Volume 05 · Issue 10 · 2013

Under the background of rapid economic development in China, the prevalence of diabetes is also increasing rapidly at an alarming rate. In 1980, the first epidemiological survey of 300,000 people in 14 provinces and cities was conducted in China. The data showed that the prevalence of diabetes in the whole population was 0.67% (the prevalence of adults was 1.0%)^[1]。 From 2007 to 2008, the Diabetology Branch of Chinese Medical Association (CDS) organized an epidemiological survey of diabetes mellitus in 14 provinces and cities in China, which showed that the prevalence of diabetes mellitus among adults over 20 years old in China was 9.7%^[2]。 In 2010, the National Center for Disease Control and the Endocrinology Branch of the Chinese Medical Association investigated the prevalence of diabetes in people over 18 years old. If the diagnostic criteria of WHO in 1999 were applied, the prevalence of diabetes was still 9.7%, while glycosylated hemoglobin (HbA1c) ≥6.5% was also used as a diagnostic criteria, reaching 11.6%^[3]。 The latter two data confirm that China may have become the country with the largest number of diabetes patients in the world. Therefore, the situation of diabetes prevention and treatment in China is unprecedentedly severe!

In recent years, the development of evidence-based medicine has confirmed that diabetes is a chronic disease that can be prevented and cured. Integrated prevention and treatment strategies with comprehensive prevention and treatment of cardiovascular risk factors as the main body can delay and prevent chronic complications of diabetes, improve prognosis and reduce medical expenses. Global diabetes prevention and treatment organizations such as the American Diabetes Society (ADA) and the European Diabetes Research Society (EASD) also recommend these effective prevention and treatment measures for clinical practice in the form of guidelines. Unfortunately, there is a big gap between clinical diagnosis and treatment practice and the requirements of the guidelines, and about 45% of patients fail to accept the diagnosis and treatment measures recommended by the guidelines. How to promote the measures recommended in the guidelines to be transformed into clinical diagnosis and treatment behavior has become an important matter to improve the level of diabetes prevention and treatment in China.

According to the report on the development of China's aging cause (2013) released recently by the Chinese Academy of Social Sciences, China's elderly population aged 60 and above is 193.9 million, accounting for 14.3% of the total population, of which 127.14 million are aged 65 and above, accounting for 9.4% of the total population. The results of the survey in China from 2007 to 2008 show that the prevalence of type 2 diabetes in the elderly (≥60 years old) is 20.4%^[1]。 Therefore, the management of diabetes in the elderly is one of the keys to control diabetes.

The 7th International Congress on Diabetes in Pregnancy was held in Italy in March 2013. The topics of the conference covered hyperglycemia control during pregnancy, diagnostic criteria, gestational diabetes mellitus (GDM) and obesity, insulin analogues, future GDM research trends and prospects, etc. The author was invited to give two special reports on the incidence and diagnostic criteria of GDM in China. The focus of the report and the main issues of the meeting are summarized as follows.

On the morning of June 24, 2013, Dr. Jens C. Brüning, Director of the Center for Endocrine and Diabetes Preventive Medicine and Director of the Max Planck Institute of Neurology, University Hospital Cologne, Germany, was honored with the "Outstanding Scientific Achievement Award" at the 73rd ADA Annual Conference at the MoCormick Place International Convention and Exhibition Center in Chicago, USA. His award-winning speech, entitled "Insulin Effects Beyond Classical Targets", discussed in detail how insulin and nutritional signals act on nerve cells and affect the important mechanisms of body's metabolism; To elucidate the role of intracerebral neural circuits and signal transduction in the development of obesity diabetes, including the involvement of inflammatory and stress signaling pathways. Dr. Brüning's basic research lasted for more than ten years. With the help of Cre recombinase/LoxP technology platform, the insulin receptor gene was specifically inactivated, and an animal model of insulin knockout by brain neurons was established. It has been proved by research that even with normal muscle, fat and liver insulin signaling, if the brain tissue-specific insulin action is lacking, weight gain and glucose metabolism will be impaired. Exquisite experiments, simple explanations, and rigorous inferences have uncovered the "layers of veils" of the central nervous system (CNS) behind the blood-brain barrier; Explore the "mysterious kingdom" of the hypothalamus, midbrain and other regions. What is presented to more than 10,000 diabetologists from around the world is seemingly familiar but relatively unfamiliar content: the target, molecular mechanism and biological effect of insulin in the brain. The main content of the speech is now introduced as follows.

To survey the characteristics of diabetes education of patients with type 2 diabetes mellitus in China and investigate the relationship between diabetes education and disease management and self-care activities of the patients.

General questionnaire and the summary of diabetes self-care activities (SDSCA) scale were adopted from April to July in 2010 in this multi-center, cross-section survey, to interview 5200 patients with type 2 diabetes mellitus from 50 medical centers. Based on the questionnaire, patients were divided into 4 groups: uneducated (971 cases), been educated in 1-2 respects (532 cases), been educated in 3-4 respects (1001 cases), been educated in 5-6 respects (2696 cases). Data of up-mentioned 4 groups were compared by analysis of variance.

Age (F=7.75, P<0.05), duration of diabetes (F=32.86, P<0.05) and incidence rate of several complications were significant different among the 4 groups. Percentages of individuals who reached the recommended level of fasting plasma glucose(FPG), two-hour postprandial plasma glucose (2 h PG) and glycated hemoglobin A1c(HbA1c) were significantly different among the 4 groups. Compared with those in the uneducated individuals, higher percentage of individuals been educated for 5-6 respects achieved the targets of FPG≤7.0 mmol/L (47.62% vs 36.81%, χ²=30.05, P<0.05), 2 h PG≤10.0 mmol/L (49.03% vs 37.76%, χ²=29.40, P<0.05) and HbA1c<7% (34.94% vs 26.65%, χ²=11.82, P<0.05). Mean scores of self-care behaviors were significantly different among the 4 groups. Individuals been educated for 5-6 respects suggested higher mean scores in diet management (4.5± 1.5 vs 3.6 ± 1.7,t=0.818, P<0.05), physical exercise (4.5± 2.5 vs 3.4±2.6,t=1.082, P<0.05), self glucose monitoring (3.2±2.6 vs 2.5±2.7,t=0.672, P<0.05), foot care (4.8±1.8 vs 3.7± 1.8,t=1.033, P<0.05) and medications (6.3± 1.5 vs 5.8±2.0,t=0.556, P<0.05) than those in uneducated individuals.

Only a few patients in China had accepted comprehensive diabetes education. Both diabetes education and its comprehensiveness might contribute to better glycemic control and self-care behaviors of patients with type 2 diabetes mellitus.

To evaluate the effects of comprehensive dietary interventions on diabetes in community populations.

Two communities in Drum-tower District of Fuzhou were randomly selected as the intervention community (Antai community) and control community(Wenquan community) respectively. Comprehensive dietary interventions were provided to the intervention community from October 2009 to October 2011, while no interventions to the control community. Two years after interventions, 30 groups with 100 families each were randomly selected according to the actual household distributions in the two communities. A total of 3702 and 3666 people in the intervention community and the control community were investigated with questionnaires on their food frequency. Physical examination (including height, weight, blood sugar, blood pressure, etc) was also conducted. There were 980, 2070 and 652 peoples in the general population, high-risk population and the diabetic population, respectively, in the intervention community; and 898, 2016 and 692 people in the 3 populations in the control community. Data were analyzed with Chi-square test on the rate check and t test on the means comparison.

There was a significant difference in archiving rate between the two communities (76.7% and 71.2% for intervention and control community respectively, χ ²=294.69, P<0.01). Compared with the control community, fasting blood glucose of the 3 populations were significant decreased; so were the body mass index and systolic blood pressure of the high-risk or the diabetic population, and the diastolic blood pressure of the high-risk population in the intervention community(t=4.289, 11.847, 8.517, 4.946, 7.838, 8.176, 12.931, 8.315, all P<0.01). In contrast to the control community, the intakes of protein and fat of the general population significantly increased(t=12.72, 11.40, both P<0.01), while carbohydrate intake decreased(t=4.11, P<0.01); protein intake increased in the high-risk population(t=9.45, P<0.01), while the intakes of carbohydrate and fat decreased(t=14.32, 7.44, P<0.01); the intakes of protein and fat of the diabetic population decreased (t=5.98, 15.22, both P<0.01) in the intervention community. In comparison with the control community, the intakes of beans, fruits, dairy and eggs significantly increased in the general population(t=6.778, 9.035, 4.718, 14.223, all P<0.01); the intakes of beans, vegetables, fruits, dairy and eggs increased while the intake of staple food, meat and oil decreased in the high-risk people(t=5.358, 2.827, 9.627, 21.346, 3.351, 12.970, 19.342, 3.241, all P<0.01); the intake of dairy and eggs increased while that of meat, aquatic products, oil, snacks and sugary drinks decreased in the diabetic patient of the intervention community(t=8.376, 2.702, 4.155, 3.121, 8.494, 6.702, 10.854, all P<0.01) in the intervention community.

Dietary intervention could effectively improve components of diet and nutrition, consequently benefit health situation related to diabetes, especially to the diabetic patients and the high-risk population. However, unreasonable diet model still remained in some subjects of the intervention community. It's indicated that the dietary intervention should be continued and more measure is in need to decrease the intake of beans and oil, and increase fibrin and dairy intake.

To study the characteristic of the molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE) isolated from diabetic foot ulcers.

Total of 24 MRSA and 18 MRSE strains were isolated from 388 diabetic-foot patients hospitalized from January 2008 to June 2010 in the Tianjin Metabolic Diseases Hospital. Pulsed-field gel electrophoresis (PFGE) was used to analyze the homology of the isolates.

The similarities of MRSA was 42%-97%. The MRSA isolates were classified into 11 PFGE types (A-K), 12 were type A (11 of them were isolated from January to May in 2008), 2 strains were type B, 2 strains were type C and the other 8 types only found in one strain. The similarities of MRSE was 34%-100% and 14 PFGE types (A-N) were identified. Among MRSE strains, 5 were type A (including 3 type A1, 1 type A2, 1 type A3), and the other 13 types found only in one strain.

An outbreak of type A MRSA probably happened from January to May in 2008. No outbreak evidences have been identified from June 2008 to June 2010. Sporadic MRSE was found from January 2008 to June 2010 and no outbreak occurred.

To investigate the effects of polychlorinated biphenyl (PCB)118 on the insulin sensitivity in rats.

Forty male Wistar rats were randomly divided into 4 groups: solvent control group, low dose, medium dose, high dose group (PCB118 0, 10, 100, 1000 μg·kg ^-1·d^-1), respectively, with PCB118 intraperitoneally for five consecutive days per week. After 13 weeks, an intraperitoneal glucose tolerance test (IPGTT) was performed, and the ratio of increment insulin to glucose concentration at 30 min after the glucose loaded (ΔI₃₀/ΔG₃₀), area under the curve (AUC) of glucose (AUCg), AUC of insulin (AUCi), AUCi/AUCg and homeostasis model assessment of insulin resistance (HOMA-IR) were calculated. One-way analysis of variance (ANOVA) was used for data analysis.

Compared with the controls, fasting insulin levels and insulin and blood glucose levels at IPGTT 30 min were significantly increased in all the PCB118-treated groups (fasting insulin levels: (19.0±7.1), (18.5±3.1), (22.1±1.2) vs (10.0±3.6) mU/L; insulin levels at IPGTT 30 min: (55.0±1.9), (55.0±2.4), (72.3±1.0) vs (25.7±1.3) mU/L; blood glucose levels at IPGTT 30 min: (22.3±2.4), (19.87±1.89), (21.90±2.88) vs (17.08±1.35) mmol/L, F values were 3.622, 8.798 and 7.024, respectively, all P<0.05). Insulin levels at IPGTT 60 min and 120 min were significantly increased only in high dose group (60 min: (46.2±1.2) vs (18.1±1.1) mU/L,t=3.287, P<0.05; 120 min: (39.5±1.3) vs (24.5±9.4) mU/L,t=2.435, P<0.05). ΔI₃₀/ΔG_30,AUCi and AUCi/AUCg were dramatically increased in all the PCB118-treated groups (F values were 15.548, 7.130 and 5.509, respectively, all P<0.05). HOMA-IR were also dramatically increased in all the PCB118-treated groups (1.26±0.42, 1.35±0.22, 1.52±0.47 vs 0.65±0.37,F=6.937, P<0.05). However, these indicators showed no significant difference among the PCB118-treated groups (P>0.05).

Continuous exposure to a low dose of PCB118 could reduce insulin sensitivity in rats.

To investigate the expression of phosphatidylinositol-3-kinase (PI3K), serine/threonine-protein kinase 2(Akt2) and nuclear transcription factor- κB (NF-κB) in skeletal muscle of ovariectomized diabetic rats.

Twenty-nine female Wistar rats were randomly divided into 3 groups: control group (NS group, n=9), diabetic group (DS group, n=10) and diabetic ovariectomized group (DOVX group, n=10). Rats in NS group were fed with a normal diet, while rats in DS and DOVX groups were fed with a high-carbohydrate/fat diet for 8 weeks and then were given an intraperitoneal injection of streptozotocin (STZ, 30 mg/kg). One week later, rats in DOVX group underwent ovariectomy, while rats in NS and DS groups were subjected to a sham operation, which was similar to ovariectomy except that only a small portion of abdominal fat was removed. Before and after ovariectomy, rats in each group were weighed, and fasting blood glucose, fasting plasma insulin were measured. At 12 weeks after the ovariectomy, the expression of PI3K, Akt2 and NF-κB in skeletal muscle of the rats was measured by immunohistochemistry and RT-PCR.

(1) The mRNA levels of PI3K (0.797±0.043) and Akt2 (0.753±0.076) in DS group were lower than the mRNA levels of PI3K (0.870±0.051) and Akt2 (0.844±0.013) in NS group (t=2.722, 3.368, respectively, both P<0.05), but higher than DOVX group (0.715±0.068, 0.666±0.038, andt=2.686, 2.526, respectively, both P<0.05). (2) The mRNA level of NF-κB in rats of DS group (0.577±0.097) was higher than that in NS group (0.433±0.112,t=-3.147, P<0.05), but less than that in DOVX group (0.696±0.090,t=-2.862, P<0.05). (3) The levels of PI3K protein (4.3±0.6) and Akt2 protein (3.4±0.7) in DS group were lower than the levels of PI3K protein (5.2±0.4) and Akt2 protein (4.7±0.7) in NS rats (t= 2.654, 3.488, respectively, both P<0.05), but lower than those in DOVX group (3.5±0.6, 2.8±0.5,t=3.473, 2.365, both P<0.05). (4) The level of NF-κB protein in DS group (6.5±0.9) was higher than that in NS group (4.9±0.8,t=-3.396, P<0.05), but lower than that in DOVX group (8.1±0.8,t=-2.954, P<0.05).

The expression of PI3K and Akt2 is decreased and the expression of NF-κB is increased in skeletal muscle of ovariectomized diabetic rats, which might lead to insulin resistance.

To study the effect of S6K1 silencing to hepatic inflammatory cytokines factors expression and explore the mechanism of S6K1 in the hepatic insulin resistance.

Forty eight male C57BL/6J mice (six-week old ) with body weight 12.6 to 14.8 g were randomly divided into four groups by using random number table: normal chow control group(ND+ pU6Ax), normal chow study group(ND+ S6K1Ax), high fat diet control group (HFD+ pU6Ax) and high fat diet study group(HFD+ S6K1Ax). For the depletion of S6K1 in the liver, C57BL/6J male mice by high fat diet and normal chow feeding for16 weeks were injected via the tail vein with S6K1shRNA recombinant adenovirus (S6K1Ax), U6 promoter recombinant adenovirus(pU6Ax) were injected into the control mice. Six days after virus injection, mice were killed and livers were obtained. Hepatic inflammatory cytokines expressions of Monocyte chemotactic protein 1(MCP-1), Tumor Necrosis Factor-α (TNF-α), Interleukin-1β(IL-1β), Interleukin-6(IL-6), Interleukin-10(IL-10) mRNA were examined by reverse transcription polymerase chain reaction, Hepatic protein expressions of S6K1, S6K1-thr389, IRS1-ser1101, IRS1-ser636/639, Akt-ser473, JNK-thr183/tyr185 were detected by western blotting.

Comparing with the high fat diet control group, inflammatory factors of MCP-1, TNF-a, IL-1β mRNA in HFD+ S6K1Ax group showed lower expressions after hepatic S6K1 silencing(MCP-1 0.871±0.081 vs 0.549±0.016, TNF-α 0.905±0.059 vs 0.635±0.079, IL-1β 1.327±0.025 vs 0.642±0.042,t=9.55, 6.71, 34.07, all P<0.05). There was no difference in IL-6 mRNA expressions between the two groups(P>0.05). Anti-inflammatory factor of IL-10 mRNA in the HFD+ S6K1Ax group increased after hepatic S6K1 silencing (0.773±0.076 vs 0.436±0.046,t=9.27, P<0.05). Compared with the HFD+ pU6Ax group, the protein expressions of ISR1-ser1101, IRS1-ser636/639, S6K1-thr389, JNK-thr183/tyr185 decreased and protein expression of Akt-ser473 increased in the HFD+ S6K1Ax group by Western blotting detection after hepatic S6K1 silencing(t=6.59, 8.44, 5.37, 3.15, 6.52, all P<0.05).

High fat diet feeding can cause low grade inflammation and medicate insulin resistance in the liver. Hepatic S6K1 maybe participate hepatic insulin resistance by promoting inflammatory cytokines and inhibiting anti-inflammatory cytokine production.

To determine the feasibility of perfusion cannula by continuous douche accompanied with negative pressure drainage applied in patients with diabetic foot complications.

Thirty six patients of Ⅲ grade diabetic foot patients were selected from January 2011 to February 2012, including male 15 and female 21. According to the random number table, 17 cases were divided into the intervention group(aged(63±8) yrs) and 19 cases in the control group(aged (65±6)yrs). The control group received routine dressing after abscess incision. The intervention group received abscess incision drainage and double tube continuous irrigation and suction with negative pressure. When the drainage fluid was clear, the double tubes were removed and changed routine dressing. Wound state of the patients in the two groups were observed and compared. Chi-square test and t test were used for statistical analysis.

Fourteen cases in intervention group were cured, three cases improved, and the curative rate was 82.4% (14/17). Eight cases in control group were cured, eight cases improved, and the curative rate was 42.1%. The difference between the two groups was statistically significant (χ²=6.12, P<0.05). However, three cases in control group had no clear improvement, including two patients were received amputation. The average time of healing was (20±3) d in the intervention group and (29±4) d in the control group with statistically significant difference (t=6.5, P<0.001).

The use of dual cannula continuous douche by negative pressure drainage may improve wound healing, alleviate sufferings, and reduce the amputation rate in patients with diabetic foot wounds grade Ⅲ.

Diabetes mellitus is one of the independent risk factors for atrial fibrillation. The results of a large-scale prospective cohort study show that diabetic patients have an increased risk of developing atrial fibrillation by 1/3 regardless of race and gender, and fasting blood glucose levels are closely related to the development of atrial fibrillation^[1]。 However, the mechanism of atrial fibrillation caused by diabetes is not very clear. Some scholars believe that the activation of protein kinasse C (PKC) in diabetic patients may play an important role in the pathophysiological process of atrial fibrillation^[2]。 This article will review this.

Omega-3 polyunsaturated fatty acids (omega-3 PUFA) are an important component of cell membrane phospholipids, which are involved in regulating membrane-mediated insulin signal transduction, the biological activity of lipase, the synthesis of eicosanoids and other biological activities, and participate in the gene expression that regulates glycolipid metabolism. They are essential fatty acids in human body. Among them, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the most deeply studied. Numerous epidemiological and clinical trials have shown that omega-3 PUFAs have cardiovascular protective effects. The American Heart Association recommends that patients with cardiovascular disease consume deep-sea fish or fish oil capsules supplemented with omega-3 PUFA (1 g/d) to reduce the incidence of cardiovascular events^[1]。

At the 2013 Diabetic Foot Disease Conference, Professor Lipsky of the University of Washington, USA, and Dr. Embil of the Center for Infectious Disease Prevention and Control of the University of Manitoba, Canada respectively presented the 2012 Guidelines for the Diagnosis and Treatment of Diabetic Foot Co-infection of the American Society of Infectious Diseases^[1]And the diagnosis and treatment of osteomyelitis were interpreted and reported. Dr. Joseph from Roxborough Memorial Hospital in the United States explained the diabetic foot complicated with low-grade infection. These reports explain in simple terms and have a good guiding role for the diagnosis and treatment of clinical diabetic foot disease infection. This article will outline the reports of these three scholars.

This article describes the treatment of an elderly diabetic patient with a medical history of 16 years. The patient gradually developed symmetrical severe edema of both lower limbs, accompanied by emaciation, numbness and tingling in the limbs. Previous history of hypertension, but blood pressure gradually dropped to normal on its own. Cardiac examination and superficial paresthesia of limbs. Laboratory tests revealed positive urine protein, hypoalbuminemia, abnormal ECG. The purpose of this article is to analyze the clinical characteristics of this case, and to analyze and answer the doubts existing in the clinical diagnosis and treatment of this case. Finally, according to the clinical manifestations of patients and the clues in various examinations, we will find the real cause hidden behind diabetes, hoping to have some inspiration for future clinical work. The report is as follows.

Increased plasma concentrations of branched chain amino acids (BCAA) and aromatic amino acids (AAA) in obese, insulin resistant and diabetic patients. Researchers from Germany explored whether these biomarkers were also present in two mouse models of obesity and diabetes.

Macrophages (ATMs) in adipose tissue can engulf the remnants of dead adipocytes in obese individuals, which may lead to increased intracellular neutral lipid content. Obesity-aggravating high-fat macrophages (i.e. foam cells, FCs) are also present in the atherosclerotic process, which contribute to pathophysiological changes in blood vessels.

When obesity occurs, adipocytes increase, and the innate immune cells in adipose tissue become an important source of pro-inflammatory response mediators. Exercise and caloric restriction are known to be two important, non-pharmacological pathways to preventing weight gain. So far, the effects of exercise and caloric restriction on adipose tissue immune cells in obese individuals, particularly on a high-fat diet, have been poorly studied.

Macrophage infiltration into adipose tissue is associated with obesity. Crosstalk and infiltration between adipose cells and macrophages have been proved to be an important pathological phenomenon of adipose tissue inflammation. Japanese researchers investigated the interaction between infiltrating macrophages and adipocytes on the regulation of adipocyte mRNA.

Phase II clinical studies found that the human glucagon-like peptide 1 (GLP-1) analog liraglutide once daily can cause clinically meaningful weight loss in obese individuals without diabetes. In this phase III randomized clinical controlled study, investigators evaluated the effectiveness of liraglutide in maintaining low-calorie diet (LSD) -induced weight loss.