Volume 13 · Issue 09 · 2021

Gestational hyperglycemia, including gestational diabetes, gestational dominant diabetes and pre-pregnancy diabetes, can bring many adverse effects on maternal and infant perinatal and long-term health. This article reviews the research situation of comprehensive blood glucose management during pregnancy in recent years, and emphasizes the advantages, limitations and future prospects of new technologies and methods of blood glucose management (such as continuous glucose monitoring, continuous subcutaneous insulin infusion, artificial pancreas, team medical model based on Internet platform, etc.) in blood glucose management during pregnancy.

Mitochondrial diabetes is diabetes caused by defects in mitochondrial function, which belongs to a special type of diabetes, accounting for about 3% of the total number of diabetics. Due to the characteristics of large clinical phenotype heterogeneity, atypical symptoms and relatively rare, mitochondrial diabetes is often missed or misdiagnosed as other subtypes of diabetes. The clinical treatment and follow-up of mitochondrial diabetes is different from other subtypes of diabetes, so early diagnosis of this subtype of diabetes will help patients to follow-up treatment and improve clinical outcomes. This expert consensus summarizes the research results and clinical examination and diagnosis strategies of mitochondrial diabetes at home and abroad, and puts forward suggestions for clinical examination and diagnosis of mitochondrial diabetes.

To explore the effects of gestational diabetes mellitus (GDM) on the perinatal outcomes in twin pregnancies, and analyze the risk factors of twin pregnancies complicated with GDM.

Retrospective analysis was performed on 757 patients of twin pregnancies who had delivered in the Third Affiliated Hospital of Sun Yat-sen University during January 2015 to June 2020. According to the results of 75 g oral glucose tolerance test (OGTT), 196 cases were in the GDM group, and 561 cases were inthe non-GDM group. The clinical characteristics of the subjects were recorded, the perinatal outcomes of the two groups were compared by using t test, Mann-Whitney U test, χ² test or Fisher exact probability method;the risk factors related to GDM were analyzed by multivariate-logistic stepwise regression.

Compared with the non-GDM group, 75 g OGTT-fasting plasma glucose (FPG), 1 h plasma glucose (PG), 2 h PG in GDM group were higher, gestational weeks and birth weight of newborn in GDM group were lower, the rate of preterm birth(<37 weeks) was higher. The incidence of neonatal respiratory distress syndrome, infection and anemia in the GDM group was higher than that in the non-GDM group (allP<0.05). There were statistically significant differences in age, pre-pregnancy body mess index (pre-BMI), gravidity, parity, proportion of in vitro fertilization and embryo transfer (IVF-ET), chorionicity, polycystic ovary syndrome (PCOS) history and family history of diabetes (allP<0.05). Risk factors were analyzed by multivariate-logistic stepwise regression, age ≥35 years (OR=2.335), pre-BMI ≥24.0 kg/m² (OR=2.356), PCOS history (OR=1.932) and family history of diabetes (OR=3.127) were independent risk factors for GDM in twin pregnancies (all P<0.05).

GDM increased the incidence of preterm birth less than 37 weeks, neonatal respiratory distress syndrome, infection and anemia in twin pregnancies. Age ≥35 years, pre-BMI ≥24.0 kg/m², PCOS history and family history of diabetes were independent risk factors for GDM in twin pregnancies.

The purpose of this study is to establish a predictive model for macrosomia in different pre-pregnancy body mass index (BMI) groups. It also explores the values of this prediction model based on the metabolic markers in the second trimester of pregnancy.

The current study is a single-center, large-sample retrospective study. One thousand seven hundred and eighty-one pregnant women in Peking Union Medical College Hospital (PUMCH) during the 24th to 28th week of pregnancy were screened from September 2016 to December 2018. Subjects with pre-gestational diabetes, hypertension, thyroid dysfunction, renal or liver disease and twin pregnancies were excluded. Eventually 1 114 subjects were divided into two groups according to pre-pregnancy BMI: normal weight group (pre-pregnancy BMI<24.0 kg/m², n=940) and overweight/obese group (pre-pregnancy BMI ≥24.0 kg/m², n=174). Clinical data were collected, including general information, glucose-lipid metabolic parameters, and pregnancy outcomes. Univariate logistic regression analysis was conducted to reveal the potential prenatal risk factors for macrosomia. Stepwise logistic regression was conducted to establish prediction models of macrosomia. The receiver operating characteristic (ROC) curve was used to calculate cut-off points and assess the predictive ability of the models. Mediation analysis was conducted using PROCESS Macro version 3.4.

Compared with the normal weight group, overweight/obese group has increased the incidence of macrosomia (OR: 2.72,95%CI: 1.75-4.23). Confounding variables include age, family history of diabetes and pregnancy loss history. After adjusting confounders, the fasting glucose (FPG), 1 h post-prandial glucose levels (1hPBG), gestational diabetes mellitus (GDM), triglycerides (TG), apolipoprotein B (ApoB), and gestational weigh gain (GWG) were associated with increased risk for macrosomia. In contrast, high-density lipoprotein cholesterol (HDL-C) was associated with decreased risk for macrosomia (all P<0.05). Stepwise logistic regression was conducted to establish the prediction models of macrosomia. Serum ApoB level, TG/HDL-C ratio and GWG were independent predictors of macrosomia in the normal weight group (n=940). Only the combination of ApoB and TG/HDL-C has predictive value in the overweight/obese group. In the normal weight group, the area under the ROC curve (AUC) reached 0.841 with a sensitivity of 82.3% and specificity of 75.2%. In the overweight/obese group, the AUC reached 0.727 with a sensitivity of 50.0% and specificity of 97.3%. The TG/HDL-C ratio plays a mediating role in the relationship between glucose metabolism and the occurrence of macrosomia.

The prediction model combined with ApoB, TG/HDL-C ratio and GWG is a useful tool with good discrimination for macrosomia risk in the second trimester of pregnancy. Maternal lipid profile rather than glucose is an independent predictor of macrosomia, especially in pre-pregnancy normal weight women.

To analyze the dietary patterns of pregnant women during pregnancy and their associations with gestational diabetes mellitus (GDM).

A cohort of 1 008 pregnant women from Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University were recruited at their first routine antenatal care from October 2018 to March 2019. Participants′ data about their demographic and lifestyle characteristics, dietary intake, physical activity, and oral glucose tolerance test (OGTT) results were collected in this study. Dietary patterns were identified using a principal component analysis. The logistic regression models were used to evaluate the association between dietary pattern scores and GDM. Multivariate linear regression models were performed to assess the association between each dietary pattern and maternal blood glucose levels.

The occurrence of GDM was 9.8% (99/1 008). Five dietary patterns were extracted: vegetables-fruit-tubers, fungi-algae-beans, fish-shrimps-crab-shellfish, refined grains-red meat-organs, and confectionery-sugary beverages dietary pattern. Higher fish-shrimps scores were associated with an increased risk of GDM (odds ratio for highest quartile vs. lowest quartile: 2.64; 95% confidence interval: 1.17-5.94; P_trend=0.012) and higher OGTT 1 h and 2 h plasma glucose levels (β=0.21, P=0.001; β=0.12, P=0.007). We further analyzed the role of macronutrients in the relationship between fish-shrimps patterns with GDM and glucose levels. The results showed that the association of the fish-shrimps-crab-shellfish score with GDM risk for comparisons of highest with lowest quartiles was no longer significant after additional adjustment for percentage of energy supply from protein or carbohydrate, or ratio of protein to carbohydrate. The association between fish-shrimps-crab-shellfish score and OGTT 1 h and 2 h plasma glucose levels disappeared after further adjusted for percentage of energy from carbohydrate, or ratio of protein to carbohydrate.

In this study, the fish-shrimp, crab and shellfish dietary pattern is characterized by high protein and low carbohydrate intake, which may increase the prevalence of GDM. In this pattern, the macronutrients energy supply ratio plays a crucial role in the results of OGTT.

To investigate the occurrence of honeymoon period and its influence on long-term islet function in type 1 diabetes mellitus (T1DM) with different onset ages.

A retrospective analysis was performed on 305 newly diagnosed T1DM patients who were regularly followed up in the T1DM General Management Clinic of the Second Xiangya Hospital of Central South University from May 2010 to October 2018. According to the age of onset, patients were divided into the child-onset group (1 to 11 years old, 118 cases), adolescent-onset group (12 to 18 years old, 71 cases), or adult-onset group(>18 years old, 116 cases). Clinical data and indicators collected during baseline and follow-up of T1DM patients were analyzed. The starting and ending time of the honeymoon period was determined according to the C-peptide level>300 pmol/L or the insulin dose-adjusted glycosylated hemoglobin ≤9 at any point during every 3 months of follow-up. Those who did not meet these criteria within 12 months of onset were defined as having no honeymoon. The duration of the honeymoon period was compared by Kaplan-Meier and Log-rank methods for survival analysis. The follow-up C-peptide data repeated measurements within 4 years of the onset of disease were analyzed by generalized estimation equation.

In the all T1DM patients (n=305), 202 had honeymoon, and the incidence rate of honeymoon was 66.2%. The occurrence of honeymoon decreased gradually in the adolescent-onset group, child-onset group, and adult-onset group, which were 87.3% (62/71), 61.0% (72/118), and 58.6% (68/116), respectively, with statistical significance (P<0.05). However, there was no statistical significance in the incidence of child-onset group compared with adult-onset group (P=0.709). The duration of honeymoon was 7.1(5.1, 13.2), 13.6 (7.3, 23.4) and 10.3 (6.5, 16.9) months in the child-onset group, adolescent-onset group and adult-onset group, respectively (P<0.05). The C-peptide analysis in the follow-up period of 4 years showed that, among the patients without honeymoon, the 2-hour C-peptide in the adult-onset group was lower than that in the child-onset group (P=0.029), and there was no significant difference in fasting C-peptide between the two groups; while in patients who experienced honeymoon, the fasting and 2-hour C-peptide in the adult-onset group were significantly higher than those in the child-onset group (P=0.018 and 0.002, respectively).

Compared with children and adult-onset type 1 diabetes patients, adolescent-onset patients have a higher proportion of honeymoon, and child-onset patients have a shorter honeymoon duration. Honeymoon occurrence is a favorable factor for adult-onset patients to preserve islet function.

To evaluate the association between the indicators of thyroid function, sensitivity to thyroid hormones and risk of diabetes in euthyroid population.

In this cross-sectional study, 4 586 euthyroid subjects who had complete baseline data from the health check-up programs in the First Hospital of China Medical University between January 2017 and December 2018 were enrolled. Relevant clinical data including thyrotropin (TSH), free triiodothyronine (FT₃), free thyroxine (FT₄), blood lipid profiles, fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA_1c) were collected. Thyroid feedback quantile based index (TFQI) and FT₃/FT₄ ratio, which reflected the central and peripheral sensitivity to thyroid hormones respectively, were calculated. Spearman correlation analysis between thyroid parameters and indicators of glucose metabolism was performed. To further exclude the interference of cofounding factors, logistic regression analysis was used to evaluate the association between thyroid parameters and the risk of diabetes.

Among 4 586 subjects enrolled in this study, 546 (11.9%) were diagnosed with diabetes. The level of fasting blood glucose was positively associated with the level of FT₃ (r=0.049, P=0.001), FT₄ (r=0.041, P=0.005) and TFQI (r=0.041, P=0.006), while negatively associated with the level of TSH (r=-0.058, P<0.01). HbA_1c was negatively associated with FT₄ (r=-0.032, P=0.032), TSH (r=-0.032, P=0.029) and TFQI (r=-0.032, P=0.032). However, multivariate logistic regression analysis adjusting for confounding factors such as age, sex and BMI, showed that the risk of diabetes was negatively associated with the level of FT₃ (OR=0.57, 95%CI 0.46 to 0.70) and FT₃/FT₄ (OR=0.78, 95%CI 0.70 to 0.86), while was not significantly associated with the level of TSH, FT₄ and TFQI.

Increased levels of FT₃ and FT₃/FT₄ (indicators of peripheral sensitivity to thyroid hormones) were associated with lower risk of diabetes in euthyroid population.

To investigate the influencing factors of mixed infection of two or more multidrug-resistant bacteria (MDRO) in elderly patients with diabetic foot ulcers (DFU).

The elderly patients with DFU in Third Affiliated Hospital of Guizhou Medical University and Qiannan People′s Hospital from February 2011 to December 2020 were recruited. The clinical data of the patients, the results of pathogen culture and strain identification of wound secretion, and two or more types of MDRO mixed infection were recorded. According to the number of MDRO species detected in wound secretion, they were divided into two or more MDRO infection group single MDRO infection group and non MDRO infection group, then χ² test, one-way analysis of variance (ANOVA) or Kruskal Wallis H test was used for comparisons among the three groups. Multivariate logistic regression analysis was performed on the related factors of mixed infection of two or more MDRO in eldly patients with DFU.

Total 945 elderly patients with DFU were included in the study. In 945 elderly patients with DFU, the mixed infection rate of two or more MDRO was 11.01% (104/945). There were 652, 189 and 104 patients in non MDRO infection group, single MDRO infection group and two or more MDRO infection group, respectively. There were statistically significant differences in combined osteomyelitis, number of hospitalization, length of stay, admission to intensive care unit (ICU) time, blood sugar, glycosylated hemoglobin, the number of combined antibiotics, replacement of antibiotics, number of dressing change, diabetic chronic kidney disease (CKD), peripheral artery disease (PAD), diabetic peripheral neuropathy (DPN) among the three groups (P<0.05). The independent risk factors of two or more MDRO mixed infection in elderly DFU patients were the number of antibiotics changed, glycosylated hemoglobin, combined antibiotics, ICU stay, PAD and DPN. The times of dressing change and surgical focus clearance were independent protective factors for two or more MDRO mixed infections in elderly patients with DFU.

Controlling the occurrence of PAD and DPN, reducing ICU stay time, continuous control of blood glucose, avoiding frequent change of antibiotics, strengthening dressing change, and timely removal of lesions can reduce the risk of two or more MDRO mixed infection in elderly DFU patients.

To investigate the relationship between visceral fat area and hepatic steatosis and fibrosis measured by transient elastography examination in patients with type 2 diabetes mellitus.

T2DM patients who were hospitalized in Third Affiliated Hospital of Southern Medical University from July 2018 to December 2019 were enrolled. Clinical data recorded by the National Metabolic Management Center such as duration of diabetes, body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), glutamic pyruvic transaminase (ALT), glutamic oxaloacetic transaminase (AST), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), γ-glutamyltransferase (GGT), updated homeostasis model assessment of insulin resistance (HOMA2-IR), updated homeostasis model assessment of β-cell function (HOMA2-%B) and so on, were collected. Hepatic steatosis was diagnosed when controlled attenuation parameter(CAP)≥240 dB/m. Liver fibrosis diagnosis was made when liver stiffness measurement(LSM) ≥7.3 kPa. All patients were divided into hepatic steatosis group, liver fibrosis group and control group according to the criterion. T test or Mann-Whitney U test was used to detect whether the differences between the two groups were statistically significant. Multivariate logistic correlation analysis was used to explore the risk factors associated with hepatic steatosis and liver fibrosis.

Among 400 patients enrolled, 295 (73.8%) patients were diagnosed as hepatic steatosis, while 255 (63.8%) patients were diagnosed as liver fibrosis. BMI, VFA, SFA, ALT, AST, TG, GGT, HOMA2-%B, HOMA2-IR in patients with hepatic steatosis and liver fibrosis were significantly higher than those in control group, whereas HDL-C was significantly lower in patients with hepatic steatosis and liver fibrosis group (P<0.05). We observed that the VFA was positively correlated with CAP and LSM in T2DM patients (r=0.700, 0.345, both P<0.01). After adjusting the SFA, HOMA2-IR and other confounding factors, We observed that high VFA and high BMI were independent risk factors of hepatic steatosis among T2DM patients (P<0.05). High VFA, high AST, low HDL-C and long duration of diabetes were independent risk factors of liver fibrosis among T2DM patient. (P<0.05).

In T2DM patients, VFA is obviously related to CAP and LSM, and the increased VFA may elevate the risk of hepatic steatosis and liver fibrosis.

To investigate the incidence of insulin injection-related subcutaneous fat hyperplasia (LH) in patients with type 1 diabetes mellitus (T1DM) and to analyze its relationship with multidimensional self-management.

139 patients with T1DM who had continuous insulin injection for ≥6 months from July 2017 to August 2020 in the Department of Endocrinology, inpatient and participated in educational activities such as summer camps and winter camps in the First Affiliated Hospital of Nanjing Medical University were selected by convenient sampling method. LH was screened by high-frequency ultrasound, and questionnaire survey was conducted by insulin injection-related self-management behavior rating scale (DBRS). Pearson correlation analysis was used to analyze the correlation between each dimension of self-management behavior and LH in patients with T1DM, and binary logistic regression analysis was used to explore the influencing factors of LH in patients.

LH was found in 111 (79.9%) of 139 patients. The results of Pearson correlation analysis showed that the total score of insulin injection-related diabetes behavior and the four dimensional scores of self-management behavior adjustment, blood glucose monitoring and control, daily basic management and insulin injection management in T1DM patients were negatively correlated with the occurrence of LH (rThe values were-0.681, -0.546, -0.473, -0.580, -0.616, allP<0.01）。 The results of binary logistic regression analysis showed that the dimension of self-behavior adjustment (OR =0.116, 95% CI 0.034~0.163), the dimension of blood glucose monitoring and control (OR 0.096, 95% CI 0.026~0.122), and the dimension of insulin injection management (OR 0.324, 95% CI 0.004~0.852) in DBRS were the influencing factors of LH occurrence in patients.

The incidence of LH in T1DM patients is high, and its occurrence is related to multi-dimensional self-management behavior. While focusing on improving patients' insulin injection technology, promoting the overall improvement of patients' insulin injection self-management behavior is an important guarantee for effective prevention of LH.

The disease of diabetic foot develops rapidly, and the rate of disability and mortality is high. The treatment of diabetic foot needs timely multidisciplinary comprehensive treatment and referral. At present, the referral process in China is cumbersome, the allocation of medical resources is unbalanced and all are carried out offline. At the same time, because most patients with foot ulcers are accompanied by mobility inconvenience, these reasons lead to the inability of diabetic foot patients to get standardized diagnosis and treatment in time, and even cause serious consequences due to delayed diagnosis and treatment. The emergence and development of medical consortia has provided a green channel for patients' referral, and the development of artificial intelligence and smart medical care has further promoted the development of medicine. Driven by social and clinical needs and policies, based on artificial intelligence technology, we have built a "palm foot benefit" intelligent diagnosis and treatment platform integrating diabetic foot grading assessment, comprehensive consultation and standardized treatment, and realized the promotion and application in the medical consortium. Now, the intelligent platform is introduced, in order to provide some theoretical support and experience for the construction of intelligent medical care.

A 55-year-old family with permanent neonatal diabetes mellitus (PNDM) caused by heterozygous mutation of insulin gene (INS) was reported. The proband was admitted to hospital with the main complaint of "blood glucose increase was found for 54 years, nausea and vomiting for 5 days", and the diagnosis of PNDM was proposed based on clinical data and family history. The peripheral blood of the proband and his son was collected for whole-exon high-throughput second-generation sequencing, and the heterozygous mutation of the INS gene c.G287A (p.C96Y) was detected in the exon region of the proband and his son. The proband was given intensive insulin therapy, and the blood sugar control was more stable than before. In this paper, the clinical characteristics, diagnosis and treatment points were discussed in combination with the literature, aiming to improve the clinical understanding of PNDM patients caused by INS gene mutation.

Rabson-Mendenhall syndrome (RMS) and Donohue syndrome (DS) are both insulin resistance-related diseases caused by insulin receptor gene mutations. This paper reports a case of a female child with 2 months onset of disease. The disease was initially diagnosed as neonatal diabetes, with ketoacidosis, hyperinsulinemia, intrauterine growth retardation, growth retardation, postprandial hyperglycemia and persistent hyperinsulinemia during follow-up. Genetic tests showed that the compound heterozygous mutation of insulin receptor (INSR) gene: c.31-54del/p.Ala10-Ala17del/c.3529+5G>T. This child is a rare case of insulin resistance caused by INSR gene mutation in neonatal diabetes. However, the cross-over phenotype of RMS and DS is difficult to distinguish, and its long-term prognosis needs further follow-up observation.

The pathophysiological mechanism of type 2 diabetes mellitus (T2DM) is complex. The combination therapy of basal insulin and glucagon-like peptide-1 (GLP-1) receptor agonist can target the multiple pathophysiological defects of T2DM, achieve complementary hypoglycemic mechanism and better exert hypoglycemic effect. IDegLira is a fixed ratio combination of a long-acting basal insulin analogue and a GLP-1 receptor agonist. The results of multiple clinical studies have shown that IDegLira is a safe and effective hypoglycemic treatment regimen. The author reviewed the progress of the compound preparation in clinical treatment from the aspects of complementary mechanism, efficacy and safety.

In recent years, the incidence of non-alcoholic fatty liver disease (NAFLD) has shown an obvious upward trend. Because it is closely related to diabetes, obesity, metabolic syndrome, etc., recently scholars have suggested that it be named metabolic-related fatty liver disease, but its pathogenesis has not been fully elucidated. Previous studies have shown that NAFLD is the result of a combination of genetic, environmental and dietary factors, and the pathological mechanisms related to its occurrence and development mainly include insulin resistance, abnormal lipid metabolism, oxidative stress, inflammation and intestinal flora imbalance. In addition, the development of amino acidomics technology provides ideas for the study of mechanisms of various metabolic diseases. Therefore, this paper intends to explore the research progress of NAFLD-related mechanisms from the amino acid level, in order to provide accurate guidance for the clinical intervention of NAFLD.