Prevalence of Impairment of Visual Acuity and Severity of Retinopathy in Patients with Diabetes Mellitus.

AIMS: No information exists on the frequency of visual impairment in people with diabetes mellitus (DM) in Germany. In this study, the prevalence of vision impairment in those individuals was investigated. METHODS: We retrospectively analyzed a cohort of 295 people (14221 consultations) at a university outpatient clinic with any type of DM and an available ETDRS-Score and visual acuity. The primary outcome was the prevalence of visual impairment, the secondary outcome was the correlation of the ETDRS-Score and limitations of visual acuity and the prevalence of higher ETDRS-Score with a visual impairment defined as a decimal-visus

Synchronous Metastatic Medullary Thyroid Carcinoma and Paraesophageal Parathyroid Adenoma Detected on 18 F-Ethylcholine PET/US Fusion Imaging.

ABSTRACT: An 80-year-old woman with osteoporosis without fractures was referred with asymptomatic primary hyperparathyroidism and elevated calcitonin level. Ultrasound, 99m Tc-pertechnetate scintigraphy, 99m Tc-MIBI scintigraphy, and CT revealed a suspicious thyroid nodule and enlarged submandibular lymph nodes. However, no parathyroid adenoma was depictable. 18 F-choline PET/CT showed increased uptake of the proximal esophagus, but neither CT nor US revealed a parathyroid lesion, and only 18 F-choline PET/US fusion imaging confirmed a paraesophageal parathyroid adenoma. Resection of both medullary thyroid carcinoma and ectopic parathyroid adenoma through a single cervicotomy was conducted (thyroidectomy, neck dissection, extirpation of parathyroid adenoma); parathyroid hormone and calcitonin dropped to normal. Multiple endocrine neoplasia IIa syndrome was suspected.

Blood Sugar Targets in Surgical Intensive Care­Management and Special Considerations in Patients With Diabetes

BACKGROUND: 30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus. METHODS: This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar. RESULTS: Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions. CONCLUSION: Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.

Metabolic control and hypoglycaemia in people with type 1 diabetes: insulin pump therapy vs. intensified insulin therapy in an unselected cohort in routine care.

AIMS: The aim of this study was to compare individuals with type 1 diabetes with continuous subcutaneous insulin infusion (CSII) and intensified insulin therapy (ICT) in routine care regarding metabolic control and treatment satisfaction. METHODS: Individuals with type 1 diabetes (CSII n = 74; ICT n = 163) were analysed regarding metabolic control, frequency of hypoglycaemia and treatment satisfaction (DTSQs range 0-36). RESULTS: Individuals with CSII (duration of CSII: 14.1 ± 7.2 years) were younger (51.1 ± 15.8 vs. 56.2 ± 16.2 years, p = 0.023), had longer diabetes duration (28.7 ± 12.4 vs. 24.6 ± 14.3 years, p = 0.033), lower insulin dosage (0.6 ± 0.2 vs. 0.7 ± 0.4 IU/kg, p = 0.004), used more frequently short-acting analogue insulin (90.5% vs. 48.5%, p < 0.001) and flash/continuous glucose monitoring (50.0% vs. 31.9%, p = 0.009) than people with ICT. HbA1c was similar between CSII and ICT (7.1 ± 0.8%/54.4 ± 9.1 mmol/mol vs. 7.2 ± 1.0%/55.7 ± 10.9 mmol/mol, p = 0.353). Individuals with CSII had higher frequency of non-severe hypoglycaemia per week (in people with blood glucose monitoring: 1.9 ± 1.7 vs. 1.2 ± 1.6, p = 0.014; in people with flash/continuous glucose monitoring: 3.3 ± 2.2 vs. 2.1 ± 2.0, p = 0.006). Prevalence of polyneuropathy (18.9% vs. 38.0%, p = 0.004) and systolic blood pressure (138.0 ± 16.4 vs. 143.9 ± 17.1 mmHg, p = 0.014) was lower in CSII. Satisfaction with diabetes treatment (26.7 ± 7.3 vs. 26.0 ± 6.8, p = 0.600) did not differ between CSII and ICT. CONCLUSIONS: CSII and ICT yielded comparable metabolic control and treatment satisfaction but CSII was associated with higher incidence of non-severe hypoglycaemia and lower insulin dosage.

Diabetes related distress is high in inpatients with diabetes.

OBJECTIVE: The aim of the present study was to assess diabetes-related distress in inpatients and its association with metabolic control in people with diabetes type 1 (DM1) and type 2 (DM2). RESEARCH DESIGN AND METHODS: In a cross-sectional study, 107 inpatients with DM1 (age 45.9 years, diabetes duration 18.7 years, HbA1c 8.4%/67.8 mmol/mol) and 109 with DM2 (age 62.0 years, diabetes duration 16.2 years, HbA1c 8.9%/74.3 mmol/mol) from a University department for endocrinology and metabolic diseases (Germany) were included over 2 years. Diabetes-related distress was assessed with the PAID questionnaire (range 0-100, higher scores imply higher diabetes-related distress, cut-off ≥ 40). The PAID questionnaire was completed by 214 of 216 participants. RESULTS: Fifty-one of 214 individuals (23.8%) showed high distress (PAID score ≥ 40). The mean PAID score was 28.1 ± 17.5 in all participants with no difference between DM1 and DM2 (28.1 ± 17.4 vs. 26.2 ± 16.9, p = 0.532). Individuals with DM2 on insulin scored higher than patients without insulin (27.8 ± 17.6 vs. 18.7 ± 8.5, p = 0.004). Additionally, people with DM1 treated with a system for continuous glucose monitoring (n = 50, 33.1 ± 18.8) scored higher than participants without such system (n = 32, 20.6 ± 13.3, p = 0.001). HbA1c was not correlated with the PAID score in both, DM1 (r = 0.040, p = 0.684) and DM2 (r = - 0.024, p = 0.804). Participants with DM2 and severe hypoglycaemia/last 12 months scored higher than people without (PAID score 43.0 ± 20.4 vs. 25.1 ± 16.5, p = 0.026). Frequency of non-severe hypoglycaemia was not associated with the PAID score in DM1 and DM2. CONCLUSIONS: Patients with diabetes treated in hospital for problems with diabetes suffer frequently from diabetes-related distress (~ 24%) regardless of diabetes type.

Overestimation of Risk and Increased Fear of Long-term Complications of Diabetes in People with Type 1 and 2 Diabetes.

OBJECTIVE: The quality report of the disease management programmes of North Rhine Westphalia 2016 showed prevalences for long-term complications (neuropathy, nephropathy, retinopathy) of less than 30% for people with diabetes type 1 (DM1) and type 2 (DM2). The aim of this study was to assess risk expectations and fear regarding long-term complications of diabetes in people with DM1 and DM2. METHODS: We assessed risk expectations and fear regarding diabetes complications in people with DM1 (n=110) and DM2 (n=143 without insulin, n=249 with insulin) visiting an University outpatient department of metabolic diseases. Fear of long-term complications was measured with the "Fear of Complications Questionnaire (FCQ)" (range 0-45 points, scores ≥30 suggest elevated fear). Participants were asked to estimate general and personal risks of long-term complications 10 years after developing diabetes in %. RESULTS: Elevated fear of complications (FCQ scores ≥30) was observed in 34.5, 25.9, and 43.0% of those with DM1, DM2 without insulin and DM2 with insulin, respectively. Participants estimated a mean general risk of diabetes-related complications after 10 years amounting to 45.9±15.8% (DM1), 49.7±15.4% (DM2 without insulin), and 52.5±16.4% (DM2 with insulin) and personal risk with 52.5±24.4% (DM1), 45.8±22.7% (DM2 without insulin), and 54.1±23.4% (DM2 with insulin), respectively. Higher risk expectations were associated with higher fear of complications (p<0.001). CONCLUSION: Risk estimations regarding long-term complications were exaggerated in people with DM1 and DM2. About one third of the participants reported elevated fear of complications. Participants' risk expectations and fear regarding diabetes complications appear excessive compared to population-based prevalence rates.

Snacking is Common in People with Diabetes Type 1 and Type 2 with Insulin Therapy and Is Not Associated With Metabolic Control or Quality of Life.

OBJECTIVE: The aim of this observational study was to analyse snacking pattern and satisfaction with snacking, and to associate snacking patterns with metabolic control and quality of life in people with diabetes type 1 and 2 on insulin therapy. METHODS: In 2017, 390 people with diabetes were interviewed in a university outpatient department: 132 diabetes type 1 (56.1y, diabetes duration 24.2y, HbA1c 7.0%), 89 diabetes type 2/biphasic insulin (72.8y, diabetes duration 22.0y, HbA1c 7.1%) and 169 diabetes type 2/prandial insulin (66.7y, diabetes duration 20.5y, HbA1c 7.0%). Standardised questionnaires were used to assess eating patterns, satisfaction with snacking, treatment satisfaction and quality of life. RESULTS: The far majority snacked regardless of diabetes type and type of insulin therapy (70.5% type 1, 80.9% type 2/biphasic insulin, 74.6% type 2/prandial insulin) and liked to do so or did not mind (type 1 diabetes 79.5%, type 2 diabetes/biphasic insulin 84.8%, type 2 diabetes/prandial insulin 83.5%). Snacking because of recommendations of healthcare professionals was rare (10.8% type 1 diabetes, 8.2% type 2 diabetes/biphasic insulin, 9.4% type 2 diabetes/prandial insulin). Snacking and not snacking participants did not differ in respect to HbA1c, quality of life or treatment satisfaction. CONCLUSIONS: Snacking seems to be a common habit in individuals with diabetes and most of them like to snack. Snacking is not associated with better or worse metabolic control or quality of life. The decision to snack or not to snack can be left to the individual and integrated into the therapy without danger for the glycaemic control.

Expectations and fear of diabetes-related long-term complications in people with type 2 diabetes at primary care level.

AIMS: The quality report of patients enrolled in the disease management programmes of North Rhine Westphalia 2016 showed prevalence of long-term complications in diabetes type 2: neuropathy 24.2%, nephropathy 12.5%, retinopathy 8.2%. The aim of this study was to assess expectations and fear of diabetes-related long-term complications in people with diabetes type 2. METHODS: We assessed expectations and fear of diabetes-related complications in 104 people with diabetes type 2 (age 67.0J, diabetes duration 6.6J, HbA1c 6.6%/48.6 mmol/mol, neuropathy 20.2%, nephropathy 11.5%, retinopathy 1.9%) in an outpatient healthcare centre at primary care level. Fear of diabetes-related complications was assessed using the "Fear of Complications Questionnaire" (FCQ) with a range of 0-45 points (≥ 30 means clinically meaningful fear, higher scores imply higher level of fear). Furthermore, study participants estimated general and personal risk of suffering from diabetes-related long-term complications after 10 years of diabetes duration on a scale of 0-100%. RESULTS: Mean FCQ score was 22.9 ± 11.5. 34/104 participants (32.7%) scored ≥ 30 points and thus had great fear. Participants estimated general risk of suffering from diabetes-related complications after 10 years of diabetes duration on 55.1% and personal risk on 46.0%. Risk of diabetes-related complications scoring highest was impaired circulation of lower limb (62.1%), eye complications (57.3%) and kidney complications (54.7%). CONCLUSION: Prevalence of diabetes-related long-term complications was overestimated in people with diabetes type 2. Approximately one third of the participants showed even great fear. Patient expectation and fear about diabetes-associated complications did not correspondent with data on clinical reality.

Hyperglycaemia-induced methylglyoxal accumulation potentiates VEGF resistance of diabetic monocytes through the aberrant activation of tyrosine phosphatase SHP-2/SRC kinase signalling axis.

Diabetes mellitus (DM) is a major cardiovascular risk factor contributing to cardiovascular complications by inducing vascular cell dysfunction. Monocyte dysfunction could contribute to impaired arteriogenesis response in DM patients. DM monocytes show blunted chemotactic responses to arteriogenic stimuli, a condition termed as vascular endothelial growth factor (VEGF) resistance. We hypothesize that methylglyoxal (MG), a glucose metabolite, induces monocyte dysfunction and aimed to elucidate the underlying molecular mechanisms. Human monocytes exposed to MG or monocytes from DM patients or mice (db/db) showed VEGF-resistance secondary to a pro-migratory phenotype. Mechanistically, DM conditions or MG exposure resulted in the upregulation of the expression of SHP-2 phosphatase. This led to the enhanced activity of SHP-2 and aided an interaction with SRC kinase. SHP-2 dephosphorylated the inhibitory phosphorylation site of SRC leading to its abnormal activation and phosphorylation of cytoskeletal protein, paxillin. We demonstrated that MG-induced molecular changes could be reversed by pharmacological inhibitors of SHP-2 and SRC and by genetic depletion of SHP-2. Finally, a SHP-2 inhibitor completely reversed the dysfunction of monocytes isolated from DM patients and db/db mice. In conclusion, we identified SHP-2 as a hitherto unknown target for improving monocyte function in diabetes. This opens novel perspectives for treating diabetic complications associated with impaired monocyte function.

[Pitfalls in the Diagnosis of Diabetes: Are we too Lax with Laboratory Parameters?] / Fallstricke bei der Diabetesdiagnostik: Wird zu lax mit Laborwerten umgegangen?

The diagnosis of diabetes is associated with pre-analytical and analytical problems. Fasting glucose (FG), oral glucose tolerance test (oGTT) and HbA1c have advantages and shortcomings and have no equal diagnostic validity. oGTT is the most sensitive test, but its reproducibility is rather poor (CV±â€Š15 %). FG detects only 70 - 80 % of overt diabetes. FG is falsified by inappropriate blood sampling, intra-individual fluctuations and mistakes with the oGTT. HbA1c despite IFC- standardization, but with a tolerable coefficient of variation of ±â€Š18 % in round robin tests and use of not commutable control material is not easy to interpret. HbA1c analysis shows also interferences and is therefore of limited diagnostic value. Its threshold value of ≥ 6.5 % (≥ 48 mmol/mol Hb) is based on consensus and not on evidence. The diagnostic effort (FG and/or oGTT+HbA1c) with serious consequences is minimal invasive, reasonable and cheap. It prevents over- and underdiagnosis.

Higher HbA1c Measurement Quality Standards are Needed for Follow-Up and Diagnosis: Experience and Analyses from Germany.

Measurement of HbA1c is an essential laboratory measure for the follow-up and therapy decision-making in patients with diabetes. HbA1c is one of the measurands in laboratory medicine that have to be successfully checked according to the criteria of the guidelines of the German Medical Association (Rili-BAEK) in external quality assurance using the reference method value concept, when applied in patient care. The allowed deviation of ±18% in external quality assessment (EQA) and ± 10% in internal quality control has been ultimately met by virtually all the different manufacturers and methods. However, such broad limits for permissible deviations are not suitable in view of medical requirements in patient care. The low-level acceptance criteria also depends on the previously used EQA materials used in Germany. In fact, HbA1c measurement results that are imprecisely measured or come from incorrectly calibrated devices are difficult to identify. With implementation of unprocessed fresh EDTA blood, the situation has changed. Until now systems with unit use reagents for point-of-care testing (POCT) of HbA1c are not mandatory to participate in EQA schemes in Germany. This paper outlines why there was a need to narrow the acceptance limits listed within the Rili-BAEK for HbA1c's internal (to ± 3%) and external (to ± 8%) quality controls in EQA schemes for Germany, which will take place after a transition period in the next years. Higher quality in HbA1c measurements will help to avoid misdiagnosis of diabetes as well as potential over- or undertreatment of patients at risk for diabetes.

Definition, Classification and Diagnosis of Diabetes Mellitus.

Aim of recommendations like this one issued by the German Diabetes Association is to provide the GP and diabetologist and his team with information he needs for his daily practice. These recommendations are updated annually. They are written by a group of experts, but they are not evidence based guidelines. This specific recommendation for diabetes diagnosis briefly describes the diabetes types and the different options for diagnosis. Also the caveats and the practical procedure are presented.

Morphologically 'invisible' proinsulin - secreting adenoma detected by Ga-68 Exendin-4 (GLP-1 Receptor) positron emission tomography/CT.

This case report of a young man suffering from recurring hypoglycaemia illustrates a rare condition of a neuroendocrine tumour, predominantly secreting proinsulin and invisible to conventional imaging approaches. Only a GLP-1 receptor PET/CT using Exendin-4 visualized the pancreatic lesion and enabled curative therapy, confirming the diagnostic value of this tracer for detection of neuroendocrine tumours. As only few publications on this topic are available, an overview of the available data is also given. The known cut-off value of 60% for proinsulin level indicating malignancy is critically discussed.

Prevalence and Progression Rate of Diabetic Retinopathy in Type 2 Diabetes Patients in Correlation with the Duration of Diabetes.

AIMS: We examined prevalence and progression of retinopathy in dependence on diabetes duration in order to estimate the probability of progression. PATIENTS/METHODS: In a retrospective cohort-analysis from an academic outpatient department of endocrinology and metabolic diseases we analyzed 17461 consultations of 4513 patients with DM2 from 1987 to 2014. 50.3% of the patients (n=2272) had at least one documented result of funduscopy. RESULTS: 25.8% of the patients had retinopathy (20.2% non-proliferative, 4.7% proliferative, 0.7% were not classified, 0.1% blindness). The prevalence of retinopathy in dependence on diabetes duration was 1.1% at diagnosis, 6.6% after 0<5 years, 12% after 5<10 years, 24% after 10<15 years, 39.9% after 15<20 years, 52.7% after 20<25 years, 58.7% after 25<30 years and 63% after ≥30 years. In a subset of 586 (25.7%) patients with retinal photography of 3 consecutive years 7.0% showed deterioration after one and 12.2% after two years; 2.6% improved after one and 2.8% after two years. 201 (34.3%) of this group had<10 years diabetes and lower deterioration (4.5% worsened after one and 9.5% after two years). Their retinopathy mainly transformed from no retinopathy to non-proliferative. Four patients (2.0%) developed proliferative retinopathy. CONCLUSIONS/INTERPRETATIONS: Within the first 10 years of diabetes duration, the prevalence of retinopathy is low and the progression infrequent. Most patients have a non-proliferative form which can be reversible and rarely requires interventions. Patients with DM2 without retinopathy and good glycaemic control do not run into additional risk from expanding funduscopy intervals to biennial.