Platelet dysfunction in type 2 diabetes

Palanisamy UD, Ahmad B, Abdul Kadir K. The Effects of Tocotrienol-Rich Vitamin E (Tocovid) on Diabetic Neuropathy: A Phase II Randomized Controlled Trial

Chronic hyperglycemia increases oxidative stress, activates inflammatory pathways and reduces nerve growth factor (NGF) among diabetic patients, which contribute to development of diabetic peripheral neuropathy (DPN). Tocotrienol-Rich Vitamin E (Tocovid) possesses potent antioxidant and anti-inflammatory properties which are postulated to target these pathogeneses in order to ameliorate DPN. This study aims to evaluate the effects of Tocovid on nerve conduction parameters and serum biomarkers among diabetic patients. This multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted on 80 eligible participants. The intervention group (n = 39) was randomly allocated to receive 200 mg of Tocovid twice a day, and the control group (n = 41) received placebo twice a day. At the end of eight weeks, the nerve conduction parameters, as assessed by nerve conduction study, as well as serum biomarkers (NGF, malondialdehyde, vascular cell adhesion molecule 1, tumor necrosis factor receptor 1 and thromboxane B2) were compared between the two groups. Compared to placebo, Tocovid significantly improves the nerve conduction velocities of all nerves (+1.25 m/s, interquartile range [IQR] 3.35, p < 0.001, median nerve; +1.60 m/s, IQR 1.80, p < 0.001, sural nerve; +0.75 m/s, IQR 2.25, p < 0.001, tibial nerve). Meanwhile, the levels of serum NGF were significantly higher in the Tocovid group as compared to placebo at eight weeks post-intervention. Participants receiving Tocovid illustrated highly significant improvement in terms of nerve conduction velocities for all nerves tested after eight weeks of supplementation. In addition, Tocovid supplementation elevated the levels of serum NGF, in which its increase is postulated to reflect enhanced neuronal functions. This novel finding suggests that Tocovid could be a disease-modifying agent targeting serum NGF to improve nerve conduction velocities.

Proteomic analysis of oxidative stress response in human umbilical vein endothelial cells (HUVECs): role of heme oxygenase 1 (HMOX1) in hypoxanthine-induced oxidative stress in HUVECs

Background

Erectile dysfunction (ED) is a well-known complication of diabetes, affecting up to 75% of diabetic men. Although the etiology of diabetic ED is multifactorial, endothelial dysfunction is considered to be a pillar of its pathophysiology. Endothelial dysfunction is caused by the harmful effects of high glucose levels and increased oxidative stress on the endothelial cells that comprise the vascular endothelium. The aim of this study was to identify the proteomic changes caused by high glucose-induced oxidative stress and explore the role of heme oxygenase 1 (HMOX1) in it.

Methods

The cellular proteomic response to hypoxanthine-induced oxidative stress in human umbilical vein endothelial cells (HUVECs) was analyzed by isobaric tags for relative and absolute quantitation (iTRAQ) combined with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Differentially expressed proteins (DEPs) were analyzed through Network and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Further validation assays was performed to validate the role of HMOX1.

Results

The results showed that 66 and 76 DEPs were markedly upregulated and downregulated, respectively, for HUVECs oxidative stress. Among these proteins, we verified eight dysregulated genes by quantitative reverse transcription PCR, including nucleolin (NCL), X-ray repair cross-complementing protein 6 (XRCC6), ubiquinol-cytochrome C reductase binding protein (UQCRB), non-POU domain containing octamer binding (NONO), heme oxygenase 1 (HMOX1), nucleobindin 1 (NUCB1), DEK, and chromatin target of prmt1 (CHTOP). Further, using overexpression and genetic knockdown approaches, we found that HMOX1 was critical for the oxidative stress response in HUVECs.

Conclusions

We found that HMOX1 was closely related to the oxidative stress response induced by hypoxanthine. To the best of our knowledge, this study is the first overview of the responses of HUVECs to oxidative stress. The findings will contribute to analyses of the detailed molecular mechanisms involved in the pathogenesis of endothelial dysfunction and related molecular mechanisms in ED patients.

Alveolar bone loss, platelet and glycosylated haemoglobin levels in 239 patients. A clinical study

Background

The relation between periodontal disease and systemic pathologies is still not widespread among general practitioners. The aim of our study is to evaluate whether or not periodontal radiological diagnosis can aid the detection of blood alterations associated with acquired systemic diseases.

Material and Methods

This is a cross sectional study. All of the participants underwent a panoramic radiograph and a complete blood test. Morphological bone loss was considered as positive in those patients who showed radiographically more than 1 tooth with bone loss greater than or equal to the middle third of the root. The statistical analysis was performed by comparing the variables using the ANOVA or U-Mann-Whitney tests for independent samples with normal conditions. The correlation coefficient was analysed using the Pearson test.

Results

239 patients were included in our study (96 men and 143 women) with an average age of 64.40 years. 59.04% of the patients were determined as morphological bone loss positive and had on average 4 teeth less than negative patients (p <0.0001). Also the average platelet levels in positive patients were lower (p = 0.024) and mean levels of HBA1c (p = 0.009) were higher.

Conclusions

Morphological bone loss parameter can be useful both for dentists and general practitioners to refer, subsequently, to periodontal specialist.

Key words:Periodontal diseases, blood chemical analysis, blood platelets, alkaline phosphatase, glycosylated haemoglobin A, alveolar bone loss.

Impact of diabetes mellitus on immature platelet fraction and its association with coronary artery disease

BACKGROUND

Higher prothrombotic status and alterations in platelet function and thrombopoiesis are associated with diabetes mellitus (DM). We assessed the impact of diabetes and glucose control on the immature platelet fraction (IPF) and their relationship with prevalence and extent of coronary artery disease (CAD).

METHODS

Consecutive patients undergoing coronary angiography were included. Significant CAD was defined as at least one vessel stenosis greater than 50%. IPF levels were measured at admission by routine blood cells count (A Sysmex XE-2100).

RESULTS

We included 1781 patients, of whom 660 (37.1%) suffered from diabetes. Diabetes was associated with advanced age and a higher cardiovascular risk profile. No difference in the mean values of IPF were observed between patients with or without DM (3.6 ± 2.5 vs 3.5 ± 2.5, P = 0.39) and neither in the rate of patients with IPF above the median (2.9%) (51.6% vs 50.6%, P = 0.73). In patients with DM, the IPF levels did not relate with glucose control parameters (glycaemia: r = -0.024, P = 0.54, glycosylated haemoglobin: r = 0.11, P = 0.72). The prevalence of CAD was significantly lower in patients with DM and IPF greater than the median (80.5% vs 86.5%, P = 0.04, adjusted odds ratio [OR] [95% confidence interval {CI}] = 0.57[0.36-0.91], P = 0.02), while not left main/three-vessel CAD (36.9% vs 38.2%, P = 0.75, adjusted OR [95%CI] = 0.91[0.64-1.28], P = 0.90).

CONCLUSION

In the present study, neither DM nor glucose control are independent predictors of IPF above the median. In patients with DM, higher IPF levels were associated with a lower prevalence of CAD and with a similar extent of severe CAD and angiographic findings. Therefore, until new data become available, elevated IPF should not be systematically applied on a large scale as cardiovascular risk marker in patients with diabetes.

Effects of Nigella sativa on endothelial dysfunction in diabetes mellitus: A review

ETHNOPHARMACOLOGICAL RELEVANCE

Endothelial dysfunction is involved in lesion generation by the promotion of both early and late mechanism(s) of atherosclerosis such as adhesion molecules up-regulation, increased chemokine secretion and leukocyte adherence, increased cell permeability, enhanced low-density lipoprotein oxidation, cytokine elaboration, platelet activation and vascular smooth muscle cell migration, and proliferation. Nigella sativa is from the Ranunculaceae family which is used in some countries for various medicinal purposes. Nigella sativa seed has been widely used in traditional medicine for the treatment of diabetes.

AIM OF THE REVIEW

This review article summarized the therapeutic effects of Nigella sativa on endothelial dysfunction.

METHODS

Databases such as PubMed, Web of Science, Google Scholar, Scopus, and Iran Medex were considered. The search terms were " Nigella sativa " or "endothelium" and " Diabetes"," endothelial dysfunction ", " Thymoquinone " and " anti-inflammatory effect ".

RESULTS

The current review shows that Nigella sativa and Thymoquinone have a protective effect on endothelial dysfunction induced by diabetes. This is done by several mechanisms such as reduction of inflammatory and apoptotic markers, improving hyperglycemia, hyperlipidemia and antioxidant function, inhibiting platelet aggregation, and regulating eNOS, VCAM-1 and LOX-1 genes expression that involve in the endothelial dysfunction. Thymoquinone also reduces expression and secretion of some cytokines such as MCP-1, interleukin-1β, TNF-α, NF-κB, and Cox-2 that result in anti-inflammation effect.

CONCLUSION

Thymoquinone, the main phenolic terpene found in Nigella sativa, has several important properties such as antidiabetic, anti-inflammatory, and antioxidant activity. Therefore, Nigella sativa can improve endothelial dysfunction.

Platelet-rich plasma counteracts detrimental effect of high-glucose concentrations on mesenchymal stem cells from Bichat fat pad

Diabetic patients display increased risk of periodontitis and failure in bone augmentation procedures. Mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) represent a relevant advantage in tissue repair process and regenerative medicine. We isolated MSCs from Bichat's buccal fat pad (BFP) and measured the effects of glucose and PRP on cell number and osteogenic differentiation potential. Cells were cultured in the presence of 5.5-mM glucose (low glucose [LG]) or 25-mM glucose (high glucose [HG]). BFP-MSC number was significantly lower when cells were cultured in HG compared with those in LG. Following osteogenic differentiation procedures, calcium accumulation, alkaline phosphatase activity, and expression of osteogenic markers were significantly lower in HG compared with LG. Exposure of BFP-MSC to PRP significantly increased cell number and osteogenic differentiation potential, reaching comparable levels in LG and in HG. Thus, high-glucose concentrations impair BFP-MSC growth and osteogenic differentiation. However, these detrimental effects are largely counteracted by PRP.

Diabetes and atherothrombosis: The circadian rhythm and role of melatonin in vascular protection

Obesity-related euglycaemic insulin resistance clusters with cardiometabolic risk factors, contributing to the development of both type 2 diabetes and cardiovascular disease. An increased thrombotic tendency in diabetes stems from platelet hyperactivity, enhanced activity of prothrombotic coagulation factors and impaired fibrinolysis. Furthermore, a low-grade inflammatory response and increased oxidative stress accelerate the atherosclerotic process and, together with an enhanced thrombotic environment, result in premature and more severe cardiovascular disease. The disruption of circadian cycles in man secondary to chronic obesity and loss of circadian cues is implicated in the increased risk of developing diabetes and cardiovascular disease. Levels of melatonin, the endogenous synchronizer of circadian rhythm, are reduced in individuals with vascular disease and those with deranged glucose metabolism. The anti-inflammatory, antihypertensive, antioxidative and antithrombotic activities of melatonin make it a potential therapeutic agent to reduce the risk of vascular occlusive disease in diabetes. The mechanisms behind melatonin-associated reduction in procoagulant response are not fully known. Current evidence suggests that melatonin inhibits platelet aggregation and might affect the coagulation cascade, altering fibrin clot structure and/or resistance to fibrinolysis. Large-scale clinical trials are warranted to investigate the effects of modulating the circadian clock on insulin resistance, glycaemia and cardiovascular outcome.

Elevated HbA1c is not associated with recurrent venous thromboembolism in the elderly, but with all-cause mortality- the SWEETCO 65+ study

The association of glycated hemoglobin (HbA1c) with venous thromboembolism (VTE) and death in the elderly is unknown. In the SWEETCO 65+ study we analyzed prospectively a Swiss Cohort of Elderly Patients with Venous Thromboembolism (SWITCO 65+). 888 patients were enrolled for the SWEETCO 65+ analysis. HbA1c was determined at baseline and divided into three categories (HbA1c < 5.7%, normal range; 5.7–6.49%, pre-diabetic range; and >6.5%, diabetic range). Median follow-up was 2.5 years. The primary endpoint was recurrent VTE. Secondary endpoints included all-cause mortality and major bleeds. The total prevalence of diabetes was 22.1%. The risk of recurrent VTE was similar in patients with HbA1c with pre-diabetes (adjusted subhazard ratio (aSHR) 1.07 [0.70 to 1.63]) and diabetes (aSHR 0.73 [0.39 to 1.37]) as compared to those with a HbA1c in the normal range. However, a HbA1c ≥ 6.5% (median IQ range 7.0 [6.70;7.60]) was significantly associated with a higher risk of all-cause mortality (adjusted hazard ratio [aHR] 1.83 [1.21 to 2.75]). In summary we found no association between HbA1c and major bleeding. Elevated HbA1c levels are not associated with recurrent VTE but with increased all-cause mortality in an elderly population with acute VTE.

Value of triglyceride-glucose index for the estimation of ischemic stroke risk: Insights from a general population

BACKGROUND AND AIMS

Recent studies have recognized triglyceride-glucose index (TyG) as a practical surrogate of insulin resistance. Previous studies have demonstrated that insulin resistance contributes to ischemic stroke via multiple mechanisms. Our study aimed to investigate the association between TyG and prevalent ischemic stroke, exploring the value of TyG to optimize the risk stratification of ischemic stroke.

METHODS AND RESULTS

This cross-sectional study included 10,900 subjects (mean age: 59.95 years, 59.8% females) from rural areas of northeast China between September 2017 to May 2018. TyG was calculated as ln[fasting triglyceride (mg/dl) × fasting plasma glucose (mg/dl)/2]. The prevalence of ischemic stroke was 5.49%. After adjusting for all covariates, each SD increment of TyG caused 22.8% additional risk for ischemic stroke. When dividing TyG into quartiles, the top quartile had a 1.776 times risk for ischemic stroke against the bottom category. Furthermore, smoothing curve fitting demonstrated this association was linear in the whole range of TyG. Finally, AUC revealed an improvement when introducing TyG into clinical risk factors (0.746 vs 0.751, p = 0.029). Consistently, category-free net reclassification index (0.195, 95% CI: 0.112-0.277, P < 0.001) and integrated discrimination index (0.003, 95% CI: 0.001-0.004, P < 0.001) confirmed the improvement by TyG to stratify ischemic stroke risk.

CONCLUSION

The prevent ischemic stroke correlated proportionally with the increment of TyG, implicating the linearity of TyG as an indicator of ischemic stroke. Our findings suggest the potential value of TyG to optimize the risk stratification of ischemic stroke in a general population.

Influence of Cardiometabolic Risk Factors on Platelet Function

Platelets are key players in the thrombotic processes. The alterations of platelet function due to the occurrence of metabolic disorders contribute to an increased trend to thrombus formation and arterial occlusion, thus playing a major role in the increased risk of atherothrombotic events in patients with cardiometabolic risk factors. Several lines of evidence strongly correlate metabolic disorders such as obesity, a classical condition of insulin resistance, dyslipidemia, and impaired glucose homeostasis with cardiovascular diseases. The presence of these clinical features together with hypertension and disturbed microhemorrheology are responsible for the prothrombotic tendency due, at least partially, to platelet hyperaggregability and hyperactivation. A number of clinical platelet markers are elevated in obese and type 2 diabetes (T2DM) patients, including the mean platelet volume, circulating levels of platelet microparticles, oxidation products, platelet-derived soluble P-selectin and CD40L, thus contributing to an intersection between obesity, inflammation, and thrombosis. In subjects with insulin resistance and T2DM some defects depend on a reduced sensitivity to mediators—such as nitric oxide and prostacyclin—playing a physiological role in the control of platelet aggregability. Furthermore, other alterations occur only in relation to hyperglycemia. In this review, the main cardiometabolic risk factors, all components of metabolic syndrome involved in the prothrombotic tendency, will be taken into account considering some of the mechanisms involved in the alterations of platelet function resulting in platelet hyperactivation.

Efficacy and Safety of Ultrathin, Bioresorbable-Polymer Sirolimus-Eluting Stents Versus Thin, Durable-Polymer Everolimus-Eluting Stents for Coronary Revascularization of Patients With Diabetes Mellitus

Patients with diabetes mellitus are prone to increased adverse outcomes after percutaneous coronary intervention, even with contemporary drug-eluting stents. Randomized controlled trials have demonstrated comparable clinical outcomes between an ultrathin bioresorbable-polymer sirolimus-eluting stent (BP-SES) and a thin-strut durable-polymer everolimus-eluting stent (DP-EES) that has specific labeling for patients with diabetes. We aimed to evaluate the safety and efficacy of the BP-SES in patients with diabetes mellitus. To determine the performance of the BP-SES in diabetic patients, patient-level data from the BIOFLOW II, IV, and V randomized controlled trials were pooled. The primary end point was target lesion failure (TLF), defined as the composite of cardiovascular death, target-vessel myocardial infarction, ischemia-driven target lesion revascularization, and definite or probable stent thrombosis, at 1 year. Among 1,553 BP-SES and 791 DP-EES patients, 757 diabetic patients were identified. Of the diabetic patients included in this analysis (494 BP-SES vs 263 DP-EES), the proportion of insulin- and noninsulin-treated patients was similar between groups. The 1-year TLF rate in the diabetic population was 6.3% in the BP-SES group and 8.7% in the DP-EES group (hazard ratio 0.82, 95% confidence interval 0.047 to 1.43, p = 0.493). There were no significant differences, based on stent type or diabetes treatment regimen, in TLF hazards. In a patient-level pooled analysis of the diabetic population from randomized trials, 1-year clinical safety and efficacy outcomes were similar in patients treated with ultrathin BP-SES and thin-strut DP-EES.

Aspirin for Primary Prevention of Cardiovascular Disease in Diabetes: a Review of the Evidence

PURPOSE OF REVIEW

People with diabetes are at a higher risk of atherosclerotic cardiovascular disease (ASCVD) compared with those without diabetes. Though aspirin has been shown to have an overall net clinical benefit when used for secondary prevention of ASCVD in people with and without diabetes, the evidence for primary prevention, especially in those with diabetes, remains inconsistent. In this article, we review the latest studies examining the risks and benefits of aspirin use for primary prevention of ASCVD in adults with diabetes, discuss key aspects in assessing the risk-benefit ratio of aspirin use for primary prevention of ASCVD, and summarize current guidelines from professional societies on aspirin use for primary prevention in adults with diabetes.

RECENT FINDINGS

In the general population, past studies have shown no difference in the beneficial effect of aspirin for primary cardiovascular disease prevention by diabetes status. However, several randomized controlled studies and meta-analyses in adults with diabetes have shown lack of net clinical benefit of aspirin use for primary prevention of ASCVD. The recent ASCEND trial documented cardiovascular benefit of aspirin for primary prevention in adults with diabetes but suggested that the increased risk of bleeding may outweigh the cardiovascular benefit. The decision to initiate aspirin for primary prevention of ASCVD must be considered carefully on an individual basis to balance the cardiovascular benefit and bleeding risk in all patients, especially those with diabetes. A multifactorial approach that focuses on managing ASCVD risk factors such as hypertension, dyslipidemia, dysglycemia, and smoking is recommended in all patients. More research is needed to identify subgroups of people with diabetes who are more likely to benefit from aspirin use for primary prevention of ASCVD and develop better antithrombotic strategies that shift the risk-benefit balance toward an overall net clinical benefit.

Platelets Are at the Nexus of Vascular Diseases

Platelets are important actors of cardiovascular diseases (CVD). Current antiplatelet drugs that inhibit platelet aggregation have been shown to be effective in CVD treatment. However, the management of bleeding complications is still an issue in vascular diseases. While platelets can act individually, they interact with vascular cells and leukocytes at sites of vascular injury and inflammation. The main goal remains to better understand platelet mechanisms in thrombo-inflammatory diseases and provide new lines of safe treatments. Beyond their role in hemostasis and thrombosis, recent studies have reported the role of several aspects of platelet functions in CVD progression. In this review, we will provide a comprehensive overview of platelet mechanisms involved in several vascular diseases.

The blood compatibility challenge. Part 3: Material associated activation of blood cascades and cells

Following protein adsorption/activation which is the first step after the contact of material surfaces and whole blood (part 2), fibrinogen is converted to fibrin and platelets become activated and assembled in the form of a thrombus. This thrombus formation is the key feature that needs to be minimized in the creation of materials with low thrombogenicity. Further aspects of blood compatibility that are important on their own are complement and leukocyte activation which are also important drivers of thrombus formation. Hence this review summarizes the state of knowledge on all of these cascades and cells and their interactions. For each cascade or cell type, the chapter distinguishes statements which are in widespread agreement from statements where there is less of a consensus. STATEMENT OF SIGNIFICANCE: This paper is part 3 of a series of 4 reviews discussing the problem of biomaterial associated thrombogenicity. The objective was to highlight features of broad agreement and provide commentary on those aspects of the problem that were subject to dispute. We hope that future investigators will update these reviews as new scholarship resolves the uncertainties of today.

Improved prediction of HIT in the SICU using an improved model of the Warkentin 4-T system: 3-T

BACKGROUND

The Warkentin 4-T scoring system for determining the pretest probability of heparin-induced thrombocytopenia (HIT) has been shown to be inaccurate in the ICU and does not take into account body mass index (BMI).

METHODS

Prospectively collected data on patients in the surgical and cardiac ICU between January 2007 and February 2016 who were presumed to have HIT by clinical suspicion were reviewed. Patients were categorized into 3 BMI groups and assigned scores: Normal weight, overweight, and obese. Multivariate analyses were used to identify independent predictors of HIT.

RESULTS

A total of 523 patients met inclusion criteria. Multivariate analysis showed that only BMI, Timing, and oTher variables were independently associated with HIT. This new 3-T model was better than a five-component model consisting of the entire 4-T scoring system plus BMI (AUC = 0.791).

CONCLUSIONS

Incorporating patient 'T'hickness into a pretest probability model along with platelet 'T'iming and the exclusion of o'T'her causes of thrombocytopenia yields a simplified "3-T" scoring system that has increased predictive accuracy in the ICU.

Correlation between oxidative stress and hematological profile abnormalities in diabetic nephropathy

AIMS

Diabetes patients with renal impairment commonly have a degree of hematological abnormalities than those non-diabetics with chronic kidney disease. The present study aimed to clarify the association between oxidative stress and hematological abnormalities with the progression of diabetic nephropathy.

METHODS

A total of 20 healthy subjects and 100 patients were enrolled in the study. Eligible renal dysfunction patients were classified according to biochemical markers into five groups (20 patients); diabetic patients, pre-renal failure patients, diabetic pre-renal failure patients, renal failure patients, and diabetic renal failure patients.

RESULTS

Erythrocytes and platelets count, hemoglobin and hematocrit levels revealed a significant decrease in all renal dysfunction groups, while leukocytes count, red cell distribution width, platelet distribution width, and mean platelet volume showed significant increases in diabetic and renal dysfunction groups as compared to the healthy control. Nitric oxide level increased significantly, while reduced glutathione showed a marked decrease in diabetic and all renal dysfunction groups compared to the healthy control.

CONCLUSION

Nitric oxide and reduced glutathione were associated with the inflammatory status in diabetic renal dysfunction patients which reflected by elevation in leukocytes and neutrophils count, red cell distribution width as well as the reduction in values of erythrocytes, platelets count, hemoglobin and hematocrit. Therefore, hematological indices can play a role in predict the progression of diabetic nephropathy.

Platelet distribution width, platelet count, and plateletcrit in diabetic retinopathy: A systematic review and meta-analysis of PRISMA guidelines

BACKGROUND

Screening and diagnosis of diabetic retinopathy (DR) mainly depends on fundus examination, which is not an intuitive and simple screening or diagnostic method. Recently, the relationship between platelet parameters and DR has become a hot topic. Whether platelet parameters have clinical value in DR is controversial.

METHODS

Literature was retrieved by formal search of electronic databases (PubMed, Embase, Cochrane library, Scopus, and CNKI) and by hand searching of reference lists of related articles from the beginning of building database to December 2017. Review manager 5.3 was utilized to deal with statistical data. This study was registered at International Prospective Register of Systematic Reviews (number: CRD42018093773).

RESULTS

This study included 1720 DR patients, 1477 type 2 diabetic mellitus (T2DM) without DR patients and 1456 health controls in 21 eligible studies. We found there was significant increase of platelet distribution width (PDW) level in the comparison of DR versus Control group (standard mean difference [SMD] [95% confidence interval [CI]] = 1.04 [0.68, 1.40]) and DR versus T2DM without DR group (SMD [95% CI] = 0.68 [0.40, 0.95]). For platelet count (PLT), it showed obvious decrease in the comparison of DR versus T2DM without DR group (SMD [95% CI] = -0.26 [-0.49, -0.03]) and no difference in comparison of DR versus Control (SMD [95% CI] = -0.26 [-0.51, -0.00]). Subgroup analysis showed that significant result of PDW level appeared in China and Turkey in all comparisons, while similar results of PLT only in China. In addition, PDW level was different in various DR-subtypes, obvious high level in proliferation DR.

CONCLUSIONS

We concluded that the guiding significance of PDW and PLT in diagnosis and monitor of DR, and especially, application of PDW to PDR management may have potential sense.

Hypercholesterolemia impairs the Glucagon-like peptide 1 action on platelets: Effects of a lipid-lowering treatment with simvastatin

BACKGROUND

The incretin hormone Glucagon-like peptide 1(GLP-1) plays a pivotal role in maintaining glucose homeostasis with effects also on the cardiovascular system. GLP-1 influences platelet functions by increasing the inhibitory action of nitric oxide (NO) and reducing oxidative stress. To date, the role of hypercholesterolemia (HyC) on platelet GLP-1 effects needs to be elucidated.

METHODS

Forty-five subjects with primary HyC and twenty normocholesterolemic controls (NoC) were enrolled. In platelets from all subjects, the native GLP-1 (7-36), the truncated GLP-1 (9-36) and the GLP-1 analogue Liraglutide were evaluated in their ability to interfere with the activation of NO/PKG/VASP, PI-3K/Akt e MAPK/ERK-1/2 pathways and oxidative stress. Furthermore, in HyC subjects the role of a lipid-lowering therapy with statin on GLP-1 related peptide effects on platelet function was evaluated.

RESULTS

Unlike in NoC, in platelets from HyC subjects the GLP-1 related peptides GLP-1 (7-36), GLP-1 (9-36) and Liraglutide all failed to: i) increase the antiaggregating effects of NO and the NO-induced VASP-ser239 phosphorylation, ii) decrease phosphorylation levels of Akt and ERK-2 and iii) reduce reactive oxygen species (ROS) generation. The treatment with simvastatin (40 mg/die) in HyC (n = 18) significantly reduced total and LDL cholesterol levels, platelet aggregability/activation, ROS production and NO action but did not modify platelet sensitivity to the GLP-1 effects.

CONCLUSION

Collectively, these results indicate that hypercholesterolemia per se is characterized by a resistance to GLP-1 effects on platelets and this impairment is not corrected by treatment with simvastatin.

The effect of mild agonist stimulation on the platelet reactivity in patients with type 2 diabetes mellitus

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) have accelerated atherosclerosis as a pro thrombotic state that is associated with the platelet activation priming. Platelets, which undergo the continuous mild stimulation, may lose their sensitivity to react to a strong stimulation. The present study aimed to investigate activation responses of platelets to mild and subsequent strong stimulations in patients with T2DM and healthy individuals.

METHODS

Blood samples, which were taken from 40 patients with T2DM and 35 healthy individuals, were collected into the citrate containing tubes. The samples were subjected to the soft centrifugation to prepare the platelet rich plasma (PRP). Platelets in PRP samples were treated at a low (1 μM) concentration and then at a high (10 μM) concentration of ADP. Before and after stimulation with different doses of ADP, levels of CD62P expression and formation of platelet micro particles (PMPs) were measured using a flow cytometry method.

RESULTS

The platelets from patients with T2DM had higher levels of CD62P expression before any stimulation (P = 0.003) than control samples. Platelets, which underwent the mild stimulation, indicated lower responses to CD62P expression, but higher PMPs formation after stimulation with high dose of ADP. Patients with T2DM had higher platelet micro particles in all states with the ADP stimulation. (P = 0.004, SD: ±74.52).

CONCLUSIONS

The flow cytometry data indicated that platelets were pre-active and associated with metabolic conditions in patients with type 2 diabetes mellitus. The induction of desensitization state helped platelets to reduce the platelet activation and sensitivity to ADP in a diabetic environment. Furthermore, the production of platelets micro-particles was high in the patients; and desensitized platelets were more susceptible to shedding of micro-particles.

Residual cardiovascular risk among people with diabetes

Type 2 diabetes (T2D) is a growing health concern across both developed and developing countries. Cardiovascular disease (CVD) remains the major cause of increased mortality in this patient population. In recent years, effective low density lipoprotein lowering treatments and other risk reduction strategies have substantially reduced the risk of atherosclerotic CVD, yet patients with T2D continue to remain at increased risk for atherosclerotic CVD. Here, we will briefly review various proposed underlying mechanisms for this residual risk with a more in-depth focus on the potential role of triglyceride-rich lipoproteins in residual risk and potential avenues to target this pharmacologically.

Hydrogen sulfide: a gaseous signaling molecule modulates tissue homeostasis: implications in ophthalmic diseases

Hydrogen sulfide (H2S) serves as a gasotransmitter in the regulation of organ development and maintenance of homeostasis in tissues. Its abnormal levels are associated with multiple human diseases, such as neurodegenerative disease, myocardial injury, and ophthalmic diseases. Excessive exposure to H2S could lead to cellular toxicity, orchestrate pathological process, and increase the risk of various diseases. Interestingly, under physiological status, H2S plays a critical role in maintaining cellular physiology and limiting damages to tissues. In mammalian species, the generation of H2S is catalyzed by cystathionine beta-synthase (CBS), cystathionine gamma-lyase (CSE), 3-mercapto-methylthio pyruvate aminotransferase (3MST) and cysteine aminotransferase (CAT). These enzymes are found inside the mammalian eyeballs at different locations. Their aberrant expression and the accumulation of substrates and intermediates can change the level of H2S by orders of magnitude, causing abnormal structures or functions in the eyes. Detailed investigations have demonstrated that H2S donors' administration could regulate intraocular pressure, protect retinal cells, inhibit oxidative stress and alleviate inflammation by modulating the function of intra or extracellular proteins in ocular tissues. Thus, several slow-releasing H2S donors have been shown to be promising drugs for treating multiple diseases. In this review, we discuss the biological function of H2S metabolism and its application in ophthalmic diseases.

The relationship between mean platelet volume and diabetic retinopathy: a systematic review and meta-analysis

BACKGROUND

Diabetic retinopathy (DR) is one of the most common diseases causing blindness in the world, and most patients are already in advanced stage. Recent years, many studies reported mean platelet volume (MPV) may be associated with development of DR, but there was no consistent conclusion reached.

METHODS

Literature was retrieved by formally searching PubMed, Embase, Cochrane library and Scopus and by hand searching of reference lists of related articles. Finally, a total of 14 literatures included, and Review manager 5.3 and STATA 14.0 statistical software were utilized for processing.

RESULTS

Meta-analysis showed that MPV values in DR were significantly higher than health controls [SMD (95% CI) = 0.92 (0.60-1.24)] and type 2 diabetes mellitus without diabetic retinopathy (T2DM without DR) [SMD (95% CI) = 0.36 (0.19-0.53)]. Subgroup analysis indicated that MPV level in proliferative diabetic retinopathy (PDR) patients was higher than T2DM without DR patients [SMD (95% CI) = 0.48 (0.28, 0.68)], but this difference didn't appear in non-proliferative diabetic retinopathy (NPDR).

CONCLUSIONS

The study demonstrated that increased MPV level was significant associated with the development of DR, and it might reflect the severity of DR, which could be provided to monitor development and progression of DR clinically.

Ticagrelor Versus Prasugrel for the Treatment of Patients with Type 2 Diabetes Mellitus Following Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

INTRODUCTION

Antiplatelet therapy is very important following percutaneous coronary intervention (PCI). New generation P2Y₁₂ inhibitors (ticagrelor and prasugrel) might potentially replace clopidogrel for the treatment of post-interventional acute coronary syndrome (ACS). In this analysis, we aimed to systematically compare the post-interventional clinical outcomes and bleeding events observed with ticagrelor versus prasugrel in patients with type 2 diabetes mellitus (T2DM).

METHODS

EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, and www.ClinicalTrials.gov were carefully searched for publications comparing the post-coronary interventional outcomes following ticagrelor versus prasugrel use in patients with T2DM. Adverse clinical outcomes and bleeding events were considered as the endpoints. Statistical analysis was carried out by the Revman software (version 5.3). Odds ratios (OR) and 95% confidence intervals (CI) were used to represent the data during subgroup analysis.

RESULTS

A total of 2004 participants with T2DM were included in this analysis. Following PCI, mortality (OR 1.00, 95% CI 0.57-1.76; P = 0.99, I² = 19%), myocardial infarction (OR 0.86, 95% CI 0.42-1.75; P = 0.67, I² = 0%), major adverse cardiac events (OR 0.73, 95% CI 0.42-1.27; P = 0.27, I² = 0%), and stroke (OR 0.72, 95% CI 0.20-2.59; P = 0.61, I² = 0%) were not significantly different between ticagrelor and prasugrel. In addition, total bleeding events (OR 0.87, 95% CI 0.55-1.40; P = 0.58, I² = 6%), Thrombolysis in Myocardial Infarction (TIMI) defined minor bleeding (OR 2.39, 95% CI 0.58-9.91; P = 0.23, I² = 0%), TIMI defined major bleeding (OR 1.42, 95% CI 0.27-7.45; P = 0.68, I² = 0%), bleeding defined according to the Bleeding Academic Research Consortium (BARC) major bleeding (OR 0.55, 95% CI 0.22-1.36; P = 0.20, I² = 0%), BARC minor bleeding (OR 1.44, 95% CI 0.52-3.99; P = 0.48, I² = 0%), and total minimal bleeding (OR 3.12, 95% CI 0.55-17.59; P = 0.20, I² = 0%) were also not significantly different.

CONCLUSION

Ticagrelor and prasugrel were not associated with significantly different adverse clinical outcomes and bleeding events in these patients with T2DM. Therefore, both antiplatelet agents might safely be used in patients with T2DM following coronary intervention. However, this head-to-head comparison still remains a major challenge which should be resolved in larger clinical trials.

Update of inflammatory proliferative retinopathy: Ischemia, hypoxia and angiogenesis

Diabetic retinopathy (DR) and retinopathy of prematurity (ROP) present two examples of proliferative retinopathy, characterized by the same stages of progression; ischemia of the retinal vessels, leads to hypoxia and to correct the problem there is the setting up of uncontrolled angiogenesis, which subsequently causes blindness or even detachment of the retina. The difference is the following; that DR initiated by the metabolic complications that are due to hyperglycemia, and ROP is induced by overexposure of the neonatal retina to oxygen. In this review, we will demonstrate the physiopathological mechanism of the two forms of proliferative retinopathy DR and ROP, in particular the role of the CD40/CD40L axis and IL-1 on vascular complications and onset of inflammation of the retina, the implications of their effects on the onset of pathogenic angiogenesis, thus understanding the link between platelets and retinal ischemia. In addition, what are the therapeutic targets that could slow its progression?

Platelet-endothelial cell interactions modulate smooth muscle cell phenotype in an in vitro model of type 2 diabetes mellitus

Platelet (PLT)-endothelial cell (EC) interaction appears to contribute to phenotypic transition of vascular smooth muscle cells (VSMCs), which play an important role in the physiological and pathological process of vascular complications in type 2 diabetes mellitus (DM2). However, the precise mechanisms by which interactions between PLTs and ECs affect VSMC phenotype have largely remained unclear. We determined the effect of diabetic PLT-EC interaction to influence VSMC migration, proliferation, and phenotypic transformation in triple-cell coculture models using the quantitative real-time PCR, Western blot, fluorescence microscopy, wound scratch assays, CCK-8 assays, and gelatin zymography assays. Our results revealed DM2 PLT-EC interaction to be associated with a significant downregulation of VSMC-specific contractile phenotypic genes and proteins, including SM22α, smooth muscle actin, Smoothelin-B, and smooth muscle-myosin heavy chain. Inversely, VSMC-specific proliferative phenotype gene and protein levels, including cyclin D1 and 2, nonmuscle myosin heavy chain B, and PCNA were in upregulation. Furthermore, the DM2-originated PLT-EC interaction promoted the expression level of transforming growth factor-β1, and the PI3K/Akt and matrix metalloproteinase 9 signaling pathway was activated subsequently. Finally, these reactions contributed to a synthetic phenotype of VSMCs, including the proliferation, migration, and gelatinolytic activities. These findings suggest that PLT-EC interaction modulates the phenotypic transition of VSMCs between a contractile and proliferative/synthetic phenotype under diabetic conditions, conceivably providing important implications regarding the mechanisms controlling the VSMC phenotypic transition and the development of cardiovascular complications.

Diabetes and Platelet Response to Low-Dose Aspirin

CONTEXT

Previous studies have suggested less cardioprotective benefit of aspirin in adults with diabetes, raising concerns about "aspirin resistance" and potentially reduced effectiveness for prevention of cardiovascular disease (CVD).

OBJECTIVE

To examine differences in platelet response to aspirin by diabetes status.

DESIGN, SETTING, PARTICIPANTS

We examined platelet response before and after aspirin (81 mg/day for 14 days) in 2113 adults (175 with diabetes, 1,938 without diabetes), in the Genetic Study of Aspirin Responsiveness cohort, who had family history of early-onset CVD.

MAIN OUTCOME MEASURES

In vivo platelet activation (urinary thromboxane B2), in vitro platelet aggregation to agonists (arachidonic acid, adenosine diphosphate, collagen), and platelet function analyzer-100 closure time.

RESULTS

Although adults with diabetes had higher in vivo platelet activation before aspirin, the reduction in in vivo platelet activation after aspirin was similar in those with vs without diabetes. Likewise, the reduction in multiple in vitro platelet measures was similar after aspirin by diabetes status. In regression analyses adjusted for age, sex, race, BMI, smoking, platelet counts, and fibrinogen levels, in vivo platelet activation remained higher in adults with vs without diabetes after aspirin (P = 0.04), but this difference was attenuated after additional adjustment for preaspirin levels (P = 0.10). No differences by diabetes status were noted for any of the in vitro platelet measures after aspirin in fully adjusted models that also accounted for preaspirin levels.

CONCLUSIONS

In vitro platelet response to aspirin does not differ by diabetes status, suggesting no intrinsic differences in platelet response to aspirin. Instead, factors extrinsic to platelet function should be investigated to give further insights into aspirin use for primary prevention in diabetes.

Significance of urinary 11-dehydro-thromboxane B2 in age-related diseases: Focus on atherothrombosis

Platelet activation plays a key role in atherogenesis and atherothrombosis. Biochemical evidence of increased platelet activation in vivo can be reliably obtained through non-invasive measurement of thromboxane metabolite (TXM) excretion. Persistent biosynthesis of TXA₂ has been associated with several ageing-related diseases, including acute and chronic cardio-cerebrovascular diseases and cardiovascular risk factors, such as cigarette smoking, type 1 and type 2 diabetes mellitus, obesity, hypercholesterolemia, hyperhomocysteinemia, hypertension, chronic kidney disease, chronic inflammatory diseases. Given the systemic nature of TX excretion, involving predominantly platelet but also extraplatelet sources, urinary TXM may reflect either platelet cyclooxygenase-1 (COX-1)-dependent TX generation or COX-2-dependent biosynthesis by inflammatory cells and/or platelets, or a combination of the two, especially in clinical settings characterized by low-grade inflammation or enhanced platelet turnover. Although urinary 11-dehydro-TXB₂ levels are largely suppressed with low-dose aspirin, incomplete TXM suppression by aspirin predicts the future risk of vascular events and death in high-risk patients and may identify individuals who might benefit from treatments that more effectively block in vivo TX production or activity. Several disease-modifying agents, including lifestyle intervention, antidiabetic drugs and antiplatelet agents besides aspirin have been shown to reduce TX biosynthesis. Taken together, these aspects may contribute to the development of promising mechanism-based therapeutic strategies to reduce the progression of atherothrombosis. We intended to critically review current knowledge on both the pathophysiological significance of urinary TXM excretion in clinical settings related to ageing and atherothrombosis, as well as its prognostic value as a biomarker of vascular events.

Immune and vascular dysfunction in diabetic wound healing

The diminished capacity for wound healing in patients with diabetes contributes to morbidity through ulceration and recurrent infections, loss of function and decreased workplace productivity, increased hospitalisation rates, and rising health-care costs. These are due to diabetes' effects on signalling molecules, cellular cascades, different cell populations, and the vasculature. The function of multiple immune system components including cellular response, blood factors, and vascular tone are all negatively impacted by diabetes. The purpose of this paper is to review the current understanding of immune and vascular dysfunction contributing to impaired wound healing mechanisms in the diabetic population. Normal wound healing mechanisms are reviewed followed by diabetic aberrations to immune and inflammatory function and atherogenesis and angiopathy.

DECLARATION OF INTEREST

The authors have no financial or personal relationships to people or organisations that could potentially and inappropriately influence their work and conclusions.

The safety profile of new antidiabetic xanthine derivatives and their chitosan based formulations

The safety profile of new antidiabetic xanthine derivatives with thiazolidine‑4‑one scaffold (6, 7) and their new chitosan based formulations (CS-6, CS-7), administrated to diabetic rats, have been evaluated in terms of biochemical markers of liver and kidney function as well as of hematological markers. The effect on lipid profile and clinic parameters (body weight, food and water intake) has been also evaluated. The treatment of diabetic rats with xanthine derivatives (6, 7) and chitosan based formulations (CS-6, CS-7) was associated with lower liver enzymes (AST, ALT, LDH) and bilirubin (direct, total) values compared to the non-treated diabetic rats, that means the tested derivatives/formulations have improved the liver function injured in diabetes mellitus conditions. Also the kidney biochemical markers (creatinine, uric acid, urea) were significantly decreased in diabetic rats treated with 6, 7 and chitosan microparticles (CS-6, CS-7). The values of biochemical markers of liver and kidney functions were even better than the values recorded for pioglitazone, used as standard antidiabetic drug. The improving effect on kidney function was proved by the histopathological study. Moreover, the xanthine derivatives and their chitosan based formulation were associated with improved hematological markers compared to the non-treated diabetic rats which mean the improving of the hemorheological state. These results support the safety profile of new xanthine derivatives with thiazolidine‑4‑one scaffold (6, 7) and their new chitosan based formulations (CS-6, CS-7) and their potential applications for the treatment of diabetes mellitus syndrome.

Effects of α-Lipoic Acid, Carnosine, and Thiamine Supplementation in Obese Patients with Type 2 Diabetes Mellitus: A Randomized, Double-Blind Study

Type 2 diabetes mellitus (T2DM) is evolving to an epidemic of the modern world. T2DM is associated with a number of pathological complications, including cardiovascular disease that is mostly promoted by the increased oxidative stress in type 2 diabetic patients. We performed a randomized double-blind placebo-controlled trial to investigate the effectiveness of an individualized oral supplementation with α-lipoic acid (ALA), carnosine, and thiamine. For that purpose, 82 obese type 2 diabetic patients were randomly assigned to 2 groups, and were either supplemented daily with 7 mg ALA/kg body weight, 6 mg carnosine/kg body weight, and 1 mg thiamine/kg body weight or placebo for 8 weeks. An array of biochemical tests including the estimation of oxidative stress and platelet aggregation were performed at baseline and at follow-up. Moreover, the antiplatelet activity of each of the supplement's components was determined ex vivo at human and washed rabbit platelets. Glucose and HbA_1c levels were significantly reduced after supplementation (135.7 ± 19.5 mg/dL vs. 126.5 ± 16.8 mg/dL and 8.3% ± 0.3% vs. 6.03% ± 0.58%, respectively, P < .05); however, insulin was significantly increased (3.6 ± 0.7 μIU/mL vs. 6.8 ± 0.2 μIU/mL, P < .05). The patients treated with the supplement recorded higher follow-up values for HOMA-IR and HOMA-β, and a significant drop in serum hydroperoxide level. Only ALA inhibited platelets aggregation ex vivo through ADP, platelet activating factor, arachidonic acid, epinephrine, collagen, and thrombin pathways. Daily supplementation with an individualized ALA, carnosine, and thiamine supplement effectively reduced glucose concentration in type 2 diabetic patients, probably by increasing insulin production from the pancreas. In addition to that, the reduction of oxidative stress and inhibition of platelet aggregation could potentially provide greater cardiovascular protection. Further studies are needed to fine-tune the supplementation dose-response effects in T2DM patients.

Quantifying Platelet Margination in Diabetic Blood Flow

Patients with type 2 diabetes mellitus (T2DM) develop thrombotic abnormalities strongly associated with cardiovascular diseases. In addition to the changes of numerous coagulation factors such as elevated levels of thrombin and fibrinogen, the abnormal rheological effects of red blood cells (RBCs) and platelets flowing in blood are crucial in platelet adhesion and thrombus formation in T2DM. An important process contributing to the latter is the platelet margination. We employ the dissipative particle dynamics method to seamlessly model cells, plasma, and vessel walls. We perform a systematic study on RBC and platelet transport in cylindrical vessels by considering different cell shapes, sizes, and RBC deformabilities in healthy and T2DM blood, as well as variable flowrates and hematocrit. In particular, we use cellular-level RBC and platelet models with parameters derived from patient-specific data and present a sensitivity study. We find T2DM RBCs, which are less deformable compared to normal RBCs, lower the transport of platelets toward the vessel walls, whereas platelets with higher mean volume (often observed in T2DM) lead to enhanced margination. Furthermore, increasing the flowrate or hematocrit enhances platelet margination. We also investigated the effect of platelet shape and observed a nonmonotonic variation with the highest near-wall concentration corresponding to platelets with a moderate aspect ratio of 0.38. We examine the role of white blood cells (WBCs), whose count is increased notably in T2DM patients. We find that WBC rolling or WBC adhesion tends to decrease platelet margination due to hydrodynamic effects. To the best of our knowledge, such simulations of blood including all blood cells have not been performed before, and our quantitative findings can help separate the effects of hydrodynamic interactions from adhesive interactions and potentially shed light on the associated pathological processes in T2DM such as increased inflammatory response, platelet activation and adhesion, and ultimately thrombus formation.

The Main Determinants of Diabetes Mellitus Vascular Complications: Endothelial Dysfunction and Platelet Hyperaggregation

Diabetes mellitus is a common disease that affects 3–5% of the general population in Italy. In some countries of northern Europe or in North America, it can even affect 6–8% of the population. Of great concern is that the number of cases of diabetes is constantly increasing, probably due to the increase in obesity and the sedentary nature of the population. According to the World Health Organization, in the year 2030 there will be 360 million people with diabetes, compared to 170 million in 2000. This has important repercussions on the lives of patients and their families, and on health systems that offer assistance to patients. In this review, we try to describe in an organized way the pathophysiological continuity between diabetes mellitus, endothelial dysfunction, and platelet hyperaggregation, highlighting the main molecular mechanisms involved and the interconnections.

High risk of coagulopathy among Type-2 Diabetes Mellitus clients at a municipal hospital in Ghana

Background

Persistent hyperglycaemia in diabetes mellitus causes coagulopathies due to glycation of haemoglobin, prothrombin, fibrinogen and other proteins involved in the clotting mechanism. Shortened activated partial thromboplastin time (APTT) and prothrombin time (PT) reflect hypercoagulable state, which is associated with an increased thrombotic risk and adverse cardiovascular effects. This study assessed the coagulation profile of type 2 diabetes mellitus (T2DM) clients at a municipal hospital in Ghana.

Methods

A hospital-based case-control study was conducted from January to April 2015 at the Agona Swedru Municipal Hospital. Sixty (60) persons with T2DM and 40 without were recruited and screened using appropriate protocols. Blood samples were collected for coagulation and biochemical tests. Demographic and clinical information were collected using pre-tested questionnaire. Data was analyzed with GraphPad Prism version 5.

Results

APTT and PT were significantly shorter among patients with T2DM compared to those without (20.88 ± 5.19 v 31.23 ± 5.41, P=0.0001; and 11.03 ± 2.06sec v 14.46 ± 1.86, P=0.0001 respectively). INR was decreased among patients with T2DM compared to those without (0.83 ± 0.18 v 1.13 ± 0.17, P=0.0001). No significant difference was found in platelet count between T2DM and non-diabetics (179.85 ± 66.15×10³ /mm³ v 168.55 ± 35.77×10³ /mm³, P=0.326). Serum magnesium was lower among the T2DM patients compared to the non-diabetics, while serum ionized calcium was significantly higher among the T2DM patients (P<0.05).

Conclusion

Clients with T2DM may have a high coagulation risk evidenced by shortened APTT, PT and a high ionized calcium compared with controls.

Funding

Study was funded by Lord Ampomah and Solomon Panford.

Changes in platelet morphology indices in relation to duration of disease and glycemic control in children with type 1 diabetes mellitus

BACKGROUND

There is limited data on platelet alterations in children with type 1 diabetes mellitus (T1DM). We planned to study the effect of glycemic control and duration of T1DM on platelet morphology in children with T1DM.

METHODS

We conducted an observational study on 260 children; 130 with T1DM (cases) and 130 healthy controls, in a tertiary care pediatric hospital. Platelet indices including Platelet count (PLT), Mean Platelet Volume (MPV), Platelet Distribution Width (PDW), Platelet-Large cell ratio (P-LCR), Plateletcrit (PCT) were measured, and their means were compared between cases and controls and various subgroups among the cases.

RESULTS

The MPV, PDW and P-LCR were significantly higher (p < 0.05) in cases when compared to controls and in children with suboptimal glycemic control compared to optimal control. PLT was considerably lower in cases compared to controls. In children with new-onset T1DM, only PDW was significantly raised when compared to controls. MPV and P-LCR had a significant positive correlation with duration of T1DM.

CONCLUSIONS

Children with T1DM have altered morphological parameter(s) which progress over time. Poor glycemic control is a significant risk factor for abnormal platelet indices.

Endothelial dysfunction and platelet hyperactivity in type 2 diabetes mellitus: molecular insights and therapeutic strategies

The incidence and prevalence of diabetes mellitus is rapidly increasing worldwide at an alarming rate. Type 2 diabetes mellitus (T2DM) is the most prevalent form of diabetes, accounting for approximately 90-95% of the total diabetes cases worldwide. Besides affecting the ability of body to use glucose, it is associated with micro-vascular and macro-vascular complications. Augmented atherosclerosis is documented to be the key factor leading to vascular complications in T2DM patients. The metabolic milieu of T2DM, including insulin resistance, hyperglycemia and release of excess free fatty acids, along with other metabolic abnormalities affects vascular wall by a series of events including endothelial dysfunction, platelet hyperactivity, oxidative stress and low-grade inflammation. Activation of these events further enhances vasoconstriction and promotes thrombus formation, ultimately resulting in the development of atherosclerosis. All these evidences are supported by the clinical trials reporting the importance of endothelial dysfunction and platelet hyperactivity in the pathogenesis of atherosclerotic vascular complications. In this review, an attempt has been made to comprehensively compile updated information available in context of endothelial and platelet dysfunction in T2DM.

High On-Treatment Platelet Reactivity in Danish Hyper-Acute Ischaemic Stroke Patients

Objective: Early anti-platelet therapy is a cornerstone in the prevention of recurrent ischaemic stroke (IS) and transient ischaemic attacks (TIAs), although the responsiveness to anti-platelet medications varies among patients. Several studies have reported that patients with ischaemic stroke who exhibit high on-treatment platelet reactivity (HTPR) 5-10 days after antiplatelet medication onset, have an increased risk of vascular events. In this study we aim to determine the prevalence of HTPR in the hyper-acute stroke phase less than 48 h from symptom onset, after the administration of a 300 mg bolus of oral clopidogrel in a real-world setting in Danish IS and TIA patients. Material and Methods: In total, 219 Danish patients with acute IS or TIA received 300 mg of oral clopidogrel on admission. Blood samples from all patients were analyzed using the VerifyNow P2Y12 system at 8-24 h after clopidogrel intake. Concomitant therapy and the intervals between ictus and blood collection, clopidogrel intake and blood collection, and blood sampling and analysis were recorded for all patients. Results: HTPR in the hyper-acute stroke phase was observed in 28.8% (63/219) samples. After adjustment for age, sex, co-morbidities, and co-medications, none of the tested variables exhibited an association with HTPR or the platelet reaction unit value measured using the VerifyNow P2Y12 system. Conclusions: The recognition of HTPR to specific anti-platelet agents in the hyper-acute phase after stroke may be the first step toward interventions that may further minimize the early recurrent stroke risk. Further large randomized trials including clinical outcome assessments are necessary.

The risk factors for oxaliplatin-induced peripheral sensory neuropathy and thrombocytopenia in advanced gastric cancer

PURPOSE

Peripheral sensory neuropathy (PSN) and thrombocytopenia are the main dose-limiting toxicities of oxaliplatin for the treatment of advanced gastric cancer (AGC). Because the risk factors for those toxicities in practice have not been clarified, we conducted this prospective study.

METHODS

AGC patients who received oxaliplatin-based therapy at any of seven institutions participating in the Kyushu Medical Oncology Group were assessed after we obtained written informed consent.

RESULTS

A total of 60 patients including 39 males and 21 females were examined. The median age was 66 years. The numbers of patients receiving oxaliplatin as the first, second, or third and later lines of therapy were 39, 16, and 5, respectively. An initial dose of 130, 100, or < 100 mg/m² oxaliplatin was administered to 12, 39, and 9 patients, respectively. S-1 or capecitabine as a concomitant drug was administered in 54 and 6 patients, respectively. In multivariate analysis, the comorbidity of diabetes mellitus was associated with ≥ grade 2 thrombocytopenia (p = 0.035). No significant risk factor was associated with ≥ grade 2 PSN. However, the accumulated dose of oxaliplatin exhibited a strong correlation with ≥ grade 2 PSN (p = 0.0043), and the predicted accumulated dose of oxaliplatin in which 10% of patients developed ≥ grade 2 PSN was 800 mg/m². The frequency of PSN in subsequent paclitaxel therapy in patients with ≥ grade 2 or worse PSN in oxaliplatin-based chemotherapy did not increase compared to those with none or grade 1 PSN in oxaliplatin.

CONCLUSION

Thrombocytopenia in AGC patients with diabetes mellitus should be carefully monitored during oxaliplatin-based therapy.

Two-year prognostic value of mean platelet volume in patients with diabetes and stable coronary artery disease undergoing elective percutaneous coronary intervention

BACKGROUND

Mean platelet volume (MPV) is a marker of platelet size and activity, and is associated with a poor prognosis of cardiovascular disease. Studies have shown a relationship between diabetes mellitus (DM) and MPV. This study examined the relationship between admission MPV and 2-year cardiac mortality in patients with DM and stable coronary artery disease (SCAD) undergoing elective percutaneous coronary intervention (PCI).

METHODS

A total of 1389 patients were enrolled and divided into two groups according to MPV as fol- lows: lower MPV (n = 908, MPV ≤ 10.9 fL) and higher MPV (n = 481, MPV > 10.9 fL).

RESULTS

Body mass index, platelet distribution width, MPV/platelet and glycated hemoglobin (HbA1c) levels were significantly higher in the higher MPV group compared with the lower MPV group (all p < 0.05). The platelet count was significantly lower in the higher MPV group compared with the lower MPV group (p < 0.05). MPV was positively associated with HbA1c and fasting plasma glucose levels (r = 0.073 and 0.061, p = 0.007 and 0.023, respectively) in bivariate correlation analysis. The 2-year cardiac mortality rate was 0.7%, and was significantly lower in the lower MPV group than in the higher MPV group in Kaplan-Meier analysis (p = 0.019). Receiver operating characteristic analysis showed a good diagnostic value for MPV at predicting long-term cardiac mortality (area under the curve: 0.735, 95% confidence interval [CI]: 0.590-0.880, p = 0.01). Elevated MPV was a significant risk factor for 2-year cardiac mortality (hazard ratio: 2.091, 95% CI: 1.075-4.070, p = 0.030) in multivariable Cox regression analysis.

CONCLUSIONS

Mean platelet volume is a strong, independent prognostic factor in PCI-treated patients with DM and SCAD.

Secondary Stroke Prophylaxis with Clopidogrel Produces Sufficient Antiplatelet Response

BACKGROUND

Antiplatelet therapy is a cornerstone prevention strategy for secondary ischemic stroke (IS) and transient ischemic attack (TIA). Yet, a proportion of patients who receive antiplatelet therapy experience recurrent ischemic cerebrovascular events. A recent meta-analysis found an increased risk of recurrent stroke in clopidogrel- or aspirin-treated patients with ischemic stroke who had high on-treatment platelet reactivity (HTPR). Few studies have focused specifically on clopidogrel HTPR. Therefore, the aim of this study was to examine the relationship between clopidogrel HTPR and recurrent ischemic events in a population of Danish patients with IS.

METHODS

We performed a prospective observational study to evaluate the relationship between HTPR defined as platelet reaction units >208 and a composite primary endpoint of recurrent stroke, TIA, acute myocardial infarction (AMI), or vascular death over a 2-year follow-up period.

RESULTS

A total of 142 patients were included in the final statistical analysis, but only 3 patients (2.1%) demonstrated clopidogrel HTPR. The median time of on-treatment platelet testing was 75 days. Recurrent IS, TIA, AMI, or vascular death occurred in 14 patients (10%). Of these, 1 new ischemic event (AMI) occurred in a HTPR patient. There was no difference in the frequency of new ischemic events between the HTPR and non-HTPR groups (P = .27); moreover, the number of patients with HTPR was too small for statistical analysis.

CONCLUSIONS

Clopidogrel HTPR does not seem to be a major contributor to recurrent ischemic events in Danish ischemic stroke patients.

Diabetes mellitus: A review of some of the prognostic markers of response to treatment and management

Background: The WHO defined ‘diabetes mellitus’ (DM) as a metabolic disorder characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from the defect in insulin secretion, or inaction, or both. When not identified early and controlled, acute and chronic life-threatening consequences may result. Identifying DM early for treatment and management, as well as clinically monitoring recovery and improvement during treatment, involves the assessments of biomarkers. The types, choice, sensitivity and descriptive information trends of these biomarkers are very important. Aim: Some prognostic biomarkers and parameters that this review identified include glycated haemoglobin, white blood cells, mean neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, total leukocytes and neutrophils, plasma low-density lipoprotein, high-density lipoprotein and very low-density lipoprotein, platelet, fibrinogen, D-dimer and C-reactive proteins. Results: These parameters display increases in DM, while red blood cell, haemoglobin concentration, activated partial thromboplastin time, prothrombin time and partial thromboplastin time are decreased. Conclusion: With sound knowledge of the variations of these markers and parameters, observed reversal during treatment and management of DM and its complications can be better monitored, and guided decisions can be made.

The Relationship Between Mean Platelet Volume and Fasting Plasma Glucose and HbA1c Levels in a Large Cohort of Unselected Health Check-Up Participants

Background

Larger platelets are more active and mean platelet volume (MPV) is an indicator of platelet activation and an independent risk factor of cardiovascular diseases. While MPV is reported to be higher in diabetic patients, the relationship between MPV and glycemic parameters in general population remains inconclusive.

Methods

In this cross-sectional study, we studied relationship between MPV and fasting plasma glucose (FPG) and HbA1c levels in 38,204 unselected participants of general health check-up aged 20 years or older in the year of 2014 who were considered to be representative of the general population. Individuals with known diabetes, coronary artery disease and/or cerebrovascular disease who were on drug therapy and those with platelet counts below 100 × 10⁹/L or above 400 × 10⁹/L were excluded.

Results

The mean age of the individuals was 52.3 ± 12.1 years and 46.1% were male. There were positive associations between MPV and both FPG (r = 0.066; P < 0.001) and HbA1c (r = 0.025; P < 0.001) levels when all individuals were analyzed as a whole. While the association was only marginal in individuals with HbA1c levels below 6.5% (r = 0.009; P = 0.068), it was significant in those with HbA1c ≥ 6.5% (r = 0.138; P < 0.001). When the individuals were categorized into four groups according to the HbA1c values: HbA1c < 5.5%, 5.5% ≤ HbA1c < 6.0%, 6.0% ≤ HbA1c < 6.5%, and HbA1c ≥ 6.5%, the mean MPV was virtually same among groups with HbA1c level < 6.5% and that of the individuals with HbA1c ≥ 6.5 was significantly higher than groups with lower HbA1c levels. Multivariate analyses adjusted with age and sex showed the same results.

Conclusion

FPG and HbA1c appeared to be associated with MPV in unselected health check-up participants; however, the association between glycemic state and MPV was apparent only in individuals with impaired glycemic control and only marginal in those with normal glycemic control. The clinical significance of the associations warrants further study.

Data mining of routine laboratory tests can predict liver disease progression in Egyptian diabetic patients with hepatitis C virus (G4) infection: a cohort study of 71 806 patients

OBJECTIVES

Hepatitis C virus (HCV) and diabetes mellitus (DM) are prevalent diseases worldwide, associated with significant morbidity, mortality, and mutual association. The aims of this study were as follows: (i) find the prevalence of DM among 71 806 Egyptian patients with chronic HCV infection and its effect on liver disease progression and (ii) using data mining of routine tests to predict hepatic fibrosis in diabetic patients with HCV infection.

PATIENTS AND METHODS

A retrospective multicentered study included laboratory and histopathological data of 71 806 patients with HCV infection collected by Egyptian National Committee for control of viral hepatitis. Using data mining analysis, we constructed decision tree algorithm to assess predictors of fibrosis progression in diabetic patients with HCV.

RESULTS

Overall, 12 018 (16.8%) patients were diagnosed as having diabetes [6428: fasting blood glucose ≥126 mg/dl (9%) and 5590: fasting blood glucose ≥110-126 mg/dl (7.8%)]. DM was significantly associated with advanced age, high BMI and α-fetoprotein (AFP), and low platelets and serum albumin (P≤0.001). Advanced liver fibrosis (F3-F4) was significantly correlated with DM (P≤0.001) irrespective of age. Of 16 attributes, decision tree model for fibrosis showed AFP was most decisive with cutoff of 5.25 ng/ml as starting point of fibrosis. AFP level greater than cutoff in patients was the first important splitting attribute; age and platelet count were second important splitting attributes.

CONCLUSION

(i) Chronic HCV is significantly associated with DM (16.8%). (ii) Advanced age, high BMI and AFP, low platelets count and albumin show significant association with DM in HCV. (iii) AFP cutoff of 5.25 is a starting point of fibrosis development and integrated into mathematical model to predict development of liver fibrosis in diabetics with HCV (G4) infection.

Vitamin D diminishes the high platelet aggregation of type 2 diabetes mellitus patients

Platelet activation is found in inflammatory conditions and implicated in the pathogenesis of chronic medical conditions, such as atherosclerosis, coronary vascular disease, cerebrovascular disease, and diabetes mellitus (DM). HbA1c is inversely related to vitamin D25 levels in individuals with and without DM. This study aimed to determine the relation between platelet aggregation, vitamin D and HbA1c among healthy individuals and those with Type 2 DM (T2DM). The direct effect of vitamin D1, 25 (calcitriol) on platelet aggregation was also investigated. The study included four groups: A. normoglycemic Control group: HbA1c<5.7%; B. Pre-diabetes (DM): 5.7% ≥ HbA1c ≤ 6.4%; C. DM on aspirin therapy: HbA1c>6.4%(+)Asp.; and D. DM not on aspirin therapy: HbA1c > 6.4%(-)Asp. Platelet aggregation was tested with and without calcitriol or saline pre-treatment, using collagen or adenosine diphosphate (ADP) as agonists. Platelet aggregation was higher in DM(-)Asp group compared to normoglycemic and DM(+)Asp, and higher, but not significant compared to pre-DM. The entire study population exhibited negative correlation between HbA1c and serum concentration of vitamin D25. Excluding DM(+)Asp, aggregation induced by collagen was significantly higher in patients with insufficient (<76 nmol/L) vitamin D25 compared to sufficient (≥76 nmol/L) vitamin D25. In this cohort, a negative correlation was found between serum concentrations of vitamin D25 and collagen-induced percent maximum (%max) aggregation and area under curve (AUC) aggregation. In the DM(-)Asp group, collagen-induced aggregation was reduced by approximately 25% after calcitriol treatment. Calcitriol decreased ADP-induced aggregation of control and DM(+)Asp groups to approximately 85% of saline treatment. We conclude that glycemic control is inversely associated with high platelet aggregation and low vitamin D25 levels. This elevated aggregation could be regulated by a novel, direct effect of calcitriol, indicating a beneficial effect of vitamin D on vascular complications related to diabetes. We offer a possible non-genomic mechanism for the vitamin D/Vitamin D receptor (VDR) pathway.

The Effect of a Simulated Commercial Flight Environment with Hypoxia and Low Humidity on Clotting, Platelet, and Endothelial Function in Participants with Type 2 Diabetes - A Cross-over Study

AIMS

To determine if clotting, platelet, and endothelial function were affected by simulated short-haul commercial air flight conditions (SF) in participants with type 2 diabetes (T2DM) compared to controls.

METHODS

10 participants with T2DM (7 females, 3 males) and 10 controls (3 females, 7 males) completed the study. Participants were randomized to either spend 2 h in an environmental chamber at sea level conditions (temperature: 23°C, oxygen concentration 21%, humidity 45%), or subject to a simulated 2-h simulated flight (SF: temperature: 23°C, oxygen concentration 15%, humidity 15%), and crossed over 7 days later. Main outcome measures: clot formation and clot lysis parameters, functional platelet activation markers, and endothelial function measured by reactive hyperemia index (RHI) by EndoPAT and serum microparticles.

RESULTS

Comparing baseline with SF conditions, clot maximal absorption was increased in controls (0.375 ± 0.05 vs. 0.39 ± 0.05, p < 0.05) and participants with T2DM (0.378 ± 0.089 vs. 0.397 ± 0.089, p < 0.01), while increased basal platelet activation for both fibrinogen binding and P-selectin expression (p < 0.05) was seen in participants with T2DM. Parameters of clot formation and clot lysis, stimulated platelet function (stimulated platelet response to ADP and sensitivity to prostacyclin), and endothelial function were unchanged.

CONCLUSION

While SF resulted in the potential of denser clot formation with enhanced basal platelet activation in T2DM, the dynamic clotting, platelet, and endothelial markers were not affected, suggesting that short-haul commercial flying adds no additional hazard for venous thromboembolism for participants with T2DM compared to controls.

Involvement of microparticles in diabetic vascular complications

Type 2 diabetes mellitus (T2DM) is associated with increased coagulability and vascular complications. Circulating microparticles (MPs) are involved in thrombosis, inflammation, and angiogenesis. However, the role of MPs in T2DM vascular complications is unclear. We characterised the cell origin and pro-coagulant profiles of MPs obtained from 41 healthy controls and 123 T2DM patients with coronary artery disease, retinopathy and foot ulcers. The effects of MPs on endothelial cell coagulability and tube formation were evaluated. Patients with severe diabetic foot ulcers expressed the highest levels of MPs originated from platelet and endothelial cells and negatively-charged phospholipidbearing MPs. MP coagulability, calculated from MP tissue factor (TF) and TF pathway inhibitor (TFPI) ratio, was low in healthy controls and in diabetic retinopathy patients (<0.7) but high in patients with coronary artery disease and foot ulcers (>1.8, p≥0.002). MPs of all T2DM patients induced a more than two-fold increase in endothelial cell TF (antigen and gene expression) but did not affect TFPI levels. Tube networks were longest and most stable in endothelial cells that were incubated with MPs of healthy controls, whereas no tube formation occurred in MPs of diabetic patients with coronary artery disease. MPs of diabetic retinopathy and diabetic foot ulcer patients induced branched tube networks that were unstable and collapsed over time. This study demonstrates that MP characteristics are related to the specific type of vascular complications and may serve as a bio-marker for the procoagulant state and vascular pathology in patients with T2DM.