analysis as a method of discovering biomarkers for diagnosis of diabetes and its complications

Diabetes mellitus (DM) is a severe chronic diseases with a global prevalence of 9%, leading to poor health and high health care costs, and is a direct cause of millions of deaths each year. The rising epidemic of diabetes and its complications, such as retinal and peripheral nerve disease, is a huge burden globally. A better understanding of the molecular pathways involved in the development and progression of diabetes and its complications can facilitate individualized prevention and treatment. High diabetes mellitus incidence rate is caused mainly by lack of non-invasive and reliable methods for early diagnosis, such as plasma biomarkers. The incidence of diabetes and its complications in the world still grows so it is crucial to develop a new, faster, high specificity and more sensitive diagnostic technologies. With the advancement of analytical techniques, metabolomics can identify and quantify multiple biomarkers simultaneously in a high-throughput manner, and effective biomarkers can greatly improve the efficiency of diabetes and its complications. By providing information on potential metabolic pathways, metabolomics can further define the mechanisms underlying the progression of diabetes and its complications, help identify potential therapeutic targets, and improve the prevention and management of T2D and its complications. The application of amino acid metabolomics in epidemiological studies has identified new biomarkers of diabetes mellitus (DM) and its complications, such as branched-chain amino acids, phenylalanine and arginine metabolites. This study focused on the analysis of metabolic amino acid profiling as a method for identifying biomarkers for the detection and screening of diabetes and its complications. The results presented are all from recent studies, and in all cases analyzed, there were significant changes in the amino acid profile of patients in the experimental group compared to the control group. This study demonstrates the potential of amino acid profiles as a detection method for diabetes and its complications.

Do Individuals Aged 50 or Older View Cognitive Conditions Differently Than Physical Conditions? Evidence From a Pooled Analysis of Illness Perceptions in Type 2 Diabetes and Mild Cognitive Impairment

Background and Objectives

Type 2 diabetes (T2DM) and mild cognitive impairment (MCI) are common late-life physical and cognitive health conditions. Illness perceptions, an individual's personal beliefs about the conditions, should be explored in the context of disease characteristics (physical or cognitive). This secondary analysis explored illness perceptions with a priori hypotheses about control (perceived controllability) and coherence (perceived understanding) dimensions among persons with T2DM and MCI, treating each as an exemplar of late-life physical and cognitive health conditions. We also explored whether age, education, and comorbid conditions moderate the relationships between T2DM or MCI condition groups and illness perceptions.

Research Design and Methods

This cross-sectional, descriptive study examined baseline data collected from 146 T2DM to 90 MCI participants in 2 independent studies. The 9-item Brief Illness Perception Questionnaire was used to identify the similarities and differences in illness perceptions among persons with T2DM and MCI. We performed hierarchical linear regression controlling for identified covariates.

Results

We found that T2DM and MCI participants had significantly different illness perceptions, including perceptions of personal control (b = -0.943, p = .009), treatment control (b = -1.619, p < .001), and coherence (b = -1.265, p = .001), after controlling for covariates. The results suggest that persons with MCI were likely to believe that their condition is less controllable (through their own strategies or medical treatment) and less understandable compared with their T2DM counterparts. Such associations remained statistically significant when the interactions were added to the models.

Discussion and Implications

As T2DM and MCI are prevalent late-life conditions, health care professionals should consider individuals' subjective perceptions about their conditions in the context of disease characteristics when counseling secondary prevention strategies for disease management. Further research on illness perceptions in other conditions is needed to ensure the replicability of our findings.

Prevalence, clinical features and complications of common forms of Maturity Onset Diabetes of the Young (MODY) seen at a tertiary diabetes centre in south India

BACKGROUND

Maturity Onset Diabetes of the Young (MODY) is a form of monogenic diabetes caused by mutations in single genes, affecting adolescents or young adults. MODY is frequently misdiagnosed as type 1 diabetes (T1). Though several studies from India have reported on the genetic aspects of MODY, the clinical profile, complications and treatments given have not been reported so far, nor compared with T1D and type 2 diabetes (T2D).

AIM

To determine the prevalence, clinical features, and complications of common forms of genetically proven MODY seen at a tertiary diabetes centre in South India and compare them with matched individuals with T1D and T2D.

METHODS

Five hundred and thirty individuals identified as 'possible MODY' based on clinical criteria, underwent genetic testing for MODY. Diagnosis of MODY was confirmed based on pathogenic or likely pathogenic variants found using Genome Aggregation Database (gnomAD) and American College of Medical Genetics (ACMG) criteria. The clinical profile of MODY was compared with individuals with type 1 (T1D) and type 2 (T2D) diabetes, matched for duration of diabetes. Retinopathy was diagnosed by retinal photography; nephropathy by urinary albumin excretion > 30 µg/mg of creatinine and neuropathy by vibration perception threshold > 20 v on biothesiometry.

RESULTS

Fifty-eight patients were confirmed to have MODY (10.9%). HNF1A-MODY (n = 25) was the most common subtype followed by HNF4A-MODY (n = 11), ABCC8-MODY (n = 11), GCK-MODY (n = 6) and HNF1B-MODY (n = 5). For comparison of clinical profile, only the three 'actionable' subtypes - defined as those who may respond to sulphonylureas, namely, HNF1A, HNF4A and ABCC8-MODY, were included. Age at onset of diabetes was lower among HNF4A-MODY and HNF1A-MODY than ABCC8-MODY, T1D and T2D. Prevalence of retinopathy and nephropathy was higher among the three MODY subtypes taken together (n = 47) as compared to T1D (n = 86) and T2D (n = 86).

CONCLUSION

This is one of the first reports of MODY subtypes from India based on ACMG and gnomAD criteria. The high prevalence of retinopathy and nephropathy in MODY points to the need for earlier diagnosis and better control of diabetes in individuals with MODY.

Clinical and biochemical profile of childhood-adolescent-onset type 1 diabetes and adult-onset type 1 diabetes among Asian Indians

AIM

To compare the clinical and biochemical profile and prevalence of complications among childhood/adolescent-onset (CAO; onset of diabetes< 20 years of age) and adult-onset (AO; onset of diabetes- ≥ 20 years of age) type 1 diabetes (T1D), seen at a tertiary care diabetes center in south India.

METHOD

Data of 5578 individuals with T1D, diagnosed based on a history of diabetic ketoacidosis or ketonuria, fasting C-peptide < 0.3 pmol/mL and stimulated C-peptide values < 0.6 pmol/mL, and requirement of insulin right from the time of diagnosis, presenting to our center between 1991 and 2021, were retrieved from our electronic medical records. Retinopathy was assessed by retinal photography, chronic kidney disease (CKD) by urinary albumin excretion ≥ 30 µg/mg of creatinine and/or eGFR < 60 mL/min, and neuropathy by vibration perception threshold >= 20v on biothesiometry.

RESULTS

Overall, 3559 (63.8%) of individuals with T1D, belonged to CAO group and 2019 (36.2%) to AO category. AO had higher prevalence of all microvascular complications compared to CAO at every diabetes duration interval, even after adjusting for A1c. Among the AO group, prevalence of retinopathy, CKD, and neuropathy was higher in the GAD negative group. Among CAO there were no differences between the GAD negative and GAD positive groups with respect to prevalence of complications of diabetes.

CONCLUSION

AO with T1D had higher prevalence of microvascular complications compared to CAO. Among AO, GAD negative individuals had higher percentage of retinopathy and CKD compared to GAD positive group.