Different effect of handle region peptide on ß-cell function in different sexes of rats neonatally treated with sodium L-glutamate.

BACKGROUND The (pro)renin receptor ((P)RR) was reported to be expressed in various tissues including the pancreas, and handle region peptide (HRP) is believed to block the function of (P)RR. This study aimed to investigate the effect of HRP on the glucose tolerance status and ß-cell function of female rats, neonatally treated with sodium L-glutamate (MSG) and to compare with the previously reported HRP effect on male rats. MATERIAL AND METHODS Female MSG rats aged 8 weeks were divided into MSG control group and HRP treated group and the normal SD rats served as control. The MSG rats were treated with HRP by osmotic minipumps with dose of 1 mg/kg per day for total 28 days. Glucose tolerance status was evaluated at the end of the study. Islets α-cell and ß-cell were marked with insulin antibody and glucagon antibody respectively. The proliferation of islet cells and expression of subunit of NADPH oxidase P22phox were marked by PCNA and P22phox antibody. Picrosirius red staining was performed for evaluating fibrosis of islets. RESULTS HRP improved the glucose status tolerance with decreasing α-cell mass, islets PCNA-positive cells, expression of P22phox and picrosirius red stained areas, and increasing ß-cell mass in female MSG rats. The indexes with obviously interacted effect of sexes and HRP for the MSG rats were the AUC of blood glucose concentration (P<0.01), α-cell mass (P<0.05), proliferation of islet cells (P<0.01) and area of picrosirius red staining (P<0.01). CONCLUSIONS HRP improved the glucose tolerance status in the females although it was previously reported to worsen the glucose tolerance in male MSG rats. Different levels of sex hormones may partly account for the disparate effects observed for HRP in different sexes.

The performance of a diabetic retinopathy risk score for screening for diabetic retinopathy in Chinese overweight/obese patients with type 2 diabetes mellitus.

INTRODUCTION: Diabetic retinopathy (DR) is a common chronic microvascular diabetic complication. The presence of DR may indicate microcirculatory dysfunction in other organ systems besides visual morbidity. The objective of this study was to develop a simple diabetic retinopathy risk score to identify DR in Chinese overweight/obese patients with type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS: A multicentre hospital-based cross-sectional study was carried out in Guangdong Province between August 2011 and March 2012. The evaluated 2699 patients included 1263 males and 1436 females, with an average age of 59.4 ± 13.0 years. RESULTS: The diabetic retinopathy risk score was conducted by age, duration of DM, history of antihypertensive drug treatment, and waist circumference. The area under the receiver operating characteristics curve for DR was 0.700 (95% CI 0.671-0.729). Comparing Youden's index of different values, the optimal cut-off point was 20 to predict DR. The odds ratio for one unit increase in the diabetic retinopathy risk score associated with the risk of DR was 1.104 (95% CI 1.089-1.120). CONCLUSIONS: Our data suggest that the diabetic retinopathy risk score could be a reliable primary screening tool for the presence of DR in Chinese overweight/obese patients with T2DM.

[Prevalence and risk factors for dyslipidemia in diabetics with overweight or obesity].

OBJECTIVE: To explore the prevalence and risk factors for dyslipidemia in diabetics with overweight or obesity. METHODS: Diabetics with overweight or obesity were recruited from 62 tertiary and secondary hospitals in Guangdong Province between August 2011 and March 2012. Dyslipidemia was diagnosed as total cholesterol (TC) ≥ 5.7 mmol/L or triglycerides (TG) ≥ 1.7 mmol/L or low-density-lipoprotein cholesterol (LDL-C) ≥ 3.6 mmol/L or high-density-lipoprotein cholesterol (HDL-C) < 1.29 mmol/L in females or HDL-C < 1.03 mmol/L in males. Binary Logistic regression was used to assess the associations between dyslipidemia and associated risk factors. RESULTS: Dyslipidemia was detected in 3160/3593 (87.9%) diabetics with overweight or obesity. And the prevalence of hypertriglyceridemia, low blood HDL-C, hypercholesterolemia and high blood LDL-C was 52.5% (1888/3593) , 54.1% (1945/3593), 33.1% (1188/3593) and 27.4% (985/3593) respectively. Among those with dyslipidemia, patients with simple and mixed dyslipidemia accounted for 34.1% and 53.9% respectively. In binary Logistic regression analysis, the presence of dyslipidemia were associated with female gender (OR = 1.593, 95%CI 1.233-2.057), hemoglobinA1c(HbA1c) (OR = 1.120, 95%CI 1.054-1.191), body mass index (OR = 1.084, 95%CI 1.022-1.150), hypertension (OR = 1.331, 95%CI 1.033-1.714), history of diabetes (OR = 1.586, 95%CI 1.186-2.120) and hyperuricacidemia (OR = 2.270, 95%CI 1.642-3.138). CONCLUSIONS: The prevalence of dyslipidemia is quite high in diabetics with overweight or obesity. The controls of blood pressure, serum uric acid level, blood glucose and body weight may reduce the prevalence of dyslipidemia, prevent and delay the development of cardiovascular complications and reduce the mortality of diabetics with overweight or obesity.

Prevalence and determinants of hyperuricemia in type 2 diabetes mellitus patients with central obesity in Guangdong Province in China.

This study investigated the prevalence and determinants of hyperuricemia in Chinese type 2 diabetes mellitus (T2DM) patients with central obesity. A multicentric hospital-based cross-sectional study was carried out in Guangdong Province between August 2011 and March 2012. At each hospital, Chinese T2DM patients with central obesity who were aged over 20 years, whose serum uric acid levels were measured, and who had lived in Guangdong Province for >=1 year, were recruited. Hyperuricemia was defined as serum uric acid >420 µmol/L in men and >360 µmol/L in women. Binary logistic regression was used to assess associated risk factors for hyperu-ricemia. A total of 2,917 T2DM patients with central obesity took part. The overall prevalence of hyperuricemia was 32.6% (36.1% for women, 28.4% for men). Binary logistic regression analyses demonstrated that women (OR: 1.576; 95% confidence interval (CI): 1.231, 2.018), high BMI (OR: 1.228; 95% CI: 1.094, 1.379), waist cir-cumference (OR: 1.135; 95% CI: 1.009, 1.276), hypertension (OR: 1.603; 95% CI: 1.263, 2.035), high total cho-lesterol (OR: 1.133; 95% CI: 1.002, 1.281), triglycerides (OR: 1.134; 95% CI: 1.069, 1.203), low HDL-cholesterol (OR: 0.820; 95% CI: 0.677, 0.995) and low estimated glomerular filtration rate (OR: 0.840; 95% CI: 0.815, 0.866) were risk factors associated with hyperuricemia. Hyperuricemia is prevalent in Chinese T2DM patients with central obesity and is significantly positively associated with women, cardiovascular risk factors such as obesity, hypertension and dyslipidemia, and low eGFR.

[A cross-sectional survey of blood pressure control in overweight or obese type 2 diabetic patients in Guangdong province].

OBJECTIVE: To investigate the current situation and influential factors of blood pressure (BP) control in type 2 diabetic patients with overweight or obesity in Guangdong province. METHODS: From August 2011 to March 2012, type 2 diabetic patients with overweight or obesity were recruited from 60 hospitals in 20 cities of Guangdong province, and received standard questionnaires. The conditions of demographic data, clinical examinations, the most recent laboratory assessment, history of disease and drug therapy were recorded. RESULTS: A total of 4029 patients were collected with age of (58.9 ± 12.9) years, and body mass index (BMI) of (27.28 ± 2.76) kg/m². Among the participants, controlled BP was achieved in 23.8% patients. Multiple logistic regression analysis showed that older age, obesity, previous history of hypertension and inadequate glycemic control were the independent factors related to unsatisfactory blood pressure control rate. Among the patients with hypertension, 53.5% took 1 kind of antihypertensive drug, 32.5% took two, and 11.3% took three or more. CONCLUSIONS: Type 2 diabetic patients with overweight or obesity in Guangdong province have poor BP control. Thus, active lifestyle interventions and drug therapy as a comprehensive management way should be taken for the population so as to reduce their cardiovascular events.

[A cross-sectional survey on current status of type 2 diabetes mellitus with overweight or obesity in Guangdong province].

OBJECTIVE: To explore the glycemic control status and related risk factors of overweight or obesity patients with type 2 diabetes mellitus (T2DM) in Guangdong province. METHODS: The medical records of overweight or obesity patients with T2DM from 60 tertiary and secondary hospitals in Guangdong Province were collected by questionnaire and physical examination. And the clinical data were analyzed to explore the influencing factors of glycemic control. The HbA1c level was used to assess glycemic control. HbA1c < 7.0% indicated that glycemic control was up to standard. RESULTS: From August 2011 to March 2012, 5241 T2DM patients were recruited. The scope of current analysis was restricted to 4768 subjects with true data and deficiency no more than 5%. There were 2252 males and 2516 females. The age range was from 16 to 90 years, a median age 59.0 (50.0 - 69.0) years, onset age of diabetes 52.0 (44.0 - 60.0) years; a range of disease duration from 1 day to 42 years and a median of 5.0 (2.0 - 11.0) years. The median body mass index was 26.33(24.88 - 28.34) kg/m(2) and median waist circumference 93.0 (88.0 - 100.0) cm. Median HbA1c was 8.1% (6.9% - 10.1%) and only 26.2% patients reached the target level of HbA1c < 7.0%. Influencing factors of poor glycemic control were central obesity, high levels of resting heart rate, concurrent fatty liver and high intensity of treatment. And influencing factors of good glycemic control were regular exercises, smoking cessation, regular glycemic monitoring and good control of total cholesterol/triglyceride. CONCLUSION: A majority of Guangdong type 2 diabetics fail to achieve target values for glycemic control. There is an urgent need for comprehensive management for improving glycemic control.

SIRT1 interacts with metabolic transcriptional factors in the pancreas of insulin-resistant and calorie-restricted rats.

Sirtuin 1 (SIRT1) is one member of the silent information regulator 2 (Sir2)-like family of proteins involved in glucose homeostasis in mammals. It has been reported that SIRT1 modulates endocrine signaling of glucose and fat homeostasis by regulating transcription factors such as forkhead transcription factor 3a (FOXO3a), glucose transporter 4 (GLUT4), peroxisome proliferator-activated receptor gamma (PPARγ) and PPARγ coactivator (PGC-1α). However, it is still not clear how SIRT1 is involved in the development of insulin resistance. To determine the location and expression of SIRT1 and its target proteins in rats and analyze the interactions and functions of these proteins in insulin resistance. Forty-eight male Sprague-Dawley rats were randomly divided into four regimen groups: normal control (NC), calorie restriction (CR), high-fat (HFa), and high-fructose (HFr). Animals were fed for 12 weeks and blood samples collected from tail veins at weeks 2, 4, 6, 8 and 12 after fasting for 16 h. Baseline metabolic parameters such as fasting blood sugar, insulin, cholesterol and triglycerides were analyzed. A glucose tolerance test was carried out at the end of the study. Visceral fat, consisting of epididymis and perirenal fat, was isolated and weighed. The pancreas from each animal was also immediately removed. Immunohistochemical staining was performed to detect the locations of SIRT1, FOXO3a, GLUT4, PPARγ and PGC-1α in the ß-cell of the rat pancreas. Expression in the pancreas was analyzed by western blotting. Blood biochemical analysis indicated that the HFa and HFr groups were insulin-resistant. Immunohistochemical staining showed that GLUT4 was a nuclear protein. SIRT1, FOXO3a, PPARγ and PGC-1α were present in both the nucleus and the cytoplasm of ß-cells of pancreatic islets. The expression of SIRT1, GLUT4 and PGC-1α increased significantly in response to CR, but decreased in the HFr and HFa groups. FOXO3a was similar in the CR and the NC groups, whereas it declined in the HFa and HFr groups. PPARγ was elevated in the HFa group, but dropped in the CR and HFr groups. These data suggest that SIRT1 and its regulators are involved in the development of insulin resistance.

Handle Region Peptide Ameliorating Insulin Resistance but Not ß Cell Functions in Male Rats Neonatally Treated with Sodium L-Glutamate.

Handle region peptide (HRP), which was recognized as a blocker of (pro)renin receptor ((P)RR), may block the function of (P)RR. The aim of this study was to investigate the effect of HRP with a large dose of 1 mg/kg/d on glucose status in the rats treated neonatally with monosodium L-glutamate (MSG). At the age of 8 weeks, the MSG rats were randomly divided into MSG control group, HRP treated group with minipump (MSG-HRP group), losartan treated group (MSG-L group), and HRP and losartan cotreated group (MSG-HRP-L group) and fed with high-fat diet for 4 weeks. Losartan but not HRP increased the levels of insulin releasing and ameliorate glucose status although both losartan and HRP improved insulin sensitivity. On the one hand, both losartan and HRP decreased levels of pancreatic local Ang-II and NADPH oxidase activity as well as its subunits P(22phox). On the other hand, losartan but not HRP decreased α -cell mass and number of PCNA-positive cells located periphery of the islets and decreased picrosirius red stained area in islets. HRP ameliorating insulin resistance but not ß -cell functions leads to hyperglycemia in the end in male MSG rats, and the dual characters of HRP may partly account for the phenomenon.

[Cross-sectional study of current situation of glycemic control with type 1 diabetes in Guangdong Province].

OBJECTIVE: To investigate the glycemic control and the related factors of type 1 diabetic patients in Guangdong Province. METHODS: Medical records and blood samples of type 1 diabetic patients were collected in 89 tertiary and secondary hospitals from all of the 21 cities in Guangdong Province. The clinical data were analyzed to explore the correlates of glycemic control. HbA1c levels, measured in Guangdong Diabetes Center, were used to assess glycemic control. RESULTS: 851 patients were enrolled from August 6, 2010 to May 25, 2011. There were 408 males and 443 females. The median (interquartile range) age was 29.6 years (20.3 - 41.3 years). The onset age of diabetes was 25.3 years (15.7 - 35.5 years). The disease duration was 3.3 years (1.0 - 7.3 years). The BMI was 19.9 kg/m(2) (17.9 - 21.8 kg/m(2)). HbA1c levels were 8.6% (6.9% - 11.0%) and only 234 (27.50%) patients reached the age-specific target levels. Correlates with poorer glycemic control were 13 - 19 years old (vs 7 - 12 and ≥ 20 years old), lower household income, not on dietary intervention, never accepting diabetic education and shorter diabetic duration. CONCLUSION: The majority of Guangdong type 1 diabetic patients did not achieve target values for glycemic control, indicating an urgent need for comprehensive management to improve glycemic control.

[Effects of glucagon on plasma ghrelin level in type 2 diabetes mellitus].

OBJECTIVE: To investigate the effect of glucagon on ghrelin secretion in type 2 diabetes mellitus (T2DM) patients. METHODS: Circulating ghrelin and C-peptide were measured during glucagon stimulation test in 38 cases with T2DM and 30 cases in normal controls (NC) at the 1st Affiliated Hospital of Shantou University from May 2006 to December 2007. RESULTS: (1) There was no significant difference in the fasting C-peptide and fasting ghrelin levels of the NC group were (1.3 +/- 0.6) microg/L and (3.0 +/- 1.0) ng/ml respectively, both not significantly different from those of the T2DM group [(1.2 +/- 0.4) microg/L and (2.7 +/- 0.8) microg/L respectively, P > 0.05 and P > 0.05]; six minutes after the injection of glucagon, the C-peptide level of the T2DM group increased to (2.0 +/- 0.8) microg/L (P < 0.01), and that of the NC group increased to (3.0 +/- 0.8) microg/L (P < 0.01), and the C-peptide level 6 min after of the T2DM group was significantly lower than that of the NC group (P < 0.01). The ghrelin level 6 min after the injection of glucagon of the NC group was (2.3 +/- 0.7) microg/L, significantly lower than that before the injection (P < 0.01). But the ghrelin level 6 min after the injection of glucagon of the T2DM group was (2.9 +/- 0.9) microg/L, NOT significantly different from that before the injection (P > 0.05). (2) Fasting ghrelin level was significantly negatively correlated with the waist circumference (r = -0.343, P < 0.05). CONCLUSION: In healthy subjects exogenous glucagon decreases the ghrelin level. Ghrelin may be associated with the beta-cell hypofunction and first-phase insulin secretion defects in T2DM. Insulin, glucagon, and ghrelin secreted influence each other to regulate glucose homeostasis.

[A survey of glucose and lipid metabolism and concomitant diseases among inpatients in Guangdong province].

OBJECTIVES: To investigate the epidemiological and clinical characteristics of dyslipidemia as well as its treatment and influence on accompanying diseases in impaired glucose status among inpatients. METHODS: A cross-sectional survey was conducted among the inpatients registered in ten university hospitals of Guangdong, China during the week before the Diabetes Day in 2004. The fasting blood glucose (FBG), lipid profiles, BMI, waist to hip ratio (WHR) and concomitant disorders of the first screen during the hospitalization period were recorded. Those who had FBG level from 5.6 to 6.9 mmol/L and not been previously diagnosed diabetes (PDM) underwent oral glucose tolerance test (OGTT). RESULTS: Of the 8753 inpatients investigated, 1067 cases had complete medical records (CMR case) including PDM cases and previously non-diagnosed diabetes ones with FBG > or = 5.6 mmol/L. Of the previously non-diagnosed diabetes cases with FBG levels from 5.6 to 6.9 mmol/L, 65.8% accepted OGTT. Of the CMR cases, 41.9% had PDM, 21.7% was newly diagnosed diabetes mellitus (NDM), 29.1% had impaired glucose regulation (IGR) and only 7.3% had normal glucose tolerance (NGT). The TG levels in NDM and PDM group were higher than those in IGR and NGT group (P < 0.05, respectively). The HDL-C levels in IGR, NDM and PDM group were lower than those in NGT group (P < 0.05, respectively). Sixty-nine point six percent of the diabetes mellitus (DM) inpatients was accompanied with dyslipidemia and the rate was higher than those in NGT (56.4%) and IGR inpatients (52.5%, P < 0.05, respectively). Only 22.8% of the PDM inpatients underwent treatment of dyslipidaemia and just 3.4% achieved the target suggested by the guideline of ATP-III. BMI was higher and waistline longer in the PDM and NDM inpatients than those in the NGT cases (P < 0.05, respectively). Seventy-two point eight percent of the PDM inpatients was complicated with more than one type of vascular diseases. Nine point seven percent and 0.2% of the NDM inpatients were tormented by diabetic nephropathy and diabetic retinopathy respectively. CONCLUSIONS: More inpatients with accompany DM or IGR had concomitant dyslipidemia than those with NGT, which included hypertriglyceridemia, hypo-high-density lipoproteinemia and metabolic syndrome. Concomitant vascular diseases were more frequently found in PDM inpatients than in the others. Some of the NDM and IGT inpatients were complicated with microvascular diseases.

Inadequate glycaemic control and antidiabetic therapy among inpatients with type 2 diabetes in Guangdong Province of China.

BACKGROUND: Diabetes mellitus has become epidemic in recent years in China. We investigated the prevalence of hyperglycaemia and inadequate glycaemic control among type 2 diabetic inpatients from ten university teaching hospitals in Guangdong Province, China. METHODS: Inadequate glycaemic control in diabetic patients was defined as HbA1c = 6.5%. Therapeutic regimens included no-intervention, lifestyle only, oral antiglycemic agents (OA), insulin plus OA (insulin + OA), or insulin only. Antidiabetic managements included monotherapy, double therapy, triple or quadruple therapy. RESULTS: Among 493 diabetic inpatients with known history, 75% had HbA1c = 6.5%. Inadequate glucose control rates were more frequently seen in patients on insulin + OA regimen (97%) than on OA regimen (71%) (P < 0.001), and more frequent in patients on combination therapy (81% - 96%) than monotherapy (75%) (P < 0.05). Patients on insulin differed significantly from patients on OA by mean HbA1c, glycemic control rate, diabetes duration, microvascular complications, and BMI (P < 0.01). CONCLUSIONS: This study showed that glycaemic control of type 2 diabetic patients deteriorated for patients who received insulin and initiation time of insulin was usually delayed. It is up to clinicians to move from the traditional stepwise therapy to a more active and early combination antidiabetic therapy to provide better glucose control.

[Differences in risk factors of diabetic foot in the patients in South and North China].

OBJECTIVE: To investigate the differences on the diabetic foot problems and its risk factors in south and north of China. METHODS: Patients with foot problems were surveyed from January 1 to December 31, 2004 in 14 teaching hospitals located in different cities in China, including demographic data, present and past history of the foot problems and peripheral artery disease (PAD), the classification of the foot ulcers based on the Wagner' system, control of the hyperglycemia and lipids disorder, medical cost in hospital and the diabetic complications. All the patients were divided into two groups due to their geographical data, south and north. RESULTS: There were 285 and 349 patients for the group south and group north. No significant differences were found for duration of diabetes or foot problems, fasting or post-meal glucose, total cholesterol, triglycerides, HDL-C, and the numbers of patients with smoke, hypertension, nephropathy or neuropathy between the two groups. There were significant differences for the age (70 yrs vs 66 yrs), percentage of the patients with average person income with over RMB 1000 per month (57.7% vs 45.6%), coronary heart disease (42.6% vs 61.0%) and retinopathy (35.7% vs 49.5%), HbA1c (7.90% vs 8.80 %), LDL-C (2.75 mmol/L vs 2.98 mmol/L), WBC (6.70 x 10(9) vs 7.40 x 10(9)/L), HCT (0.37 vs 0.38), creatinine (87 micromol/L vs 76 micromol/L) and uric acid (333 mmol/L vs 271 mmol/L), and amputation rate (2.6% vs 9.7%) between south and north groups. Logistic analysis showed that severity of the foot problems was associated with ABI and WBC in south group, and with ABI, PLT and HCT in north group. CONCLUSION: Diabetic foot problems were more severe, with more risk factors and with more medical cost in north patients.

[A multicenter survey on the diabetic foot and its neuropathy in China].

OBJECTIVE: To investigate the characteristics of diabetic foot with neuropathy and its related factors. METHODS: 530 out- and in-patients in 14 grade A class 3 comprehensive hospitals in China with foot problems were surveyed. 337 of the 500 patients (63.58%) suffered from neuropathy, 172 (32.45%) with diabetic foot with simple neuropathy and 165 (31.13%) with simple neuropathy combined with peripheral artery disease (PAD). 193 of the 500 patients (36.42%) suffered from peripheral artery disease (PAD). 77.7% of ulcer were caused by physical factors. Questionnaire survey was conducted to collect the demographic data, present and past history, history of the hyperglycemia and lipid disorders, classification and phases of the foot ulcers based on Wagner' system and Texas system, characteristics of neuropathy and other diabetic complications, and relative risk factors. Detailed physical examination was performed, including 10 g nylon filament sensation examination. RESULTS: The duration of diabetic foot of the patients with simple neuropathy was 3 (1, 60) months, significantly shorter than that of the diabetic foot patients with PAD [5 (1, 96) months, P < 0.001]. The Wagner degree of ulcer was related to the duration of diabetes, economic income, foot deformity, nerve reflection, diapason vibration sensation of foot, sensation point of 10 g nylon filament, ankle/brachial index (ABI), foot artery pulse, fasting blood sugar (FBS) and glycated hemoglobin (HbA1c). Stepwise regression analysis revealed that ABI of left posterior tibial artery, vibration detection threshold and economic income were the most significant influencing factors of the degree of ulcer. CONCLUSION: Neuropathy ulcer is common in diabetic foot patients. The prognosis of healing in diabetic foot with neuropathy is prior to that of diabetic foot with PAD. The neuropathy and PAD of foot influence each other and aggravate the condition of diabetic foot. The examinations of diapason vibration sensation of foot, sensation point of 10 g nylon filament, and Achilles tendon reflex are simple and practical, and are worth recommending.

[The medical cost of diabetic patients with foot problems due to peripheral artery disease].

OBJECTIVE: To investigate the medical cost of diabetic patients with foot problems and peripheral artery disease. METHODS: Type 2 diabetic patients with foot problems admitted into the endocrinology departments of 14 teaching hospitals from Jan. 1 to Dec. 31, 2004 were surveyed for their type and phase of foot ulcers, diabetic complications, medical cost and general personal characteristics. RESULTS: The average medical cost of the hospitalization of these patients was RMB yen 14,906 +/- 7072 (about US $ 1640 +/- 873); medication and examination cost was separately 56% and 19% of the total cost. There was obviously higher medical cost for these patients with longer diabetes duration of over 20 years and with the occupation of laborer and retired worker. Patients with kidney disease had significantly higher medical cost than those without (RMB yen 11 690.7 vs yen 9493.0; P = 0.0013), even if the hospital stay was nearly the same (21 days vs 20 days). The medical cost increase with the severity of diabetic foot problems based on the classification of Wagner System or Texas System. Patients with infection, ischemic foot and gangrene foot stayed in the hospitals longer and had much higher medical cost. CONCLUSION: The medical cost is higher for diabetic patients with foot problems and is related with the presence of complicating kidney disease, infection and ischemia as well as the severity of foot ulcers.