Frontiers in clinical diabetes and healthcare最新文献

Pancreatogenic diabetes is a frequent and often underestimated consequence of acute and chronic pancreatitis. This form of diabetes shows clinical characteristics intermediate between type 2 and type 1 diabetes, presenting both insulin resistance and an insulin secretory defect that often requires earlier initiation of insulin therapy. We describe the case of a 60-year-old man with a history of obesity and family predisposition to diabetes who developed diabetes after necrotizing hemorrhagic acute pancreatitis complicated by portal vein thrombosis. The patient expressed great concern about his persistent hyperglycemia and marked glucose variability. Despite intensive treatment with oral antihyperglycemic agents and a basal-bolus insulin regimen, glycemic control remained suboptimal and characterized by wide fluctuations. Given the very high basal-to-bolus insulin ratio and the need for dynamic insulin delivery, the mylife Loop insulin delivery system was initiated. This resulted in a rapid and sustained improvement of glycemic control, with the Time in Range (TIR) increasing from 43% to 72% after one month and up to 88% at three months, while the Glucose Management Indicator (GMI) decreased from 7.9% to 6.5%. Benefits were stable at six months. To our knowledge, this is the first report describing the use of hybrid closed-loop insulin delivery system in diabetes following pancreatitis, and highlights how this technology can be particularly useful in achieving optimal glycemic control in patients in whom oral therapy is insufficient and conventional basal-bolus regimens are limited by the inability to personalize insulin delivery throughout the day. Automated insulin delivery proved effective in addressing the peculiar challenges of pancreatogenic diabetes, including high glycemic variability and a more complex management of prandial insulin therapy.

SGLT2 inhibitors have transformed the care of patients with diabetes, chronic kidney disease (CKD), and cardiovascular disease. Nevertheless, the efficacy of SGLT2 inhibitors as well as potential associated risks remains to be further clarified in the setting of advanced diabetic kidney disease. Indirect evidence and secondary analyses from the landmark SGLT2 trials as well as emerging data from recent studies including exclusively patients with diabetes and advanced CKD, indicate that the renal and cardiovascular benefits of SGLT2 inhibitors persist even in these patients. Although the use of SGLT2 inhibitors in patients with diabetes undergoing dialysis remains investigational, preliminary evidence from experimental and clinical studies seems promising in terms of multifaceted positive outcomes, including preservation of residual kidney function. Furthermore, the available data until now does not indicate an increase in risk in patients with diabetes and advanced CKD regarding acute impairment of kidney function or other adverse outcomes of interest including diabetic ketoacidosis, infections, fractures risk and amputations. The aim of this review is to present the current knowledge available on the utility of SGLT2 inhibitors in patients with diabetes and advanced CKD so as to provide a foundation for their implementation in clinical practice. Future experimental research shall further elucidate the pleiotropic effects of SGLT2 inhibitors so as to expand their indications in the setting of diabetes and advanced CKD. Finally, the results of ongoing clinical trials in patients with diabetes and kidney failure as well as in dialysis patients are much anticipated.

Introduction: Hand conditions in diabetes, namely, limited joint mobility (LJM), flexor tenosynovitis (FT), carpal tunnel syndrome (CTS), and Dupuytren disease (DD), share a common pathophysiological process involving pro-fibrotic inflammation in flexor structures. A unified, quantitative measure of disease severity across these conditions is lacking, limiting correlational research. We evaluated mean metacarpophalangeal (MCP) joint extension as a potential measure of severity.

Methods: We assessed 2,405 adults, including individuals with type 1 diabetes (n=291), type 2 diabetes (n=877), prediabetes (n=326), and non-diabetic controls (n=911). MCP extension was calculated as the average maximum passive extension of the second to fifth fingers, measured with a protractor. Validity was determined by correlating MCP extension with physician-rated severity (convergent) and hand grip strength and the Duruöz Hand Index (DHI, both divergent). Inter-rater reliability was tested in 128 individuals, and sensitivity to change was evaluated in 143 participants assessed at two time points.

Results: Mean MCP extension was significantly lower in individuals with all hand conditions (42.4° LJM, 42.8°FT, 39.9° DD, 51.7 °CTS) than in those without (58.6°, all p<0.05). MCP extension correlated with physician-rated severity (-0.5, p<0.01) and weakly with DHI (R² = 0.03) and grip strength (R² = 0.07). Inter-rater reliability was strong (ICC 0.72), and MCP extension demonstrated sensitivity to change, worsening over 8 months (SRM -0.61).

Conclusion: Mean MCP extension is a valid, reliable, and responsive measure for assessing fibro-inflammatory hand conditions in diabetes.

Clinical trial registration: https://ctri.nic.in/Clinicaltrials/login.php, identifier CTRI/2020/12/030057.

Objective: To determine the feasibility and acceptability of a coordinated community-based intervention for low-income adults with type 2 diabetes (T2D) that included (1) screening and referral, (2) shared decision-making (SDM), and (3) diabetes self-management education and support (DSMES).

Methods: Participants were screened for T2D through a mobile health unit in a low-income community in Guadalajara, Jalisco, Mexico, and referred for follow-up in a primary care health center serving that community. Primary care physicians (PCPs) within the health center were trained on SDM for T2D, and community health workers (CHWs) were trained to deliver DSMES. Feasibility was measured by the number of community members screened and referred for care, the number of PCPs implementing SDM, and the number of CHWs hired and trained on DSMES. Acceptability was assessed by the percentage of participants who completed the 3-month DSMES program. Potential clinical impact was determined by effect sizes of changes in HbA1c between baseline and 3 months. Other measurements included waist circumference (WC), body weight, diabetes distress, and diabetes self-care activities, assessed at baseline, and at 1 and 3 months during the study period.

Results: With respect to feasibility, all PCPs from the clinic completed the SDM training and were able to implement it in their primary practice. The DSMES training was completed by 4 (50%) of CHWs, and 3 were selected to deliver the course to study participants. Related to acceptability, 182 community members were screened, of which 42 were eligible for participation and 23 were successfully enrolled. Out of six programmed sessions, average participant attendance was 80% with 60.9% of participants retained at three months. Changes in HbA1c from baseline to 3 months were 10.1 ± 2.7 to 9.4 ± 3.1.

Discussion: The use of community screening to refer low-income people living with T2D to a clinic-based SDM and DSMES intervention was feasible with large effect sizes for changes in HbA1c. The high attrition rates suggest that alternative strategies may be necessary to keep patients engaged in care.

Migration, while often motivated by safety, education, or economic opportunity, often heightens the risk of obesity and metabolic syndrome. Resettlement in industrialized nations is associated with sedentary lifestyles, irregular sleep schedules, and Westernized dietary patterns rich in ultra-processed, high-fat, and high-sugar foods. These changes disrupt metabolic homeostasis through endocrine and circadian dysregulation, promoting insulin resistance, visceral adiposity, and systemic inflammation. Migration alters the composition and diversity of the gut microbiome, suggesting that the characteristics of the microbiome could be important in linking migration to changes in health outcomes after resettlement. However, the precise mechanisms underlying these microbiome-mediated effects remain poorly understood. We propose that a dynamic metabolic interface is reshaped via a rapid "microbiome acculturation", which is a process by which the gut microbiome rapidly adapts to a new cultural and environmental milieu, such as caused by migration, shifting from traditional, fiber-rich microbial profiles to Westernized, Bacteroides-dominant communities associated with metabolic dysfunction. This is characterized by the depletion of fiber-fermenting Prevotella and enrichment of Bacteroides species, leading to reduced short-chain fatty acid production, impaired gut barrier function, and increased endotoxemia. Dietary transitions, chronic psychosocial stress, circadian disruption to night-shift work, and reduced physical activity experienced by immigrants reshapes gut microbial composition and function to a pro-inflammatory milieu and enhancing insulin resistance. Thus, gut dysbiosis serves as both a biomarker and mechanistic driver of post-migration metabolic deterioration, integrating dietary, behavioral, and environmental stressors into a unified pathogenic pathway. Effective prevention should target the gut-brain-metabolic axis using multidimensional strategies: restoring microbial diversity using high-fiber, prebiotic, and probiotic nutrition; promoting physical activity and circadian alignment; and addressing social determinants of health such as work patterns, food access, and acculturation stress.

Background: For most patients with pregnancy hyperglycemia, treatment includes lifestyle behavioral counseling for a healthy diet and physical activity (PA). Outside of pregnancy, emerging evidence suggests that the timing of PA (e.g., in the morning vs. evening) may modify its glucose-lowering effects. PA is an evidence-based, non-pharmacological strategy for managing glucose levels, and recommendations for PA timing could improve glucose levels in individuals with pregnancy hyperglycemia.

Objective: To describe the rationale and protocol of the Time to Move Randomized Crossover Trial, which evaluates the effects of morning vs. evening PA on glucose levels across the 24-hour cycle.

Methods: The eligibility criteria include singleton pregnancies in patients aged 18-40 years, identified as having gestational glucose intolerance [(GGI), a non-fasted, 50-g glucose challenge test, 1-hour value ≥130 mg/dl] or gestational diabetes mellitus [(GDM), by the one- or two-step procedure, at ≥24 weeks]. Participants who provide consent are randomized to first perform either morning PA (between 5 a.m. and 9 a.m., within 30 min-40 min of starting breakfast) or evening PA (between 4 p.m. and 8 p.m., within 30 min-40 min of starting dinner). All PA episodes consist of 30 min of moderate-intensity walking or stepping. Participants ultimately contribute 2 days in each of the three treatment conditions: morning PA, evening PA, and no PA, with one washout day between treatment conditions. Timestamped glucose measurements are obtained using Dexcom G6 or G7 continuous glucose monitors (CGM). The primary analysis will be intention-to-treat; per-protocol associations will also be explored. PA adherence is assessed using ActiGraph PA monitoring devices (i.e., the CentrePoint Insight Watch, worn on the non-dominant wrist), which provide continuous timestamped estimates of movement. Participants upload photos (i.e., in real time) of all foods and beverages consumed throughout the study period, and the timestamps of these photos are used to identify postprandial periods. One 24-hour dietary recall, aided by photo uploads, is also completed for each treatment condition.

Conclusions: The Time to Move Randomized Crossover Trial addresses the gap in scientific knowledge regarding whether the timing of PA may be leveraged to maximize glucose control in individuals with pregnancy hyperglycemia.

Clinical trial registration: ClinicalTrials.gov, identifier NCT06125704.

Carbohydrates are the main macronutrient of interest for dosing insulin and managing glycemia in type 1 diabetes (T1D) due to their direct impact on blood glucose levels, however, the influence of protein on glycemia and pancreatic islet hormone secretions in people living with either T1D or type 2 diabetes (T2D) should not be overlooked. Protein ingestion plays a key role in the secretion of both insulin and glucagon, making it a key regulator of blood glucose levels in health and diabetes. The glycemic response to protein is affected by many factors including the protein's form, source, digestion rate, whether it is consumed on its own or in a mixed meal, as well as its timing in relation to other meals and/or physical activity. Additionally, the hormonal and glycemic response to protein differs markedly between non diabetic individuals, T1D, and T2D. The unique ability of protein to modify post-prandial glycemia makes it a potential tool that individuals with diabetes or prediabetes can utilize to help manage their own glycemia. This review will discuss the ways in which protein intake and supplementation with certain protein types may be able to improve overall glycemia and time in range for individuals living with diabetes or prediabetes.

Introduction: Diabetes and hypertension (HTN) are non-communicable chronic diseases that pose a significant challenge to global public health. However, substantial disparities in the performance of these essential check-ups among diagnosed patients have been identified.

Objective: 1) To determine the existing disparities in the check-ups of patients with diabetes and HTN, 2) To observe the trend of these check-ups over the years through a Peruvian national survey.

Methods: A cross-sectional analytical study using information from Peru's Demographic and Family Health Survey between 2014 and 2022. The main variables were performance in the last year of ophthalmic, blood pressure, and glucose check-ups.

Results: Regarding the prevalence of check-ups in the last year, it was high for ophthalmic examinations (HTN: 65.46%, diabetes: 70.54%), blood pressure measurements (HTN: 81.82%, diabetes: 79.92%), and glucose measurements (HTN: 56.72%, diabetes: 83.76%). In the trend analysis for patients with diabetes, minimal variation was observed between the evaluations from 2014 to 2019, with a notable decrease in 2020 and 2021, particularly in ophthalmic check-ups, followed by a recovery in 2022. The most consistent determinants of check-up performance across both conditions were older age (≥60 years), higher educational level, higher socioeconomic status, and having health insurance. Female sex was associated with higher check-up rates in patients with HTN. Geographic and ethnic disparities were also observed, with urban residents and certain ethnic groups showing different check-up patterns.

Conclusions: This study has revealed significant disparities in the performance of essential health check-ups among Peruvian patients with diabetes and HTN, showing that various determinants play a crucial role in the frequency of these check-ups.