Quantifying the risk of infectious diseases for people with diabetes

1,5-Anhydroglucitol attenuates cytokine release and protects mice with type 2 diabetes from inflammatory reactions

1,5-anhydroglucitol (1,5-AG) decreases in diabetic patients and is used as a marker of glycemic control. Type 2 diabetic patients are susceptibile to lipopolysaccharides (LPS), which stimulate macrophages to release large quantities of tumor necrosis factor (TNF)-alpha and interleukin (IL)-6. This study examines the effects of 1,5-AG on lung inflammation induced by LPS and consequent systemic inflammation to determine whether the decrease of 1,5-AG concentration induces susceptibility to LPS. Before the challenge with LPS (1 mg/kg in vivo and 500 ng/ml in vitro), we pretreated db/db mice and RAW264.7 cells with 1,5-AG at 38.5 mg/kg and 500 microg/ml, respectively. The levels of IL-6, TNF-alpha, macrophage chemoattractant protein (MCP)-1 and IL-1beta in the serum and in the cell supernatants were measured. We also measured macrophage recruitment and the expression of inducible nitric oxide synthase (iNOS) in pulmonary tissues. We found that 1,5-AG attenuated serum cytokine release and protected db/db mice from LPS-induced pulmonary inflammation. In addition, 1,5-AG suppressed cytokine release and iNOS expression by suppressing Akt/NF-kB activity in RAW264.7 cells. These results suggest that 1,5-AG may be a mediator in, as well as marker for diabetes, and 1,5-AG intake may confer tolerance to LPS in patients with type 2 diabetes.

Skin and soft tissue infections in hospitalised patients with diabetes: culture isolates and risk factors associated with mortality, length of stay and cost

AIMS/HYPOTHESIS

Skin and soft tissue infections (SSTIs) cause substantial morbidity in persons with diabetes. There are few data on pathogens or risk factors associated with important outcomes in diabetic patients hospitalised with SSTIs.

METHODS

Using a clinical research database from CareFusion, we identified 3,030 hospitalised diabetic patients with positive culture isolates and a diagnosis of SSTI in 97 US hospitals between 2003 and 2007. We classified the culture isolates and analysed their association with the anatomic location of infection, mortality, length of stay and hospital costs.

RESULTS

The only culture isolate with a significantly increased prevalence was methicillin-resistant Staphylococcus aureus (MRSA); prevalence for infection of the foot was increased from 11.6 to 21.9% (p < 0.0001) and for non-foot locations from 14.0% to 24.6% (p = 0.006). Patients with non-foot (vs foot) infections were more severely ill at presentation and had higher mortality rates (2.2% vs 1.0%, p < 0.05). Significant independent risk factors associated with higher mortality rates included having a polymicrobial culture with Pseudomonas aeruginosa (OR 3.1), a monomicrobial culture with other gram-negatives (OR 8.9), greater illness severity (OR 1.9) and being transferred from another hospital (OR 5.1). These factors and need for major surgery were also independently associated with longer length of stay and higher costs.

CONCLUSIONS/INTERPRETATION

Among diabetic patients hospitalised with SSTI from 2003 to 2007, only MRSA increased in prevalence. Patients with non-foot (vs foot) infections were more severely ill. Independent risk factors for increased mortality rates, length of stay and costs included more severe illness, transfer from another hospital and wound cultures with Pseudomonas or other gram-negatives.

Type 2 diabetes mellitus is associated with impaired cytokine response and adhesion molecule expression in human endotoxemia

PURPOSE

Type 2 diabetes is associated with an increased risk of acquiring infectious diseases and developing sepsis. This may partly be due to immune dysfunction. We investigated the in vivo innate immune response of type 2 diabetic persons to an intravenous injection of E. coli lipopolysaccharide (LPS).

METHODS

After ethics approval, informed consent and a thorough physical examination, 19 type 2 diabetic patients and 23 healthy controls were included. LPS was given as an intravenous bolus injection of 0.3 ng/kg. Physiological variables, white blood cell count, and plasma concentrations of tumour necrosis factor (TNF), interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1ra), and the adhesion molecules E-selectin, vascular adhesion molecule (VCAM)-1, and intracellular adhesion molecule (ICAM)-1 were measured hourly for 8 h.

RESULTS

LPS injection induced a systemic inflammatory response with increases in neutrophils, temperature, heart rate and plasma concentrations of cytokines and adhesion molecules in healthy and type 2 diabetic volunteers. Type 2 diabetes was associated with less pronounced LPS-induced increases in TNF, IL-1ra, VCAM-1 and ICAM-1. There was a trend towards an attenuated upregulation of E-selectin in diabetics, even though the plasma concentration tended to be generally higher compared to healthy controls.

CONCLUSIONS

Patients with type 2 diabetes exhibit an attenuated increase in plasma levels of TNF and IL-1ra, as well as an attenuated upregulation of VCAM-1 and ICAM-1 to LPS in vivo. This finding may provide a mechanistic explanation for the adverse outcome seen during infectious diseases in diabetic patients.

CD14+ monocytes are vulnerable and functionally impaired under endoplasmic reticulum stress in patients with type 2 diabetes

OBJECTIVE

Although patients with diabetes suffer from increased infections and a higher incidence of cancer due to impaired immune function, details on diabetes-induced decrease in immunity are lacking. We assessed how immune-mediating peripheral blood mononuclear cells (PBMCs) are affected in diabetes.

RESEARCH DESIGN AND METHODS

From 33 patients with type 2 diabetes and 28 healthy volunteers, we obtained PBMCs and investigated their susceptibility to apoptosis and functional alteration.

RESULTS

In a subpopulation of PBMCs, monocytes derived from patients with diabetes were more susceptible to apoptosis than monocytes from healthy volunteers. Monocytes from patients with diabetes had decreased phagocytotic activity and were less responsive to Toll-like receptor (TLR) ligands, although the expression of TLRs did not differ significantly between the two groups. Furthermore, monocytes from patients with diabetes had a distinctly different gene expression profile compared with monocytes from normal volunteers as assessed with DNA microarray analysis. Specifically, quantitative real-time detection PCR measurements showed an elevated expression of the markers of endoplasmic reticulum (ER) stress in diabetic monocytes, and electron microscopic examination of monocytes revealed morphologic alterations in the ER of cells derived from patients with diabetes. Consistently, the ER stress inducer tunicamycin increased apoptosis of otherwise healthy monocytes and attenuated the proinflammatory responses to TLR ligands.

CONCLUSIONS

These data suggest that monocytes comprise a substantially impaired subpopulation of PBMCs in patients with diabetes and that ER stress is involved in these pathologic changes mechanistically. This implies that the affected monocytes should be investigated further to better understand diabetic immunity.

Diabetes does not alter mortality or hemostatic and inflammatory responses in patients with severe sepsis

OBJECTIVE

Diabetes patients have an increased risk of sepsis. Several inflammatory and coagulant pathways that are activated during sepsis are also up-regulated in diabetes patients. We tested our a priori hypothesis that the presence of diabetes adversely affects the outcome of sepsis.

DESIGN

Retrospective analysis of a previously published study.

SETTING

Intensive care units of 164 centers in 11 countries.

PATIENTS

Eight hundred thirty severe sepsis patients who were admitted to the intensive care unit and who received standard critical care treatment.

INTERVENTIONS

Patients were stratified into diabetic and nondiabetic patient groups. Mortality was assessed after 28 and 90 days, causative microorganisms were evaluated, and markers of coagulation, fibrinolysis, and inflammation were measured at several time points.

MEASUREMENTS AND MAIN RESULTS

Diabetes was present in 22.7% of all sepsis patients. Throughout the study, plasma glucose levels were higher in diabetic patients. Mortality was equal in diabetic and nondiabetic patients (31.4% vs. 30.5% after 28 days). Markers of coagulation, fibrinolysis, and inflammation were generally equal in diabetic and nondiabetic patients, although on admission diabetic patients had slightly higher levels of anticoagulation markers. Interestingly, nondiabetic patients with admission hyperglycemia (>11.1 mmol/L; 200 mg/dL) had a higher mortality rate compared to those without admission hyperglycemia (43.0% vs. 27.2%).

CONCLUSIONS

Although diabetes is a risk factor for sepsis, once established, the outcome of severe sepsis does not appear to be significantly influenced by the presence of diabetes. In nondiabetic patients, however, admission hyperglycemia is associated with an increased mortality.

Efficacy of inactivated vaccine against H5N1 influenza virus infection in mice with type 1 diabetes

We sought to determine susceptibility to highly pathogenic avian influenza (HPAI) H5N1 virus and to explore immune protection of inactivated H5N1 vaccine in streptozotocin-induced type 1 diabetic mice. Susceptibility of diabetic mice to an H5N1 virus was evaluated by comparing the median lethal dose (LD(50)) and the lung virus titers with those of the healthy after the viral infection. To evaluate the influence of diabetes on vaccination, diabetic and healthy mice were immunized once with an inactivated H5N1 vaccine and then challenged with a lethal dose of H5N1 virus. The antibody responses, survival rates, lung virus titers and body weight changes were tested. Mice with type 1 diabetes had higher lung virus titers and lower survival rates than healthy mice after H5N1 virus infection. Inactivated H5N1 vaccine induced protective antibody in diabetic mice, but the antibody responses were postponed and weakened. In spite of this, diabetic mice could be protected against the lethal virus challenge by a single dose of immunization when the amount of the antigen increased. These results indicated that type 1 diabetic mice were more susceptible to H5N1 influenza virus infection than healthy mice, and can be effectively protected by inactivated H5N1 vaccine with increased antigen.

Tuberculosis and diabetes mellitus: convergence of two epidemics

The link between diabetes mellitus and tuberculosis has been recognised for centuries. In recent decades, tuberculosis incidence has declined in high-income countries, but incidence remains high in countries that have high rates of infection with HIV, high prevalence of malnutrition and crowded living conditions, or poor tuberculosis control infrastructure. At the same time, diabetes mellitus prevalence is soaring globally, fuelled by obesity. There is growing evidence that diabetes mellitus is an important risk factor for tuberculosis and might affect disease presentation and treatment response. Furthermore, tuberculosis might induce glucose intolerance and worsen glycaemic control in people with diabetes. We review the epidemiology of the tuberculosis and diabetes epidemics, and provide a synopsis of the evidence for the role of diabetes mellitus in susceptibility to, clinical presentation of, and response to treatment for tuberculosis. In addition, we review potential mechanisms by which diabetes mellitus can cause tuberculosis, the effects of tuberculosis on diabetic control, and pharmacokinetic issues related to the co-management of diabetes and tuberculosis.

Advanced glycation end products and lipopolysaccharide synergistically stimulate proinflammatory cytokine/chemokine production in endothelial cells via activation of both mitogen-activated protein kinases and nuclear factor-kappaB

It has been well documented that both endogenous inflammatory mediator advanced glycation end products (AGEs) and exogenous inflammatory inducer lipopolysaccharide play key roles in the initiation and development of inflammatory diseases. However, the combined inflammation-stimulatory effect of AGEs and lipopolysaccharide on endothelial cells, and, furthermore, the underlying signal transduction pathways involved, have not been fully elucidated. We found that in vitro co-stimulation with AGE-human serum albumin (HSA) and lipopolysaccharide exhibits a synergistic effect on proinflammatory cytokine/chemokine interleukin-6, interleukin-8 and monochemoattractant protein-1 production in human umbilical vein endothelial cells. Similar to lipopolysaccharide, AGE-HSA stimulation induced mitogen-activated protein kinase phosphorylation and nuclear factor-kappaB nuclear translocation in human umbilical vein endothelial cells, which was further enhanced by a combination of the two stimulants. Pharmacological inhibitions of each individual signaling pathway, including p38, extracellular signal-regulated kinase 1/2, Jun N-terminal kinase and nuclear factor-kappaB, revealed that activation of all of these four pathways is necessary for the effective induction of interleukin-6, interleukin-8 and monochemoattractant protein-1 by both AGE-HSA and lipopolysaccharide. These results suggest that AGEs and lipopolysaccharide cooperatively induce proinflammatory cytokine/chemokine production by activating mitogen-activated protein kinases and nuclear factor-kappaB in endothelial cells, thus amplifying the inflammatory response and resulting in tissue damage.

Psychoneuroimmune implications of type 2 diabetes: redux

A sizable body of knowledge has arisen demonstrating that type 2 diabetes (T2D) is associated with alterations in the innate immune system. The resulting proinflammatory-leaning imbalance is implicated in the development of secondary disease complications and comorbidities, such as delayed wound healing, accelerated progress of atherosclerosis, and retinopathy, in people who have T2D. New experimental data and the results of recently published health-related quality-of-life surveys indicate that individuals who have T2D experience diminished feelings of happiness, well being, and satisfaction with life. These emotional and psychological consequences of T2D point to altered neuroimmunity as a previously unappreciated complication of T2D. This article discusses recent data detailing the impact of T2D on a person's PNI response.

Prognosis of primary care patients aged 80 years and older with lower respiratory tract infection

BACKGROUND

Predictors for a complicated course of a lower respiratory tract infection (LRTI) episode among patients aged > or =80 years are unknown.

AIM

To determine prognostic factors for hospital admission or death within 30 days after first onset of LRTI among primary care patients aged > or =80 years.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

Utrecht General Practitioner Research Network.

METHOD

Data were obtained using the computerised database of the research network over the years 1997 to 2003. Multivariable logistic regression analysis was applied to estimate the independent association of predictors with 30-day hospitalisation or death.

RESULTS

In all, 860 episodes of LRTI were observed in 509 patients; 13% of patients were hospitalised or died within 30 days. Type of LRTI, diabetes, use of oral glucocorticoids, use of antibiotics in the previous month, and hospitalisation in the previous 12 months were independently associated with the combined outcome. Patients with insulin-dependent diabetes mellitus had a greater risk of 30-day hospitalisation or death compared with patients with non-insulin-dependent diabetes.

CONCLUSION

Independent of age, serious comorbidity - notably the presence of insulin-dependent diabetes or exacerbation of chronic obstructive pulmonary disease requiring oral glucocorticoids - increases the risk for complications, including hospital admissions, in patients aged > or =80 years with an LRTI.

Incidence and antibiotic prescription rates for common infections in patients with diabetes in primary care over the years 1995 to 2003

OBJECTIVE

To assess changes in incidence and in antibiotic prescription rates for infections of the lower respiratory tract (LRTI) and urinary tract (UTI) in patients with diabetes (DM) over the years 1995 to 2003.

METHODS

This was a retrospective cohort study as part of the University Medical Center Utrecht General Practitioners Research Network. We included patients with DM aged > or = 45 years. We assessed incidence and antibiotic prescription rates for LRTI and UTI. Incidence rates were calculated as episodes per 1000 person-years. Antibiotic prescription rates were calculated per 100 episodes of LRTI and UTI.

RESULTS

The study population increased over the years 1995 to 2003. The male-to-female ratio and mean age of the study population remained constant over these years. The incidence rate for LRTI remained stable (13%; p=0.442), and for UTI the incidence rate increased by 40% (p=0.037). Antibiotic prescription rates increased in LRTI by 60% (p<0.001) and in cystitis by 15% (p=0.029).

CONCLUSIONS

Incidence rates for UTI and antibiotic prescription rates for LRTI in diabetes have increased over the years 1995 to 2003. In particular, attention should be paid to the increasing use of antibiotics in DM patients with LRTI.

Evaluation of cytokine production from peripheral blood mononuclear cells of type 1 diabetic patients

This study aims to evaluate the production of cytokines, tumor necrosis factor (TNF), and interleukin 10 (IL-10) in peripheral blood mononuclear cells (PBMCs) from type 1 diabetic (T1D) patients by means of intracellular staining, flow cytometry, and ELISA and to correlate it with inadequate (IN) and adequate (A) metabolic controls. We studied 28 patients with T1D and 20 healthy individuals (C) paired by sex and age. T1D patients were divided in patients with IN and A metabolic control. PBMC cultures were stimulated with LPS to evaluate TNF or were stimulated with PMA/ionomycin or concanavalin A to evaluate IL-10. The TNF levels in supernatant of stimulated cultures, evaluated by ELISA, of diabetic patients were similar to those of healthy individuals, although the percentage of CD 33(+) cells that were positive for TNF was higher in the T1D IN group compared to the T1D A group (P= 0.01). Similarly, the IL-10 levels evaluated by ELISA in stimulated cultures of T1D patients were not different from those in the control group; moreover, the percentage of CD3(+) cells positive for intracellular IL-10 were higher in the T1D IN group compared to C groups (P= 0.007). The increased levels of cytokines in T1D IN diabetic patients, with reduction in the A group, suggests that hyperglycemia stimulates an inflammatory state that can result in a deficient immune cellular response. The data suggest that assessment by intracellular staining seems to be more accurate than the ELISA technique in evaluating diabetic patients.

Tracking down immune markers from alternative system pathway factors in a diabetic population

Hyperglycemia associated with type 1 diabetes (T1D) alters the host immune system, resulting in a predisposition to infectious diseases. The high risk of infection in the diabetic population may lead to life-threatening situations. The early proteins of the alternative complement system pathway, constituting factors P, B, and D, have been shown to play an important role in preventing infection because they form a membrane attack complex (MAC)-C5-9, which debilitates the target microbes and/or molecules via cytotoxic and cytolytic reactions. Patients who are devoid of or contain low levels of these proteins may be susceptible to developing chronic infections. We have observed striking differences in partially fractionated serum proteins in diabetic patients (type 2) relative to controls, through single and two-dimensional gel electrophoresis. Our data, obtained from 50 diabetic patients in the age group of 25-45 years, who had the disease for fewer than 5 years, indicated patterns in low- and high-molecular-weight proteins, which could be grouped into five different categories with minor differences in their respective levels of protein expression. Immunoblot assay could barely detect the presence of properdin expression in diabetic patients. Quantization by ELISA in 99 patients indicated low levels of properdin expression in 70% of 50 diabetic patients (6.5 +/- 3 mug/mL) when compared to nondiabetic controls (19.5 +/- 8.5 mug/mL). This study concluded that patients with low expression of properdin should be advised to take extensive preventive measures and seek early management with appropriate treatments against infection.

Effect of the glycemic control on intracellular cytokine production from peripheral blood mononuclear cells of type 1 and type 2 diabetic patients

AIMS

To evaluate the intracellular production of tumor necrosis factor (TNF-alpha), interleukine-6 (IL-6), INF-gamma, IL-8 and IL-10 in peripheral blood lymphomononuclear cells from type 1 and type 2 diabetic patients, stratified according to the glycemic control.

METHODS

Thirty-five diabetic patients (17 type 1 and 18 type 2) and nine healthy individuals paired to patients in terms of sex and age were studied. Nine patients of each group were on inadequate glycemic controls. Intracellular cytokines were evaluated using flow cytometry. Cell cultures were stimulated with LPS to evaluate TNF-alpha and IL-6 or with PMA and Ionomycin to evaluate IFN-gamma, IL-8 and IL-10 intracellular staining.

RESULTS

The percentages of CD33(+) cells bearing TNF-alpha and CD3(+) cells bearing IL-10 were increased in type 1 diabetic patients with inadequate glycemic control in relation to those with adequate control. In contrast, the percentage of CD3(+) cells bearing IL-8 was decreased in type 2 patients under inadequate glycemic control.

CONCLUSIONS

The glycemic control is important for the detection of intracellular cytokines, and may contribute towards the susceptibility to infections in diabetic patients.

Diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study

OBJECTIVE

To examine whether diabetes is a risk factor for hospitalization with pneumonia and to assess the impact of A1C level on such risk.

RESEARCH DESIGN AND METHODS

In this population-based, case-control study we identified patients with a first-time pneumonia-related hospitalization between 1997 and 2005, using health care databases in northern Denmark. For each case, 10 sex- and age-matched population control subjects were selected from Denmark's Civil Registration System. We used conditional logistic regression to compute relative risk (RR) for pneumonia-related hospitalization among subjects with and without diabetes, controlling for potential confounding factors.

RESULTS

The study included 34,239 patients with a pneumonia-related hospitalization and 342,390 population control subjects. The adjusted RR for pneumonia-related hospitalization among subjects with diabetes was 1.26 (95% CI 1.21-1.31) compared with nondiabetic individuals. The adjusted RR was 4.43 (3.40-5.77) for subjects with type 1 diabetes and 1.23 (1.19-1.28) for subjects with type 2 diabetes. Diabetes duration >or=10 years increased the risk of a pneumonia-related hospitalization (1.37 [1.28-1.47]). Compared with subjects without diabetes, the adjusted RR was 1.22 (1.14-1.30) for diabetic subjects whose A1C level was <7% and 1.60 (1.44-1.76) for diabetic subjects whose A1C level was >or=9%.

CONCLUSIONS

Type 1 and type 2 diabetes are risk factors for a pneumonia-related hospitalization. Poor long-term glycemic control among patients with diabetes clearly increases the risk of hospitalization with pneumonia.

Differences in the pattern of antibiotic prescription profile and recurrence rate for possible urinary tract infections in women with and without diabetes

OBJECTIVE

Women with diabetes have a high incidence and complication rate of urinary tract infections (UTIs). Our aims were to compare current treatment strategies with respect to recurrence rates in women with diabetes with those without diabetes.

RESEARCH DESIGN AND METHODS

We used a Dutch registration database containing pharmacy dispensing data. A total of 10,366 women with diabetes (17.5% premenopausal) (aged < or =55 years) and 200,258 women without diabetes (68% premenopausal) who received a first course of trimethoprim, nitrofurantoin, fosfomycin, or norfloxacin between January 1999 and January 2006 were included. We compared short (< or or =5 days) with long (>5 days) prescriptions and norfloxacin with trimethoprim, nitrofurantoin, and fosfomycin. A recurrence was defined as a second prescription for one of the above-mentioned agents or a first with amoxicillin (clavulanic acid), fluoroquinolones, or trimethoprim/sulfamethoxazole between 6 and 30 days after inclusion.

RESULTS

Premenopausal women with diabetes more often received a long (26.5 vs. 19.2%; P < 0.001) treatment with norfloxacin (10.7 vs. 6.2%; P < 0.001) but still had a higher recurrence rate (16.1 vs. 12.2%; P = 0.003) compared with those without diabetes. Similarly, postmenopausal women with diabetes more often received a longer (32.8 vs. 28.8%; P < 0.001) treatment with norfloxacin (15.2 vs. 12.7%; P < 0.001) but had a higher recurrence rate (19.1 vs. 16.4%; P < 0.001) compared with those without diabetes.

CONCLUSIONS

Despite the fact that patients with diabetes more often received longer and more potent initial treatment than patients without diabetes, pre- and postmenopausal women with diabetes more often had recurrences of their UTIs.

N-3 polyunsaturated fatty acids modulate in-vitro T cell function in type I diabetic patients

In this work, we assessed the in-vitro effects of eicosapentaenoic acid (EPA; C20:5n-3) and docosahexaenoic acid (DHA; C22:6n-3) (final concentration, 15 microM) on T cell blastogenesis, interleukin-2 and -4 (IL-2, IL-4) secretion, fatty acid composition and intracellular oxidative status in type I diabetic patients with or without complications. Con A stimulated lymphocyte proliferation, glucose uptake, intracellular reduced glutathione levels and catalase activity were lower in diabetics as compared to controls, regardless to the presence of complications. EPA and DHA diminished T-lymphocyte proliferation and IL-2 production but enhanced IL-4 secretion in both diabetic and control groups. No changes in the levels of reduced glutathione and in the activities of catalase and SOD were observed in control T cells cultured in the presence of EPA and DHA. However, in diabetic patients, addition of n-3 PUFA to culture induced an increase in T cell levels of reduced glutathione and hydroperoxide, and in activities of catalase and SOD. Low levels of arachidonic acid (C20:4n-6) were found in plasma membrane phospholipids of lymphocytes from diabetic patients compared to controls. Incubation of lymphocytes with EPA and DHA was associated with an incorporation of these fatty acids in membrane phospholipids. In conclusion, the beneficial effects of n-3 PUFA on T cell functions in type I diabetes could be attributed to their suppressive action and modulation of cytokine secretion, and to the improvement of intracellular oxidative status.

Diabetes-induced alteration of F4/80+ macrophages: a study in mice with streptozotocin-induced diabetes for a long term

Macrophages as an early stage of immune responses form a bridge between innate and acquired immunity and shape the adaptive immune response. The immunoregulatory functions of macrophages in hosts with a prolonged exposure to a diabetic milieu remain to be determined. The levels, phenotype, and immunity including antigen-presenting ability, phagocytosis and immunogenicity of F4/80+ splenic macrophages (SPMs), and peritoneal exudates macrophages (PEMs) were detected in age-matched control mice and mice with streptozotocin (STZ)-induced diabetes for 16 weeks. The numbers of F4/80+ SPMs and PEMs significantly decreased in STZ-induced diabetic mice, compared with age-matched non-diabetic mice (control) at 16 weeks after diabetes induction. Functional analysis showed that F4/80+ SPMs and PEMs in STZ-induced diabetic mice exhibit significantly lower immunogenicity and nonopsonic phagocytosis to allogeneic T cells than those of control mice both in vitro and in vivo. Coincidently, the antigen-presenting capacity of F4/80+ PEMs, but not F4/80+ SPMs, in mice with STZ-induced diabetes for 16 or more weeks is also significantly lower than that of control mice. Our results showed that total cell number and immune function of F4/80+ macrophages were significantly defective in mice with a prolonged exposure to a diabetic milieu, which may be a mechanism responsible for the increased macrophage-related complications in diabetic patients such as the high prevalence of infection and cardiovascular mortality.

Hyperglycemia enhances coagulation and reduces neutrophil degranulation, whereas hyperinsulinemia inhibits fibrinolysis during human endotoxemia

Type 2 diabetes is associated with altered immune and hemostatic responses. We investigated the selective effects of hyperglycemia and hyperinsulinemia on innate immune, coagulation, and fibrinolytic responses during systemic inflammation. Twenty-four healthy humans were studied for 8 hours during clamp experiments in which either plasma glucose, insulin, both, or none was increased, depending on randomization. Target plasma concentrations were 5 versus 12 mM for glucose, and 100 versus 400 pmol/L for insulin. After 3 hours, 4 ng/kg Escherichia coli endotoxin was injected intravenously to induce a systemic inflammatory and procoagulant response. Endotoxin administration induced cytokine release, activation of neutrophils, endothelium and coagulation, and inhibition of fibrinolysis. Hyperglycemia reduced neutrophil degranulation (plasma elastase levels, P < .001) and exaggerated coagulation (plasma concentrations of thrombin-antithrombin complexes and soluble tissue factor, both P < .001). Hyperinsulinemia attenuated fibrinolytic activity due to elevated plasminogen activator-inhibitor-1 levels (P < .001). Endothelial cell activation markers and cytokine concentrations did not differ between clamps. We conclude that in humans with systemic inflammation induced by intravenous endotoxin administration hyperglycemia impairs neutrophil degranulation and potentiates coagulation, whereas hyperinsulinemia inhibits fibrinolysis. These data suggest that type 2 diabetes patients may be especially vulnerable to prothrombotic events during inflammatory states.

Short-term effects of an educational program on health-seeking behavior for infections in patients with type 2 diabetes: a randomized controlled intervention trial in primary care

OBJECTIVE

The aim of this study was to assess the short-term effects of an educational program on (determinants of) self-reported health-seeking behavior for infections of the urinary tract (UTIs) and lower respiratory tract (LRTIs) in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In a randomized controlled trial, 1,124 patients with type 2 diabetes aged between 44 and 85 years participated. The intervention consisted of a multifaceted educational program with an interactive meeting, a leaflet, a Web site, and a consultation with the diabetes care provider. The program focused on the needs of patients, apparent from a prior focus group and questionnaire study. The primary outcome measure was an indicator of health-seeking behavior for UTIs and LRTIs, defined as the proportion of participants with a positive score on at least seven of nine determinants, six from the Health Belief Model and the additional three domains of knowledge, need for information, and intention. The primary outcome was measured with questionnaires at baseline and after 5 months.

RESULTS

Complete outcome data were available for 468 intervention group patients and 472 control group patients. In all, 68% of the intervention group patients attended the meeting. At baseline, 28% of the participants from the intervention group had a positive score on seven of the nine determinants, compared with 27% from the control group. After the educational program, these percentages were 53 and 32%, respectively (P < 0.001).

CONCLUSIONS

Our educational program positively influenced determinants of health-seeking behavior for common infections in patients with type 2 diabetes.

Urinary tract infections in patients with diabetes mellitus: epidemiology, pathogenesis and treatment

Patients with diabetes mellitus (DM) have a higher prevalence of asymptomatic bacteriuria (ASB) and incidence of urinary tract infections (UTIs) compared with patients without DM. They also more often have bacteraemia, with the urinary tract as the most common focus for these infections, as well as a higher mortality outside the hospital compared with patients without DM. It appears that the increased prevalence of ASB in diabetic women is not the result of a difference in causative bacteria, as the same virulence factors and resistance to antimicrobials were found in Escherichia coli isolated from the urine of diabetic women with ASB compared with non-diabetic controls. Bacterial growth in vitro is increased after the addition of glucose, however glucosuria is not a risk factor for ASB or for the development of UTIs in vivo. No differences in granulocyte function tests were demonstrated among diabetic women with ASB, non-bacteriuric women and healthy control subjects, but women with both ASB and DM had lower urinary cytokine and leukocyte concentrations than women with ASB without DM. Finally, it was found that E. coli expressing type 1 fimbriae adhere better to uroepithelial cells of women with DM compared with those isolated from women without DM. There are no randomised trials that answer the question as to the optimal duration of treatment for UTIs in diabetic patients. It has been recommended to consider these patients as having a complicated UTI and therefore to treat them for a period of 7-14 days.

Necrotizing fasciitis in adolescents with poorly controlled type 1 diabetes mellitus: report of two cases

Necrotizing fasciitis (NF) is a potentially fatal bacterial infection of the subcutaneous soft tissues. Two cases of polymicrobial NF in adolescents with type 1 diabetes mellitus and poor glycemic control are reported. The perineal region was involved in both cases. One case was precipitated by apparently minimal trauma, the other by high-impact trauma. Diabetes mellitus has been identified as a common comorbidity and predictor of increased mortality in adult patients with NF. The associations between diabetes and the incidence or outcome of NF in children and adolescents are not known. In all cases, early identification and aggressive surgical intervention are important for limiting morbidity and mortality.

Impaired cytokine production by peripheral blood mononuclear cells in type 1 diabetic patients

AIMS

The objective of the present investigation was to study the production of IL-1, IL-6, IL-10, IFNgamma and TNFalpha in cultures of peripheral blood mononuclear cells (PBMC) taken from type 1 diabetic patients with inadequate metabolic control.

METHODS

Seventeen type 1 diabetic patients and a gender- and age-matched group of 17 healthy individuals were studied. PBMC cultures were stimulated with phytohemagglutinin (PHA; 20 microg/ml) and lipopolysaccharide (LPS; 10 microg/ml), and enzyme immunoassay (Elisa) was used to measure IL-1, IL-6, IL-10, IFNgamma and TNFalpha in the cell-culture supernatants.

RESULTS

IFNgamma levels in PHA-stimulated cultures were lower in the type 1 diabetics than in the non-diabetic controls (P<0.0001) while, in contrast, IL-10 levels were increased in the PHA-stimulated culture supernatants of the diabetics compared with the controls (P<0.0001). In addition, supernatant levels of the cytokines IL-1, IL-6 and TNFalpha released in the presence of LPS in the cell cultures from the diabetic patients were significantly lower than in the non-diabetic subjects (P<0.0001, P<0.0001 and P<0.03, respectively).

CONCLUSIONS

The impaired production of IL-1, IL-6, TNFalpha and IFNgamma, and the increased production of IL-10, in PBMC cultures from type 1 diabetics with inadequate metabolic control compared with healthy subjects may be an indication of a deficiency in mononuclear cell activation and, consequently, a deficient immune cellular adaptive response that, in turn, may be the cause of the increased incidence of infections in people with type 1 diabetes.

Acceptability and effects of an educational leaflet on infections in type 2 diabetes patients: a randomized controlled trial in primary care

AIM

To determine the acceptability of an educational leaflet regarding the prevention and treatment of infections of the lower respiratory tract (LRTIs) and urinary tract (UTIs) and to determine the effects of the leaflet on knowledge and attitude of DM2 patients in primary care.

METHOD

In a randomized controlled intervention trial 200 DM2 patients enlisted in two practices, one urban and one rural, from the Utrecht general practitioners Research Network (HNU) were selected. Per practice, 50 patients were randomly assigned to the intervention group and 50 to the control group. The intervention was a leaflet on diabetes and LRTIs and UTIs based on the results of focus group interviews. The leaflet was sent to the patients homes. The outcome measures were acceptability of the leaflet and differences in knowledge and attitude, measured by a questionnaire.

RESULTS

The mean age was 68 years and 55% was male. There were no substantial differences in characteristics between the two groups. Among the intervention group, the leaflet was appreciated as understandable (100%) and inviting (79%). Compared to the control group, specific knowledge and attitude did not substantially differ. Patients in the intervention group had a slightly more positive attitude about 'being attentive to signs indicating pneumonia' (median difference, 1 point; p=.003) and they also answered 'UTI is mostly caused by a bacteria' more often correctly (risk difference, 18%; 95% CI, 4-33%, p=.016).

CONCLUSION

A leaflet on prevention and treatment of LRTIs and UTIs is considered acceptable among DM2 patients, but a multi-faceted educational approach may be needed to improve health behavioral determinants.

Increased Fructose 2,6-bisphosphate in peripheral blood mononuclear cells of patients with diabetes

Fructose 2,6-bisphosphate (F2,6BP) is a powerful allosteric activator of 6-phosphofructo-1-kinase, which is the rate-limiting enzyme for glycolysis. Mitogenic stimulation of lymphocytes is related to an enhanced rate of glucose utilization and F2,6BP mediated activation of glycolysis. To determine the effect of hyperglycemia on intracellular glycolysis of lymphocytes, we measured intracellular F2,6BP content in peripheral blood mononuclear cells obtained from patients with diabetes and normal subjects. A total of 62 subjects participated in the present study. Venous blood samples were collected and peripheral blood mononuclear cells were separated by Ficoll gradients. Intracellular F2,6BP levels in peripheral blood mononuclear cells from normal control subjects were significantly lower than age-matched diabetic subjects. We observed a significant positive correlation between intracellular F2,6BP levels and long term glycemic control, as assessed by HbA1c. These data suggest that hyperglycemia increases intracellular F2,6BP in immune cells. These findings may help to clarify the impaired function in immune cells in patients with diabetes.

Results of general internal medicine consultations for diabetes mellitus in 283 cancer patients

BACKGROUND

Diabetes is a major reason for patient referral to the General Internal Medicine (GIM) Department at M.D. Anderson Cancer Center. Previous studies of various factors that affect diabetes care have not focused on cancer patients. The objective of this study was to examine the level of diabetic care received by cancer patients.

METHODS

We conducted a retrospective chart review of 283 consecutive GIM patients with diabetes in the years 2000 to 2001. For each patient, data were collected about the cancer, diabetes-related history, and the general internist's recommendations for further diabetes care. Patients were stratified by whether their cancer was controlled (stable or in remission) or uncontrolled (being actively treated by an oncologist or said to be progressive). chi tests and t tests were used to compare means for controlled cancer and uncontrolled cancer patient groups, with a value of P < 0.05 being considered significant.

RESULTS

Patients with controlled cancer were more likely to have a lipid profile ordered (P < 0.001) or to be referred for diabetes-specific ophthalmology evaluation (P = 0.02). On logistic regression analysis, increasing patient age was associated with less frequent HgbA1c testing (P = 0.01), and both advanced age and uncontrolled cancer were associated with less lipid testing and ophthalmology referral.

CONCLUSIONS

Patients with uncontrolled advanced cancer were not as aggressively treated for diabetes, especially if they were elderly. Further work should evaluate whether the observed level of diabetes care was appropriate and could affect patient outcome.

Increased polymorphonuclear leukocyte respiratory burst function in type 2 diabetes

The predisposition to infection and chronic inflammation in diabetes may in part be related to the effects of hyperglycemia or other metabolic abnormality on polymorphonuclear leukocytes (PMN). We evaluated oxidative respiratory burst activity (superoxide production) in non-stimulated and stimulated PMN from 70 stable type 2 Hispanic diabetic patients, as compared to 70 healthy Hispanic individuals without diabetes. The influences of protein kinase C (PKC) inhibitors and certain antibiotics on superoxide production were examined. Both resting and stimulated (PMA, zymosan) PMN from diabetic individuals produced more superoxide than PMN from controls. Inhibitors of PKC, a possible mediator of the augmented respiratory burst activity, decreased superoxide production in all (resting and stimulated) diabetic and control PMN. Azithromycin, which is markedly concentrated by PMN, profoundly inhibited superoxide generation in all groups of diabetic and control cells. PMN from Hispanic diabetic patients produced greater quantities of superoxide than non-diabetic controls. This increased oxidative respiratory burst activity may predispose to infection and chronic inflammation in diabetes. PKC inhibitors and azithromycin inhibited this respiratory burst response. The possible role of PKC (especially PKC beta) as the mediator of this augmented respiratory burst response requires further evaluation, and may lead to therapeutic studies with appropriate inhibitors.

Influence of diabetes and hyperglycaemia on infectious disease hospitalisation and outcome

AIMS/HYPOTHESIS

Diabetes mellitus is believed to increase susceptibility to infectious diseases. The effects of hyperglycaemia per se on infectious disease risk are unknown and the influence of diabetes on infectious disease outcome is controversial.

MATERIALS AND METHODS

We studied 10,063 individuals from the Danish general population, who were participants in The Copenhagen City Heart Study, over a follow-up period of 7 years. Risk of hospitalisation caused by any infectious disease, and subsequent risk of disease progression to death were estimated by Cox proportional hazards regression analysis.

RESULTS

At baseline, 353 individuals reported having diabetes. During 71,509 person-years of follow-up, a total of 1,194 individuals were hospitalised because of an infection. The risk of pneumonia (adjusted hazard ratio [aHR] 1.75, 95% CI 1.23-2.48), urinary tract infection (aHR 3.03, 95% CI 2.04-4.49) and skin infection (aHR 2.43, 95% CI 1.49-3.95) was increased in subjects with diabetes compared with subjects without. Each 1 mmol/l increase in plasma glucose at baseline was associated with a 6-10% increased relative risk of pneumonia, urinary tract infection and skin infection after adjustment for other possible confounders. Among patients hospitalised for urinary tract infection, diabetic patients were at an increased risk of death at 28 days after admission compared with non-diabetic subjects (HR 3.90, 95% CI 1.20-12.66).

CONCLUSIONS/INTERPRETATION

In the Danish general population, diabetes and hyperglycaemia are strong and independent risk factors for hospitalisation as a result of pneumonia, urinary tract infection and skin infection. Further, diabetes has a negative impact on the prognosis of urinary tract infection.

Antibiotic prescribing for chronic skin wounds in primary care

The aim of this study was to describe and quantify systemic antibiotic prescribing for patients with chronic skin wounds presenting at the primary care, nonspecialist setting. Data for 1 year were extracted from a general practice morbidity database comprising approximately 185,000 patients attending family medical practitioners in Wales. Patients with chronic wounds (PCW) were identified using Read Codes and compared with nonwound patients who were randomly selected after matching for age-band, sex, and general practice. PCW received a significantly greater number of antibiotic courses than nonwound patients (p<0.001). This increased level of prescribing was evident for flucloxacillin, co-amoxiclav, cefaclor, cefalexin, erythromycin, trimethoprim, metronidazole, and ciprofloxacin (p<0.01 for all). While PCW also had a significantly higher prevalence of diabetes (16.5% compared with 6.6%, p<0.001), and attended at general practice significantly more frequently than nonwound patients (median (interquartile range) of 25 (17-40) visits per year compared with 12 (4-20), p<0.001), importantly, exclusion of diabetic patients and analysis of the proportion of visits on which patients received antibiotics did not affect the significance of the difference in antibiotic consumption. These data show a strong association between occurrence of chronic wounds and prescribing of antibiotics in primary health care, and wide variation in the type and duration of antibiotic therapy for chronic wounds. Further work is now indicated to rationalize this prescribing and determine the role that this exposure to antibiotics plays in the prevalence of antibiotic resistance in this at-risk elderly population.

Augmented Lipopolysaccharide-Induced TNF-α Production by Peritoneal Macrophages in Type 2 Diabetic Mice Is Dependent on Elevated Glucose and Requires p38 MAPK

Dysregulated inflammation is a complication of type 2 diabetes (T2D). In this study, we show that augmented LPS-induced TNF-alpha production by resident peritoneal macrophages (PerMphi) in type 2 diabetic (db/db) mice is dependent on elevated glucose and requires p38 MAPK. Intraperitoneal LPS administered to db/db and nondiabetic (db/+) mice induced 3- and 4-fold more TNF-alpha in the peritoneum and serum, respectively, of db/db mice as compared with db/+ mice. Examination of the TLR-4/MD2 complex and CD14 expression showed no difference between db/db and db/+ PerMphi. Ex vivo stimulation of PerMphi with LPS produced a similar 3-fold increase in TNF-alpha production in db/db PerMphi when compared with db/+ PerMphi. PerMphi isolated from db/+ mice incubated in high glucose (4 g/L) medium for 12 h produced nearly 2-fold more TNF-alpha in response to LPS than PerMphi incubated in normal glucose medium (1 g/L). LPS-dependent stimulation of PI3K activity, ERK1/2 activation, and p38 kinase activity was greater in PerMphi from db/db mice as compared with db/+ mice. Only inhibition of p38 kinase blocked LPS-induced TNF-alpha production in PerMphi from db/db mice. Taken together, these data indicate that augmented TNF-alpha production induced by LPS in macrophages during diabetes is due to hyperglycemia and increased LPS-dependent activation of p38 kinase.

Common infections in diabetes: pathogenesis, management and relationship to glycaemic control

Specific defects in innate and adaptive immune function have been identified in diabetic patients in a range of in vitro studies. However, the relevance of these findings to the integrated response to infection in vivo remains unclear, especially in patients with good glycaemic control. Vaccine efficacy seems adequate in most diabetic patients, but those with type 1 diabetes and high glycosylated haemoglobin levels are most likely to exhibit hypo-responsiveness. While particular infections are closely associated with diabetes, this is usually in the context of extreme metabolic disturbances such as ketoacidosis. The link between glycaemic control and the risk of common community-acquired infections is less well established but could be clarified if infection data from large community-based observational or intervention studies were available. The relationship between hospital-acquired infections and diabetes is well recognized, particularly among post-operative cardiac and critically ill surgical patients in whom intensive insulin therapy improves clinical outcome independent of glycaemia. Nevertheless, further research is needed to improve our understanding of the role of diabetes and glycaemic control in the pathogenesis and management of community- and hospital-acquired infections.

Macro and microvascular complications are determinants of increased infection-related mortality in Brazilian type 2 diabetes mellitus patients

OBJECTIVE

To investigate infection-related mortality and its predictors in Brazilian type 2 diabetic patients.

METHODS

It was carried out a long-term prospective study with 471 type 2 diabetic outpatients. Several clinical, laboratory and electrocardiographic variables were recorded at baseline. Predictive factors for infection-related mortality were evaluated by Kaplan-Meyer estimation of survival curves, univariate and multivariate Cox survival analysis. Excess infection-related mortality in this cohort was evaluated by comparing its rate with that of the Rio de Janeiro background population and calculating standardized mortality rates (SMR).

RESULTS

During a median follow up of 57 months (range: 1-86 months), 40 (33.1%) patients died from infection-related causes. After adjusting for age and sex, the infection-related SMR was 6.6 (95% confidence interval [95% CI]: 4.8-9.0). In Cox multivariate analysis the predictors of infection-related mortality were older age (hazard ratio [HR]: 1.91; 95% CI: 1.35-2.70), pre-existing peripheral arterial disease (HR: 3.86; 95% CI: 1.80-8.28) and cerebrovascular disease (HR: 3.28; 95% CI: 1.24-8.70), lower HDL-cholesterol (HR: 2.50; 95% CI: 1.32-4.74) and increased 24h-proteinuria (HR: 1.22; 95% CI: 1.08-1.37). After excluding patients with peripheral and cerebrovascular disease at baseline, neuropathy and coronary heart disease were selected as predictors of mortality, besides older age and proteinuria.

CONCLUSIONS

Brazilian type 2 diabetic patients have a six-fold excess infection-related mortality than the general population. This increased mortality is mainly determined by the presence of micro and macrovascular complications. Multifactorial risk interventions are needed in order to decrease this burden of infection-related mortality.

Influence of perioperative blood glucose levels on outcome after infrainguinal bypass surgery in patients with diabetes

BACKGROUND

High glucose levels are associated with increased morbidity and mortality after coronary surgery and in intensive care. The influence of perioperative hyperglycaemia on the outcome after infrainguinal bypass surgery among diabetic patients is largely unknown. The aim was to determine whether high perioperative glucose levels were associated with increased morbidity after infrainguinal bypass surgery.

METHODS

Ninety-one consecutive diabetic patients undergoing primary infrainguinal bypass surgery were identified from a prospective vascular registry. Risk factors, indication for surgery, operative details and outcome data were extracted from the medical records. Exposure to perioperative hyperglycaemia was measured using the area under the curve (AUC) method; the AUC was calculated using all blood glucose readings during the first 48 h after surgery.

RESULTS

Multivariable analysis showed that the AUC for glucose (odds ratio (OR) 13.35, first versus fourth quartile), renal insufficiency (OR 4.77) and infected foot ulcer (OR 3.38) was significantly associated with poor outcome (death, major amputation or graft occlusion at 90 days). Similarly, the AUC for glucose (OR 14.45, first versus fourth quartile), female sex (OR 3.49) and tissue loss as indication (OR 3.30) was associated with surgical wound complications at 30 days.

CONCLUSION

Poor perioperative glycaemic control was associated with an unfavourable outcome after infrainguinal bypass surgery in diabetic patients.

Osteomyelitis in the diabetic foot: diagnosis and management

Neuropathic ulcerations and altered immune function place the diabetic patient at increased risk for polymicrobial osteomyelitis of the foot and ankle. The optimal method for evaluation and management of this difficult condition is controversial, and further studies are needed. Infected ulcers with exposed or palpable bone can be assumed to have underlying osteomyelitis. Although plain film should be ordered in each case, MRI is most often used for evaluation and surgical planning. Difficult cases, such as those associated with Charcot osteoarthropathy, may require labeled leukocyte scanning or bone biopsy to arrive at the diagnosis. A multidisciplinary team approach is best, allowing optimal treatment of all associated conditions that commonly affect patients with diabetes mellitus. Vascular evaluation and intervention are critical in the presence of vascular insufficiency or ischemia. Empiric, usually broad-spectrum antibiotics and meticulous local wound care may achieve remission of mild to moderately severe infections and should be included in all treatment regimens. Severe, infections, ischemia, or sepsis requires an aggressive surgical approach. Bone resection, correction of deformity, or amputation often are necessary and should be done with the goal of salvaging a functional foot.

Diabetic foot disorders. A clinical practice guideline (2006 revision)

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal.

Psychoneuroimmune Implications of Type 2 Diabetes

The idea that type 2 diabetes is associated with augmented innate immune function characterized by increased circulating levels of acute phase reactants and altered macrophage biology is fairly well established, even though the mechanisms involved in this complex interaction still are not entirely clear. To date, the majority of studies investigating innate immune function in type 2 diabetes are limited to the context of wound healing, atherosclerosis, stroke, and other commonly identified comorbidities. Several important recurring themes come out of these data. First, type 2 diabetes is associated with a state of chronic, subclinical inflammation. Second, in macrophages, type 2 diabetic conditions enhance proinflammatory reactions and impair anti-inflammatory responses. Third, after acute activation of the innate immune system in type 2 diabetes, recovery or resolution of inflammation is impaired. The consequences of type 2 diabetes-associated inflammatory alterations on PNI processes have been recognized only recently. Given the impact of diminished emotional well-being on the quality of life in patients who have type 2 diabetes, diabetes-induced exacerbation of PNI responses should be considered a serious complication of type 2 diabetes that warrants further clinical attention.

Effect of metabolic control on the in vitro proliferation of peripheral blood mononuclear cells in type 1 and type 2 diabetic patients

CONTEXT AND OBJECTIVE

Diabetes mellitus is a clinical syndrome that frequently leads to the development of chronic complications and high susceptibility to infections. It is probably due to defective immunological defense, which may be related to metabolic control of the disease. The aim of this study was to evaluate the effect of metabolic control on immune-cell behavior in type 1 and type 2 diabetic patients. For this, the in vitro proliferation of peripheral blood mononuclear cells (PBMC) was analyzed in patients with inadequate and adequate metabolic control.

DESIGN AND SETTING

Experimental/laboratory study at a university hospital.

METHODS

Eleven type 1 and thirteen type 2 diabetic patients were studied, together with 21 healthy individuals divided in two groups (11/10), who were matched by sex and age with those diabetic patients. PBMC cultures stimulated with concanavalin-A (Con-A) were used to measure 3H-thymidine incorporation after 72 hours of cell culturing. For patients with inadequate metabolic control, culturing was performed on the first day of patient hospitalization and again after intensive treatment to achieve adequate control.

RESULTS

The proliferation index for Con-A-stimulated cultures from type 1 diabetic patients was significantly greater than that for cultures from healthy individuals and type 2 diabetic patients, independent of metabolic control. A negative correlation between the proliferation cell index and body mass index and serum C-reactive protein levels was also observed.

CONCLUSION

The increase in the proliferation capacity of type 1 diabetic T lymphocytes was probably not caused by hyperglycemia and/or insulinopenia related to inadequate metabolic control.

[Diabetes and heart transplantation]

Diabetes is frequently encountered in patients presenting with end-stage heart failure to be listed for transplantation. While diabetes used to be a contra-indication for heart transplantation, careful preoperative evaluation and individualized postoperative medication lead to long-term outcome after heart transplantation equal to non-diabetic patients. About 1/3 of transplanted patients develop a post-transplant diabetes. Several risk factors have been identified leading to this condition. Mostly, post-transplant diabetes is of temporary nature. Several studies have shown no impact of diabetes on the incidence of rejection, malignancies, and transplant vasculopathy. However, glucose intolerance must be taken into consideration when planing immunosuppressive therapy since different medications have distinct impact on glucose metabolism after transplant. A multidisciplinary team allows for closely monitoring and treating patients with diabetes after heart transplant.

Diabetes and risk of acute infectious conjunctivitis--a population-based case-control study

AIMS

To examine whether diabetes mellitus is associated with an increased risk of acute infectious conjunctivitis (AIC) in adults, as measured by treatment with topical ocular antibiotics.

METHODS

A population-based, case-control study in North Jutland County, Denmark. Incident cases of AIC were defined as persons aged more than 15 years redeeming a first-time prescription for a topical ocular antibiotic during 1999 in the County Prescription Database. Five gender- and age-matched population control subjects per case were selected using a unique personal identifier, the Civil Registry Number. Diabetes prior to the ocular antibiotic prescription was determined by record-linkage with the Prescription Database and Hospital Discharge Registry in the county. Odds ratios (ORs) for acute infectious conjunctivitis among diabetic individuals and control subjects were estimated, adjusting for a range of potential risk factors.

RESULTS

Among 16 193 adults treated with topical ocular antibiotics, 3.1% had diabetes as compared with 2.5% of the control subjects. The overall adjusted OR for acute infectious conjunctivitis in patients with diabetes was 1.24 [95% confidence interval (CI): 1.13-1.38]. Risk estimates of acute infectious conjunctivitis in individuals with diabetes were consistently increased for both women and men, for all age groups, and for different types of ocular antibiotics prescribed.

CONCLUSIONS

This study suggests that diabetes is a risk factor for acute infectious conjunctivitis.

Diabetes and 30-day mortality from peptic ulcer bleeding and perforation: a Danish population-based cohort study

OBJECTIVE

Diabetes may influence the outcome of complicated peptic ulcer disease, due to angiopathy, blurring of symptoms, and increased risk of sepsis. We examined whether diabetes increased 30-day mortality among Danish patients hospitalized with bleeding or perforated peptic ulcers.

RESEARCH DESIGN AND METHODS

This population-based cohort study took place in the three Danish counties of North Jutland, Viborg, and Aarhus between 1991 and 2003. Patients hospitalized with a first-time diagnosis of peptic ulcer bleeding or perforation were identified using the counties' hospital discharge registries. Data on diabetes, other comorbidities, and use of ulcer-associated drugs were obtained from discharge registries and prescription databases. The Danish Civil Registry System allowed complete follow-up for mortality. The outcome under study was 30-day mortality in diabetic versus nondiabetic patients, adjusted for potential confounders.

RESULTS

We identified 7,232 patients hospitalized for bleeding ulcers, of whom 731 (10.1%) had diabetes. The 30-day mortality among diabetic patients was 16.6 vs. 10.1% for other patients with bleeding ulcers. The adjusted 30-day mortality rate ratio (MRR) for diabetic patients was 1.40 (95% CI 1.15-1.70). We also identified 2,061 patients with perforated ulcers, of whom 140 (6.8%) had diabetes. The 30-day mortality among diabetic patients was 42.9 vs. 24.0% in other patients with perforated ulcers, corresponding to an adjusted 30-day MRR of 1.51 (1.15-1.98).

CONCLUSIONS

Among patients with peptic ulcer bleeding and perforation, diabetes appears to be associated with substantially increased short-term mortality.

A case of type 2 diabetes with a large abscess of the gastric wall successfully treated with a glycemic control and systemic antibiotics

A case of type 2 diabetic patient, a 67-year-old woman, with a large abscess of the gastric wall which seemed to be a primary lesion is described for the first time. Fortunately, patient was successfully treated with both the maintenance of a good glycemic control and systemic antibiotics without laparotomy or drainage. Thus, a tight glycemic control and awareness of this disease should be reemphasized, and this may improve the prognosis of this rare and fatal one, even a poorly-controlled diabetes.

Community-acquired infections in type 2 diabetic patients and their nondiabetic partners. The Fremantle Diabetes Study

AIMS

The aim of this study was to investigate the association between Type 2 diabetes and community-acquired infections.

METHODS

We recruited 68 patients (mean+/-S.D. age=64.9+/-9.1 years; 57.4% males) from a community-based cohort and their nondiabetic partners (age=63.8+/-9.9 years; mean relationship duration=37.3+/-11.5 years) to a prospective observational matched-pair cohort study. Participants were assessed for infection risk factors and were required to complete an infection diary over the following year.

RESULTS

Sixty patient-partner pairs returned completed diaries. A greater proportion of patients than partners had received influenza vaccination in the past year (73.3% vs. 60.0%; P=.057), but pneumococcal vaccination coverage in the previous 5 years was similar (11.7% vs. 10.0%; P=1.0). The proportions of patients and partners reporting no infections were similar (51.7% vs. 58.3%; P=.52), but the diabetic patients were more likely to have experienced more than one infection (33.3% vs. 18.3%: P=.022). Baseline glycosylated hemoglobin levels in patients with and without at least one infection were similar, and there was no association between multiple infections and glycosylated hemoglobin (P>.2 in each case). After adjusting for age and gender, the probability of at least one infection during follow-up was not associated with diabetes (P=.33), but the number of infections was positively associated with diabetes (P=.005).

CONCLUSION/INTERPRETATION

Although similar proportions of Type 2 diabetic patients and their nondiabetic partners remained infection-free over a 12-month period, the diabetic patients who developed infections had a greater number of episodes. Glycemic control did not predict the risk or frequency of community-acquired infections in the diabetic group.

Association of type 2 diabetes mellitus and seroprevalence for cytomegalovirus

BACKGROUND

Infection is known to play a role in type 1 diabetes, but there is a paucity of information on its role in diabetes mellitus type 2. We examined the seroprevalence of selected viruses in a group of predominantly Hispanic patients with type 2 diabetes and control subjects without diabetes.

METHODS

One hundred thirteen patients, 83 with type 2 diabetes and 30 control subjects, all undergoing hemodialysis at the same facility in San Antonio, Texas, were tested for antibodies against coxsackie B viruses, cytomegalovirus (CMV), and parvovirus. Sixty-six of these patients and 25 control subjects were tested bimonthly for 6 months.

RESULTS

We observed a greater seroprevalence of anti-CMV IgG antibodies among patients with diabetes (97.6%), compared with control subjects (86.7%), and the difference was statistically significant [OR = 6.2, 95% CI: 1.1 to 36.0, P < 0.05]. Three draws on a subset of 91 patients produced still greater odds [OR = 12.4, 95% CI: 1.3 to 117, P < 0.05]. There were significantly more (P < or = 0.001) vascular complications among patients with diabetes. There was a colinearity of trends between diabetes, seropositivity to CMV, and age.

CONCLUSIONS

Our findings indicated an up to 12 times greater odds of having type 2 diabetes for persons previously exposed to CMV. Since accelerated atherosclerosis is also associated with diabetes and CMV, past CMV infection may be a common factor that links atherosclerosis and diabetes. No other viruses tested in this study, either coxsackie B viruses or parvovirus, showed a significant association with type 2 diabetes.

Dermatoses em pacientes com diabetes mellitus

OBJETIVO: Ainda é desconhecida a relação do diabetes com fatores determinantes ou precipitantes de lesões dermatológicas em pacientes diabéticos. Assim, o objetivo do estudo foi investigar a presença de lesões cutâneas, não referidas pelo paciente diabético e sua relação com o controle metabólico da doença. MÉTODOS: Foram examinados 403 pacientes, dos quais 31% eram diabéticos do tipo 1 e 69% do tipo 2. Em ambulatório de um hospital universitário, os pacientes foram atendidos por endocrinologista para a avaliação endócrino-metabólica e por dermatologista para a avaliação dermatológica. O grau de controle metabólico foi documentado em 136 pacientes por meio da dosagem de hemoglobina glicada. RESULTADOS: Houve predomínio de dermatofitoses (82,6%), seguido de grupo de dermatoses como acne e degeneração actínica (66,7%), piodermites (5%), tumores cutâneos (3%) e necrobiose lipoídica (1%). Entre as dermatoses mais comuns em diabéticos, foram confirmados com exame histológico: dois diagnósticos de necrobiose (0,4%), cinco de dermopatia diabética (1,2%) e três casos de mal perfurante plantar (0,7%). Os valores da hemoglobina glicada foram: 7,2% em pacientes com controle metabólico adequado nos dois tipos de diabetes e de 11,9% e 12,7% nos tipos 1 e 2, respectivamente, com controle inadequado. Nos pacientes com controle metabólico inadequado foi observada freqüência maior de dermatofitoses, em ambos os tipos de diabetes. CONCLUSÕES: Os dados revelaram freqüência elevada de lesão dermatológica nos pacientes diabéticos, especialmente dermatofitoses. Dessa forma, o descontrole metabólico do diabético propicia maior suscetibilidade a infecções cutâneas.