Table of Content

20 May 2023, Volume 26 Issue 15

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Editorial

Glycemic Management for Hospitalized Patients with Diabetes in Non-endocrine Wards

CHEN Xiangyang, LI Sheyu

2023, 26(15):  1799-1803.  DOI: 10.12114/j.issn.1007-9572.2022.0793

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Diabetes is a disease frequently encountered in hospitals in China. Good glycemic management can improve clinical outcomes and shorten the length of stay of diabetic patients, enhance healthcare efficiency and save medical resources. To provide a reference for clinical glycemic management and associated research, we reviewed relevant literature, then summarized the characteristics and applicable settings of different blood glucose management modes, and detailed the advantages and limitations of three major glycemic management models, including general-specialist consultation, hospital-wide glycemic management program, and smart decision support system for blood glucose management. With the support of information technology, different glycemic management modes will contribute to the continuous improvement of efficiency and quality of hospital care.

Monographic Research of Inpatient Glucose Menitoring

Consultations for Blood Glucose Management among Inpatients with Diabetes in Non-endocrinology Department

CHEN Xiangyang, ZHOU Yiling, WANG Miye, LI Nan, ZHANG Rui, ZHANG Shengzhao, SHI Qingyang, NONG Kailei, ZOU Xinyu, LI Shenghan, QIAO Zhi, XIA Yilin, LI Sheyu

2023, 26(15):  1804-1810.  DOI: 10.12114/j.issn.1007-9572.2022.0354

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Background

Diabetes is one of the common diseases among inpatients in non-endocrinology department. Patients with diabetes require assistance from endocrinologists in their blood glucose management.

Objective

To investigate consultation of blood glucose management for inpatients with diabetes in non-endocrinology department and analyze the quality of consultation and the needs of patients.

Methods

The inpatients with diabetes in non-endocrinology department consulted by the endocrinologists in West China Hospital, Sichuan University from January 1, 2013 to May 23, 2019 were selected and reviewed. The consultation and medical record information was recorded and organized. The recommended medications for the patients were analyzed to determine the potential contraindications according to drug instructions.

Results

During the study period, we identified 145 428 inpatients with diabetes in non-endocrinology department, 24 499 of them had 31 369 consultations from endocrinologists (0.17 consultations/inpatients), and 20 486 of them had 24 343 consultations for blood glucose management (0.17 consultations/inpatients). The top three departments with the most blood glucose management consultations per patient were neurology (0.30 consultations/inpatients), respiratory medicine (0.25 consultations/inpatients), and cardiology (0.18 consultations/inpatients). There were 18 306 blood glucose management consultations (16 269 inpatients) with complete suggestions, and the most commonly recommended hypoglycemic regimen was the combination of insulin with a meal and basal insulin, accounting for 32.34% (5 921/18 306). Among the all consultations, 1.16% (212/18 306) patients' hypoglycemic regimens had drug contraindications.

Conclusion

A large number of inpatients with diabetes in non-endocrinology department need specialized blood glucose management. The overall quality of the consultation for blood glucose management is relatively high but far from meeting the management requirements.

Performance Surveillance of Active Blood Glucose Management during Hospitalization Based on the PDCA Cycle: a Practical Study

ZHOU Yi, GAO Yunyi, LI Sheyu, TONG Nanwei, CHEN Min, LI Dajiang, JIANG Yan, ZHANG Weiyi, CHEN Xiangjun

2023, 26(15):  1811-1816.  DOI: 10.12114/j.issn.1007-9572.2022.0821

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The increased clinical demand for glycemic control in hospitalized patients has led to a new transformation of clinical technologies and medical models, which has brought challenges to medical management. We built an active blood glucose intervention operation and management model for inpatients using the Plan-Do-Check-Action (PDCA) cycle: Firstly, we concertized the practical management problems through root cause analysis, namely man - machine - material - method - environment. Then, we used PDCA cycle quality management tools to facilitate the construction of the operation and management models based on the PDCA cycle. We finally formed an efficient multidepartment cooperation mechanism and tiered management system and process for inpatients, and established an information system of glycemic management, quality control system and operational performance guarantee system. By use of the model, the blood glucose management has been successfully promoted with some achievements obtained, and the rate of blood glucose meeting the target level within 72 hours after glycemic management has increased month by month in West China Hospital, Sichuan University. This model developed by our hospital may be used as a reference for other hospitals to conduct glycemic management, and it also has great significance for improving the inpatient blood glucose management.

Analysis of the Effect of Human-computer Interaction Intelligent Management on Blood Glucose Control in New-onset Type 2 Diabetes Mellitus Patients

WANG Lingxiao, DONG Rongna, ZHOU Bing, GUO Lina, LI Jing

2023, 26(15):  1817-1823.  DOI: 10.12114/j.issn.1007-9572.2022.0784

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Background

Early intervention of blood glucose control in patients with new-onset type 2 diabetes mellitus (T2DM) can help delay the progression of diabetes. As a new form of health management, the effect of human-computer interaction intelligent blood glucose monitoring management on the progression of new-onset T2DM patients has not been clarified.

Objective

To explore the effect of human-computer interaction intelligent management on blood glucose control and self management capability in new-onset T2DM patients, so as to provide the reference for optimizing the control strategy in new-onset T2DM patients.

Methods

From June 2016 to December 2016, 200 patients with new-onset T2DM admitted to the Tianjin Medical University, Chu Hsien-I Memorial Hospital were selected by convenient sampling and randomly divided into the control group (n=100) and the monitoring group (n=100). The interventions in the monitoring group were the same as those in the control group except for the human-computer interaction intelligent monitoring. Blood glucose indexes〔fasting blood glucose (FBG), 2 h postprandial glucose (2 hPG) and glycated hemoglobin (HbA_1c) 〕and self-management capability indexes〔diabetes management self-efficacy scale (DMSES), summary of diabetes self-care activities (SDSCA), diabetes self-care scale (2-DSCS) 〕were recorded at the time of enrollment and after 3 months of follow-up in the two groups.

Results

After 3 months of follow-up, the monitoring group included 95 cases, the control group included 97 cases. Compared with the pre-intervention period, FBG, 2 hPG and HbA_1c levels decreased in both groups after the intervention (P<0.05), and the scores of DMSES scores increased in both groups (P<0.05). FBG, 2 hPG and HbA_1c were significantly lower in the post-intervention period of glucose monitoring group compared with the control group (P<0.05). 67 patients (70.5%) in the monitoring group reached the target level of FBG, 31 patients (32.0%) in the control group as well; besides 49 patients (51.6%) in the monitoring group reached the target level of 2 hPG, 30 patients (30.9%) in the control group as well; moreover, 67 patients (70.5%) in the monitoring group reached the target level of HbA_1c, 29 cases (29.9%) in the control group as well, all the above rates of reaching in the monitoring group was higher than those in the control group (P<0.05). The total DMSES score, 2-DSCS score and SDSCA score in the monitoring group were higher than those in the control group (P<0.05). The score of DMSES in new-onset T2DM patients was positively correlated with the scores of 2-DSCS and SDSCA (r_s=0.909, 0.872, P<0.01). The 2-DSCS scale score was positively correlated with the SDSCA scale score (r_s=0.917, P<0.01). Multiple regression analysis showed that diet control, regular exercise, taking medication as instructed, blood glucose monitoring, prevention and management of high and low blood glucose behaviors were favorable factors for HbA_1c reduction (P<0.05). The general diet, special diet and taking medication as instructed were the favorable factors for FBG and 2 hPG levels reduction (P<0.05), and the blood glucose monitoring was positive for 2 hPG levels reduction.

Conclusion

Human-computer interaction intelligent management was able to improve blood glucose control of new-onset T2DM patients effectively, which can promote the reaching to target blood glucose level, the subjective initiative of health behavior mainly through improving compliance of blood glucose monitoring, healthy diet, exercise and taking medication as instructed, which provide advice on effective intervention methods for new-onset T2DM patient management.

Targets for Individualized Inpatient Management of Hyperglycemia

LIU Li, LI Jing, LIU Xiaofang, HE Jidong

2023, 26(15):  1824-1830.  DOI: 10.12114/j.issn.1007-9572.2022.0792

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Inpatient hyperglycemia is common in clinical practice, and is associated with various in-hospital adverse outcomes, increased mortality in critically ill patients, and prolonged hospital stay in non-critically ill patients. Currently, guidelines in endocrinology and metabolism at home and abroad all recommend systematic management of inpatient hyperglycemia, and highlight the principle of individualized management, namely, recommend that glycemic targets should be set individualized based on the patient's individual characteristics. We reviewed the definition, management status, glycemic targets and monitoring methods of inpatient hyperglycemia in worldwide guidelines, and discussed the advances in inpatient hyperglycemia management from a perspective of comparing the similarities and differences in glycemic targets set for different types of inpatient populations and for inpatients with different conditions. This review clearly indicates that the inpatient management of hyperglycemia still needs to adhere to the principle of individualized management, thereby reducing the incidence of complications and all-cause mortality related to hyperglycemia.

Original Research·Diabetes Complications

Association between Serum Uric Acid and the Risk of Type 2 Diabetes Mellitus: a Population-based Prospective Cohort Study

SONG Hualong, GAO Ying

2023, 26(15):  1831-1839.  DOI: 10.12114/j.issn.1007-9572.2022.0785

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Background

Hyperuricemia (HUA) caused by elevated serum uric acid (SUA) has become the fourth most common disease after hyperglycemia, hyperlipidemia, and hypertension, and the second most common metabolic disease after diabetes. It has been shown that elevated SUA levels are significantly associated with the risk of type 2 diabetes mellitus (T2DM). However, there is a lack of studies on Chinese population and studies on HUA combined with unhealthy lifestyle or chronic disease.

Objective

To investigate the association between baseline SUA levels, HUA combined with unhealthy lifestyle or chronic diseases and the risk of T2DM in health examination population.

Methods

A total of 17 626 individuals meeting the inclusion and exclusion criteria who had underwent at least two physical examinations from 2017 to 2020 in Preventive Treatment & Health Management Center, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine were selected as the subjects. Information about their demographics, lifestyle, physical examination results, and laboratory indicators was collected. A follow-up was carried out with them until the onset of T2DM or the end of follow-up (2020-12-31), during which the onset day of T2DM and clinical visit information for T2DM were collected. The cumulative incidence and incidence density of T2DM in the total population, and cumulative incidence of T2DM in subgroups were calculated. The Cox proportional-hazards model was used to investigate the association between baseline SUA level and the risk of T2DM. And stratified multivariate Cox proportional-hazards regression model was used to further analyze their association in different subgroups.

Results

The subjects had a median age of 38.2 (31.9, 49.6) years, a median baseline SUA level of 304.50 (248.00, 374.00) μmol/L, and an overall prevalence of HUA of 13.12%. The cumulative follow-up was 54 633 person-years, with a median follow-up of 3.10 years. There were 479 new cases of T2DM. The incidence density was 8.77 〔95%CI (8.00, 9.59) 〕 /1 000 person-years and the cumulative incidence rate was 2.72%〔95%CI (2.48%, 2.97%) 〕. Higher cumulative incidence rate of T2DM was found in older age group (≥60 years old), male cases, or those with current smoking, current alcohol drinking, BMI≥28.0 kg/m², hypertension, dyslipidemia, or HUA. The multivariate-adjusted Cox proportional hazards regression model showed that HUA patients had an increased risk of T2DM, with an HR of 1.32〔95%CI (1.04, 1.67), P=0.023〕. For every 10 μmol/L increase in baseline SUA level, the risk of T2DM increased by 3%〔HR=1.03, 95%CI (1.01, 1.04), P<0.001〕. Stratified analysis of multivariate Cox proportional hazards regression model showed that the risk of T2DM increased in 60-year-olds and above〔HR=6.78, 95%CI (4.16, 11.03), P<0.001〕, females 〔HR=2.31, 95%CI (1.54, 3.45), P<0.001〕, current smokers 〔HR=1.79, 95%CI (1.23, 2.60), P=0.002〕, current alcohol drinkers 〔HR=1.61, 95%CI (1.23, 2.10), P<0.001〕, individuals with BMI≥28.0 kg/m²〔HR=1.69, 95%CI (1.07, 2.68), P=0.026〕, hypertensioners 〔HR=2.89, 95%CI (2.15, 3.89), P<0.001〕, or individuals with dyslipidemia 〔HR=2.39, 95%CI (1.80, 3.16), P<0.001〕with HUA.

Conclusion

Elevated baseline SUA levels are associated with a high risk of T2DM in health examination population, and the risk may be even higher in elderly people, females, current smokers, current drinkers, individuals with obesity, hypertension, or dyslipidemia with HUA.

The Effect of Type 2 Diabetes Mellitus on the Prognosis of Patients with Dilated Cardiomyopathy

WANG Haiyan, HUANG Yuan, GUI Chun

2023, 26(15):  1840-1846.  DOI: 10.12114/j.issn.1007-9572.2022.0751

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Background

Type 2 diabetes mellitus increases the risk of early onset of cardiovascular disease in patients, which poses a major threat to human health. Exploring the impact of type 2 diabetes mellitus on prognosis of patients with dilated cardiomyopathy is good for patient management.

Objective

To evaluate the effect of type 2 diabetes mellitus on the prognosis of patients with dilated cardiomyopathy.

Methods

This study retrospectively analyzed 313 patients with dilated cardiomyopathy who were admitted to the Department of Cardiology in the First Affiliated Hospital of Guangxi Medical University from January 2015 to May 2020. Patients were divided to a diabetic group (n=66) or a non-diabetic group (n=247) according to whether they suffered from type 2 diabetes mellitus. General date and laboratory indices were collected. Follow-up was conducted until December 31, 2021. The primary endpoint was all-cause death. This study used landmark analysis to compare survival rate between these two groups. A multivariate Cox proportional hazards regression model was used to analyze the influencing factors of all-cause mortality in patients with dilated cardiomyopathy.

Results

Landmark analysis showed that there was no significant difference in one-year survival rate between these two groups (χ²=1.520, P=0.218). After 1 year, the survival rate in the diabetic group was lower than that of the non-diabetic group (χ²=4.414, P=0.036). In the multivariate Cox proportional hazards regression model constructed by piecewise fitting method, systolic blood pressure〔HR=0.965, 95%CI (0.948, 0.982) 〕, N-terminal pro-B-type natriuretic peptide〔HR=9.928, 95%CI (4.791, 20.576) 〕 and β-receptor blocker〔HR=0.317, 95%CI (0.168, 0.598) 〕 were the influencing factors of all-cause mortality in patients with dilated cardiomyopathy within one year (P<0.05), while LVEDD〔HR=1.057, 95%CI (1.028, 1.087) 〕and type 2 diabetes mellitus〔HR=1.756, 95%CI (1.011, 3.050) 〕were influencing factors of all-cause mortality in patients with dilated cardiomyopathy after one year (P<0.05) .

Conclusion

Type 2 diabetes mellitus was not associated with adverse outcomes in patients with dilated cardiomyopathy at 1 year of follow-up, but was strongly associated with poor outcomes after 1 year in patients with dilated cardiomyopathy.

Bibliometric Analysis of Artificial Intelligence in Diabetic Retinopathy

LIU Chun, JIAN Wenyuan, DUAN Junguo

2023, 26(15):  1847-1856.  DOI: 10.12114/j.issn.1007-9572.2022.0851

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Background

In recent years, artificial intelligence (AI) has shown rapid development in the medical field, and its application in diabetic retinopathy (DR) has been expanding.

Objective

To summarize the application of AI in DR through bibliometric analysis and elucidate the current status, hot spots and emerging trends of AI-related research in DR, with a view to providing ideas for future research.

Methods

The research was performed on the Web of Science database for the researches related to AI applications in DR from inception to 2022-11-04 and used CiteSpace software to conduct bibliometric analysis of the number of articles, countries, institutions, authors, co-citation and keywords in the literature.

Results

A total of 1 770 papers were obtained, with an overall increasing trend in the number of publications and a peak of 402 papers in 2021. China was the top country in terms of the number of publications (440), and the UK was the country with the highest intermediary centrality (0.26). A total of 436 institutions were included in the institutional collaboration network mapping, represented by Sun Yat-sen University and Capital Medical University. A total of 601 authors were included in the author collaboration network mapping, represented by JIA Y L and HWANG T. Three highly cited authors, GULSHAN V, ABRàMOFF M D and TING D W, have made important contributions to the field. Ophthalmology, Invest Ophth Vis Sci and Ieee T Med Imaging are the three most influential journals in the field of AI applied to DR. The research hot spots were mainly focused on lesion segmentation and DR diagnosis. The future research trends may be efficacy prediction of diabetic macular edema as a complication of DR, disease management and improvement of AI algorithm performance.

Conclusion

Researchers can refer to the research hot spots and trends shown by this bibliometric analysis, focusing on AI in DR diagnosis, disease management and improvement of AI algorithm performance.

A Case-control Study of Risk Factors for Recurrence of Diabetic Foot Ulcer after Complete Healing

WANG Gang, YUE Rensong, GONG Guangming

2023, 26(15):  1857-1862.  DOI: 10.12114/j.issn.1007-9572.2022.0888

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Background

Diabetic foot ulcer (DFU) is a serious diabetic complication with a high recurrence rate after healing. There is a lack of systematic evidence-based studies on multiple risk factors associated with its recurrence.

Objective

To investigate the risk factors for DFU recurrence after healing, providing evidence to inform the prevention and treatment of DFU.

Methods

A case-control study design was used. Patients with an initial inpatient diagnosis of DFU were selected from Hospital of Chengdu University of TCM from January 1, 2016 to February 1, 2019 as the source population, among whom those with and without a recurrence within three years after healing were assigned to case and control groups, respectively. Baseline characteristics, information related to diabetes and DFU were collected from both groups. Risk factors for DFU recurrence were screened by unconditional multivariate Logistic regression analysis. The relationships of DFU recurrence with the number of risk factors and the time to recurrence were further analyzed.

Results

Among the source population (n=256), 210 had healed DFU, and 190 of them were included for final analysis after excluding 12 missing cases and 8 with incomplete information. The overall recurrence rate within three years after DFU healing was 45.3% (86/190). Multivariate Logistic regression analysis showed that age >60 years〔OR=3.270, 95%CI (1.335, 8.005), P=0.010〕, HbA_1c >7.5%〔OR=2.691, 95%CI (1.242, 7.687), P=0.045〕, peripheral arterial disease (PAD) 〔OR=2.241, 95%CI (1.185, 5.101), P=0.044〕, osteomyelitis〔OR=3.256, 95%CI (1.369, 7.744), P=0.008〕, callus〔OR=2.068, 95%CI (1.262, 4.446), P=0.043〕, ankle-brachial index (ABI) <0.9〔OR=3.616, 95%CI (1.436, 9.102), P=0.006〕, plantar ulcers〔OR=2.192, 95%CI (1.061, 4.998), P=0.042〕, and Wagner grade ≥3〔OR=5.522, 95%CI (2.484, 12.273), P<0.001〕 were risk factors for DFU recurrence. The number of comorbid risk factors mainly ranged from 5 to 9 in the case group (n=86), and 2 to 5 in the control group (n=104). The number of recurrent cases within one, two and three years in the case group was 35, 28 and 23, respectively. The one-, two- and three-year cumulative recurrence rates were 18.4% (35/190), 33.2% (63/190), and 45.3% (86/190), respectively.

Conclusion

The high recurrence rate of DFU may be associated with risk factors such as age >60 years, HbA_1c >7.5%, PAD, osteomyelitis, callus, ABI <0.9, plantar ulcers, and Wagner grade ≥3.

Original Research·Clucose Fluctuation

Characteristics and Influencing Factors of Glycemic Fluctuation in Patients with Coronary Heart Disease with Type 2 Diabetes during the Peri-PCI Period

XU Di, TIAN Jinping, LIU Yunyue, XUE Leng, ZHANG Lin, SUN Guozhen, WANG Liansheng, XU Jingjing

2023, 26(15):  1863-1872.  DOI: 10.12114/j.issn.1007-9572.2022.0580

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Background

The glycemic fluctuation in peri-percutaneous coronary intervention (PCI) period is closely related to the short-term and long-term prognosis in patients with coronary heart disease (CHD). At present, there are few studies on glycemic fluctuation and its influencing factors in peri- PCI period in these patients.

Objective

To explore the characteristics and influencing factors of glycemic fluctuation during peri-PCI period in patients with CHD and type 2 diabetes (T2DM) .

Methods

One hundred and fifty-six patients undergoing PCI in the cardiology ward of Jiangsu Provincial People's Hospital from April 2021 to November 2021 were selected. General demographics were collected by general demographics questionnaire. Perioperative glycemic fluctuation was collected by glycemic data questionnaire. The patients were stratified according to the normal reference value range of blood glucose fluctuation evaluation indicators: normal standard deviation of blood glucose level (SDBG) group (<2.0 mmol/L, n=58) and high SDBG group (≥2.0 mmol/L, n=98) by the SDBG level; normal amplitude of postprandial glycemic excursions (PPGE) group (<2.2 mmol/L, n=28) and high PPGE group (≥2.2 mmol/L, n=128) by the PPGE; normal largest amplitude of glycemic excursion (LAGE) group (<4.4 mmol/L, n=39) and high LAGE group (≥4.4 mmol/L, n=117) by the LAGE. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality. The Hospital Anxiety and Depression Scale (HAD) was used to identify depression and anxiety. The Numeric Rating Scale (NRs) used to assess pain intensity in peri-PCI period. Pearson and Spearman correlation analyses were used to study the correlation of factors related to blood glucose fluctuation during the peri-PCI period. Multiple linear regression analysis was used to explore the factors associated with blood glucose fluctuation during the peri-PCI period.

Results

Normal and high SDBG groups had statistically significant differences in course of diabetes, use of glucose control regimen, mean values of HbA_1c, changes in dieatary intake during perioperative period, operation start time, operation duration, and NRs score; as well as stent/balloon implantation prevalence (P<0.05). HbA_1c in normal SDBG group was lower than that in high SDBG group. There were statistically significant differences in use of glucose control regimen, mean values of BMI and TC, as well as perioperative dietary intake between normal and high PPGE groups (P<0.05). The mean values of BMI and TC of normal PPGE group were higher than those of high PPGE group. There were statistically significant differences in the duration of diabetes, use of glucose control regimen, mean values of TC, HbA_1c and NRS score between normal and high LAGE groups (P<0.05). The normal LAGE group had higher TC and lower HbA_1c than high LAGE group. The results of repeated measures ANOVA showed that the mean values of SDBG, PPGE and LAGE on the day before PCI, the day of PCI and the day after PCI were significantly different (P<0.05). Correlation analysis showed that during the peri-PCI period, SDBG was positively correlated with age, NRs score and PSQI score (r=0.216, 0.188, 0.295, P<0.05). PPGE was positively correlated with age, duration of diabetes (r_s=0.179, P<0.05) and NRs score (r_s=0.165, P<0.05), and negatively correlated with BMI and TG (r_s=-0.254, -0.196, P<0.05). LAGE was positively correlated with the duration of diabetes, HbA_1c and HAD score (r_s=0.355, 0.171, 0.158, P<0.05). Multiple linear regression analysis showed that age; diet, PSQI score, and the time from the final meal before PCI to the start of PCI were independent factors influencing SDBG, with an explanatory degree of 19.3% (P<0.05). Education level, BMI, glucose control regimen, the time from the end of PCI to the first meal after PCI, and the time from the final meal before PCI to the start of PCI were independent factors influencing PPGE, with an explanation degree of 21.3% (P<0.05). The duration of diabetes, systolic blood pressure, PSQI score, location of domicile, perioperative exercise time, NRs score, the time from the end of PCI to the first meal after PCI; and time of surgery initiation were independent factors influencing LAGE, with an explanation degree of 47.8% (P<0.05) .

Conclusion

The influencing factors of blood glucose fluctuation during the peri-PCI period in patients with CHD and T2DM may include age, diabetes course, systolic blood pressure, registered permanent residence, education level, BMI, diet, perioperative exercise time, sleep quality, pain level, the time from the end of PCI to the first meal after PCI; the time from the final meal before PCI to the start of PCI, time of surgery initiation, and glycemic control plan. Based on these factors, personalized plans can be designed to control blood sugar fluctuations to improve the prognosis.

Analysis of the Correlation between Time in Range and Diabetic Kidney Disease

SHU Tao, GUO Zheng, WANG Fei, CHEN Shuyan

2023, 26(15):  1873-1879.  DOI: 10.12114/j.issn.1007-9572.2022.0749

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Background

Time in range (TIR) is a new indicator of glycemic management in diabetes mellitus which has been thriving in recent years. Studies have confirmed that TIR is closely associated with chronic complications of diabetes. Previous studies have confirmed a close association between TIR and chronic complications of diabetes. Current studies on TIR and diabetic kidney disease (DKD) mainly focus on proteinuria, however the role of glomerular filtration rate (eGFR) in it is often neglected, and there are few studies on the cut points of TIR in evaluating glycemic control.

Objective

To investigate the relationship between TIR and the development of DKD in type 2 diabetes mellitus (T2DM), so as to provide theoretical foundations for the timely clinical detection, diagnosis and treatment of DKD in patients with T2DM.

Methods

A total of 214 T2DM patients admitted to the Department of Endocrinology in Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from July 2021 to December 2021 were included. The general data, laboratory indices and medication use were collected. The included patients were divided into group of DKD〔UACR ≥ 30 mg/g and/or eGFR < 60 ml·min^-1 (1.73 m²) ^-1, n=58〕 and group of T2DM alone〔UACR<30 mg/g and eGFR≥60 ml·min^-1 (1.73 m²) ^-1, n=156〕 based on the urinary albumin/creatinine ratio (UACR) and eGFR results, the included patients were further divided into TIR1 group (TIR>85%, n=90), TIR2 group (70%<TIR≤85%, n=51), TIR3 group (40%<TIR≤70%, n=57), and TIR4 group (TIR≤40%, n=16) using TIR values of 40%, 70%, and 85% as the cut points. Multivariate Logistic regression analysis was used to analyze the relationship between TIR and the development of DKD in T2DM patients.

Results

The detection rate of DKD in T2DM patients tended to increase with decreasing TIR levels (P_trend <0.05). The results of multivariate Logistic regression analysis showed that TIR was an influencing factor for the development of DKD in T2DM patients after adjusting for variables〔OR=0.976, 95%CI (0.953, 0.999), P=0.047〕; TIR3 and TIR4 groups were influencing factors for the development of DKD in T2DM patients compared to TIR1 group〔OR=5.287, 95%CI (1.897, 14.737), P=0.001; OR=4.712, 95%CI (1.143, 19.424), P=0.032〕 after adjusting for various confounding variables, and the incidence risk of DKD in T2DM patients tended to increase with decreasing TIR levels (P_trend=0.010) .

Conclusion

TIR is an influencing factor for the development of DKD in T2DM patients; the incidence rate of DKD in T2DM patients increases significantly with the decreasing levels of TIR.

Impact of Protein Preload Meals on Postprandial Blood Glucose Excursions in Patients with Type 1 Diabetes Mellitus

CAI Yunying, LI Mengge, ZHANG Lun, LI Juan, SU Heng

2023, 26(15):  1880-1884.  DOI: 10.12114/j.issn.1007-9572.2022.0512

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Background

Postprandial glucose excursions is the main cause of elevated glycated hemoglobin levels in patients with diabetes mellitus. Controlling postprandial glucose is also an important strategy for preventing and treating chronic complications of diabetes.

Objective

To evaluate the effect of protein preload meal pattern on postprandial glucose excursions in patients with type 1 diabetes mellitus (T1DM) .

Methods

This study is a randomized, open-label, within-subject crossover clinical registration study. We selected thirty-one T1DM patients aged 18-45 years with a course of disease >1 year who were admitted to the First People's Hospital of Yunnan Province from February 2019 to December 2021. After ten hours fasting, all patients ate two isocaloric test meals with the same ingredients, one is protein preload meals and another is mixed meals, on the 4th and 7th days of wearing continuous glucose monitoring systems (CGM), respectively. CGM was used to analyze the CGMS data 5 hours after a meal, including peak postprandial glucose, time to peak postprandial glucose, average blood glucose level; area under curve (AUC) for blood glucose, incremental area under curve (iAUC) for blood glucose, mean amplitude of glycemic excursions (MAGE), the incremental glucose peak (?Peak) and low (?Low), and the proportion of time of hypoglycemia and hyperglycemia events. We also used a generalized linear mixed model to compare the difference in blood glucose excursions during five hours post-prandial.

Results

Twenty-six T1DM patients were included in the statistical analysis. There was no significant difference in fasting blood glucose, peak blood glucose, mean blood glucose from 0 to 300 min, mean blood glucose from 180 to 300 min, the proportion of time when blood glucose>10 mmol/L (%), the proportion of time when blood glucose>13.9 mmol/L (%), MAGE, and ?Peak between protein preload meals and mixed meals (P>0.05). The peak time and ?Low of the protein preload meals were higher than those of the mixed meals, and the mean blood glucose (0-180 min) of the protein preload meals was lower than that of the mixed meals (P<0.05). No hypoglycemia event occurred in the mixed meals group. iAUC_0-30, iAUC_0-60, iAUC_0-90, iAUC_0-120, iAUC_0-150, iAUC_0-180, and iAUC_0-210 of protein preload meals were lower than those of mixed meals (P<0.05). The blood glucose excursion at 0-30 min, 31-60 min, and 181-210 min of protein preload meals were significantly lower than those of mixed meals (P<0.05) .

Conclusion

This study showed that protein preload meal pattern can improve postprandial glucose levels and reduce postprandial glucose variability in adults with T1DM.

Correlation of Blood Glucose Variability with Infarct Burden and Cognitive Impairment in Patients with Type 2 Diabetes Mellitus Complicated with Recent Small Subcortical Infarct

MENG Qizhe, XI Zhi, WANG Ming, WANG Yang, YANG Xiaopeng

2023, 26(15):  1885-1891.  DOI: 10.12114/j.issn.1007-9572.2022.0856

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Background

Recent small subcortical infarct (RSSI) is one of the manifestations of lacunar infarction. It is a common brain disease and can lead to the clinical outcome of disability or dementia in many patients. However, the relationship of infarction burden and cognitive impairment with blood glucose fluctuation in type 2 diabetes mellitus (T2DM) patients with RSSI is not very clear.

Objective

To explore the correlation of blood glucose variability (GV) with infarction burden and cognitive impairment in T2DM patients with RSSI, and based on this, to build a risk prediction model.

Methods

A total of 140 patients with T2DM and RSSI who were treated in the Second Affiliated Hospital of Zhengzhou University from January 2021 to June 2022 were retrospectively selected. The basic clinical data of the patients were collected. The 72-hour continuous blood glucose monitoring was performed. The infarct burden was evaluated by the magnetic resonance imaging performance (the study subjects were divided into the high infarction burden group including 45 cases and the low infarction burden group including 95 cases according to the imaging performance). The cognitive function was evaluated by the Montreal Cognitive Assessment (MoCA). Spearman correlation analysis was used to explore the correlation between GV and cognitive function (MoCA score). Multivariate Logistic regression analysis was used to explore the influencing factors of infarction burden and cognitive dysfunction in T2DM patients with RSSI. The receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of GV on cognitive impairment in T2DM patients with RSSI, and the nomogram predictive model was constructed and the predictive value was analyzed.

Results

In terms of GV-related indicators, the high infarction burden group had higher standard deviation (SD) and percentage of coefficient of variation (%CV) and lower time in range (TIR) than the low infarction burden group, with statistically significant differences (P<0.05). The results of Spearman correlation analysis showed that SD (r_s=0.272, P=0.001) and %CV (r_s=0.391, P<0.001) were directly proportional to MoCA score, and TIR (r_s=-0.325, P<0.001) was inversely proportional to the MoCA score in T2DM patients with RSSI. The results of multivariate Logistic regression analysis showed that elevated SD〔OR=4.201, 95%CI (1.380, 12.788), P=0.011〕 and %CV〔OR=1.218, 95%CI (1.096, 1.354), P<0.001〕were risk factors for high infarction burden in patients with T2DM and RSSI, while increased TIR〔OR=0.866, 95%CI (0.814, 0.921), P<0.001〕 was a protective factor. Elevated SD〔OR=2.947, 95%CI (1.150, 7.548), P=0.024〕 and %CV〔OR=1.174, 95%CI (1.072, 1.287), P=0.001〕were risk factors for cognitive impairment, while elevated TIR〔OR=0.954, 95%CI (0.917, 0.992), P=0.018〕 was a protective factor in T2DM patients with RSSI. The area under the curve (AUC) of %CV for predicting cognitive impairment in patients with T2DM and RSSI was 0.758〔95%CI (0.660, 0.856), P<0.001〕, with an optimal cut-off value of 29.5%, 66.7% sensitivity and 76.0% specificity. The AUC of TIR in predicting cognitive impairment in T2DM patients with RSSI was 0.714〔95%CI (0.624, 0.804), P<0.001〕, with an optimal cut-off value of 60.5%, 97.2% sensitivity and 44.2% specificity. The nomogram prediction model based on SD, %CV, and TIR for the risk of cognitive impairment in T2DM patients with RSSI demonstrated great clinical benefits, and the internal correction suggested that the actual prediction results were similar to the ideal prediction results.

Conclusion

Elevated GV indicators such as SD and %CV may be independent risk factors, and increased TIR may be a protective factor for high infarct burden and cognitive dysfunction in T2DM patients with RSSI. %CV and TIR had good predictive value for cognitive dysfunction in T2DM patients with RSSI.

Original Research·Diabetes Medication

Effectiveness of Continuous Subcutaneous Insulin Injection in Type 2 Diabetes in Older Adults: a Meta-analysis and Trial Sequential Analysis

YANG Bei, HAN Lin, WANG Yin, CHENG Kangyao

2023, 26(15):  1892-1901.  DOI: 10.12114/j.issn.1007-9572.2022.0574

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Background

As an important part of diabetes treatment, insulin can be administered either by multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) via an insulin pump, but there are still controversies around the effectiveness of insulin administered by both methods in type 2 diabetes mellitus (T2DM) among older adults.

Objective

To evaluate the effectiveness of CSII in T2DM in older adults using meta-analysis, and to test the validity of the analysis results using trial sequential analysis (TSA) .

Methods

Cochrane Library, PubMed, Embase, Medline, Scopus, Web of Science, CNKI, Wanfang Data, CQVIP and SinoMed were retrieved for randomised controlled trials (RCTs) from inception to December 2021 regarding the effectiveness of CSII via an external insulin pump compared with that of MDI of insulin for older adults with T2DM. The primary outcomes included fasting plasma glucose (FPG), 2-hour postprandial plasma glucose (2 hPG), HbA_1c and incidence of hypoglycaemia. The secondary outcomes included the mean amplitude of glycemic excursions (MAGE), total daily dose of insulin, and the time to achieve glycemic target. Two researchers independently carried out literature enrolment, quality evaluation and data extraction. RevMan 5.3 was adopted for meta-analysis. TSA v0.9 (Copenhagen Trial Unit) was adopted for TSA.

Results

Sixteen RCTs were included in total. Meta-analysis demonstrated that CSII via an external insulin pump outperformed MDI of insulin in improving FPG〔MD=-0.82, 95%CI (-1.09, -0.54), P<0.05〕, 2 hPG〔MD=-0.76, 95%CI (-1.39, -0.14), P<0.05〕, HbA_1c〔SMD=-1.23, 95%CI (-2.23, -0.23), P<0.05〕, incidence of severe hypoglycaemia〔RD=-0.10, 95%CI (-0.17, -0.03), P<0.05〕, total daily dose of insulin〔MD=-9.63, 95%CI (-12.35, -6.92), P<0.05〕, and MAGE〔MD=-1.19, 95%CI (-1.40, -0.97), P<0.05〕. Better improved primary outcomes by CSII via an external insulin pump were also found by a TSA, namely more significantly reduced FPG, 2 hPG, and HbA_1c.

Conclusion

CSII via an external insulin pump has been shown to be more effective in improving glycaemic control, reducing the incidence of hypoglycaemia and MAGE among older patients with T2DM.

Clinical Research Progress of Tirzepatide: a New Hypoglycemic Agent

ZHANG Lina, WANG Yan, ZHANG Kanghuai, LI Youjia

2023, 26(15):  1902-1908.  DOI: 10.12114/j.issn.1007-9572.2022.0644

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Despite the availability of various drugs for the treatment of diabetes worldwide, many patients still fail to achieve the recommended target blood sugar levels. Therefore, it is urgent to develop and apply new hypoglycemic drugs. In May 2022, FDA approved tirzepatide, a dual receptor agonist for GIP and GLP-1, administrated once a week to improve blood glucose control in adults with type 2 diabetes by assisting diet and exercise. Numerous clinical studies have proven its effectiveness and safety in type 2 diabetes, and its potential applications in obesity, cardiovascular diseases, non-alcoholic steatohepatitis and so on. In this paper, the mechanism of action, efficacy and safety of tirzepatide were reviewed to provide a reference for its clinical application after marketed in China.

Review & Perspectives

Association of Phosphatase and Tensin Homologue-induced Putative Kinase 1 with Refractory Diabetic Wound Healing: a Review

YANG Jiaqi, ZHANG Peihua, HUANG Haili

2023, 26(15):  1909-1915.  DOI: 10.12114/j.issn.1007-9572.2022.0466

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Chronic and refractory wounds are serious complications of diabetes mellitus, and have no effective treatments. Numerous studies have confirmed that events such as inflammatory response, angiopoiesis and matrix remodeling are closely related to mitochondrial function during diabetic wound healing. Phosphatase and tensin homologue-induced kinase 1 (PINK1) is a serine/threonine protein kinase primarily located in mitochondria, which is involved in regulating mitochondrial autophagy to protect cells from oxidative stress, and plays an important role in regulating inflammatory responses and promoting lipid metabolism. Mutations in the PINK1 gene are closely related to the onset of Parkinson's syndrome. Recent studies also show that PINK1 may be involved in regulating the development of type 2 diabetes. We gave a description of the mechanism of action of PINK1 in regulating diabetic wound healing after reviewing the latest relevant research, and found that existing studies have failed to reveal the molecular mechanism and the time sequence and interaction of signal transduction process involved by PINK1 in different stages of wound healing. Moreover, there is still a lack of in vivo research on PINK1 regulating the healing of refractory diabetic wounds. It is hoped that further clinical research could provide more ideas for the treatment of refractory diabetic wounds.

Advances in Urate Excretion and Urate Transporters in Hyperuricemia

XIN Jiadong, ZHOU Jiabao, WU Zhiyuan, ZHANG Xuming, GAO Jiandong

2023, 26(15):  1916-1922.  DOI: 10.12114/j.issn.1007-9572.2022.0747

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Hyperuricemia is a heterogeneous disease caused by dysregulation of the homeostasis of urate production and excretion, which leads to the elevation of blood uric acid beyond the normal range. It has been found that three common genes ABCG2, SLC2A9 and SLC22A12 have a great influence on serum uric acid level in human body. Other urate transporter genes, such as SLC16A9, SLC22A6, SLC22A7, SLC22A8, SLC22A9, SLC22A11, SLC22A13 and ABCC4 also play a crucial role in the regulation of urate levels. This article reviews the urate transporters mentioned above that have been found to be related to the development of hyperuricemia, including uric acid reabsorption transporter and uric acid secretion transporter in kidney, uric acid transporter in intestine, aiming at providing theoretical and data support for future clinical treatment.

Practice Tips

Clinical Manifestations and Experience of Diagnosis and Treatment of Lymphoid Tissue Infection Caused by Pseudomonas Aeruginosa

LI Yafeng

2023, 26(15):  1923-1926.  DOI: 10.12114/j.issn.1007-9572.2022.0339

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Pseudomonas aeruginosa is a conditional pathogen, which is a common pathogen in nosocomial infections and relatively rare in community infections. At present, there are few reports on the clinical manifestations of Pseudomonas aeruginosa infection, especially regarding the lymphoid tissue infection caused by Pseudomonas aeruginosa. This paper reported a case of lymphoid tissue infection caused by Pseudomonas aeruginosa, summarized its clinical manifestations and treatment process, in order to improve the clinical understanding of the diagnosis and treatment of this disease.