Type 2 diabetes mellitus (T2DM) represents a growing public health challenge in low- and middle-income countries (LMICs), where urbanization and socioeconomic disparities amplify its burden. This study examined the influence of individual- and neighborhood-level socioeconomic factors on T2DM risk using a multilevel framework. Cross-sectional data from 14 nationally representative Demographic and Health Surveys conducted between 2013 and 2023 were analyzed, including 1,090,328 individuals within 38,174 neighborhoods. Multilevel logistic regression models were fitted to estimate associations between socioeconomic indicators and T2DM risk. Contextual variation was quantified using variance partition coefficients and median odds ratios. Higher individual-level wealth was associated with increased odds of T2DM (OR = 1.30, 95% CI: 1.24-1.36), while education showed no protective association. At the neighborhood level, urban residence (OR = 1.09, 95% CI: 1.01-1.17) and greater community socioeconomic disadvantage were independently associated with higher T2DM risk. Neighborhood factors accounted for 32.2% of the total variance, and moving to a higher-risk neighborhood was associated with a 3.29-fold increase in median odds. Socioeconomic contexts at both individual and contextual levels independently shape T2DM risk in LMICs, underscoring the importance of place-based public health strategies alongside individual-level interventions.

DNA methylation is a critical epigenetic mechanism involved in the regulation of gene expression, including genes implicated in glucose metabolism. Despite growing evidence indicating that epigenetic mechanisms are involved in the pathogenesis and progression of type 2 diabetes mellitus (T2DM), available data remain limited. This study analyzed the genetic association of two single-nucleotide polymorphisms (SNPs) in the DNA methyltransferase 3A (DNMT3A) gene, rs11683424 and rs1550117, with T2DM susceptibility and investigated their potential associations with global DNA methylation.

Total antioxidant status (TAS) and total oxidant status (TOS) were evaluated, the oxidative stress index (OSI) was calculated, and diabetes-related parameters were assessed in T2DM patients and healthy controls, including HbA1c, fasting blood glucose (FBG), insulin, insulin sensitivity (IS), and insulin resistance (IR). Global DNA methylation was determined, and rs11683424 and rs1550117 were genotyped. Associations between metabolic and oxidative stress parameters, global DNA methylation, DNMT3A genotypes, and T2DM status were statistically analyzed.

T2DM patients exhibited significantly higher HbA1c, FBG, insulin, and IR levels than healthy controls (p=0.001), whereas IS was significantly lower (p=0.001). TAS, TOS, and OSI were significantly increased in T2DM patients compared with controls (p=0.001), as was global DNA methylation (p=0.001). In patients, a weak but statistically significant inverse correlation was observed between 5mC levels and BMI. Global methylation showed weak inverse associations with TAS and TOS; however, these associations did not reach statistical significance. No significant associations (p>0.05) were observed between 5mC levels and the other studied biomarkers. Neither regression model for predictors of global DNA methylation was statistically significant in T2DM patients (F(5,94)=0.852, p=0.516) or healthy controls (F(4,95)=0.592, p=0.669), and all variance inflation factor (VIF) values were <2.0. For rs11683424, the CT genotype was detected in 15.6% of T2DM patients compared with 2.6% of controls (OR=6.81, 95% CI=1.50-31.25, χ²=7.902, p=0.005). The T allele was present at frequencies of 7.8% and 1.3%, respectively (χ²=7.502, p=0.006). In contrast, rs1550117 was not significantly associated with T2DM. Linkage disequilibrium analysis indicated incomplete or moderate linkage disequilibrium between the two SNPs. The CG haplotype was the most common in both groups, whereas the TG and TA haplotypes were enriched among patients and showed increased disease odds, particularly TG (OR=7.89); however, neither association reached statistical significance. Genotype-phenotype analyses revealed only limited differences in global DNA methylation among the investigated genotypes.

T2DM was associated with altered oxidative stress parameters and increased global DNA methylation. The findings further indicate a potential association between DNMT3A rs11683424 and T2DM susceptibility, whereas rs1550117 was not significantly associated with disease status. However, the data do not establish a direct relationship between the investigated DNMT3A variants, oxidative stress, and global DNA methylation. These findings warrant validation in larger, multi-ethnic cohorts.

Diabetic retinopathy (DR) is a leading cause of preventable vision loss among individuals with type 2 diabetes mellitus (T2DM). Despite the availability of effective screening and treatment, adherence to regular eye examinations remains suboptimal in Saudi Arabia. Understanding patients' knowledge, attitudes, and practices (KAP) toward DR is crucial for developing targeted interventions within primary healthcare.

To evaluate the KAP regarding DR among patients with T2DM attending primary healthcare clinics in Riyadh, Saudi Arabia.

A cross-sectional study was conducted among 400 patients with T2DM using a validated, structured questionnaire. Descriptive statistics, Mann-Whitney U, Kruskal-Wallis tests, and Spearman's rank correlation were applied to examine KAP scores and their associations with sociodemographic and clinical variables.

Only 28.5% of participants had undergone DR screening within the past year, and just 10.5% recalled receiving physician advice to do so. Knowledge scores were moderate (mean = 1.77 ± 0.23), but attitudes were largely negative (mean = 1.20 ± 0.20). Screening practices were suboptimal (mean practice score = 1.53 ± 0.29). Education level, gender, occupation, and duration of diabetes were significantly associated with KAP domains (P < 0.05).

Despite moderate awareness of DR, most participants demonstrated poor attitudes and limited adherence to recommended screening. Our study emphasized the physician-related barriers and highlighted the importance of culturally tailored education and integrated primary care approaches to improve DR screening uptake.

Autoimmune polyglandular syndrome type 2 (APS-2) is a rare autoimmune disorder characterized by the coexistence of primary adrenal insufficiency with autoimmune thyroid disease and/or type 1 diabetes mellitus. Because its initial manifestations are often nonspecific, diagnosis may be substantially delayed until advanced disease or adrenal crisis develops. We report the case of a 28-year-old Portuguese woman living in California who presented with a nine-month history of progressive fatigue, unintentional weight loss, nausea, vomiting, abdominal pain, and a previous syncopal episode. Recognition of diffuse mucocutaneous hyperpigmentation involving the palmar creases and tongue prompted targeted endocrine investigation. Laboratory evaluation confirmed autoimmune primary adrenal insufficiency and autoimmune hypothyroidism, establishing the diagnosis of APS-2. Treatment with intravenous hydrocortisone and fluid resuscitation was followed by levothyroxine and fludrocortisone replacement, resulting in rapid clinical improvement, the normalization of biochemical abnormalities, and complete recovery. This case highlights the diagnostic value of meticulous physical examination in patients presenting with otherwise unexplained constitutional symptoms. Recognition of these characteristic physical findings may facilitate the early diagnosis of autoimmune primary adrenal insufficiency, enabling appropriate hormone replacement before progression to adrenal crisis.

Melkersson-Rosenthal syndrome (MRS) is a rare granulomatous disorder classically characterized by recurrent orofacial edema, relapsing peripheral facial palsy, and fissured tongue. However, the complete triad is uncommon, and incomplete forms may create a diagnostic challenge. We report the case of a 48-year-old man with type 2 diabetes mellitus who was admitted with recurrent swelling of both lips and a fissured tongue. The symptoms had begun 15 days earlier with an episode of bilateral macrocheilitis initially attributed to a food allergy. The swelling temporarily improved with antihistamine therapy but recurred one week later. Oral examination revealed marked bilateral lip edema, a fissured tongue, and gingival inflammation, without aphthous lesions, ulceration, xerostomia, or an obvious dental infectious focus. Neurological examination showed no evidence of peripheral facial palsy or facial sensory impairment. Laboratory investigations showed no major abnormalities. Serum calcium and angiotensin-converting enzyme levels were within normal limits. Thoracoabdominopelvic computed tomography and spirometry were unremarkable. QuantiFERON-TB Gold testing and sputum GeneXpert MTB/RIF were negative. A minor salivary gland biopsy was performed to assess granulomatous inflammation and demonstrated chronic non-caseating epithelioid and giant-cell granulomatous sialadenitis without histological evidence of malignancy. Based on the recurrent macrocheilitis, fissured tongue, and compatible granulomatous histology, an incomplete form of MRS was diagnosed. The patient received intralesional triamcinolone acetonide at a dose of 40 mg once monthly for six months, resulting in marked improvement in lip swelling. This case highlights the importance of considering an incomplete form of MRS in patients with recurrent unexplained lip swelling and fissured tongue, even in the absence of facial palsy.

Type 2 diabetes mellitus (T2DM) is associated with adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Despite emergency percutaneous coronary intervention (PCI), in-hospital heart failure (HF) remains an important complication. This study aimed to identify factors independently associated with new-onset in-hospital HF and to develop an internally validated prediction model in patients with T2DM and STEMI undergoing emergency PCI.

This retrospective observational study included 306 adult patients with T2DM and STEMI who underwent emergency PCI at the People's Hospital of Xinjiang Uygur Autonomous Region between January 2022 and February 2026. Patients were classified into HF (n=65) and non-HF (n=241) groups according to new-onset clinically documented HF during the index hospitalization; all patients classified as having HF had a maximum Killip class ≥ II. Natriuretic peptides and echocardiographic findings were used as supportive evidence and were not included as predictors. Clinical, laboratory, echocardiographic, and selected procedural variables were analyzed using univariate and multivariable binary logistic regression. Model performance was assessed using discrimination, calibration, 10-fold cross-validation, and bootstrap optimism correction.

Independent positive associations with in-hospital HF were observed for prior myocardial infarction (OR = 6.205, 95% CI: 2.692-14.299, P<0.001), smoking (OR = 5.552, 95% CI: 2.517-12.247, P<0.001), regional wall motion abnormalities (OR = 2.415, 95% CI: 1.091-5.344, P = 0.030), higher white blood cell count (OR = 1.143 per 10⁹/L, 95% CI: 1.072-1.219, P<0.001), higher systolic blood pressure (OR = 1.018 per mmHg, 95% CI: 1.001-1.034, P = 0.032), and age ≥75 years (OR = 4.792, 95% CI: 1.394-16.472, P = 0.013). Hemoglobin (OR = 0.971 per 1 g/L increase, 95% CI: 0.952-0.990, P = 0.003) and LVEF (OR = 0.953 per 1 percentage-point increase, 95% CI: 0.911-0.998, P = 0.040) were inversely associated with HF, indicating greater HF odds at lower values. The model showed an apparent AUC of 0.881 and an optimism-corrected AUC of 0.843, with Hosmer-Lemeshow P = 0.826.

Readily available admission variables were associated with in-hospital HF in T2DM-STEMI patients undergoing emergency PCI. The internally validated model showed good discrimination and calibration; however, given the retrospective single-center design and limited number of HF events, external validation in an independent population is required before clinical implementation.

Despite guidelines recommending sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) for type 2 diabetes mellitus (T2DM) patients with cardiovascular risk, utilization remains low. This study evaluated the knowledge, attitudes, and practices (KAP) of physicians in Saudi Arabia toward these agents.

A nationwide cross-sectional study was conducted among 399 physicians in Saudi Arabia between December 2024 and November 2025. Participants completed an online survey assessing pharmacological knowledge, their attitude, and prescribing practices. Multivariable logistic regression was used to identify independent determinants of KAP outcomes.

Theoretical knowledge was high, with 91.0% of physicians demonstrating adequate knowledge of SGLT-2i and 78.4% for GLP-1RA. Conversely, only 23.6% held an overall positive attitude, while 75.4% met the threshold for appropriate practice. Notably, 90.0% of physicians identified medication availability and patient accessibility as constant prescribing barriers. Multivariable analysis showed that while knowledge scores were generally high, they did not independently guarantee a positive attitude. Older age was significantly associated with higher odds of inappropriate practice, whereas specialist status and higher attitude scores were linked to better clinical practices.

The study highlights a significant dissociation between high theoretical knowledge and attitudinal hesitancy among Saudi physicians. These findings suggest that under-prescribing may be associated more with attitudinal and structural factors, such as limited medication access, than with knowledge deficits. Future interventions should prioritize building clinical confidence through academic detailing and addressing systemic access issues to optimize evidence-based management for patients with T2DM.

Children with type 1 diabetes mellitus (T1DM) in India face a dual burden of disease-related stress and socioeconomic constraint, with insulin pumps and continuous glucose monitors (CGMs) unaffordable for most families. Carbohydrate (carb) counting is a low-cost, education-based self-management skill linked to improved glycemic control in other populations. We hypothesized that carb counting is associated with better quality of life (QoL) in children with T1DM primarily through improved glycemic control, and tested this pathway using a cross-sectional mediation analysis at a tertiary center in North India.

In this hospital-based, cross-sectional study, 50 children with T1DM (age 2-18 years) attending the pediatric endocrinology outpatient clinic of a tertiary care hospital in Dehradun, Uttarakhand, were enrolled. QoL was assessed using the Quality-of-Life Instrument for Indian Diabetes patients (QOLID; 34 items across eight domains). Glycated hemoglobin (HbA1c), self-monitored blood glucose, insulin regimen, and carb-counting practice were recorded. Associations were analyzed using independent-samples t-tests, Pearson correlation, and simple linear regression, with sensitivity analyses (Welch's t-test, Mann-Whitney U), exploratory multivariable linear regression, and Baron-Kenny mediation analysis (Sobel test and bootstrap confidence intervals) used to test whether HbA1c mediates the carb-counting-QoL association. p<0.05 was considered significant.

The mean QOLID score was 82.08±9.06%; 19 (38%) children had impaired QoL (score <80%). Financial worries were the lowest-scoring domain (69.50±17.00), impaired in 44 (88%) children, despite 47 (94%) being on basal-bolus insulin therapy and only one (2%) child using an insulin pump. HbA1c showed the strongest negative correlation with total QoL (r=-0.675, p<0.001). Thirty (60%) children practiced carb counting; they had significantly lower HbA1c (7.27±1.02% vs 8.96±2.50%, p=0.0017) and higher total QOLID scores (148.37±12.46 vs 139.40±18.43, p=0.045) than those who did not. Mediation analysis showed that HbA1c fully mediated the carb counting-QoL association: the indirect effect via HbA1c was significant (a×b=9.26, Sobel z=2.87, p=0.0041; bootstrap 95% CI: 2.74-16.82), while the direct effect of carb counting on QoL was negligible and non-significant after accounting for HbA1c (c'=-0.29, p=0.938), with an estimated 103% of the total effect statistically mediated through glycemic control.

Carb counting was associated with better QoL primarily, and statistically fully, through its association with better glycemic control rather than through an independent pathway -- a mechanistically coherent, testable explanation for how a free, education-based skill could plausibly improve QoL in settings where insulin pumps and CGMs remain unaffordable. Financial worry remained the most impaired QoL domain despite near-universal use of low-cost insulin regimens, underscoring the broader economic burden of care. As this mediation pattern is statistical rather than temporally confirmed, prospective or interventional studies are needed before structured carb-counting education can be recommended as an evidence-based strategy in resource-constrained pediatric diabetes care.

Smoking is associated with accelerated progression of diabetes, whereas smoking cessation supports better disease control. This study aimed to determine the smoking prevalence, factors associated with quitting, and the barriers to and needs for smoking cessation among diabetic patients, in order to provide a basis for targeted smoking cessation interventions.

This cross-sectional study was conducted from July to December 2025. A convenience sampling method was used to survey 1736 diabetic patients with a self-administered questionnaire at 10 community health service centers in Chongqing, China. Data were collected on sociodemographic characteristics, glycemic control, history of comorbid chronic conditions, history of diabetic complications, smoke-free home environment, knowledge of the association between smoking and diabetes, and attitudes or beliefs about smoking cessation. Chi-squared tests, Kruskal-Wallis H tests, and multivariate logistic regression were used to identify factors associated with smoking cessation. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated for the logistic regression models.

Among the 1736 diabetic patients, 25.6% were current smokers, 16.0% were former smokers, and 58.4% were never smokers. Glycemic control (AOR=0.61; 95% CI: 0.37-1.00), history of comorbid chronic conditions (AOR=3.91; 95% CI: 1.93-7.92), smoke-free home environment (AOR=3.12; 95% CI: 1.99-4.87), knowledge of the association between smoking and diabetes (AOR=1.11; 95% CI: 1.06-1.16), and attitudes or beliefs about smoking cessation (AOR=1.40; 95% CI: 1.31-1.48) were associated with smoking cessation among diabetic patients. Overall, 50.6% of the patients attributed their barriers to cessation to strong nicotine addiction and discomfort after quitting.

The smoking rate among diabetic patients in Chongqing is relatively high, and fewer than half of current smokers reported an intention to quit smoking. Smoking cessation among diabetic patients was associated with glycemic control, history of comorbid chronic conditions, smoke-free home environment, knowledge of the association between smoking and diabetes, and attitudes or beliefs about smoking cessation.

Type 2 diabetes mellitus (T2DM) is associated with substantial cardiovascular and renal morbidity and premature mortality. Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists reduce cardiorenal events beyond their glucose-lowering effects. This systematic review compared cardiovascular, heart failure, kidney, mortality, metabolic, and safety outcomes of the two classes of medications and evaluated evidence for complementary use. Randomized controlled trials, systematic reviews and meta-analyses, and large comparative observational studies of adults with type 2 diabetes reporting relevant cardiovascular, renal, mortality, metabolic, or safety outcomes were eligible. Glycemia-only studies without relevant clinical outcomes, pediatric and preclinical studies, case reports, editorials, and noninformative reports were excluded. PubMed/MEDLINE, Embase, and Cochrane CENTRAL were searched from January 2010 through August 30, 2026, supplemented by Google Scholar and backward and forward citation searching. Risk of bias was assessed using RoB 2 for randomized trials, ROBINS-I for nonrandomized comparative studies, and AMSTAR 2 for systematic reviews and meta-analyses. Certainty of evidence was assessed at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Because of heterogeneity across populations, interventions, outcomes, and study designs, results were evaluated using a structured narrative synthesis rather than a de novo meta-analysis. Thirty-eight studies were included, comprising 14 randomized controlled trials, 12 nonrandomized comparative studies, and 12 systematic reviews or meta-analyses. SGLT2 inhibitors showed particularly consistent benefit for heart failure and kidney outcomes, whereas GLP-1 receptor agonists showed strong atherosclerotic cardiovascular benefit and greater weight reduction. Certainty was moderate for the principal comparative cardiovascular and kidney outcomes and lower for real-world comparative effectiveness and combination therapy. Evidence supported potentially complementary cardiorenal effects with combined use, although superiority of combination therapy over appropriately selected monotherapy was not established. Safety profiles differed, with genital infections, volume depletion, and rare diabetic ketoacidosis more closely associated with SGLT2 inhibitors and gastrointestinal adverse effects more common with GLP-1 receptor agonists. Interpretation was limited by heterogeneity in study populations, interventions, outcome definitions, follow-up periods, and study designs, residual confounding in observational evidence, and the possibility of publication and selective-reporting bias. Overall, the findings support individualized treatment selection according to cardiovascular and renal risk, heart failure, weight goals, safety, tolerability, and access, with combined use considered when complementary benefits are clinically appropriate.