Volume 12 · Issue 09 · 2020

Obesity and diabetes are worldwide public health problems that seriously threaten human health. Metabolic surgery, as a new treatment method, has unique advantages in weight loss, diabetes relief and other cardiovascular risks. In the joint statement of the International Diabetes Organization released in June 2016, metabolic surgery was written into the treatment path of type 2 diabetes for the first time, providing good compliance for clinical practice. However, metabolic surgery is like a double-edged sword. To maximize the benefits, it is necessary to take into account the individualization and precision of surgical procedures, as well as the standardization and scientificalization of postoperative management, and find the best balance between long-term effectiveness and safety.

Hypoglycemia and blood glucose fluctuations have been the focus of attention in the field of diabetes treatment in recent years, especially in diabetic patients treated with insulin. Both hypoglycemia and blood sugar fluctuations can affect overall blood sugar control, leading to the occurrence of microvascular and macrovascular lesions, and even life-threatening. The latest foreign guidelines have officially regarded the time within the target range, an indicator of blood sugar fluctuation, as one of the indicators of blood sugar management. The author summarized the differences in the risk of hypoglycemia and the stable control of blood glucose in diabetic patients treated with different basal insulin, aiming at optimizing the treatment choice of basal insulin and improving the quality of life and prognosis of diabetic patients.

Insulin therapy is the main measure to control blood sugar. FREE study is the first in the world to use glycosylated hemoglobin (HbA_1c) As the main efficacy index, the clinical study of needleless syringes, FREE research shows that needleless syringes can alleviate patients' fear of needle for traditional needle injection pens, reduce injection pain, reduce the occurrence of injection-related complications such as fat hyperplasia, reduce insulin dosage, better control blood sugar while not increasing the risk of hypoglycemia and weight gain, and improve the quality of life of patients receiving insulin therapy.

In 2019, the International Diabetic Foot Working Group updated the guidelines for the prevention and treatment of diabetic foot. The section on the use of interventions to promote diabetic foot healing makes 13 recommendations. 3 newly added recommendations: Consider the use of oligosaccharide dressings in addition to the best standard of treatment for difficult-to-heal neuro-ischemic ulcers; Consider the use of autologous leukocytes, platelets and fibrin patches in addition to the best standard of treatment for difficult-to-heal ulcers; Consider topical use of placenta-derived products in addition to optimal standard treatment. There are 10 recommendations consistent with the 2015 version of the guidelines, including 5 strong recommendations and 5 weak recommendations. Understanding the update of the guidelines is of great benefit to clinical and scientific research work of diabetic foot.

To investigate the associations between retinol-binding protein 4 (RBP4) levels and dyslipidemia in Chinese children and adolescents with overweight and obesity.

A total of 1 875 overweight and obese children aged 6－18 years were recruited from the Beijing Child and Adolescent Metabolic Syndrome (BCAMS) study in 2004. Levels of RBP4, triglyceride (TG), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and homeostasis model assessment of insulin resistance (HOMA-IR) were measured. Dyslipidemia was defined by the presence of anyone of the following: TC≥5.18 mmol/L; TG≥1.70 mmol/L; LDL-C≥3.37 mmol/L; HDL-C≤1.04 mmol/L. Correlations between RBP4 and metabolic features including lipid profiles were examined by partial correlation analysis. Logistic regression models were used to anaylze the association between RBP4 and dyslipidemia.

Among children with overweight and obesity, 34.5% (647/1 875) had dyslipidemia. RBP4 levels were elevated in overweight and obese children with dyslipidemia, compared with those without dyslipidemia [36.65(30.63，44.08） vs 33.24（28.42，39.98）μg/ml，P<0.01]. RBP4 levels were positively associated with body mass index (BMI), TG, TC, LDL-C and HOMA-IR levels (r=0.079, 0.216, 0.192, 0.180, 0.135, respectively; allP<0.01), but not with HDL-C levels (P>0.05). In addition, participants in the highest RBP4 quartile were more likely to have dyslipidemia ［odds ratios (95% confidence interval) was 2.05 (1.53-2.75),P<0.01］, hypertriglyceridemia ［3.22 (2.10-4.95),P<0.01］, hypercholesteremia ［2.34 (1.36-4.02),P<0.01］ and elevated LDL-C levels ［2.51 (1.65-3.83),P<0.01］ than those in the lowest quartile. Further adjustment for BMI and HOMA-IR didn′t modify the associations of RBP4 with lipid disorders (allP<0.01).

Increment of RBP4 level may be associated with dyslipidemia in obese children and might be a potential early biomarker and therapy target for dyslipidemia.

To explore the effect of of follow-up frequency on self-management ability and metabolic profiles in patient with type 2 diabetes mellitus who have been visiting Internet plus Shared Care clinic for more than 2 years.

A retrospective study was conducted in 496 patients with type 2 diabetes who completed quarterly or annual follow-up visit in the diabetes shared care clinic of Peking University First Hospital in the first quarter, the fourth quarter of 2018 and the fourth quarter of 2019. According to the actual number of follow-up visits from January to December in 2018, the subjects were divided into follow-up≥4 times group (n=330), 3 times follow-up group (n=128), and follow-up≤2 times group (n=38). SDSCA-6 was used to evaluate self-management behavior of patients. Age, gender, disease duration of diabetes, baseline metabolic indexes ［body mass index, HbA_1c, low-density lipoprotein-cholesterol (LDL-C), systolic blood pressure, diastolic blood pressure］, baseline insulin use and baseline self-management ability score were used as covariates to analyze three groups′ propensity score weighting by using R3.4.4 and TWANG package. The differences in the scores of self-management ability (average treatment effect in the population, ATE) at 1-year follow-up and the difference in metabolic profiles (ATE) at 1-year and 2-year follow-up in each group were compared by ANOVA or nonparametric test.

Compared with follow-up≤2 times group, the scores of exercise (+1.16 points, P<0.01), self-monitoring blood glucose (+0.82 points,P=0.04) and foot examination (+0.99 points, P<0.05) in follow-up≥4 times group at 1-year were significantly improved. The scores of exercise (+1.50 points,P<0.01) and self-monitoring blood glucose (+1.10 points,P=0.02) in 3 times follow-up group at 1-year were significantly improved. HbA_1c showed improved trend in follow-up≥4 times group at 1-year follow-up (compared with 3 times follow-up group -0.25%, P=0.05; compared with follow-up≤2 times group -0.34%, P=0.06), but was significantly improved in follow-up≥4 times group at 2-year follow-up (compared with 3 times follow-up group -0.34%, P=0.01; compared with follow-up≤2 times group -0.55%, P<0.01). There was no significant difference in other self-management ability at 1-year nor body mass index, LDL-C or other metabolic indexes at 1-year or 2-year follow-up (P>0.05).

In patients with type 2 diabetes mellitus who follow up regularly in the Internet plus Diabetes Shared Care clinic, the frequency of 3－4 visits per year can significantly improve their self-management ability on exercise and self-monitoring blood glucose. The frequency of 4 visits per year can significantly improve the self-management ability on foot examination and significantly improve blood glucose control status continually.

To evaluate the effects of metformin plus pioglitazone as a sequential therapy after short-term intensive insulin therapy （SIIT) in patients with newly diagnosed type 2 diabetes mellitus （T2DM).

This study was a randomized，double-blinded，placebo controlled trial. In total，50 patients with newly diagnosed T2DM were enrolled from September 2016 to December 2018. Patients were randomized into sequential treatment group （n=25) and control group （n=25). All the patients received SIIT to achieve and maintain glycemic targets （fasting or pre-meal blood glucose 4.4-6.0 mmol/L，2 h post-prandial glucose 4.4-7.8 mmol/L) for 14 days. Afterwards，metformin and pioglitazone fixed dose tablets （metformin 500 mg plus pioglitazone 15 mg per tablet) or placebo were given to the sequential treatment group or the control group respectively at a dose of 1 tablet bid for 3 months. Homeostasis model assessments and indices derived from oral glucose tolerance tests were used to evaluate β-cell function ［homeostasis model assessment of β cell function （HOMA-β)， ΔI_{30 min}/ΔG_{30 min}， AUC_insulin/AUC_glucose， insulin secretion-sensitivity index-2 （ISSI-2)］ and insulin sensitivity ［homeostasis model assessment of insulin resistance （HOMA-IR)， Matsuda index］. The ttest or Mann-Whiteney U were used for comparison between groups，and covariance analysis was used for correction of confusions for indicators of islet function or insulin resistance.

In both groups，blood glucose levels were remarkably decreased while β-cell function and insulin sensitivity were improved after SIIT. At 3 month， β-cell indices such as ΔI_{30 min}/ΔG_{30 min} ［3.2 （1.9，5.9) vs 2.1 （1.2，4.0)， Z=-1.93， P=0.049］， ISSI-2 ［245.3 （170.5，330.0) vs 158.9 （122.2， 236.9)， Z=-2.13， P=0.03］ and AUC_insulin/AUC_glucose （3.0±1.7 vs 1.9±0.9， F=5.17， P=0.028) and HOMA-β （56.9±30.7 vs 36.0±22.5， F=5.25， P=0.037) were significantly higher in the sequential treatment group than the control group， while fasting blood glucose ［(6.0±1.0) vs （6.6±1.0) mmol/L， t=-2.04， P=0.048］ and glycated hemoglobin A_1c [（6.2±1.1)% vs (6.5±0.4)%， t=-2.16， P=0.04] were lower in the sequential treatment group，the differences were all statistically significant.

After SIIT，metformin plus pioglitazone as sequential therapy can persistently improve β-cell function and maintain optimal blood glucose in patients with newly diagnosed T2DM.

To evaluate the effects of gestational diabetes mellitus (GDM) on the perinatal outcomes among women with twin pregnancy.

PubMed, Embase, Web of Science, Cochrane, CNKI, Wanfang database, Weipu database and SinoMed were searched for twin pregnancy observational studies comparing the maternal and fetal outcomes from January 1, 2000 to May 31, 2019. RevMan 5.3 software was used for data analysis.

A total of 18 cohort studies were included in the analysis. Compared with the non-GDM group, the risks of hypertensive-related diseases (gestational hypertension and preeclampsia), premature delivery (<37 weeks), neonatal intensive care unit (NICU) admission, and respiratory distress syndrome (RDS) were all increased (OR=1.78，95%CI：1.53-2.07；OR=1.22，95%CI：1.11-1.34；OR=1.34，95%CI：1.21-1.48；OR=1.29，95%CI：1.05-1.59；OR=1.45，95%CI：1.05-2.01, respectively); the risks of SGA and 5-minute-Apgar scores<7 were decreased in GDM group (OR=0.87， 95%CI：0.80-0.93 and OR=0.65，95%CI：0.52-0.81, respectively). Cohort studies using international diabetes and pregnancy research group (IADPSG) criteria were investigated as subgroup analysis, however, GDM did not increase the risks of hypertensive-related diseases, NICU admission or RDS (OR=1.05, 95%CI：0.69-1.60； OR=1.12，95%CI：0.77-1.61；OR=0.82，95%CI：0.39-1.74, respectively).

GDM may increase the risks of hypertensive-related diseases (gestational hypertension and preeclampsia), preterm delivery, cesarean section, NICU admission and RDS in women with twin pregnancies while the risk of SGA and 5-minute-Apgar scores<7 were decreased. More studies are required for the diagnosis and treatment of GDM in women with twin pregnancies.

To investigate whether the serum cytokines in latent autoimmune diabetes in adults (LADA) patients were abnormal and whether sitagliptin could exert effects on the serum cytokines levels of LADA patients.

(1) There were thirty LADA patients and thirty normal subjects matched with age and sex were selected and their fasting serum were collected. (2) LADA patients were randomized to group A treated with insulin and sitagliptin (n=15) and group B treated with insulin only (n=15). The intervention lasted for 12 months and the patients were followed at the baseline, 6 and 12 months seperately. Fasting and 2-hour postprandial serum samples and clinical data were collected at each point. 3. Serum Adiponectin, interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1RA), inflammatory protein-10 (IP-10) and leptin levels were determined by the human premixed multi-analyte kit. All the cytokines were compared between LADA patients (baseline data) and normal controls. Meanwhile, they were also monitored in the above two LADA groups at the baseline, 6 month and 12 months during the follow-up. Differences between groups were analyzed using independent samples t test. Analysis of variance of repeated measurements was used to compare all the points during the following period within the two groups and between the two groups.

(1) The serum Adiponectin ［1.11 (0.99, 1.28) vs. 0.96 (0.73, 1.12) ng/ml］ and IL-1RA ［865.63 (682.04, 1 044.55) vs. 718.63 (478.39, 807.89) pg/ml］ levels in LADA patients were significantly higher than those in normal controls (P<0.05), whereas the serum Leptin level ［4 832.72 (1 751.39, 9 084.29) vs. 8 123.8 (4 844.48, 14 157.95) pg/ml］ in LADA patients was lower than that in normal controls(P<0.05). There was no significant differences in serum IL-6 and IP-10 levels between the two groups (P>0.05). Moreover, the serum Leptin level in LADA patients was positively correlated to BMI (r=0.535, P=0.002) and was negatively correlated to GADA titers (r=-0.551, P=0.002).(2) Twelve months later, the serum IL-1RA level in insulin with sitagliptin group and insulin without sitagliptin group both decreased compared with those in the baseline. However, there was no significant differences in the serum IL-1RA, Adiponectin, Leptin, IL-6 and IP-10 levels between the two groups during the whole treatment(P>0.05).

Adipocytokines and anti-inflammatory markers are abnormal in LADA patients. It was not found that sitagliptin can improve the inflammation in LADA from this pilot study temporarily.

To explore the relationship between distal symmetric polyneuropathy and muscle mass loss in patients with type 2 diabetes mellitus (T2DM).

The inpatients in the Department of Endocrinology and Metabolism of the Affiliated Hospital of Qingdao University from January to August 2019 were selected as subjects; 469 patients with type 2 diabetes who met the enrollment criteria were included. According to the diagnostic criteria of the Asian Working Group for Sarcopenia (AWGS),the patients were divided into muscle mass loss group and non-muscle mass loss group (300 cases). The differences in the observed indicators between the two groups were compared; According to the guidelines for the prevention and treatment of type 2 diabetes in China,the patients were divided into DSPN group (296 cases) and non-DSPN group （173 cases）, the prevalence of muscle mass loss between the two groups was compared,and the correlation between DSPN and muscle mass loss was explored using a binary logistic model,Mann-whitney U test was used for comparison between groups.

A total of 469 patients with T2DM were included,including 169 patients with muscle mass loss. The prevalence of muscle mass loss in the DSPN group was significantly higher than that in the non-DSPN group (40.88%vs27.75%, P<0.05). Univariate logistic regression results showed that DSPN was a risk factor for muscle mass loss in T2DM patients (OR=1.786, 95%CI 1.190-2.680, P=0.005). After adjusting for age, BMI and other factors,the correlation between DSPN and muscle mass loss still exists (OR=1.807, 95%CI 1.162-2.809, P=0.009).

Muscle mass loss is more common in DSPN patients with T2DM, which is a risk factor for muscle mass loss.

To investigate the association between triglyceride (TG) to high-density lipoprotein-cholesterol (HDL-C) ratio and sarcopenia in patients with type 2 diabetes mellitus (T2DM).

A total of 1 104 inpatients with T2DM admitted to Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University from June 2013 to December 2015 were enrolled in this retrospective cross-sectional study. The basic information, medical history, chronic complications of diabetes and biochemical indicators of all patients were collected. According to the latest consensus diagnostic criteria of the Asian sarcopenia working group in 2014, sarcopenia was defined as skeletal muscle index (SMI)<7.0 kg/m² for males and <5.4 kg/m ² for females. After exclusion, 1 002 cases were enrolled and divided into four groups according to the quartiles of TG/HDL-C ratio: Q1: ≤0.80 (n=250), Q2: 0.81-1.23 (n=250), Q3: 1.24-2.11 (n=253), Q4: ≥2.12(n=249). The detection rate of sarcopenia in each quantile group was measured by Chi-square test, the clinical characteristics of the population were tested by one-way ANOVA, Chi-square test and K-W test. Odds ratio of muscle mass reduction was calculated by binary logistic regression analysis of the quartile of TG/HDL-C ratio.

In patients with T2DM, with the increase of TG/HDL-C ratio, the detection rate of sarcopenia gradually decreased, which were 27.6% (69/250), 19.2% (48/250), 18.2% (46/253) and 12.0% (30/249) respectively. There was a significant difference between the quartile arrays (χ²=19.22, P<0.01). People with the lowest quartile of TG/HDL-C ratio had the lowest low-density lipoprotein cholesterol (H=46.239, P<0.01), total cholesterol (H=37.949, P<0.01), skeletal muscle index (F=13.059, P<0.01). Compared with the lowest quartile of TG/HDL-C ratio, the odds ratio value (95% confidence interval) of the highest quartile of the TG/HDL-C ratio for muscle mass reducing was 0.39 (0.22-0.70,P=0.016) after adjusting multiple confounding factors.

The lower TG/HDL-C ratio is associated with increased risk of muscle mass reducing in patients with T2DM, and this trend persists after adjusting for multiple confounding factors.

A 23-year-old male patient with diabetes mellitus and proteinuria was diagnosed as adolescent adult-onset diabetes mellitus (MODY) type 5 based on laboratory, imaging and genetic tests. The patient developed severe right kidney atrophy and renal function damage caused by double kidney cysts, and the serum magnesium ion concentration was lower than the normal value. Genetic test indicated that the patient's hepatocyte nuclear factor 1 β (HNF-1B) gene had a nonsense mutation, c.1132C>T, p.Gln378Ter, and the parents were wild-type, so this mutation was a new mutation. According to relevant literature research, hypomagnesemia may occur earlier than diabetes. Combined with the clinical characteristics of this case, it is suggested that MODY patients with renal structural malformation and hypomagnesemia should be alert to the variation of HNF-1B.

Prader-Willi syndrome (PWS) is a genetic disease with deletion of the parental gene, and the clinical presentation varies depending on age. With the increase of age, developmental abnormalities, hyperappetite, obesity and complicated abnormal glucose and lipid metabolism become the main symptoms and affect their long-term prognosis. A case of adolescent diagnosed with PWS due to complicated diabetes was reported. The clinical characteristics and key points of diagnosis and treatment were discussed, aiming at improving the understanding of PWS complicated with abnormal glucose metabolism and putting forward effective preventive and therapeutic measures.

At the end of 2019, the American Diabetes Association released the latest diabetes diagnosis and treatment standards in 2020. The author excerpted the chapter on diabetic microvascular disease and podiatry (Chapter 11), which mainly included the revised part of the recommendations and theoretical basis for chronic kidney disease and diabetic foot disease. Interpret. The purpose of this chapter is to provide clinical practice suggestions for the treatment of diabetic microvascular disease and podiatry, and provide a basis for clinical diagnosis and treatment.

Lifestyle factors play an important role in the occurrence and development of diabetes. Studies suggest that smoking can increase the risk of developing diabetes and accelerate blood vessel damage in diabetics. This article reviews the evidence on the effects of smoking on diabetic patients, especially type 2 diabetes, and its complications, and discusses more rational management approaches for diabetic patients in the future.

Ketoacidosis is one of the acute complications of diabetes. In recent years, several studies have shown that sodium-glucose cotransporter 2 (SGLT2) inhibitors can cause non-hyperglycemic ketoacidosis (euDKA). Its pathogenesis is mainly to inhibit insulin secretion and promote glucagon secretion, reduce blood volume, promote metabolism from carbohydrate to lipid, etc., resulting in an increase in ketogenesis in the body, and reduce the clearance ability of kidney to ketone bodies, etc., thus leading to ketone body accumulation. In addition, due to increased urinary glucose excretion, decreased renal gluconeogenesis and other factors, the blood glucose level in the body is not elevated, and it is manifested as euDKA, which is often ignored or missed. This article reviews the pathogenesis of SGLT2 inhibitor-induced diabetic euDKA.

With the increasing prevalence of obesity worldwide, the clinical significance of non-alcoholic fatty pancreatic disease (NAFPD) has attracted increasing attention. Compared with the liver, although the pancreas is more prone to ectopic fat deposition, due to the limitation of detection technology, there are few in-depth reports on NAFPD. Recent studies have shown that NAFPD can induce β-cell dysfunction, insulin resistance and inflammatory states, which can lead to metabolic syndrome and diabetes. In-depth exploration of the effects of NAFPD on β cell function and insulin resistance and the association between NAFPD and glucose metabolism disorders will help to provide new ideas for diabetes treatment.

Diabetic foot ulcer is the primary cause of non-traumatic amputation, and accelerating healing has become a research hotspot. Regulation of repair-related factors plays an important role in promoting healing. The involvement of matrix metalloproteinase family in the regulation of diabetic foot ulcer repair and the possible related mechanisms were discussed.

Sepsis is often combined with glucose metabolism disorders, resulting in increased mortality. By expounding the mechanism, control measures and goals of glucose metabolism disorder in sepsis, the author provides reference for blood glucose control in sepsis patients.

To evaluate the cardiovascular benefits and safety of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with type 2 diabetes mellitus (T2DM) by systematic review and Meta-analysis.

PubMed and other databases were searched for randomized controlled trials published up to October 2019, which including cardiovascular outcome of SGLT2 inhibitors in patients with T2DM. Meta-analysis was performed by RevMan 5.3 and STATA14.0 software. Odds ratio (OR) or relative ratio (RR) with 95% confidence intervals (95%CI) were used to evaluate the effect of randomized treatment allocation on the primary outcomes across trials.

Data from three identified trials with 34 322 patients were included (19 064 in SGLT2 inhibitors group and 15 258 in control group) with high quality and low risk of bias. SGLT2 inhibitors reduced HbA_1c more than control ［mean difference 0.44% (0.33% to 0.58%), P<0.01］. SGLT2 inhibitors led to a statistically decrease in the risk of major adverse cardiovascular events ［RR:0.89; 95%CI(0.83, 0.96); P=0.001］ compared with the control group, with a similar benefit reducing the risk of hospitalization for heart failure ［RR:0.69; 95%CI(0.61, 0.79); P<0.01］, myocardial infarction ［RR:0.89; 95%CI(0.80, 0.98); P=0.018］, all-cause mortality ［RR:0.83; 95%CI(0.70, 0.99); P=0.034］ and progression of renal disease ［RR:0.55; 95%CI(0.48, 0.64); P<0.01］. There was no statistical difference between the two groups in the risk of cardiovascular death ［RR:0.81; 95%CI(0.63, 1.05); P=0.116］ and stroke ［RR:1.00; 95%CI(0.88, 1.13); P=0.948］. In addition, SGLT2 inhibitors had a neutral effect on urinary tract infection, hypoglycemia, hypovolemia, amputation and fracture (P>0.05), but with a significant increase risk of genital infection ［RR:4.74; 95%CI(2.76, 8.16); P<0.01］ and diabetic ketoacidosis ［RR:2.34; 95%CI(1.26, 4.35); P=0.007］.

SGLT2 inhibitors have cardiovascular and renal protective effects on patients with type 2 diabetes mellitus and high-risk cardiovascular risk, and, to some extent, increase the risk of genital infection and diabetic ketoacidosis.