Renal replacement therapy in patients with diabetes and end-stage renal disease

The number of patients who have diabetes and ESRD and are being admitted to renal replacement treatment (RRT) is increasing dramatically worldwide, and in many countries, diabetes has become the single most frequent cause of ESRD. Although the prognosis of patients who have diabetes and are receiving RRT has greatly improved, survival and medical rehabilitation rates continue to be significantly worse than those of nondiabetic patients, mainly because of preexisting severely compromised cardiovascular conditions. The most common RRT modality in patients with diabetes is still hemodialysis, but it gives rise to a number of clinical problems, in particular difficulties in the management of the vascular access and high frequency of intradialytic hypotension. However, patients who have diabetes and are on peritoneal dialysis have to face a progressive increase in peritoneal permeability, loss of ultrafiltration, and peritoneal fibrosis, all phenomena being accelerated in patients with diabetes and ultimately leading to an increased technique failure. The results of observational studies and national registries, although conflicting, suggest that these two dialytic modalities are somehow comparable in terms of outcomes, whereas accumulating evidence shows that both survival and medical rehabilitation of patients with diabetes are significantly better after renal transplantation, which should be the first-choice option for patients who have diabetes and reach ESRD but unfortunately still accounts for only a limited proportion of RRT treatments in these patients.     

Role of phytoestrogens in prevention and management of type 2 diabetes

Type 2 diabetes(T2D)has become a major public health threat across the globe.It has been widely acknowledged that diet plays an important role in the development and management of T2D.Phytoestrogens are polyphenols that are structurally similar to endogenous estrogen and have weak estrogenic properties.Emerging evidence from pre-clinical models has suggested that phytoestrogens may have anti-diabetic function via both estrogendependent and estrogen-independent pathways.In the current review,we have summarized the evidence linking two major types of phytoestrogens,isoflavones and lignans,and T2D from epidemiological studies and clinical trials.The cross-sectional and prospective cohort studies have reported inconsistent results,which may due to the large variations in different populations and measurement errors in dietary intakes.Long-term intervention studies using isoflavone supplements have reported potential beneficial effects on glycemic parameters in postmenopausal women,while results from short-term smallsize clinical trials are conflicting.Taken together,the current evidence from different study designs is complex and inconsistent.Although the widespread use of phytoestrogens could not be recommended yet,habitual consumption of phytoestrogens,particularly their intact food sources like soy and whole flaxseed,could be considered as a component of overall healthy dietary pattern for prevention and management of T2D.     

KMAP-O framework for care management research of patients with type 2 diabetes

AIM To review impacts of interventions involving self-management education, health coaching, and motivational interviewing for type 2 diabetes. METHODS A thorough review of the scientific literature on diabetes care and management was executed by a research team. RESULTS This article summarizes important findings in regard to the validity of developing a comprehensive behavioral system as a framework for empirical investigation. The behavioral system framework consists of patients' knowledge(K), motivation(M), attitude(A), and practice(P) as predictor variables for diabetes care outcomes(O). Care management strategies or health education programs serve as the intervention variable that directly influences K, M, A, and P and then indirectly affects the variability in patient care outcomes of patients with type 2 diabetes. CONCLUSION This review contributes to the understanding of the KMAP-O framework and how it can guide the care management of patients with type 2 diabetes. It will allow the tailoring of interventions to be more effective through knowledge enhancement, increased motivation, attitudinal changes, and improved preventive practice to reduce the progression of type 2 diabetes and comorbidities. Furthermore, the use of health information technology for enhancing changes in KMAP and communications is advocated in health promotion and development.     

Pharmacologic adjunctive to insulin therapies in type 1 diabetes:The journey has just begun

Treatment of type 1 diabetes(T1 D) is currently based exclusively on insulin replacement therapy. However, there is a need for better glycemic control, lower hypoglycemia rates, more effective weight management, and further reduction of cardiovascular risk in people with T1 D. In this context, agents from the pharmaceutical quiver of type 2 diabetes are being tested in clinical trials, as adjunctive to insulin therapies for T1 D patients. Despite the limited amount of relevant evidence and the inter-class variability, it can be said that these agents have a role in optimizing metabolic control, assisting weight management and reducing glycemic variability in people with T1 D. Specific safety issues, including the increased risk of hypoglycemia and diabetic ketoacidosis, as well as the effects of these treatments on major cardiovascular outcomes should be further assessed by future studies, before these therapeutic choices become widely available for T1 D management.     

Effects of exercise on brain functions in diabetic animal models

Human life span has dramatically increased over several decades,and the quality of life has been considered to be equally important.However,diabetes mellitus(DM) characterized by problems related to insulin secretion and recognition has become a serious health problem in recent years that threatens human health by causing decline in brain functions and finally leading to neurodegenerative diseases.Exercise is recognized as an effective therapy for DM without medication administration.Exercise studiesusing experimental animals are a suitable option to overcome this drawback,and animal studies have improved continuously according to the needs of the experimenters.Since brain health is the most significant factor in human life,it is very important to assess brain functions according to the different exercise conditions using experimental animal models.Generally,there are two types of DM; insulin-dependent type 1 DM and an insulin-independent type 2 DM(T2DM); however,the author will mostly discuss brain functions in T2 DM animal models in this review.Additionally,many physiopathologic alterations are caused in the brain by DM such as increased adiposity,inflammation,hormonal dysregulation,uncontrolled hyperphagia,insulin and leptin resistance,and dysregulation of neurotransmitters and declined neurogenesis in the hippocampus and we describe how exercise corrects these alterations in animal models.The results of changes in the brain environment differ according to voluntary,involuntary running exercises and resistance exercise,and gender in the animal studies.These factors have been mentioned in this review,and this review will be a good reference for studying how exercise can be used with therapy for treating DM.     

Benefits of healthy adipose tissue in the treatment of diabetes

The major malfunction in diabetes mellitus is severe perturbation of glucose homeostasis caused by deficiency of insulin. Insulin deficiency is either absolute due to destruction or failure of pancreatic β cells, or relative due to decreased sensitivity of peripheral tissues to insulin. The primary lesion being related to insulin, treatments for diabetes focus on insulin replacement and/or increasing sensitivity to insulin. These therapies have their own limitations and complications, some of which can be life-threatening. For example, exogenous insulin administration can lead to fatal hypoglycemic episodes; islet/pancreas transplantation requires life-long immunosuppressive therapy; and anti-diabetic drugs have dangerous side effects including edema, heart failure and lactic acidosis. Thus the need remains for better safer long term treatments for diabetes. The ultimate goal in treating diabetes is to re-establish glucose homeostasis, preferably through endogenously generated hormones. Recent studies increasingly show that extra-pancreatic hormones, particularly those arising from adipose tissue, can compensate for insulin, or entirely replace the function of insulin under appropriate circumstances. Adipose tissue is a versatile endocrine organ that secretes a variety of hormones with far-reaching effects on overall metabolism. While unhealthy adipose tissue can exacerbate diabetes through limiting circulation and secreting of pro-inflammatory cytokines, healthy uninflamed adipose tissue secretes beneficial adipokines with hypoglycemic and anti-inflammatory properties, which can complement and/or compensate for the function of insulin. Administration of specific adipokines is known to alleviate both type 1 and 2 diabetes, and leptin mono-therapy is reported to reverse type 1 diabetes independent of insulin. Although specific adipokines may correct diabetes, administration of individual adipokines still carries risks similar to those of insulin monotherapy. Thus a better approach is to achieve glucose homeostasis with endogenously-generated adipokines through transplantation or regeneration of healthy adipose tissue. Our recent studies on mouse models show that type 1 diabetes can be reversed without insulin through subcutaneous transplantation of embryonic brown adipose tissue, which leads to replenishment of recipients’ white adipose tissue; increase of a number of beneficial adipokines; and fast and long-lasting euglycemia. Insulin-independent glucose homeostasis is established through a combination of endogenously generated hormones arising from the transplant and/or newly-replenished white adipose tissue. Transplantation of healthy white adipose tissue is reported to alleviate type 2 diabetes in rodent models on several occasions, and increasing the content of endogenous brown adipose tissue is known to combat obesity and type 2 diabetes in both humans and animal models. While the underlying mechanisms are not fully documented, the beneficial effects of healthy adipose tissue in improving metabolism are increasingly reported, and are worthy of attention as a powerful tool in combating metabolic disease.     

Functional foods-based diet as a novel dietary approach for management of type 2 diabetes and its complications: A review

Type 2 diabetes is a complicated metabolic disorder with both short- and long-term undesirable complications. In recent years, there has been growing evidence that functional foods and their bioactive compounds, due to their biological properties, may be used as complementary treatment for type 2 diabetes mellitus. In this review, we have highlighted various functional foods as missing part of medical nutrition therapy in diabetic patients. Several in vitro, animal models and some human studies, have demonstrated that functional foods and nutraceuticals may improve postprandial hyperglycemia and adipose tissue metabolism modulatecarbohydrate and lipid metabolism. Functional foods may also improve dyslipidemia and insulin resistance, and attenuate oxidative stress and inflammatory processes and subsequently could prevent the development of long-term diabetes complications including cardiovascular disease, neuropathy, nephropathy and retinopathy. In conclusion available data indicate that a functional foods-based diet may be a novel and comprehensive dietary approach for management of type 2 diabetes.     

腹腔镜袖状胃切除术在减重与代谢外科中应用的评价

大量临床资料证明,减重．代谢手术是治疗肥胖及2型糖尿病长期有效的方法。其中腹腔镜袖状胃切除术由于操作简便、安全性高且疗效明显,近年来得到了迅速普及。随着相关研究的开展,减重与代谢外科领域对该术式的认识逐渐深入。本文就腹腔镜袖状胃切除术在减重与代谢外科中的应用现状做一文献综述。     

Initial experiences with telerehabilitation and contingency management programs for the prevention and management of pressure ulceration in patients with spinal cord injuries.

Two alternative treatment methods for preventive interventions for pressure ulcers, tele-rehabilitation and contingency management, are discussed. Telerehabilitation uses a videophone that transmits both audio and still images over a telephone line. Using this technology, the WOC nurse can interview a patient who cannot be present at a clinic because of physical condition or distance. Telerehabilitation allows the nurse to assess a patient's pressure ulcer, consult with appropriate caregivers, and make recommendations for treatment. Contingency management procedures are designed for patients with high rates of noncompliance in skin care. The patients are seen as outpatients and are compensated systematically for appropriate skin care (ie, the lack of pressure ulcers). Examples of each of these patient interventions is described, discussed, and contrasted.     

Sugar intake from sweetened beverages and diabetes: A narrative review

Type 2 diabetes mellitus (T2DM) is one of the fastest growing public health concerns around the world. Sugar-sweetened beverage (SSB) consumption has been proven to be associated with adverse health consequences in the diabetic population. Reducing SSB consumption, body weight control, healthy diets, and increased physical activity have been suggested as strategies to improve diabetes prevention and management. This literature review provides an overview of: (1) The association between SSB consumption and the risk of T2DM; (2) Types of SSB consumption and T2DM; (3) The effect of obesity and inflammation on the association between SSB consumption and risk of T2DM; and (4) SSB consumption in T2DM patients. There is still work to be done to determine how SSB consumption is related to T2DM, but the current research on identifying the association between SSB consumption and T2DM is promising, with the most promising studies confirming the connection between SSBs, T2DM risk, and diabetes management. Future studies should explore more effective SSB related diabetes prevention and management interventions.     

Rehabilitation nach Rotatorenmanschettenrekonstruktion – Umsetzung im deutschen Gesundheitswesen

Adequate postoperative therapy is at least as important as the quality of the surgery itself. In addition to the surgeon’s experience, the surgical entry point into the patient’s body, and the surgical techniques including selection of materials, the success of any surgery also depends on the type and extent of postoperative treatment and rehabilitation. Thus, after surgical rotator cuff repair, the prospects for restoration of full functionality of an injured shoulder depends to a large extent on good follow-up treatment, but there are also risks associated with inadequate postoperative therapy of the tendon. Recent consensus-building of the German Society of Shoulder and Elbow Surgery (DVSE) has established cornerstones for rehabilitation after rotator cuff repair. Each cornerstone has been calibrated and thus prioritized according to the levels of evidence found. In addition to these evidence-based medical findings, the issue of limited resources has become a key issue in modern health care. Recommendations for follow-up treatments will only achieve substantial acceptance if they can be properly implemented using the resources available. The aim of this work is therefore to show how the recommendations for follow-up treatments after rotator cuff repair developed by the current consensus of the DVSE can be practically implemented in the German healthcare network.     

Evidence based review of type 2 diabetes prevention and management in low and middle income countries

AIM:To identify the newest approaches to type 2diabetes(T2DM)prevention and control in the developingworld context.METHODS:We conducted a systematic review of published studies of diabetes prevention and control programs in low and middle-income countries,as defined by the World Bank.We searched Pub Med using Medical Subject Headings terms.Studies needed to satisfy four criteria:(1)Must be experimental;(2)Must include patients with T2DM or focusing on prevention of T2DM;(3)Must have a lifestyle intervention component;(4)Must be written in English;and(5)Must have measurable outcomes related to diabetes.RESULTS:A total of 66 studies from 20 developing countries were gathered with publication dates through September 2014.India contributed the largest number of trials(11/66).Of the total 66 studies reviewed,all but 3 studies reported evidence of favorable outcomes in the prevention and control of type 2 diabetes.The overwhelming majority of studies reported on diabetes management(56/66),and among these more than half were structured lifestyle education programs.The evidence suggests that lifestyle education led by allied health professionals(nurses,pharmacists)were as effective as those led by physicians or a team of clinicians.The remaining diabetes management interventions focused on diet or exercise,but the evidence to recommend one approach over another was weak.CONCLUSION:Large experimental diabetes prevention/control studies of dietary and exercise interventions are lacking particularly those that consider quality rather than quantity of carbohydrates and alternative exercise.     

Powered lower limb orthoses for gait rehabilitation

Bodyweight supported treadmill training has become a prominent gait rehabilitation method in leading rehabilitation centers. This type of locomotor training has many functional benefits but the labor costs are considerable. To reduce therapist effort, several groups have developed large robotic devices for assisting treadmill stepping. A complementary approach that has not been adequately explored is to use powered lower limb orthoses for locomotor training. Recent advances in robotic technology have made lightweight powered orthoses feasible and practical. An advantage to using powered orthoses as rehabilitation aids is they allow practice starting, turning, stopping, and avoiding obstacles during overground walking.     

Critical review of bone health,fracture risk and management of bone fragility in diabetes mellitus

The risk of fracture is increased in both type 1 diabetes mellitus(T1DM) and type 2 diabetes mellitus(T2DM). However, in contrast to the former, patients with T2DM usually possess higher bone mineral density. Thus, there is a considerable difference in the pathophysiological basis of poor bone health between the two types of diabetes. Impaired bone strength due to poor bone microarchitecture and low bone turnover along with increased risk of fall are among the major factors behind elevated fracture risk. Moreover, some antidiabetic medications further enhance the fragility of the bone. On the other hand, antiosteoporosis medications can affect the glucose homeostasis in these patients. It is also difficult to predict the fracture risk in these patients because conventional tools such as bone mineral density and Fracture Risk Assessment Tool score assessment can underestimate the risk. Evidence-based recommendations for risk evaluation and management of poor bone health in diabetes are sparse in the literature. With the advancement in imaging technology, newer modalities are available to evaluate the bone quality and risk assessment in patients with diabetes. The purpose of this review is to explore the patho-physiology behind poor bone health in diabetic patients. Approach to the fracture risk evaluation in both T1DM and T2DM as well as the pragmatic use and efficacy of the available treatment options have been discussed in depth.     

Inter-relationships between gastric emptying and glycaemia: Implications for clinical practice

Gastric emptying (GE) exhibits a wide inter-individual variation and is a major determinant of postprandial glycaemia in health and diabetes; the rise in blood glucose following oral carbohydrate is greater when GE is relatively more rapid and more sustained when glucose tolerance is impaired. Conversely, GE is influenced by the acute glycaemic environment acute hyperglycaemia slows, while acute hypoglycaemia accelerates it. Delayed GE (gastroparesis) occurs frequently in diabetes and critical illness. In diabetes, this poses challenges for management, particularly in hospitalised individuals and/or those using insulin. In critical illness it compromises the delivery of nutrition and increases the risk of regurgitation and aspiration with consequent lung dysfunction and ventilator dependence. Substantial advances in knowledge relating to GE, which is now recognised as a major determinant of the magnitude of the rise in blood glucose after a meal in both health and diabetes and, the impact of acute glycaemic environment on the rate of GE have been made and the use of gut-based therapies such as glucagon-like peptide-1 receptor agonists, which may profoundly impact GE, in the management of type 2 diabetes, has become commonplace. This necessitates an increased understanding of the complex inter-relationships of GE with glycaemia, its implications in hospitalised patients and the relevance of dysglycaemia and its management, particularly in critical illness. Current approaches to management of gastroparesis to achieve more personalised diabetes care, relevant to clinical practice, is detailed. Further studies focusing on the interactions of medications affecting GE and the glycaemic environment in hospitalised patients, are required.     

Hypertension and kidney protection in the elderly: what is the evidence in 2007?

Hypertension and diabetes mellitus are the two most widely recognized risk factors for cardiovascular disease (CVD), chronic kidney disease (CKD), and end-stage renal disease (ESRD) requiring dialysis/transplantation; both become increasingly important as one ages. Common pathways and mechanisms are involved in the development of renal vascular lesions in both conditions, and effective treatments for each are now available to reduce morbidity, mortality and progression of organ damage. Although this review will focus primarily on the ability to protect the kidney and vasculature elsewhere by lowering blood pressure in the elderly, other approaches, specifically dietary restriction of protein, strict control of diabetes mellitus, and the management of the different dyslipidemias, must be used in conjunction with the antihypertensive agents to obtain optimum protection.     

Can the management of depression in type 2 diabetes be democratized?

Both type 2 diabetes and depression are common and are projected to increase. There is increasing evidence for a bidirectional relationship between the two. Diabetes is a risk factor for depression; contrariwise, individuals with depression are at greater risk of developing diabetes. They are a burden for both the individual and the society. Co-existent depression worsens diabetic control because of obesity, insulin resistance and the adverse metabolic effects of anti-diabetes medicines. In addition, compliance to lifestyle measures required for diabetes is also compromised such as following a specific diet, taking proper medications on time, getting metabolic parameters assessed and maintaining a sleep cycle. Depression occurs in many grades; mild depression is more common in diabetes than frank or full-blown depression leading to suicide. Unfortunately, there are not enough trained and accessible mental health professionals such as psychologists or psychiatrists to deal with the increasing burden of depression in diabetes. Therefore, alternate models for management of mild to moderate depression are required. There is evidence that a team-approach by employing health care assistants can lower the risk of cardiac risk factors. INtegrating DEPrEssioN and Diabetes treatmENT study was carried out to determine whether the team-approach using non-health care professionals could be effective in managing mild to moderate depression and to study its effects on metabolic parameters among subjects with type 2 diabetes mellitus. The international study, carried out in four independent centers in India assessed the impact of a trained but not qualified non-psychiatrist in coordinating and forming a fulcrum between the patient, the family and the consultant endocrinologist/diabetologist. The interventions were fine-tuned to be culturally appropriate by qualitative interviews before they began. It was shown that the outcomes of both depression and diabetes could be improved by the employment of a clinical care coordinator. It is possible to scale up the studies to wider geographical areas and health-care organizations.     

麻醉科医师在睡眠医学中的作为

作为人类最重要的生命活动之一，睡眠对人类的身体健康具有至关重要的作用。近年来，随着经济社会的飞速发展，快节奏生活的到来，罹患睡眠障碍的患者越来越多，失眠作为最常见的睡眠障碍之一，其病患率近年来呈明显上升趋势，与此同时，睡眠医学的重要性也日益凸显。我国睡眠医学发展迅速，已经由最初的睡眠实验室发展成为如今拥有5 000多家的睡眠诊疗中心，虽已初具规模，但仍存在诸多问题，如学科整合度不高，对于顽固性失眠缺乏有效治疗方案等。由于医学学科分类越来越细，麻醉科医师目前多专注于事临床麻醉，虽局限于手术室，但在某些疑难杂症的治疗上，麻醉科医师却拥有先天优势，如针对顽固性失眠，麻醉科医师可利用熟练掌握的麻醉技术及麻醉药物帮助患者迅速纠正睡眠债务、斩断恶性循环；此外，由失眠的认知行为疗法、星状神经节阻滞、针灸、麻醉睡眠、康复理疗等多种治疗方案构成的多模式睡眠治疗，为临床上经传统药物治疗效果不佳的失眠患者提供了有效、可靠的选择。在社会飞速发展的新时代，麻醉科医师应当充分利用自身优势，在更广泛的领域有所作为。     

Alphabet Strategy for diabetes care: A multi-professional,evidence-based,outcome-directed approach to management

With the rising global prevalence in diabetes, healthcare systems are facing a growing challenge to provide efficient and effective diabetes care management in the face of spiralling treatment costs. Diabetes is a major cause of premature mortality and associated with devastating complications especially if managed poorly. Although diabetes care is improving in England and Wales, recent audit data suggests care remains imperfect with wide geographical variations in quality. Diabetes care is expensive with a sizeable amount of available expenditure used for treating the complications of diabetes. A target driven, long-term, multifactorial intervention in patients with type 2 diabetes has been shown to reduce mortality and morbidity. The alphabet strategy is a novel approach to effective diabetes care provision, aiming to address patient education and empowerment, provide consistent comprehensive care delivered in a timely fashion, and allowing multidisciplinary team work.     

胰高血糖素样肽1及其受体在代谢外科手术治疗机制中的作用

目前外科手术已经成为治疗2型糖尿病治疗方式之一,但对于其治疗机制仍然还不明确.很多试验证明,糖尿病外科手术以后,解剖生理结构的改变导致了与代谢有关胃肠道分泌的激素和神经肽类分子水平的明显变化,这些分子在功能上与葡萄糖代谢、胰岛细胞功能、胰岛素敏感性相关,其中研究较为深入的是胰高血糖素样肽 -1（gucagon-like peptide-1 GLP-1）,其在外科手术治疗糖尿病中所起的重要作用已得到人们越来越多的认可.而GLP-1必须与GLP-1受体（GLP-1 receptor GLP-1R）结合后才能发挥其生理作用.本文就GLP-1及其受体在代谢外科手术治疗机制中的作用作一综述.