Expert Consensus on Screening and Prevention of Diabetic Microvascular Disease for Primary Care (2024)

Diabetic microvascular disease (DMiVD) is the most common chronic complication of diabetes mellitus, and early identification and effective intervention can significantly improve patients' quality of life and prognosis. The Diabetes and Microcirculation Professional Committee of Chinese Society of Microcirculation and the Primary Endocrine and Metabolic Diseases Group of the Chinese Society of Endocrinology have convened experts in the field to revise the Expert Consensus on Screening and Prevention of Diabetic Microvascular Diseases for Primary Care (2024), based on the 2021 edition, considering the latest research advances and the specific needs of primary care. This consensus elaborates the screening methods, comprehensive management and prevention strategies for DMiVD (diabetic retinopathy, diabetic kidney disease, distal symmetric polyneuropathy and diabetic cardiomyopathy), clarifies the graded diagnosis and treatment and referral processes, emphasizes the importance of preventing and treating DMiVD, and offers guidance and recommendations for physicians, particularly primary care physicians and general practitioners. The aim is to reduce the incidence, progression, and disability associated with DMiVD, ultimately lowering morbidity and mortality rates

Biomarkers of pituitary adenoma behaviour

The pathological behaviour of pituitary adenomas (PAs) is complex and difficult to predict. In this study, the proliferation marker, Ki-67, pituitary tumour transforming gene (PTTG), vascular endothelial growth factor (VEGF), cyclin D1, c-MYC and pituitary adenylate cyclase-activating peptide (PACAP) protein expression were analyzed using immunohistochemistry in 74 PA samples (48 non-functional PAs, 26 functional PAs) and correlated with tumour characteristics including size, extension and tumour behaviour patterns. Correlation of protein marker expression with clinical characteristics yielded significant results. A correlation between PTTG expression and age at diagnosis, tumour size, tumour regrowth and Ki-67 was observed. Cyclin D1 and c-MYC also showed significant correlations with gender, tumour size, age at diagnosis and other protein markers. Significant differences in protein expression in the chosen markers were also observed between different tumour types, between patients treated pre-operatively with somatostatin analogues and in tumours with different intensity on MR imaging). Significant correlations were also observed between the markers themselves, with a possible direct link between two of the studied markers which substantiate data from other in vitro studies. Differences in protein localization were also analyzed to identify possible differences in biological behaviour arising in relation to nuclear vs cytoplasmic localization of the studied biomarkers. VEGF and PACAP similarly appeared interesting but exhibited few statistically significant correlations on detailed analysis. In conclusion, interesting and novel observations on the differences in expression of tumour markers studied are reported. Specifically, Ki-67 and PTTG appear to be very strongly correlated to tumour regrowth/recurrence and may be considered useful tools in predicting the proliferative potential of the resected tumours. Further data on the differential role of Cyclin D1 and cMYC in pituitary tumorigenesis and possibly tumour prognosis are presented.Principal author (MG, JV) was funded by the University of Malta Research funds (MEDRP02-05) and the Faculty of Medicine and Surgery (MDSIN08-22).RF is funded by the REACH HIGH Scholars Programme – Post-Doctoral Grant. The Research work disclosed in this publication is partially funded by the REACH HIGH Scholars Programme – Post Doctoral Grants. The grant is part-financed by the European Union, Operational Programme II – Cohesion Policy 2014 – 2020 “Investing in human capital to create more opportunities and promote the wellbeing of society” – European Social Fund.peer-reviewe

The High Prevalence of Vitamin D Insufficiency across Australian Populations Is Only Partly Explained by Season and Latitude

Background Inadequate sun exposure and dietary vitamin D intake can result in vitamin D insufficiency. However, limited data are available on actual vitamin D status and predictors in healthy individuals in different regions and by season.Methods We compared vitamin D status [25-hydroxyvitamin D; 25(OH)D] in people &lt; 60 years of age using data from cross-sectional studies of three regions across Australia: southeast Queensland (27&deg;S; 167 females and 211 males), Geelong region (38&deg;S; 561 females), and Tasmania (43&deg;S; 432 females and 298 males).Results The prevalence of vitamin D insufficiency (&le; 50 nmol/L) in women in winter/spring was 40.5% in southeast Queensland, 37.4% in the Geelong region, and 67.3% in Tasmania. Season, simulated maximum daily duration of vitamin D synthesis, and vitamin D effective daily dose each explained around 14% of the variation in 25(OH)D. Although latitude explained only 3.9% of the variation, a decrease in average 25(OH)D of 1.0 (95% confidence interval, 0.7&ndash;1.3) nmol/L for every degree increase in latitude may be clinically relevant. In some months, we found a high insufficiency or even deficiency when sun exposure protection would be recommended on the basis of the simulated ultraviolet index.Conclusion Vitamin D insufficiency is common over a wide latitude range in Australia. Season appears to be more important than latitude, but both accounted for less than one-fifth of the variation in serum 25(OH)D levels, highlighting the importance of behavioral factors. Current sun exposure guidelines do not seem to fully prevent vitamin D insufficiency, and consideration should be given to their modification or to pursuing other means to achieve vitamin D adequacy.<br /

Hip fracture risk in relation to vitamin D supplementation and serum 25-hydroxyvitamin D levels: a systematic review and meta-analysis of randomised controlled trials and observational studies

<p>Abstract</p> <p>Background</p> <p>Vitamin D supplementation for fracture prevention is widespread despite conflicting interpretation of relevant randomised controlled trial (RCT) evidence. This study summarises quantitatively the current evidence from RCTs and observational studies regarding vitamin D, parathyroid hormone (PTH) and hip fracture risk.</p> <p>Methods</p> <p>We undertook separate meta-analyses of RCTs examining vitamin D supplementation and hip fracture, and observational studies of serum vitamin D status (25-hydroxyvitamin D (25(OH)D) level), PTH and hip fracture. Results from RCTs were combined using the reported hazard ratios/relative risks (RR). Results from case-control studies were combined using the ratio of 25(OH)D and PTH measurements of hip fracture cases compared with controls. Original published studies of vitamin D, PTH and hip fracture were identified through PubMed and Web of Science databases, searches of reference lists and forward citations of key papers.</p> <p>Results</p> <p>The seven eligible RCTs identified showed no significant difference in hip fracture risk in those randomised to cholecalciferol or ergocalciferol supplementation versus placebo/control (RR = 1.13[95%CI 0.98-1.29]; 801 cases), with no significant difference between trials of <800 IU/day and ≥800 IU/day. The 17 identified case-control studies found 33% lower serum 25(OH)D levels in cases compared to controls, based on 1903 cases. This difference was significantly greater in studies with population-based compared to hospital-based controls (χ²₁(heterogeneity) = 51.02, p < 0.001) and significant heterogeneity was present overall (χ²₁₆(heterogeneity) = 137.9, p < 0.001). Serum PTH levels in hip fracture cases did not differ significantly from controls, based on ten case-control studies with 905 cases (χ²₉(heterogeneity) = 149.68, p < 0.001).</p> <p>Conclusions</p> <p>Neither higher nor lower dose vitamin D supplementation prevented hip fracture. Randomised and observational data on vitamin D and hip fracture appear to differ. The reason for this is unclear; one possible explanation is uncontrolled confounding in observational studies. Post-fracture PTH levels are unrelated to hip fracture risk.</p

Project TENDR: Targeting environmental neuro-developmental risks. the TENDR consensus statement

Children in America today are at an unacceptably high risk of developing neurodevelopmental disorders that affect the brain and nervous system including autism, attention deficit hyperactivity disorder, intellectual disabilities, and other learning and behavioral disabilities. These are complex disorders with multiple causes—genetic, social, and environmental. The contribution of toxic chemicals to these disorders can be prevented. Approach: Leading scientific and medical experts, along with children’s health advocates, came together in 2015 under the auspices of Project TENDR: Targeting Environmental Neuro-Developmental Risks to issue a call to action to reduce widespread exposures to chemicals that interfere with fetal and children’s brain development. Based on the available scientific evidence, the TENDR authors have identified prime examples of toxic chemicals and pollutants that increase children’s risks for neurodevelopmental disorders. These include chemicals that are used extensively in consumer products and that have become widespread in the environment. Some are chemicals to which children and pregnant women are regularly exposed, and they are detected in the bodies of virtually all Americans in national surveys conducted by the U.S. Centers for Disease Control and Prevention. The vast majority of chemicals in industrial and consumer products undergo almost no testing for developmental neurotoxicity or other health effects. Conclusion: Based on these findings, we assert that the current system in the United States for evaluating scientific evidence and making health-based decisions about environmental chemicals is fundamentally broken. To help reduce the unacceptably high prevalence of neurodevelopmental disorders in our children, we must eliminate or significantly reduce exposures to chemicals that contribute to these conditions. We must adopt a new framework for assessing chemicals that have the potential to disrupt brain development and prevent the use of those that may pose a risk. This consensus statement lays the foundation for developing recommendations to monitor, assess, and reduce exposures to neurotoxic chemicals. These measures are urgently needed if we are to protect healthy brain development so that current and future generations can reach their fullest potential

The prismatic forms of diabetes in pediatrics : natural evolution, strategies for ß-cell replacement, and tolerance to physical activity

I. Title of the proposal: The prismatic forms of diabetes in pediatrics: natural evolution, strategies for β-cell replacement, and tolerance to physical activity. II. Results obtained a) Study of glycemic control and β-cell mass evolution after onset of T1D in pediatrics We characterized the principal determinants of partial remission (PR) in a pediatric cohort of patients with type 1 diabetes (T1D) 1. We developed a new formula (GTAA1C score) to predict PR in youngsters with T1D, based on routine clinical parameters of glycemic variability 2. More recently, we demonstrated the positive residual impact of PR on short-term post-PR glycemic control (i.e., at 6 months post-PR) in a cohort of children (n=189) with T1D 3. In our DIABHONEY study, while residual post-PR effects were correlated to PR duration, these were not sustained: long PR induced better glycemic control at 6 months post-PR (compared to short PR or PR- controls) but did not impact glycemic variability indexes one year after PR. Inside the DiaType consortium (Bridge 2017 – Innoviris), we evaluated the evolution of patients with atypical forms of diabetes to better understand genetic and metabolic determinants of residual β-cell function, and propose etiology-based, patient-centered therapeutic approaches. Our pediatric initiative, called the GENEPEDIAB study, gattered six diabetes convention centers inside the French-speaking part of Belgium. We created a new score (DIAMODIA), based on typical clinical features, to identify patients with atypical diabetes. So far, out of 1550 patients with “type 1 or type 2 diabetes”, we isolated a subgroup of 149 patients presenting atypical forms of diabetes (called “ADia cohort”). This ADia cohort was subjected to a stepwise genetic screening (routine gene panel → whole exome sequencing (WES) → genome sequencing) to screen for a potential molecular diagnosis. Routine MODY gene panel analysis identified 34 patients with class V variant (the “MODY” cohort). In-depth WES analysis identified 37 ADia patients with class III variant, providing our DIAMODIA score a yield of 31% for class V and 34% for class III variant positivity. Our DIAMODIA score was cross-validated on a MODY cohort (vs typical T1D cohort) to ensure the external validity and the predictive value of this new tool for the diagnosis of patients carrying a potential gene variant. These results were presented at ISPAD and ESPE 2022 Scientific Sessions 4,5 and were submitted for publication. Our group is also leading the DIATAG consortium study that gathers eight diabetes convention centers in Belgium. This study aims at identifying biomarkers of β-cell mass evolution in children and adolescents with new-onset T1D and to stratify patients in their capacity to enter or not in PR. In this cohort, we identified new determinants of PR by evaluating composite scores of serum biomarkers and parameters of glucose control. We observed that CGM metrics strongly correlated with clinical parameters and were sufficient to distinguish remitters from non-remitters. CGM metrics (or indexes) are thus minimal-invasive tools with strong potential to identify PR, as opposed to more demanding dynamic β-cell residual secretion testing. Also, thorough CGM analysis allowed us to identify four novel glucotypes that segregate patients into subgroups and mirror the evolution of remission after diabetes onset 6. This work was presented at ADA (poster) and ENDO (oral) in 2022. Also, we identified new makers of remission status using a comprehensive multi-parametric analysis of pancreatic structure of patients with new-onset T1D. Our current analyses confirm the significant decrease in volume (50%) and pancreatic ratio in these patients, compared to matched controls. We also observed a negative correlation of the pancreatic ratio with HbA1C levels at diagnosis. Correlation analyses with other parameters of disease controls and markers of β-cell function were performed and results were presented during ENDO 2022 7 and submitted for publication. In DIATAG, Proteomic analysis of the sera is being performed by collaboration with the MASSPROT platform at de Duve Institute (S. Pyr dit Ruys, D. Vertrommen, UCLouvain) for the setting-up of the assays (e.g. protein purification, annihilation of background noise) and for the running of experiments using 2D-LC-MS/MS without protein tagging. On a pilot series of plasmas from 6 DIATAG patients, using TMT labeling, we identified 1487 unique plasma proteins (FDR <0.01), covering a dynamic range of 107. When comparing remitters vs non-remitters to identify proteins exhibiting a different level of expression, we identified 11 candidate proteins, among those sCD14, thrombospondin-1, and gastric inhibitory polypeptide play a role in the pathophysiology of T1D. Achievement of the abundance ratio of sCD14 and GIP correlated with IDAA1C at three months (R=-0.94, p=0.005). We are now measuring the abundance of these proteins by targeted mass spectrometry in the entire DIATAG cohort. In our evaluation of markers of glycemic control in pediatric patients with T1D, we recently described the new concept of “post-hypoglycemic hyperglycemia” (PHH) (i.e. hypoglycemia that recover to hyperglycemia in any circumstance) and studied factors likely to influence PHH characteristics in a cohort of young patients with established T1D. Our EPHICA study 8 highlighted the importance of PHH as a prominent component of hyperglycemia in some children and adolescents with T1D. Factors associated with PHH features were age, BMI and parameters of glycemic control. Young and lean children were more prone to experience hypoglycemia that recovered with hyperglycemia, but adolescents and obese children tended to experience hyperglycemia of longer duration. This PHH parameter is now thoroughly evaluated by our team in the circumstance of PR in patients with new-onset T1D. b) Study of secondary forms of diabetes Secondary forms of diabetes mellitus are commonly understudied and underdiagnosed. For example, despite the evidence suggesting that glucocorticoids, asparaginase, radiotherapy, and immunosuppressants increase the risk of developing diabetes, its incidence, associated risk factors and biological prediction markers remain unknown. Yet it is important to study diabetes incidence and risk in contexts of organ transplantation and oncologic treatments, since developing diabetes in these settings is associated with unfavorable outcome and increase in cardiovascular events. The objectives of our DIABGRAFT and DIABONCO 9 studies are to identify early markers of glycemic dysregulation respectively in transplanted (liver and kidney) patients and cancer survivors, to eventually improve clinical management of these conditions, both in terms of treatment and follow-up. Results of our retro- and prospective DIABGRAFT study were submitted for publication and are currently under review. c) Types 1 diabetes and inflammation It is accepted that β-cell destruction occurs via cytokine secretion and activation of specific receptors and lymphocytes. A current objective of our research is to evaluate whether knockdown strategies, directed toward key protein components of islet inflammation 10, might be combined to a pharmacological alleviation of glucotoxicity in an effort to protect β-cell mass against destruction, during the early events leading to β-cell demise in T1D. In a subsidiary study of this research project 11, we evaluated whether glucotoxicity could contribute to β-cell mass destruction through participation to islet inflammation. We evaluated the potential of empagliflozin and GABA respectively to protect β-cell mass against glucotoxicity and to increase β-cell mass after diagnosis of T1D. In a streptozotocin-treated mouse model of T1D, we observed that empagliflozin and/or GABA had the potential to improve glucose homeostasis and pancreatic insulin content in treated animals, as compared to diabetic controls. We noticed that the effects of empagliflozin were associated with a reduction of islet ER stress and inflammation, whereas in mice co-treated with empagliflozin and GABA, β-cell mass increased after a first burst of proliferation of the α-cell compartment. Our next goal is to evaluate whether these effects of empagliflozin and GABA might be translated into longer-term protocols in the NOD mouse model. d) Diabetes cell therapy Our group has discovered pancreatic progenitor cells with the potential to produce new β cells in vitro and to decrease glucose levels of diabetic animals after transplantation 12-15. We developed a new system for overexpression of MAFA transcription factor using synthetic modified mRNA. We observed that the overexpression of MAFA mRNA was sufficient and efficient to drive our pancreas progenitors toward glucose-responsive β-like cells 13. e) Diabetes and exercise During physical activity, patients with T1D have to face various challenges to maintain blood glucose levels into the normal range. In the TREAD-DIAB trial 16, we evaluated the needs of children and adolescents in terms of insulin and carbohydrate modifications during sports. We developed an algorithm that helps us to precisely adapt insulin and carbs during exercise sessions, specifically for each individual patient. Our results showed the possibility to normalize blood glucose for patients under pump therapy. Because this was more challenging in young patients under insulin injections, we have now conducted a new study (CAR2DIAB), to evaluate whether we might provide fine-tuning of insulin injections and carb intake to every patient with diabetes. In this pediatric investigation, the application of algorithmic and individual adaptations of treatment globally improved glycemic control during 15h after exercises performed in real life by children and adolescents (n=12) with T1D 17. We are now extending this trial to a larger group of patients (CAR2DIAB-2 study). III. References 1. Pecheur A, Barrea T, Vandooren V, Beauloye V, Robert A, Lysy PA. Characteristics And Determinants Of Partial Remission In Children With Type 1 Diabetes using the Insulin-Dose-Adjusted A1C Definition. J Diabetes Res. 2014;2014:851378. 2. Nielens N, Pollé O, Robert A, Lysy PA. Integration Of Routine Parameters Of Glycemic Variability In A Simple Screening Method For Partial Remission In Children With Type 1 Diabetes. J Diabetes Res. 2018 Jan 17;2018:5936360. 2018 UCLouvain Medical School prize for best master thesis (N. Nielens). 3. Boutsen L, Costenoble E, Pollé O, Erdem K, Bugli C, Lysy PA. Influence of the Occurrence and Duration of Partial Remission On Short-term Metabolic Control in Type 1 Diabetes: the DIABHONEY Pediatric Study. Therapeutic Advances in Endocrinology and Metabolism. 2022, accepted for publication (IF: 4.435). 4. Welsch S, Gallo P, Beckers D, Lebrethon MC, Mouraux T, Seret N, Lysy PA. Etiology-based diagnosis of pediatric patients with atypical diabetes using routine and omic-based phenotyping and genotyping: results from the GENEPEDIAB study. Horm Res Paediatr 2022;95:1–616. https://doi.org/10.1159/000525606. Poster. 5. Welsch S, Gallo P, Beckers D, Lebrethon MC, Mouraux T, Seret N, Lysy PA. Etiology-based diagnosis of pediatric patients with atypical diabetes using routine and omic-based phenotyping and genotyping: results from the GENEPEDIAB study. Pediatric Diabetes. 20 October 2022. https://doi.org/10.1111/pedi.13399. Oral presentation. 6. Pollé OG, Delfosse A, Martin M, Louis J, Gies I, den Brinker M, Seret N, Lebrethon MC, Mouraux T, Gatto L, Lysy PA; DIATAG Working Group. Glycemic Variability Patterns Strongly Correlate With Partial Remission Status in Children With Newly Diagnosed Type 1 Diabetes. Diabetes Care. 2022 Oct 1;45(10):2360-2368. doi: 10.2337/dc21-2543. IF: 19.112. 7. Pollé, O. G., Delfosse, A., Michoux, N., Peeters, F., Duchene, G., Mouraux, T., Clapuyt, P., Louis, J., Gies, I., den Brinker, M., Lebrethon, M-C., Seret, N., & Lysy, P. A. (2022). Deep Characterization of Pancreas Volume of New-Onset Type 1 Diabetes Patients Reveals Puberty-Specific Patterns and New Topographic Correlations with Pancreatic Functions. Journal of the Endocrine Society, 6 (Supplement_1), 424. Poster with oral presentation. 8. Colinet V, Lysy PA. Characterization of Post-Hypoglycemic Hyperglycemia in Children and Adolescents With Type 1 Diabetes: The EPHICA Study. Front Endocrinol (Lausanne). 2022 Jun 27;13:887976. doi: 10.3389/fendo.2022.887976. PMID: 35832426; PMCID: PMC9272988. 9. Welsch S, Sawadogo K, Brichard B, de Ville de Goyet M, Van Damme A, Boulanger C, Lysy PA. Characterization and risk factors of hyperglycaemia during treatment of childhood hematologic malignancies. Diabet Med. 2021 Oct 15:e14720. doi: 10.1111/dme.14720. Epub ahead of print. PMID: 34652870. 10. Daems C, Vanderroost J, Sokal E, Lysy PA. Partial CRISPR/Cas9 IL1R1 & IFNGR1 Knock-Down Improves β-cell Survival And Function Under Cytokine-Induced Inflammation. Submitted as an abstract to the ESPE Congress 2019 (Vienna) and was awarded the Henning Andersen Prize, and the best award prize from the 2019 meeting. 11. Daems C, Welsch S, Boughaleb H, Vanderroost J, Robert A, Sokal E, Lysy PA. Early Treatment with Empagliflozin and GABA Improves β-Cell Mass and Glucose Tolerance in Streptozotocin-Treated Mice. J Diabetes Res. 2019;2019:2813489. doi:10.1155/2019/2813489. 12. Corritore E, Dugnani E, Pasquale V, Misawa R, Witkowski P, Lei J, Markmann J, Piemonti L, Sokal EM, Bonner-Weir S, Lysy PA. β-Cell Differentiation Of Human Pancreatic Duct-Derived Cells After In Vitro Expansion. Cell Reprogram, 2014 Dec;16(6):456-66. 13. Corritore E, Lee YS, Pasquale V, Liberati D, Hsu MJ, Lombard CA, Van Der Smissen P, Vetere A, Bonner-Weir S, Piemonti L, Sokal E, Lysy P. V-Maf Musculoaponeurotic Fibrosarcoma Oncogene Homolog A Synthetic Modified mRNA Drives Reprogramming of Human Pancreatic Duct-Derived Cells Into Insulin-Secreting Cells. Stem Cells Transl Med. 2016 Jul 12. pii: sctm.2015-0318. Stem Cells Translational Medicine Young Investigator Award for Best 2016 paper. 14. Yamada T, Cavelti-Weder C, Caballero F, Lysy P, Guo L, Sharma A, Li W, Zhou Q, Bonner-Weir S, Weir GC. Reprogramming Mouse Cells With a Pancreatic Duct Phenotype to Insulin-Producing β-Like Cells. Endocrinology, 2015, Apr 2:en20141987. 15. Yuan Y, Hartland K, Boskovic Z, Wang Y, Walpita D, Lysy PA, Zhong C, Young DW, Kim YK, Tolliday NJ, Sokal EM, Schreiber SL, Wagner BK, A small-molecule inducer of PDX1 expression identified by high-throughput screening. Chem Biol. 2013 Dec 19;20(12):1513-22. 16. Moniotte S, Owen M, Barrea T, Robert A, Lysy PA. Outcomes of algorithm-based modifications of insulinotherapy during exercise in MDI vs insulin pump-treated children with type 1 diabetes: results from the TREAD-DIAB study. Pediatr Diabetes 2017. doi: 10.1111/pedi.12509. 17. Lysy P.A., Absil H., Gasser E., Boughaleb H., Barrea T., Moniotte S. Combined algorithm-based adaptations of insulin dose and carbohydrate intake during exercise in children with type 1 diabetes: results from the CAR2DIAB study (submitted)