T helper 17 cells and interleukin-17 immunity in type 1 diabetes: From pathophysiology to targeted immunotherapies

Type 1 diabetes (T1D) is a chronic organ-specific autoimmune disorder characterized by a progressive loss of the insulin-secreting pancreatic beta cells, which ultimately results in insulinopenia, hyperglycemia and lifelong need for exogenous insulin therapy. In the pathophysiological landscape of T1D, T helper 17 cells (Th17 cells) and their hallmark cytokine, interleukin (IL)-17, play pivotal roles from disease onset to disease progression. In this narrative mini-review, we discuss the dynamic interplay between Th17 cells and IL-17 in the context of T1D, providing insights into the underlying immunologic mechanisms contributing to the IL-17-immunity-mediated pancreatic beta-cell destruction. Furthermore, we summarized the main animal and clinical studies that investigated Th17- and IL-17-targeted interventions as promising immunotherapies able to alter the natural history of T1D.

Dysfunctional glucose metabolism triggers oxidative stress to induce kidney injury in diabetes

In this editorial, we discussed the article published in the recent issue of the World Journal of Diabetes. To understand the effect of mizagliflozin on kidney injury induced by diabetes, we focused on the mechanisms by which high glucose triggers oxidative stress and contributes to kidney injury in diabetes. The high level of unmetabolized glucose reaching the kidney triggers glucose reabsorption by renal tubules, which elevates the cellular glucose level of renal cells. High glucose induces lactate dehydrogenase overexpression and thus shifts glucose metabolism, which causes mitochondrial dysfunction. Mitochondria generate approximately 90% of the reactive oxygen species in cells, whose dysfunction further alters glucose metabolism and enhances reactive oxygen species generation. Oxidative stress stimulates proinflammatory factor production and kidney inflammatory injury. Mizagliflozin decreases glucose reabsorption and thus ameliorates diabetes-induced kidney injury.

MicroRNA-122-5p is upregulated in diabetic foot ulcers and decelerates the transition from the inflammatory to the proliferative stage

BACKGROUND

Shifting from the inflammatory to the proliferative phase represents a pivotal step during managing diabetic foot ulcers (DFUs); however, existing medical interventions remain insufficient. MicroRNAs (miRs) highlight notable capacity for accelerating the repair process of DFUs. Previous research has demonstrated which miR-122-5p regulates matrix metalloproteinases under diabetic conditions, thereby influencing extracellular matrix dynamics.

AIM

To investigate the impact of miR-122-5p on the transition from the inflammatory to the proliferative stage in DFU.

METHODS

Analysis for miR-122-5p expression in skin tissues from diabetic ulcer patients and mice was analyzed using quantitative real-time polymerase chain reaction (qRT-PCR). A diabetic wound healing model induced by streptozotocin was used, with mice receiving intradermal injections of adeno-associated virus -DJ encoding empty vector or miR-122. Skin tissues were retrieved at 3, 7, and 14 days after injury for gene expression analysis, histology, immunohistochemistry, and network studies. The study explored miR-122-5p’s role in macrophage-fibroblast interactions and its effect on transitioning from inflammation to proliferation in DFU healing.

RESULTS

High-throughput sequencing revealed miR-122-5p as crucial for DFU healing. qRT-PCR showed significant upregulation of miR-122-5p within diabetic skin among DFU individuals and mice. Western blot, along with immunohistochemical and enzyme-linked immunosorbent assay, demonstrating the upregulation of inflammatory mediators (hypoxia inducible factor-1α, matrix metalloproteinase 9, tumor necrosis factor-α) and reduced fibrosis markers (fibronectin 1, α-smooth muscle actin) by targeting vascular endothelial growth factor. Fluorescence in situ hybridization indicated its expression localized to epidermal keratinocytes and fibroblasts in diabetic mice. Immunofluorescence revealed enhanced increased presence of M1 macrophages and reduced M2 polarization, highlighting its role in inflammation. MiR-122-5p elevated inflammatory cytokine levels while suppressing fibrotic activity from fibroblasts exposed to macrophage-derived media, highlighting its pivotal role in regulating DFU healing.

CONCLUSION

MiR-122-5p impedes cutaneous healing of diabetic mice via enhancing inflammation and inhibiting fibrosis, offering insights into miR roles in human skin wound repair.

Hemoglobin glycation index among adults with type 1 diabetes: Association with double diabetes features

BACKGROUND

The hemoglobin glycation index (HGI) represents the discrepancy between the glucose management indicator (GMI) based on mean blood glucose levels and laboratory values of glycated hemoglobin (HbA1c). The HGI is a promising indicator for identifying individuals with excessive glycosylation, facilitating personalized evaluation and prediction of diabetic complications. However, the factors influencing the HGI in patients with type 1 diabetes (T1D) remain unclear. Autoimmune destruction of pancreatic β cells is central in T1D pathogenesis, yet insulin resistance can also be a feature of patients with T1D and their coexistence is called “double diabetes” (DD). However, knowledge regarding the relationship between DD features and the HGI in T1D is limited.

AIM

To assess the association between the HGI and DD features in adults with T1D.

METHODS

A total of 83 patients with T1D were recruited for this cross-sectional study. Laboratory HbA1c and GMI from continuous glucose monitoring data were collected to calculate the HGI. DD features included a family history of type 2 diabetes, overweight/obesity/central adiposity, hypertension, atherogenic dyslipidemia, an abnormal percentage of body fat (PBF) and/or visceral fat area (VFA) and decreased estimated insulin sensitivity. Skin autofluorescence of advanced glycation end products (SAF-AGEs), diabetic complications, and DD features were assessed, and their association with the HGI was analyzed.

RESULTS

A discrepancy was observed between HbA1c and GMI among patients with T1D and DD. A higher HGI was associated with an increased number of SAF-AGEs and a higher prevalence of diabetic microangiopathy (P = 0.030), particularly retinopathy (P = 0.031). Patients with three or more DD features exhibited an eight-fold increased risk of having a high HGI, compared with those without DD features (adjusted odds ratio = 8.12; 95% confidence interval: 1.52-43.47). Specifically, an elevated PBF and/or VFA and decreased estimated insulin sensitivity were associated with high HGI. Regression analysis identified estimated insulin sensitivity and VFA as factors independently associated with HGI.

CONCLUSION

In patients with T1D, DD features are associated with a higher HGI, which represents a trend toward excessive glycosylation and is associated with a higher prevalence of chronic diabetic complications.

Clinical utility of glycated albumin and 1,5-anhydroglucitol in the screening and prediction of diabetes: A multi-center study

BACKGROUND

Despite being the gold standard, the use of glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) for diagnosing dysglycemia is imperfect. In particular, a low level of agreement between HbA1c and FPG in detecting prediabetes and diabetes has led to difficulties in clinical interpretation. Glycated albumin (GA) and 1,5-anhydroglucitol (1,5-AG) may potentially serve as biomarkers for the detection and prediction of diabetes, as well as glycemic monitoring.

AIM

To explore the diagnostic performance of GA and 1,5-AG for screening dysglycemia; assess whether they can be used for glycemic monitoring in Chinese morbidly-obese patients; and examine their predictive ability for incident diabetes in a Chinese community-based cohort.

METHODS

GA and 1,5-AG concentrations were measured in 462 morbidly-obese patients from the Obese Chinese Cohort (OCC). A sub-group of diabetes subjects (n = 24) was prospectively followed-up after bariatric surgery. Differences between baseline and post-surgery biomarker values were converted to percentage change from baseline to assess the response to glycemic control. Predictive ability of the biomarkers was assessed in 132 incident diabetes cases and 132 matched non-diabetes controls in the community-based Cardiovascular Risk Factor Prevalence Study (CRISPS). A prediction model was developed and compared with clinical models based on conventional risk factors.

RESULTS

GA exhibited an excellent diagnostic value with an area under the receiver operating characteristic curve (AUC) of 0.919 (95%CI: 0.884-0.955) for identifying diabetes and a high agreement in the classification of diabetes with both FPG and HbA1c in the OCC. GA demonstrated the fastest response to glycemic control. In CRISPS, the ‘B3A’ prediction model, which consisted of body mass index (BMI) and 3 biomarkers (HbA1c, GA and 1,5-AG), achieved a comparable predictive value [AUC (95%CI): 0.793 (0.744-0.843)] to that of a clinical model comprising BMI, HbA1c, FPG and 2-hour glucose (2hG) [AUC (95%CI): 0.783 (0.733-0.834); DeLong P value = 0.736]. The ‘B3A’ was significantly superior to a clinical model including BMI, HbA1c, FPG and triglycerides [AUC (95%CI): 0.729 (0.673-0.784); DeLong P value = 0.027].

CONCLUSION

GA and 1,5-AG have the potential to act as robust biomarkers for the screening and risk prediction of diabetes. FPG and 2hG may be replaced by GA and 1,5-AG in future diabetes predictions.

Antidiabetic combination therapy and cardiovascular outcomes: An evidence-based approach

Type 2 diabetes mellitus is associated with a 2-4 times increased risk of cardiovascular (CV) disease. Glucagon-like polypeptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) are two important classes of drugs with CV benefits independent of their antihyperglycemic efficacy. The CV outcome trials of both GLP1RA and SGLT2i have demonstrated CV superiority/neutrality concerning major adverse CV events (MACE). While GLP1RAs have exhibited a significant reduction in ischemic stroke and myocardial infarction (MI), SGLT2i have demonstrated a uniformly significant reduction in hospitalization for heart failure (HF) as a class effect. The unique clinical benefits and the distinct but complementary mechanisms of action make the combination of these drugs a mechanistically sound one. Recent meta-analyses suggest an independent and additive benefit of combination therapy of GLP1RA/SGLT2i vs monotherapy. Zhu et al, in a recent issue of the World Journal of Diabetes, demonstrates a numerically lower hazard ratio (HR) for CV outcomes with combination therapy vs monotherapy with either agent, with a reduction in MACE compared to GLP1RA alone [HR = 0.51, 95% confidence interval (CI): 0.16-1.65], or SGLT2i alone (HR = 0.48, 95%CI: 0.15-1.54). The CV death rate was also lower with combination therapy compared to GLP1RA alone (HR = 0.58, 95%CI: 0.08-3.39), or SGLT2i alone (HR = 0.55, 95%CI: 0.07-3.25). Fatal and non-fatal MI and fatal and non-fatal stroke were reduced with combination therapy compared to GLP1RA alone (HR = 0.45, 95%CI: 0.10-2.18 and HR = 0.86, 95%CI: 0.12-6.23, respectively), or SGLT2i alone (HR = 0.44, 95%CI: 0.09-2.10 and HR = 0.74, 95%CI: 0.10-5.47, respectively). Hospitalization for HF was prevented with combination therapy compared to GLP1RA alone (HR = 0.26, 95%CI: 0.03-1.88), or SGLT2i alone (HR = 0.33, 95%CI: 0.04-2.53). They also demonstrated that GLP1RA or SGLT2i monotherapy may not provide significant improvement in CV death and recurrent MI in patients with prior MI or HF, proposing a role for combination therapy in this subgroup. Appropriate patient selection is vital to optimize CV risk reduction as well as the cost-effectiveness of this combination therapy.

Systematic review and critical appraisal of predictive models for diabetic peripheral neuropathy: Existing challenges and proposed enhancements

BACKGROUND

The trend of risk prediction models for diabetic peripheral neuropathy (DPN) is increasing, but few studies focus on the quality of the model and its practical application.

AIM

To conduct a comprehensive systematic review and rigorous evaluation of prediction models for DPN.

METHODS

A meticulous search was conducted in PubMed, EMBASE, Cochrane, CNKI, Wang Fang DATA, and VIP Database to identify studies published until October 2023. The included and excluded criteria were applied by the researchers to screen the literature. Two investigators independently extracted data and assessed the quality using a data extraction form and a bias risk assessment tool. Disagreements were resolved through consultation with a third investigator. Data from the included studies were extracted utilizing the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies. Additionally, the bias risk and applicability of the models were evaluated by the Prediction Model Risk of Bias Assessment Tool.

RESULTS

The systematic review included 14 studies with a total of 26 models. The area under the receiver operating characteristic curve of the 26 models was 0.629-0.938. All studies had high risks of bias, mainly due to participants, outcomes, and analysis. The most common predictors included glycated hemoglobin, age, duration of diabetes, lipid abnormalities, and fasting blood glucose.

CONCLUSION

The predictor model presented good differentiation, calibration, but there were significant methodological flaws and high risk of bias. Future studies should focus on improving the study design and study report, updating the model and verifying its adaptability and feasibility in clinical practice.

Plantamajoside mitigates endoplasmic reticulum stress-mediated pancreatic β-cell apoptosis in type 2 diabetes via DNAJC1 upregulation

Diabetes mellitus (DM) is a metabolic disorder characterized by persistent hyperglycemia and other symptoms, which pose significant challenges to individual health, life expectancy, and public healthcare systems. The escalating global prevalence of diabetes underscores the need for innovative therapeutic interventions. In this article, we critically comment on the study by Wang et al, published in the World Journal of Diabetes, which elucidates the therapeutic potential of Plantamajoside (PMS) in type 2 DM (T2DM) management. The authors provide evidence for the mechanism of action of PMS in T2DM models, demonstrating prevention of endoplasmic reticulum stress and apoptosis of pancreatic β-cells via activation of DNAJC1. This manuscript provides a brief review of the pathogenesis of T2DM, explores the various roles of PMS in disease therapy in addition to the DNAJC-related apoptotic and autophagic functions, critically evaluates the experimental approaches employed by Wang et al, and provides recommendations for advancing future research.

Intracellular calcium channels: Potential targets for type 2 diabetes mellitus?

Type 2 diabetes mellitus (T2DM) is a prevalent metabolic disorder. Despite the availability of numerous pharmacotherapies, a range of adverse reactions, including hypoglycemia, gastrointestinal discomfort, and lactic acidosis, limits their patient applicability and long-term application. Therefore, it is necessary to screen novel therapeutic drugs for T2DM treatment that have high efficacy but few adverse effects. AMP-activated protein kinase (AMPK) stands out as one of the most powerful targets for T2DM treatment. It can be activated through energy-sensing or calcium signaling. Medications that activate AMPK through the energy-sensing mechanism exhibit remarkable potency, but they are accompanied by lactic acidosis, carrying an alarmingly high mortality rate. Interestingly, medications that activate AMPK through calcium signaling, such as gliclazide, seldom induce lactic acidosis. However, the efficacy of gliclazide is much lower than metformin. Therefore, it is necessary to explore targets that activate AMPK via calcium signaling to avoid lactic acidosis while maintaining high potency. Ion channels are the main controller of intracellular calcium flow. Specific agonists and inhibitors targeting ion channels have been reported to activate AMPK. In this review, we will summarize the structure and function of calcium-permeable ion channels and discuss the potential of targeting these calcium channels for T2DM treatment.

Exploring a novel mechanism for targeting β-arrestin-2 in the management of diabetic nephropathy

Diabetic nephropathy (DN) is a well-known microvascular complication in patients with diabetes mellitus, which is characterized by the accumulation of extracellular matrix in the glomerular and tubulointerstitial compartments, along with the hyalinization of intrarenal vasculature. DN has recently emerged as a leading cause of chronic and end-stage renal disease. While the pathobiology of other diabetic microvascular complications, such as retinopathy, is largely understood and has reasonable therapeutic options, the mechanisms and management strategies for DN remain incompletely elucidated. In this editorial, we comment on the article by Liu et al, focusing on the mechanisms underlying the detrimental impact of β-arrestin-2 on the kidneys in the context of DN. The authors suggest that inhibiting β-arrestin-2 could alleviate renal damage through suppressing apoptosis of glomerular endothelial cells (GENCs), highlighting β-arrestin-2 as a promising therapeutic target for DN. The study proposed that β-arrestin-2 triggers endoplasmic reticulum (ER) stress via the ATF6 signaling pathway, thereby promoting GENC apoptosis and exacerbating DN progression. Given the novel and crucial role of β-arrestin-2 in ER stress-related DN, it is imperative to further explore β-arrestin-2, its roles in ER stress and the potential therapeutic implications in DN.

Double-edged sword of L-arginine in diabetes: Exploring anti-inflammatory and antioxidant strategies

The article by Mansouri et al provides a comprehensive investigation into the effects of L-arginine (L-Arg) on diabetic cardiomyopathy. The authors conclude that while a low dose (0.5 g/kg) of L-Arg improves lipid profiles and reduces body weight, higher doses (≥ 1 g/kg) exacerbate oxidative stress, inflammation, and myocardial damage. In this letter, we aim to expand on the potential role of anti-inflammatory and antioxidant strategies in mitigating these adverse effects. Specifically, we focus on nuclear factor erythroid 2-related factor 2 activation and nitric oxide synthase modulation. These strategies could enhance the clinical utility of L-Arg by preserving its metabolic benefits while reducing its cardiotoxic risks. We believe this perspective will stimulate future research on L-Arg-based therapies in patients with diabetes, with an emphasis on optimizing dosage and exploring synergistic co-therapies.

Dl-3-n-butylphthalide ameliorates diabetic foot ulcer by inhibiting apoptosis and promoting angiogenesis

BACKGROUND

Diabetic foot ulcers (DFU) are estimated to affect about 18.6 million people worldwide annually. The pathogenesis of DFU is complex, and the available drugs are not effective. Dl-3-n-butylphthalide (NBP) is a synthetic mixture of racemates used in China for the treatment of ischemic stroke. It was initially isolated from the seeds of Apium graveolens Linn, with studies showing its potential role in treating diabetes and its complications.

AIM

To predict and validate the mechanism by which NBP treats DFU.

METHODS

Network pharmacological analysis was performed to identify pharmacological targets and signaling pathways mediating the treatment effect of NBP on DFU. In vivo and in vitro experiments were conducted to validate the therapeutic effects and mechanisms of NBP on DFU.

RESULTS

Network pharmacology analysis identified 26 pharmacological targets of NBP and predicted that NBP could treat DFU partially by modulating apoptosis and vascular signaling pathways. Results from animal experiments showed that NBP significantly improved DFU by increasing neovascularization and fibroblast proliferation. In vitro tests demonstrated that NBP treatment promoted the migration and proliferation of human umbilical vein endothelial cells and human dermal fibroblasts, while inhibiting the apoptosis of human umbilical vein endothelial cells, human dermal fibroblasts, and human keratinocytes cells.

CONCLUSION

This study found that NBP could treat DFU by decreasing the rate of apoptosis and increasing angiogenesis via the advanced glycation end products-receptor of advanced glycation end products signaling pathway and binding to the heme oxygenase 1, caspase 3, B cell leukemia/lymphoma 2, brain derived neurotrophic factor, and nuclear factor erythroid 2 L2 genes.

Curcumol ameliorates diabetic retinopathy via modulating fat mass and obesity-associated protein-demethylated MAF transcription factor G antisense RNA 1

BACKGROUND

Diabetic retinopathy (DR) is a major microvascular complication of diabetes mellitus, leading to significant visual impairment and blindness among adults. Current treatment options are limited, making it essential to explore novel therapeutic strategies. Curcumol, a sesquiterpenoid derived from traditional Chinese medicine, has shown anti-inflammatory and anti-cancer properties, but its potential role in DR remains unclear.

AIM

To investigate the therapeutic effects of curcumol on the progression of DR and to elucidate the underlying molecular mechanisms, particularly its impact on the fat mass and obesity-associated (FTO) protein and the long non-coding RNA (lncRNA) MAF transcription factor G antisense RNA 1 (MAFG-AS1).

METHODS

A streptozotocin-induced mouse model of DR was established, followed by treatment with curcumol. Retinal damage and inflammation were evaluated through histological analysis and molecular assays. Human retinal vascular endothelial cells were exposed to high glucose conditions to simulate diabetic environments in vitro. Cell proliferation, migration, and inflammation markers were assessed in curcumol-treated cells. LncRNA microarray analysis identified key molecules regulated by curcumol, and further experiments were conducted to confirm the involvement of FTO and MAFG-AS1 in the progression of DR.

RESULTS

Curcumol treatment significantly reduced blood glucose levels and alleviated retinal damage in streptozotocin-induced DR mouse models. In high-glucose-treated human retinal vascular endothelial cells, curcumol inhibited cell proliferation, migration, and inflammatory responses. LncRNA microarray analysis identified MAFG-AS1 as the most upregulated lncRNA following curcumol treatment. Mechanistically, FTO demethylated MAFG-AS1, stabilizing its expression. Rescue experiments demonstrated that the protective effects of curcumol against DR were mediated through the FTO/MAFG-AS1 signaling pathway.

CONCLUSION

Curcumol ameliorates the progression of DR by modulating the FTO/MAFG-AS1 axis, providing a novel therapeutic pathway for the treatment of DR. These findings suggest that curcumol-based therapies could offer a promising alternative for managing this debilitating complication of diabetes.

Jejunoileal side-to-side anastomosis as a promising option for type 2 diabetes

In this editorial, I discuss the article by Wang et al, published in the World Journal of Diabetes, which explores jejunoileal side-to-side anastomosis as a novel surgical intervention for type 2 diabetes mellitus (T2DM). T2DM, often associated with obesity, remains a global health challenge, as sustained remission is difficult to achieve with conventional pharmacological therapy. Jejunoileal anastomosis offers a promising alternative, particularly for patients with normal or relatively high body mass index, and addresses the unique challenges posed by diverse patient populations. This procedure preserves gastric anatomy while simultaneously improving metabolic parameters, such as glycemic control, lipid profiles, and pancreatic β-cell function. Unlike traditional metabolic surgeries that involve permanent anatomical alterations, this approach provides advantages such as reversibility, shorter operative times, and minimal nutritional complications, making it appealing to patients for whom conventional bariatric surgery is unsuitable. Advances in gut hormone physiology and incretin modulation support these findings. This innovative approach represents a potential paradigm shift in T2DM treatment, offering insights into the evolving role of surgical interventions in metabolic regulation. While early findings show promising diabetes remission rates and metabolic improvements at six months post-surgery, further studies with longer follow-up periods and broader patient cohorts are required.

Reasons for discontinuing tirzepatide in randomized controlled trials: A systematic review and meta-analysis

BACKGROUND

Despite therapeutic benefits, discontinuation of tirzepatide is common in randomized controlled trials (RCTs) due to adverse events (AEs) and other causes. No previous systematic reviews have explored the reasons for discontinuing tirzepatide in the RCTs.

AIM

To explore the reasons for permanent discontinuation of tirzepatide vs controls [placebo, insulin, and glucagon-like peptide-1 receptor agonists (GLP-1Ras)] in RCTs.

METHODS

Relevant RCTs were systematically searched using related terms through multiple databases such as MEDLINE (via PubMed), Scopus, Cochrane Central Register, and ClinicalTrials.gov from their inception until June 20, 2024. RevMan web was used to conduct meta-analysis using random-effects models. Outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI).

RESULTS

Seventeen RCTs (n = 14645), mostly having low risks of bias, were analyzed. Compared to placebo, the risk of permanent discontinuation of the study drug was substantially lower with tirzepatide 10 mg (RR: 0.69, 95%CI: 0.51-0.93, P = 0.02) and similar with tirzepatide 5 mg (RR: 0.74, 95%CI: 0.47-1.17, P = 0.20) and 15 mg (RR: 0.94, 95%CI: 0.68-1.31, P = 0.71). Tirzepatide had identical discontinuation risks when compared to insulin at 5 mg (RR: 0.96, 95%CI: 0.75-1.24, P = 0.77) and 10 mg (RR: 1.19, 95%CI: 0.77-1.82, P = 0.44) doses, whereas such risk was higher with tirzepatide 15 mg than insulin (RR: 1.31, 95%CI: 1.03-1.67, P = 0.03). Compared to GLP-1RA, the permanent discontinuation risk was similar with tirzepatide 5 mg (RR: 0.98, 95%CI: 0.70-1.37, P = 0.90) but was higher with tirzepatide 10 mg (RR: 1.40, 95%CI: 1.03-1.90, P = 0.03) and 15 mg (RR: 1.70, 95%CI: 1.27-2.27, P = 0.0004). Tirzepatide, at all doses, had higher risks of AE-related discontinuation than insulin; such risks were only greater with higher doses of tirzepatide than with placebo or GLP-1RA. Discontinuation risk due to withdrawal by the study subjects was lower with tirzepatide than with placebo or insulin. Compared to the placebo, tirzepatide (all doses) conferred a lower risk of study drug discontinuation due to other causes not specifically mentioned.

CONCLUSION

The discontinuation risk is not higher in tirzepatide group than in the placebo arm. Many factors other than AEs led to drug discontinuation in the included RCTs.

B-type natriuretic peptide efficacy compared to fragmented QRS for diastolic dysfunction screening in patients with type 2 diabetes

BACKGROUND

Early diagnosis of left ventricular diastolic dysfunction (LVDD) is essential for preventing heart failure. B-type natriuretic peptide (BNP) is a viable marker for predicting LVDD, as elevated BNP levels have been associated with worsening LVDD in patients with diabetes over time. However, the utility of BNP as a diagnostic marker in diabetes is controversial, as BNP levels are often low in overweight individuals.

AIM

To examine the effectiveness of BNP levels and fragmented QRS (fQRS) on electrocardiography for diagnosing LVDD in patients with type 2 diabetes.

METHODS

This retrospective cohort study included 303 patients with type 2 diabetes (67.4 ± 12.3 years old) with preserved ejection fraction (EF) ≥ 50% admitted to Toyama University Hospital for glycemic management and comorbidity evaluation between November 2017 and April 2021. All participants underwent plasma BNP measurement, electrocardiography, and echocardiography. Cardiologists who were blinded to the BNP results assessed the electrocardiograms and echocardiograms. Subgroup analyses were conducted for overweight individuals.

RESULTS

Receiver operating characteristic (ROC) curve analysis determined optimal BNP cut-off values of 34.8 pg/mL and 7.2 pg/mL for diagnosing LVDD in non-overweight [area under the ROC curve (AUC): 0.70] and overweight (AUC: 0.55) groups, respectively (P = 0.040). In the overweight subgroup, fQRS showed greater diagnostic accuracy for LVDD (AUC: 0.67), indicating moderate diagnostic utility compared with the low performance of the BNP cutoff of 35 pg/mL (AUC: 0.52) (P = 0.010). Multivariate analyses confirmed that fQRS was superior to BNP for LVDD diagnosis regardless of the patient’s weight.

CONCLUSION

A BNP level ≥ 35 pg/mL in non-overweight individuals may be a reliable LVDD marker. Additionally, fQRS was more effective than BNP in diagnosing LVDD irrespective of the patient’s weight. fQRS can complement BNP in the early detection of LVDD, especially in overweight patients, potentially improving early detection and mitigating progression to heart failure with preserved EF in patients with type 2 diabetes.

Role and mechanism of Roux-en-Y gastric bypass in the treatment of diabetic urinary bladder hyperactivity by reducing TRPV1 and P2X3

BACKGROUND

Diabetes mellitus (DM) is linked to an earlier onset and heightened severity of urinary complications, particularly bladder dysfunction, which profoundly impacts patient quality of life. Overactive bladder (OAB) is a common storage disorder of the lower urinary tract and is characterized by urgency, frequency, and nocturia. Several factors contribute to bladder dysfunction in diabetic individuals, including changes in urothelial signaling, detrusor morphology, and central nervous system regulation. The transient receptor potential vanilloid type 1 channel, expressed by bladder urothelial cells, is upregulated in OAB and plays a crucial role in ATP release during bladder filling. This ATP release subsequently activates purinergic receptor P2X3, further exacerbating OAB symptoms.

AIM

To clarify the mechanism of Roux-en-Y gastric bypass (RYGB) metabolic surgery to improve OAB in type 2 DM (T2DM).

METHODS

The model of T2DM was induced by feeding a high-fat diet to mice for 16 weeks. After 16 weeks, sham operation and RYGB operation were performed. The related indexes of glucose metabolism were also detected to evaluate the therapeutic effect, and the recovery degree of bladder function and micturition behavior of mice was assessed by urodynamics and micturition spot analysis.

RESULTS

Compared with the normal mice in the sham group, T2DM mice had increased urine spot count, uncontrolled urination behavior, shortened urination interval, and reduced bladder capacity. Immunohistochemistry and immunofluorescence costaining showed that Transient receptor potential vanilloid type 1 (TRPV1) and purinergic receptor P2X3 were both expressed in mouse bladder epithelial layer, and they had the same localization. In the bladder of T2DM mice, the mRNA and protein expression of TRPV1 and P2X3 were significantly increased. The ATP content in urine of T2DM mice was significantly higher than that of the sham group. After RYGB operation, the glucose metabolism index of the RYGB group was significantly improved compared with the OAB group. Comparing the results of urine spots, urodynamics, and histology, it was found that the function and morphological structure of the bladder in the RYGB group also recovered obviously. Compared with the OAB group, the expression of TRPV1 and P2X3 in the RYGB group was downregulated, and the level of inflammatory factors was significantly decreased. RYGB significantly decreased the content of ATP in urine and activated AMPK signaling.

CONCLUSION

RYGB downregulated the expression of TRPV1 by inhibiting inflammatory factors, thus inhibiting the enhancement of P2X3 by TRPV1. RYGB directly inhibited the activity of P2X3 by inhibiting ATP synthesis in the bladder epithelium to improve OAB.

Prevalence and associated factors of depressive symptoms in Chinese diabetic patients: A study based on Andersen’s behavioral model

BACKGROUND

Diabetes mellitus (DM) is a rapidly growing global health emergency of the 21^st century. Comorbidities, such as DM and depression, are common, presenting challenges to the healthcare system.

AIM

To investigate the prevalence of depression and its associated factors in patients with DM and to strengthen the management of depression in this patient group.

METHODS

Participants were selected from the 2018 China Health and Retirement Longitudinal Study. Depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale, with a score of 10 or more indicating depression. Group differences were compared using analysis of variance and χ² tests. Binary logistic regression was conducted to explore the odds ratios (ORs) of independent variables. Following Andersen’s behavioral model, predisposing, enabling, health need, and health behavior variables were introduced stepwise into the logistic model.

RESULTS

Of the 1673 patients with diabetes, 41.4% had depressive symptoms. Regarding the predisposing characteristics, patients who were male (OR 0.426, P < 0.05), married (OR 0.634, P < 0.05), and received a high school education or higher (OR 0.432, P < 0.05) reported fewer depressive symptoms. Healthcare needs, including better self-rated health (OR 0.458 for fair and OR 0.247 for good, P < 0.05) and more sleep (OR 0.642, P < 0.05), were associated with a lower likelihood of depressive symptoms. In contrast, pain (OR 1.440 for mild and OR 2.644 for severe, P < 0.05) and impairment in the basic activities of daily living (OR 1.886, P < 0.05) were inversely associated. Additionally, patients highly satisfied with healthcare services (OR 0.579, P < 0.05) were less likely to have depressive symptoms.

CONCLUSION

Nearly half of the patients with DM reported depressive symptoms, which were strongly associated with predisposing characteristics and healthcare needs, particularly physical pain and impairment in basic activities of daily living. Our study emphasizes the significance of enhanced screening and intervention for depression in diabetes care along with improved management of functional impairments.

Coronary imaging characteristics and risk factors in patients with type 2 diabetes mellitus with coronary heart disease complication

BACKGROUND

Coronary heart disease (CHD) is a prevalent type 2 diabetes mellitus (T2DM) complication. Further, the risk stratification before angiography may help diagnose T2DM with CHD early. However, few studies have investigated the coronary imaging characteristics and risk factors of patients with T2DM complicated with CHD.

AIM

To compare the differences in coronary imaging between patients with T2DM with and without CHD, determine the risk factors of T2DM complicated with CHD, and establish a predictive tool for diagnosing CHD in T2DM.

METHODS

This study retrospectively analyzed 103 patients with T2DM from January 2022 to May 2024. They are categorized based on CHD occurrence into: (1) The control group, consisting of patients with T2DM without CHD; and (2) The observation group, which includes patients with T2MD with CHD. Age, sex, smoking and drinking history, CHD family history, metformin (MET) treatment pre-admission, body mass index, fasting blood glucose (FBG), triglyceride (TG), total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), serum creatinine, blood urea nitrogen (BUN), alanine aminotransferase, aspartate aminotransferase, glycosylated hemoglobin (HbA1c), and coronary imaging data of both groups were collected from the medical record system. Logistic risk analysis was conducted to screen risk factors. The prediction model’s prediction efficiency was evaluated with receiver operating characteristic curves.

RESULTS

The control and observation groups consisted of 48 and 55 cases, respectively. The two groups were statistically different in terms of age (t = 2.006, P = 0.048), FBG (t = 6.038, P = 0.000), TG (t = 2.015, P = 0.047), LDL-C (t = 2.017, P = 0.046), and BUN (t = 2.035, P = 0.044). The observation group demonstrated lower proportions of patients receiving MET (χ² = 5.073, P = 0.024) and higher proportions of patients with HbA1c of > 7.0% (χ² = 6.980, P = 0.008) than the control group. The observation group consisted of 15, 17, and 23 cases of moderate stenosis, severe stenosis, and occlusion, respectively, with a greater number of coronary artery occlusion cases than the control group (χ² = 6.399, P = 0.041). The observation group consisted significantly higher number of diffuse lesion cases at 35 compared with the control group (χ² = 15.420, P = 0.000). The observation group demonstrated a higher right coronary artery (RCA) stenosis index (t = 6.730, P = 0.000), circumflex coronary artery (LCX) stenosis index (t = 5.738, P = 0.000), and total stenosis index (t = 7.049, P = 0.000) than the control group. FBG [odds ratio (OR) = 1.472; 95% confidence interval (CI): 1.234-1.755; P = 0.000] and HbA1c (OR = 3.197; 95%CI: 1.149-8.896; P = 0.026) were independent risk factors for T2DM complicated with CHD, whereas MET (OR = 0.350; 95%CI: 0.129-0.952; P = 0.040) was considered a protective factor for CHD in T2DM.

CONCLUSION

Coronary artery occlusion is a prevalent complication in patients with T2DM. Patients with T2MD with CHD demonstrated a higher degree of RCA and LCX stenosis than those with T2DM without CHD. FBG, HbA1c, and MET treatment history are risk factors for T2DM complicated with CHD.

Metabolic improvement effects of jejunoileal side-to-side anastomosis in patients with type 2 diabetes and the glucagon-like peptide-1 mechanism

Wang et al explored the metabolic improvement effects of jejunoileal side-to-side anastomosis in patients with type 2 diabetes mellitus (T2DM), focusing on its multitarget metabolic regulatory potential through enhanced secretion of glucagon-like peptide-1. This surgical procedure alters the direction of nutrient flow, activates distal ileal L cells, and increases endogenous glucagon-like peptide-1 levels, supporting glucose homeostasis, enhancing insulin sensitivity, regulating body weight, and improving cardiovascular health. This structural adjustment transforms the gastrointestinal tract into an active endocrine regulatory organ, providing a pathway for metabolic improvement in patients with T2DM and other complex metabolic disorders. Although this procedure demonstrates significant metabolic improvements within 3-6 months after surgery, integrating hormone level measurements, metabolic marker analysis, and long-term follow-up has become crucial for exploring the complex mechanisms of T2DM in the field of metabolic surgery and T2DM management. Multidisciplinary collaboration involving support from endocrinology, nutrition, and rehabilitation teams before and after surgery is becoming increasingly vital in the long-term management of patients with T2DM. This collaboration optimizes surgical outcomes and enhances metabolic management. Side-to-side anastomosis shows potential in the multitarget metabolic management of T2DM, providing an additional intervention option for patients with T2DM and metabolic disorders.

Elevated waist-to-hip ratio, as an abdominal obesity index, predicts the risk of diabetic kidney injury

BACKGROUND

Diabetic nephropathy (DN) is associated with a high incidence of type 2 diabetic mellitus (T2DM) in Asia. Central obesity is an important risk factor for DN, represented by a series of indices, including waist circumference, waist-to-hip ratio (WHR), hip circumference, and visceral to subcutaneous fat area ratio (VSR). However, limited research has focused on the association between these indices and DN.

AIM

To elucidate the relationship between central fat distribution, as measured by WHR and VSR, and the DN progression.

METHODS

Between August 2018 and April 2023, a total of 991 individuals were retrospectively recruited from the Rui’an People’s Hospital for this cross-sectional analysis. The 753 individuals with T2DM were divided into three groups according to the urinary albumin/creatinine ratio (ACR): normal albuminuria (n = 513, ACR < 30 mg/g), microalbuminuria (n = 166, 30 ≤ ACR < 300 mg/g), and clinical proteinuria (n = 45, ACR ≥ 300 mg/g).

RESULTS

Our results indicated that WHR and VSR were closely correlated with sex, ageing, body mass index, hypertension, T2DM causes, and experience of drinking and smoking, and potential relationships between these factors and DN progression were observed. WHR, but not VSR, gradually increased with the severity of early-stage renal injury. Abnormal serum lipid levels in T2DM patients with early-stage renal injury were strongly correlated with WHR. Logistic regression analysis revealed that WHR may be an independent risk factor for early-stage renal injury.

CONCLUSION

In patients with T2DM, WHR level, rather than VSR level, is closely associated with early-stage renal injury. An abnormal serum lipid spectrum was common in all stages of renal injury and was strongly related to high WHR. Thus, WHR measurement might be a valuable tool for the early prevention of renal injury, which could guide clinical monitoring and prevent diabetic complications.

Characteristic dysbiosis in patients with type 2 diabetes and hyperuricemia, and the effect of empagliflozin on gut microbiota

BACKGROUND

Gut microbiota play a crucial role in metabolic diseases, including type 2 diabetes (T2DM) and hyperuricemia (HUA). One-third of uric acid is excreted into the intestinal tract and further metabolized by gut microbiota. Thus, the gut microbiota might be a new therapeutic target for HUA. Empagliflozin significantly lowers serum uric acid levels and contributes to cardiovascular benefits which are partly attributed to altered gut microbiota. We hypothesize that gut dysbiosis in patients with diabetes and HUA, and the reduction of uric acid by empagliflozin, may be mediated by gut microbiota.

AIM

To investigate dysbiosis in patients with T2DM and HUA, and the effect of empagliflozin on gut microbiota associated with purine metabolism.

METHODS

In this age and sex-matched, case-control study, we recruited 30 patients with T2DM and HUA; 30 with T2DM; and 30 healthy controls at the Henan Provincial People’s Hospital between February 2019 and August 2023. Nine patients with T2DM and HUA were treated with empagliflozin for three months. Gut microbiota profiles were assessed using the 16S rRNA gene.

RESULTS

Patients with T2DM and HUA had the highest total triglycerides (1.09 mmol/L in heathy control vs 1.56 mmol/L in T2DM vs 2.82 mmol/L in T2DM + HUA) and uric acid levels (302.50 μmol/L in heathy control vs 288.50 μmol/L in T2DM vs 466.50 μmol/L in T2DM + HUA) among the three groups. The composition of the gut microbiota differed significantly between patients with T2DM and HUA, and those with T2DM/healthy controls (P < 0.05). Notably, patients with T2DM and HUA demonstrated a deficiency of uric acid-degrading bacteria such as Romboutsia, Blautia, Clostridium sensu stricto 1 (P < 0.05). Empagliflozin treatment was associated with significantly reduced serum uric acid levels and purine metabolism-related pathways and genes in patients with T2DM and HUA (P < 0.05).

CONCLUSION

Gut dysbiosis may contribute to the pathogenesis of HUA in T2DM, and empagliflozin may partly restore the gut microbiota related to uric acid metabolism.

Platelets indices clinical implications in diabetes mellitus: A broader insight

Platelet indices (PIs) including high mean platelet volume (MPV), plateletcrit (PLC), and platelet distribution width (PLDW) are associated with poor glycemic control. In addition, they can indicate prothrombotic and procoagulation risk among patients with diabetes. PI measurement is cheap, quick and fits healthcare system needs in remote outreaching areas in low-income countries. However, a broader insight into their clinical implications in diabetes is lacking. To achieve a wider understanding, we reviewed PubMed/MEDLINE, Google Scholar and Cochrane Library for relevant articles investigating the role of PIs in diabetes mellitus. No limitation to the publication date was applied, which included all articles published up to August 17, 2024. The terms used were MPV, PLC, PLDW, platelet large cell ratio, glycated hemoglobin (HbA1c), PIs, platelet activity and diabetes mellitus. Out of the 790 articles retrieved, 187 full texts were reviewed, and 44 were included. PIs, when measurements are done promptly and within 2 h, could be short-term pointers to glycemic control in the life span of the platelets (2 wk). PIs are easy to perform, cheap and useful in remote outreaching areas with limited facilities where measurement of HbA1c is not available or cost-effective. However, PIs are not specific and are affected by demographic factors, such as pregnancy, renal failure, medications, hemoglobin and duration of diabetes. PIs could be implemented with daily blood glucose to inform doctors in low-income countries about their patients' glycemic control and cardiovascular risk. An important application might be when blood glucose control is needed quickly (before elective surgery).

Effect of systolic blood pressure status on coronary inflammation and high-risk plaque characteristics

BACKGROUND

Inadequately controlled hypertension often leads to an increased cardiovascular death rate in type 2 diabetes mellitus (T2DM). It remains unclear whether systolic blood pressure (SBP) status of hypertension is related to coronary inflammation and plaques in T2DM.

AIM

To evaluate whether SBP variability (SBPV) and levels of hypertension are related to coronary inflammation and plaques in T2DM patients using coronary computed tomography angiography (CCTA).

METHODS

This retrospective study involved 881 T2DM patients with CCTA images, including 668 hypertension and 213 normotension patients. Hypertension patients were subgroup based on SBP status: (1) SBPV: Low (< 8.96 mmHg) and high (≥ 8.96 mmHg) groups; and (2) SBP levels: Controlled (< 140 mmHg) and uncontrolled (≥ 140 mmHg) groups. Pericoronary adipose tissue (PCAT) attenuation, high-risk plaques (HRPs) and obstructive stenosis (OS) were evaluated by CCTA. Propensity score matching was utilized to compare these CCTA findings for these groups. The impact of SBPV and SBP levels of hypertension on these CCTA findings in T2DM patients were evaluated by multivariate logistic regression and multivariable linear regression.

RESULTS

PCAT attenuation of the left anterior descending artery (LAD), any low attenuation plaque (LAP), any spotty calcification (SC), any positive remodeling (PR), and OS had significant differences between the hypertension group and the normotension group, as well as between the high SBPV or uncontrolled SBP group and the low SBPV or controlled SBP group (all P < 0.05). Hypertension was independently positively correlated with LAD-PCAT attenuation (β = 1.815, P = 0.010), LAP (OR = 1.612, P = 0.019), SC (OR = 1.665, P = 0.013), PR (OR = 1.549, P = 0.033), and OS (OR = 1.928, P = 0.036) in all T2DM patients. Additionally, high SBPV and uncontrolled SBP were independently positively correlated with LAD-PCAT attenuation (high SBPV: β = 1.673, P = 0.048; uncontrolled SBP: β = 2.370, P = 0.004) and PR (high SBPV: OR = 1.903, P = 0.048; uncontrolled SBP: OR = 2.230, P = 0.013) in T2DM patients with hypertension.

CONCLUSION

Inadequately controlled hypertension, including high SBPV and/or uncontrolled SBP levels, may be related to increased coronary artery inflammation, HRPs, and OS in T2DM, leading to increased cardiovascular risk. Achieving both low SBPV and controlled SBP levels simultaneously, especially in individuals with T2DM and hypertension, warrants clinical attention.

Comprehensive impact of PPARG mutations in familial partial lipodystrophy type 3: Diagnosis, therapeutic strategies

This article reviews a paper in the World Journal of Diabetes. The study uncovers the link between PPARG gene mutations and metabolic disorders, such as insulin resistance, diabetes, and hypertriglyceridemia, and emphasizes the crucial role of genetic testing in precise diagnosis and personalized treatment. This article further points out that in-depth investigation into the clinical heterogeneity of PPARG mutations and their underlying mechanisms can contribute to optimizing management strategies. Meanwhile, the development of more effective targeted therapies and the conduct of extensive genomic research are of great significance for understanding familial partial lipodystrophy type 3 and related metabolic syndromes.