Awareness and knowledge of diabetic ketoacidosis in people with type 1 diabetes: a cross-sectional, multicenter survey

INTRODUCTION

To evaluate awareness and knowledge of diabetic ketoacidosis (DKA), a common and potentially life-threatening complication in people living with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

A survey was developed to assess individuals' current knowledge, management, and unmet needs regarding DKA. The study was conducted in six Swiss and three German endocrine outpatient clinics specialized in the treatment of diabetes.

RESULTS

A total of 333 participants completed the questionnaire (45.7% female, mean age of 47 years, average duration of T1D at 22 years). Surprisingly, 32% of individuals were not familiar with the term 'diabetic ketoacidosis'. Participants rated their own knowledge of DKA significantly lower than their physicians (p<0.0001). 46% of participants were unable to name a symptom of DKA, and 45% were unaware of its potential causes. 64% of participants did not test for ketones at all. A significant majority (67%) of individuals expressed the need for more information about DKA.

CONCLUSIONS

In patients treated in specialized centers, knowledge of DKA was found to be inadequate, with a lack of understanding regarding symptoms and causes. Healthcare professionals tended to overestimate individuals' knowledge. Future efforts should focus on addressing these knowledge gaps and incorporating protective factors into the treatment of T1D.

Determinants of Low Bone Turnover in Type 2 Diabetes-the Role of PTH

Determinants of low bone turnover in type 2 diabetes (T2DM) are poorly understood. To investigate the relationship between markers of bone turnover, glycaemic control, disease duration and calciotropic hormones in T2DM we assessed baseline biochemical data from the DiabOS Study, a prospective multicenter observational cohort study. In a cross-sectional study-design data from 110 postmenopausal women and men aged 50-75 years diagnosed with T2DM for at least 3 years and 92 non-diabetic controls were evaluated. Biochemical markers of bone formation (N-terminal propeptide of type I procollagen [PINP]), bone-specific alkaline phosphatase [BAP]) and resorption (C-terminal cross-linking telopeptide of type I collagen [CTX]), measures of calcium homeostasis (intact parathormone [iPTH], 25-Hydroxyvitamin D, calcium, magnesium) and glycaemic control were assessed. After adjustment for age, gender and body mass index (BMI), patients with T2DM had lower serum levels of PINP (p &lt; 0.001), CTX (p &lt; 0.001), iPTH (p = 0.03) and magnesium (p &lt; 0.001) compared to controls. Serum calcium, creatinine, 25-Hydroxyvitamin D and sclerostin did not differ between both groups. In multivariate linear regression analyses only serum iPTH remained an independent determinant of bone turnover markers in T2DM (PINP: p = 0.02; CTX: p &lt; 0.001 and BAP: p &lt; 0.01), whereas glycated haemoglobin (HbA1c), disease duration, age and BMI were not associated with bone turnover. In conclusion low bone turnover in T2DM is associated with low iPTH. The underlying mechanism remains to be elucidated.

Designing a bilingual health prevention website: challenges of using a participatory approach

Issue/problem

For some migrants, specific health information tools are needed in order to counterbalance lack of access to information both in countries of origin and of destination.

Description of the problem

Migrants originating from Pakistan and newly arrived in France are highly affected by for instance hepatitis C. Many of them have a low level of litteracy, including health litteracy. We decided to create a bilingual Urdu/French website, to provide information on hepatitis C, but also on sexual and mental health. The project was conceptualized in a participary manner, in order to fit the targeted population needs. The project started in June 2021 and the website is expected to be launched by September 2022. We report here some of the key challenges which emerged when working with such hard-to-reach community.

Results

The participatory approach involving community members consisted of 3 steps. In step 1, we confirmed content needs, and assessed preferences in terms of type of media to be used and media styles. About 30 themes were prioritized and the preferred media was video with formal style. After writing scripts, we organized focus-groups discussions to create culturally-appropriate messages. A third and last step will be the selection of titles and keywords for internet search, after shooting videos.

Lessons

Despite working closely with a Pakistani cultural association and urdu-speaking health professionnals, recruitment of community members for participating in the website design happened to be extremely difficult. Despite initial enthusiasm, interests in the project tended to decrease according to sometimes hidden motivations. Focus groups dynamics were at times affected by significant differences in social situations between participants. Despite these challenges, the participatory process allowed us to reshape part of the content according to the community's communications codes, in order to enhance the efficiency of the messages.

Key messages

• Working with socially disadvantaged community members is crucial in order to reduce social inequalities in health.

• However, caution is needed to anticipate and decrease unfulfilled expectations.

Effect of large doses of parenteral vitamin D on glycaemic control and calcium/phosphate metabolism in patients with stable type 2 diabetes mellitus: a randomised, placebo-controlled, prospective pilot study

OBJECTIVE

Vitamin D (D₃) status is reported to correlate negatively with insulin production and insulin sensitivity in patients with type 2 diabetes mellitus (T2DM). However, few placebo-controlled intervention data are available. We aimed to assess the effect of large doses of parenteral D3 on glycosylated haemoglobin (HbA(₁c)) and estimates of insulin action (homeostasis model assessment insulin resistance: HOMA-IR) in patients with stable T2DM.

MATERIALS AND METHODS

We performed a prospective, randomised, double-blind, placebo-controlled pilot study at a single university care setting in Switzerland. Fifty-five patients of both genders with T2DM of more than 10 years were enrolled and randomised to either 300,000 IU D₃ or placebo, intramuscularly. The primary endpoint was the intergroup difference in HbA(₁c) levels. Secondary endpoints were: changes in insulin sensitivity, albuminuria, calcium/phosphate metabolism, activity of the renin-aldosterone axis and changes in 24-hour ambulatory blood pressure values.

RESULTS

After 6 months of D₃ supply, there was a significant intergroup difference in the change in HbA(₁c) levels (relative change [mean ± standard deviation] +2.9% ± 1.5% in the D₃ group vs +6.9% ± 2.1% the in placebo group, p = 0.041) as HOMA-IR decreased by 12.8% ± 5.6% in the D₃ group and increased by 10% ± 5.4% in the placebo group (intergroup difference, p = 0.032). Twenty-four-hour urinary albumin excretion decreased in the D₃ group from 200 ± 41 to 126 ± 39, p = 0.021). There was no significant intergroup difference for the other secondary endpoints.

CONCLUSIONS

D₃ improved insulin sensitivity (based on HOMA-IR) and affected the course of HbA(₁c) positively compared with placebo in patients with T2DM.

Pre-clinical diabetic cardiomyopathy: prevalence, screening, and outcome

AIMS

Diabetic cardiomyopathy, characterized by left ventricular (LV) dysfunction and LV hypertrophy independent of myocardial ischaemia and hypertension, could contribute to the increased life-time risk of congestive heart failure seen in patients with diabetes. We assessed prospectively the prevalence, effectiveness of screening methods [brain natriuretic peptide (BNP) and C-reactive protein in combination with clinical parameters], and outcome of pre-clinical diabetic cardiomyopathy.

METHODS AND RESULTS

We studied 100 adults (mean age 57.4 +/- 10.2 years, 44% females) with diabetes and no previous evidence of structural heart disease. By echocardiography, diabetic cardiomyopathy was present in 48% of patients. Screening with combinations of clinical parameters (gender, systolic blood pressure, and body mass index), but not BNP, resulted in high negative predictive values for diabetic cardiomyopathy. During a mean follow-up of 48.5 +/- 9.0 months, in the groups with and without diabetic cardiomyopathy, 12.5 vs. 3.9% (P < 0.2) patients died or experienced cardiovascular events and 37.5 vs. 9.6% (P < 0.002) had a deterioration in NYHA functional class. Overall event-free survival was 54 vs. 87% (P = 0.001) in the groups with and without diabetic cardiomyopathy, respectively. Brain natriuretic peptide was an independent predictor of events [odds ratio 3.5 (1.1-10.9), P = 0.02].

CONCLUSION

Pre-clinical diabetic cardiomyopathy is common. Screening with combinations of simple clinical parameters, but not BNP, can be useful to identify those patients needing further evaluation. Patients with pre-clinical diabetic cardiomyopathy are at increased risk for functional deterioration and possibly cardiovascular events during follow-up. Brain natriuretic peptide was shown to be an independent predictor of future events.

First evidence of a food poisoning outbreak due to staphylococcal enterotoxin type E, France, 2009

At the end of 2009, six food poisoning outbreaks caused by staphylococci were reported in France. Soft cheese made from unpasteurized milk was found to be the common source of the outbreaks. Staphylococcal enterotoxin type E was identified and quantified in the cheese using both official and confirmatory methods of the European Union Reference Laboratory (EU-RL). To our knowledge, this is the first report of food poisoning outbreaks caused by staphylococcal enterotoxin type E in France.

Low-density lipoprotein size and subclasses are markers of clinically apparent and non-apparent atherosclerosis in type 2 diabetes

The atherogenic lipoprotein phenotype is characterized by an increase in plasma triglycerides, a decrease in high-density lipoprotein (HDL), and the prevalence of small, dense low-density lipoprotein (LDL) particles. The present study investigated the clinical significance of LDL size and subclasses as markers of atherosclerosis in diabetes type 2. Thirty-eight patients with type 2 diabetes, total cholesterol of less than 6.5 mmol/L, and hemoglobin A1c (HbA1c) of less than 9% were studied. Median age was 61 years, mean (+/-SD) body mass index 29 +/- 4.3 kg/m2 , and mean HbA1c 7.1 +/- 0.9 %. Laboratory parameters included plasma lipids and lipoproteins, lipoprotein (a), apolipoprotein (apo) A-I, apo B-100, apo C-III, and high-sensitivity C-reactive protein. Low-density lipoprotein size and subclasses were measured by gradient gel electrophoresis and carotideal intima media thickness (IMT) by duplex ultrasound. By factor analysis, 10 out of 21 risk parameters were selected: age, body mass index, systolic blood pressure, smoking (in pack-years), HbA1c, high-sensitivity C-reactive protein, lipoprotein (a), LDL cholesterol, HDL cholesterol, and LDL particle size. Multivariate analysis of variance of these 10 risk parameters identified LDL particle size as the best risk predictor for the presence of coronary heart disease (P = .002). Smaller LDL particle size was associated with an increase in IMT (P = .03; cut-off >1 mm). Within the different lipid parameters (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apo B, apo A-I, apo C-III, LDL particle size), LDL particle size was most strongly associated with the presence of coronary heart disease (P = .002) and IMT (P = .03). It is concluded that LDL size is the strongest marker for clinically apparent as well as non-apparent atherosclerosis in diabetes type 2.

Actions of endotoxin and morphine

In summary, our current studies show that treatment with a bacterial endotoxin, lipopolysaccharide (LPS), induces the expression of mu opioid receptors in the rat mesentery. This induction may be mediated through IL-1's actions on mu opioid receptors. Morphine stimulates the expression of adhesion molecules in human brain microvascular endothelial cells (HBMEC) isolated from pathological tissues. Under pathological conditions, mu opioid receptor-dependent pathways may be modulated through the induction of mu opioid receptors, especially in endothelial cells. Treatment with morphine increases [14C]-inulin permeability of an in vitro microvascular endothelial cell barrier, and decreases endothelial cell viability. Morphine pre-treatment potentiates the effects of LPS on endothelial cell viability, and on LPS induction of IL-1beta secretion from 1alpha, 25-dihydroxy-vitamin D3-treated HL-60 human leukemia cells. Previously, it was suggested that an opioid-dependent pathway may be involved in the recovery from endotoxin shock (D'Amato and Holaday, 1984). Induction of mu opioid receptors by treatment with high doses of endotoxin suggests that mu opioid receptor-dependent pathways may be involved in mediating the response to endotoxins. Taken together, these data provide valid evidence for an association between endotoxins and opioid actions. These studies suggest that opioid-dependent pathways in disease or in endotoxin exposure may be modified by cytokine-induced expression of opioid receptors in endothelial cells. In a pathological condition, an alteration of the opioid-dependent pathway may be expected. When morphine is used for its therapeutic values, it may, indeed, potentiate LPS' effects in an adverse manner. From a clinical perspective, these data indicate that morphine and an endotoxin, such as LPS, may interact in a positive 'feedback type of reaction, and thereby modulate the body's immune responses with unexpected and detrimental results.

Chronic cocaine alters hemodynamics and leukocyte-endothelial interactions in rat mesenteric venules

We investigated the effects of chronic cocaine exposure on the microcirculation in the rat mesenteric venules under both non-inflammatory and FMLP-induced inflammatory conditions. Chronic cocaine significantly increased WBC rolling flux in both conditions, and potentiated FMLP-induced leukocyte-endothelial cell adhesion (LEA). In cocaine-treated animals, total WBC number increased by 91%, and the ratio of white blood cell to red blood cell velocity was significantly lower, while vessel diameter was unchanged. Chronic cocaine decreased serum levels of tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6), but had no effect on interleukin-1 beta (IL-1beta). Expression of intercellular adhesion molecule-1 (ICAM-1) was increased in mesenteric venules following chronic cocaine exposure, and may be one of the mechanisms underlying enhancement of FMLP-induced LEA. The increase in WBC count, WBC flux and LEA, and the change in cell velocity seen in the cocaine-treated animals could cause a decrease in effective vessel diameter and a change in intravascular resistance, and may underlie the progressive vascular damage seen in chronic cocaine-abusing individuals.

Lateral hypothalamic relations with medial hypothalamus and limbic areas in geese

Spontaneous unit activity was recorded in the posteromedial hypothalamic (PMH) and preventricular magnocellular (PVM) nuclei, septal area (S) and hippocampal formation (Hp). Modifications of cellular firing induced by lateral hypothalamic area (LHA) stimulation were examined. Both thiopental anaesthetized and chronic non anaesthetized geese were used. Thiopental appeared to significantly decrease the spontaneous discharge frequency of PMH neurons, and to block both orthodromic and antidromic activations elicited by LHA stimulation. The results indicated that LHA has a predominantly inhibitory influence on PMH as well as on PVM and septal area. The study of antidromic evoked responses in the four areas investigated (PMH, PVM, S, Hp) demonstrated that these structures in turn exert a feed-back control onto LHA. These results are compared with previous electrophysiological, anatomical and behavioral feeding data and an attempt is made to establish some comparisons between birds and mammals.

A goose head holder device for chronic experiments

A special device is described which allows experiments to be performed on chronic non-anaesthetized geese. This system is composed of two elements: one is fixed to the stereotaxic apparatus, the other is implanted on the goose skull. The use of ear bars and eye and bill pieces is thus eliminated. This non-painful adaptation is well tolerated by the bird. In addition, the position of the animal with regard to stereotaxic coordinates is unchanged. This technique provides an essential tool for furthering investigations on the central nervous system in geese.

Effect of induced hypothalamic hyperphagia and forced-feeding on organ weight and tissular development in Landes geese

The effects of induced hypothalamic hyperphagia and forced-feeding were studied in 30 geese of the Landes breed. They were housed in individual cages under a dark-light cycle of 12 hrs light-12 hrs darkness. Eleven geese with ventromedian hypothalamic (VMH) lesions and 8 controls were fed ad libitum. A third lot of 11 force-fed animals was pair-fed with the operated geese. The study lasted 4 weeks after an adaptation period to the new environmental conditions. The daily food intake of the geese and their weekly liveweight gain were monitored. After VMH lesions, the mean food intake of the geese increased by 169 p. 100 so that after each treatment their liveweight increased and they became obese (P less than 0.001). The tissue distribution of the group with lesions showed a higher amount of subcutaneous fat (P less than 0.05), while the mesenteric fat (P less than 0.05) was more abundant after forced-feeding. The liver weight was much higher in all cases; its increment reached 311 p. 100 in geese with VMH lesions and 193 p. 100 in the force-fed. However, those values were too low when compared to the means obtained by traditional forced-feeding. Hyperphagia in the geese was very marked as compared to that in rats, but it was insufficient to produce a considerable hepatic steatosis.