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Abstract
Current findings from the literature on the multifactorial genesis of macroangiopathy of diabetes mellitus (DM) were compiled using the PubMed database. The primary aim was to find an explanation for the morphological, immunohistochemical and molecular characteristics of this form of atherosclerosis. The roles of advanced glycation end products (AGE), defective signal transduction and imbalance of matrix metalloproteinases in the increased progression of atherosclerosis in coronary and cerebral arteries as well as peripheral vascular disease are discussed. The restricted formation of collateral arteries (arteriogenesis) in diabetic patients with postischemic lesions is also a focus of attention. The increased level of prothrombotic factors and the role of diabetic neuropathy in DM are also taken into account. Therapeutic influences of AGE-RAGE (receptor of AGE) interactions on the vascular wall and the effects of endothelial progenitor cells in the repair of diabetic vascular lesions are additionally highlighted.
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Affiliation(s)
- J Kunz
- Lilienthalstr. 19, 14612, Falkensee, Deutschland.
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202
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The effects of initial and subsequent adiposity status on diabetes mellitus. Int J Cardiol 2012; 168:511-4. [PMID: 23063478 DOI: 10.1016/j.ijcard.2012.09.196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 09/26/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Obesity in adulthood is associated with increased risk for diabetes mellitus (DM). It is uncertain whether this risk is attenuated in adulthood who are overweight or obese initially but not obese subsequently. METHODS AND RESULTS The data were collected in 1992 and then again in 2007 from the same group of 687 participants (male: 58.1%, age: 48.1 ± 6.2 years).The participants were categorized into four groups on the basis of adiposity status in 1992 and 2007: group I included subjects with a normal BMI in 1992 and 2007; group II, those with a normal BMI in 1992 who were overweight or obese in 2007; group III, those who were overweight or obese in 1992 but normal BMI in 2007; and group IV, those who were overweight or obese in 1992 and 2007. With group I as reference, the HR is 0.818 for group II (95% CI: 0.341-1.962, p=0.653), 2.231 for group III (95% CI: 1.087-4.579, p=0.029) and 1.855 for group IV (95% CI: 1.049-3.279, p=0.034) after adjustment for confounders. It was not significantly different between groups I and II, as well as between groups III and IV. CONCLUSION In adulthood, becoming nonobese could not reverse the adverse effects of obesity on DM, as compared with the subjects who persist being overweight or obese. Keeping weight in the normal BMI range should be emphasized in the public for preventing DM.
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203
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Nemerovski CW, Salinitri FD, Morbitzer KA, Moser LR. Aspirin for primary prevention of cardiovascular disease events. Pharmacotherapy 2012; 32:1020-35. [PMID: 23019080 DOI: 10.1002/phar.1127] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aspirin has been used for the prevention and treatment of cardiovascular disease (CVD) for several decades. The efficacy of aspirin for secondary prevention of cardiovascular disease is well established, but the clinical benefit of aspirin for primary prevention of CVD is less clear. The primary literature suggests that aspirin may provide a reduction in CVD events, but the absolute benefit is small and accompanied by an increase in bleeding. For aspirin to be beneficial for an individual patient, the risk of a future CVD event must be large enough to outweigh the risk of bleeding. The estimation of CVD risk is multifaceted and can involve numerous risk scores and assessments of concomitant comorbidities that confer additional CVD risk. Numerous guidelines provide recommendations for the use of aspirin for primary prevention, but they often contradict one another despite being based on the same clinical trials. Additional literature suggests that the presence of comorbidities that increase CVD risk, such as diabetes mellitus, asymptomatic peripheral arterial disease, or chronic kidney disease, does not ensure that aspirin therapy will be beneficial. Ongoing clinical trials may provide additional insight, but until more data are available, an individualized assessment of CVD risk with careful evaluation of risk and benefit should be performed before recommending aspirin therapy for primary prevention of CVD.
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Affiliation(s)
- Carrie W Nemerovski
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, Michigan 48202, USA.
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204
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Kadoglou NPE, Vrabas IS, Kapelouzou A, Lampropoulos S, Sailer N, Kostakis A, Liapis CD, Angelopoulou N. The impact of aerobic exercise training on novel adipokines, apelin and ghrelin, in patients with type 2 diabetes. Med Sci Monit 2012; 18:CR290-5. [PMID: 22534708 PMCID: PMC3560628 DOI: 10.12659/msm.882734] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accumulating data support the atheroprotective role of the novel adipokines, apelin and ghrelin. The aim of the present randomized study was to investigate the effects of aerobic exercise training on these adipokines in patients with type 2 diabetes mellitus (T2DM). MATERIAL/METHODS Fifty-four overweight (BMI >25 kg/m²) patients with T2DM, but without vascular complications, were randomized to either the aerobic exercise training group (EG, N=27), 4 times/week, 45-60 min/session; or to the control group (CG, N=27), orally instructed to increase physical activity. Clinical glycemic and lipid parameters, exercise capacity (VO₂peak), insulin, HOMA-IR, and serum levels of apelin and ghrelin were assessed at baseline and after 12 weeks. RESULTS Aerobic exercise significantly improved lipid and glycemic profile and insulin sensitivity compared to CG (p<0.05). Furthermore, between-groups comparison showed a considerable exercise-induced upregulation in apelin (p=0.007) and VO₂peak (p<0.001) levels. Negligible changes in body-weight, waist-hip ratio and ghrelin concentrations were detected within and between groups after the completion of the study (p>0.05). However, subgroup analysis revealed a considerable increment in ghrelin levels only in the exercise-treated women compared to their control counterparts (p=0.038). LDL and HOMA-IR reduction were found to be independent predictors of apelin increment in multiple regression analysis (R²=0.391, p=0.011). CONCLUSIONS In patients with T2DM, systemic, long-term, aerobic exercise exerts positive effects on apelin and ghrelin (only in women), even in the absence of significant weight loss, suggesting its pleiotropic effects.
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Affiliation(s)
- Nikolaos P E Kadoglou
- Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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205
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Tricco AC, Alateeq A, Tashkandi M, Mamdani M, Al-Omran M, Straus SE. Histamine H2 receptor antagonists for decreasing gastrointestinal harms in adults using acetylsalicylic acid: systematic review and meta-analysis. OPEN MEDICINE : A PEER-REVIEWED, INDEPENDENT, OPEN-ACCESS JOURNAL 2012; 6:e109-17. [PMID: 23687524 PMCID: PMC3654505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND It is unclear if histamine H2 receptor antagonists (H2 blockers) prevent a variety of gastrointestinal harms among patients taking acetylsalicylic acid (ASA) over long periods. METHODS Electronic databases (e.g., MEDLINE, Embase and Cochrane Central Register of Controlled Trials; from inception to November 2010) and reference lists of retrieved articles were searched. Randomized placebo-controlled trials (RCTs) assessing the efficacy of H2 blockers in reducing gastrointestinal harms (bleeding, ulcers) among adults taking ASA for 2 weeks or longer were included. Two reviewers independently abstracted study and patient characteristics and appraised study quality using the Cochrane risk-of-bias tool. Peto odds ratio (OR) meta-analysis was performed, 95% confidence intervals (CIs) were calculated, and statistical heterogeneity was assessed using the I (2) and χ(2) statistics. RESULTS Six RCTs (4 major publications and 2 companion reports) with a total of 498 participants (healthy volunteers or patients with arthritis, cardiovascular or cerebrovascular disease, or diabetes mellitus) were included. One trial adequately reported allocation concealment and sequence generation, with the other 3 trials being judged as unclear for both aspects. In one RCT, no statistically significant differences for gastrointestinal hemorrhage requiring admission to hospital (p = 0.14) or blood transfusion (p = 0.29) were observed between the group receiving concomitant famotidine and ASA and the group receiving concomitant placebo and ASA. After a median of 8 weeks' follow-up, H2 blockers were more effective than placebo in reducing gastrointestinal hemorrhage (2 RCTs, total of 447 patients, OR 0.07, 95% CI 0.02-0.23) and peptic ulcers (3 RCTs, total of 465 patients, OR 0.21, 95% CI 0.12-0.36) among patients taking ASA for 2 weeks or longer. Despite substantial clinical heterogeneity across the studies, including types of H2 blockers, dosing of ASA and underlying conditions, no statistical heterogeneity was observed. INTERPRETATION H2 blockers reduced gastrointestinal harm among patients taking ASA for 2 weeks or longer. These results should be interpreted with caution, because of the small number of studies identified for inclusion.
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Affiliation(s)
- Andrea C Tricco
- St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
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206
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Rana JS, Dunning A, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Cheng VY, Chinnaiyan K, Chow BJW, Cury R, Delago A, Feuchtner G, Hadamitzky M, Hausleiter J, Kaufmann P, Karlsberg RP, Kim YJ, Leipsic J, Labounty TM, Lin FY, Maffei E, Raff G, Villines TC, Shaw LJ, Berman DS, Min JK. Differences in prevalence, extent, severity, and prognosis of coronary artery disease among patients with and without diabetes undergoing coronary computed tomography angiography: results from 10,110 individuals from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes): an InteRnational Multicenter Registry. Diabetes Care 2012; 35:1787-94. [PMID: 22699296 PMCID: PMC3402246 DOI: 10.2337/dc11-2403] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We examined the prevalence, extent, severity, and prognosis of coronary artery disease (CAD) in individuals with and without diabetes (DM) who are similar in CAD risk factors. RESEARCH DESIGN AND METHODS We identified 23,643 consecutive individuals without known CAD undergoing coronary computed tomography angiography. A total of 3,370 DM individuals were propensity matched in a 1-to-2 fashion to 6,740 unique non-DM individuals. CAD was defined as none, nonobstructive (1-49% stenosis), or obstructive (≥ 50% stenosis). All-cause mortality was assessed by risk-adjusted Cox proportional hazards models. RESULTS At a 2.2-year follow-up, 108 (3.2%) and 115 (1.7%) deaths occurred among DM and non-DM individuals, respectively. Compared with non-DM individuals, DM individuals possessed higher rates of obstructive CAD (37 vs. 27%) and lower rates of having normal arteries (28 vs. 36%) (P < 0.0001). CAD extent was higher for DM versus non-DM individuals for obstructive one-vessel disease (19 vs. 14%), two-vessel disease (9 vs. 7%), and three-vessel disease (9 vs. 5%) (P < 0.0001 for comparison), with higher per-segment stenosis in the proximal and mid-segments of every coronary artery (P < 0.001 for all). Compared with non-DM individuals with no CAD, risk of mortality for DM individuals was higher for those with no CAD (hazard ratio 3.63 [95% CI 1.67-7.91]; P = 0.001), nonobstructive CAD (5.25 [2.56-10.8]; P < 0.001), one-vessel disease (6.39 [2.98-13.7]; P < 0.0001), two-vessel disease (12.33 [5.622-27.1]; P < 0.0001), and three-vessel disease (13.25 [6.15-28.6]; P < 0.0001). CONCLUSIONS Compared with matched non-DM individuals, DM individuals possess higher prevalence, extent, and severity of CAD. At comparable levels of CAD, DM individuals experience higher risk of mortality compared with non-DM individuals.
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Affiliation(s)
- Jamal S Rana
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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207
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Otaki Y, Arsanjani R, Gransar H, Cheng VY, Dey D, Labounty T, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan K, Chow BJW, Delago A, Hadamitzky M, Hausleiter J, Kaufmann P, Maffei E, Raff G, Shaw LJ, Villines TC, Dunning A, Cury RC, Feuchtner G, Kim YJ, Leipsic J, Berman DS, Min JK. What have we learned from CONFIRM? Prognostic implications from a prospective multicenter international observational cohort study of consecutive patients undergoing coronary computed tomographic angiography. J Nucl Cardiol 2012; 19:787-95. [PMID: 22689072 PMCID: PMC4284147 DOI: 10.1007/s12350-012-9582-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Coronary computed tomographic angiography (CCTA) employing CT scanners of 64-detector rows or greater represents a novel non-invasive method for detection of coronary artery disease (CAD), providing excellent diagnostic information when compared to invasive angiography. In addition to its high diagnostic performance, prior studies have shown that CCTA can provide important prognostic information, although these prior studies have been generally limited to small cohorts at single centers. The Coronary CT Angiography EVALUATION FOR CLINICAL OUTCOMES: An International Multicenter registry, or CONFIRM, is a large, prospective, multinational, dynamic observational cohort study of patients undergoing CCTA. This registry currently represents more than 32,000 consecutive adults suspected of having CAD who underwent ≥ 64-detector row CCTA at 12 centers in 6 countries between 2005 and 2009. Based on its large sample size and adequate statistical power, the data derived from CONFIRM registry have and will continue to provide key answers to many important topics regarding CCTA. Based on its multisite international national design, the results derived from CONFIRM should be considered as more generalizable than prior smaller single-center studies. This article summarizes the current status of several studies from CONFIRM registry.
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Affiliation(s)
- Yuka Otaki
- Department of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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208
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Zambrowicz B, Freiman J, Brown PM, Frazier KS, Turnage A, Bronner J, Ruff D, Shadoan M, Banks P, Mseeh F, Rawlins DB, Goodwin NC, Mabon R, Harrison BA, Wilson A, Sands A, Powell DR. LX4211, a dual SGLT1/SGLT2 inhibitor, improved glycemic control in patients with type 2 diabetes in a randomized, placebo-controlled trial. Clin Pharmacol Ther 2012; 92:158-69. [PMID: 22739142 PMCID: PMC3400893 DOI: 10.1038/clpt.2012.58] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Thirty-six patients with type 2 diabetes mellitus (T2DM) were randomized 1:1:1 to receive a once-daily oral dose of placebo or 150 or 300 mg of the dual SGLT1/SGLT2 inhibitor LX4211 for 28 days. Relative to placebo, LX4211 enhanced urinary glucose excretion by inhibiting SGLT2-mediated renal glucose reabsorption; markedly and significantly improved multiple measures of glycemic control, including fasting plasma glucose, oral glucose tolerance, and HbA(1c); and significantly lowered serum triglycerides. LX4211 also mediated trends for lower weight, lower blood pressure, and higher glucagon-like peptide-1 levels. In a follow-up single-dose study in 12 patients with T2DM, LX4211 (300 mg) significantly increased glucagon-like peptide-1 and peptide YY levels relative to pretreatment values, probably by delaying SGLT1-mediated intestinal glucose absorption. In both studies, LX4211 was well tolerated without evidence of increased gastrointestinal side effects. These data support further study of LX4211-mediated dual SGLT1/SGLT2 inhibition as a novel mechanism of action in the treatment of T2DM.
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Affiliation(s)
- B Zambrowicz
- Lexicon Pharmaceuticals, Inc., The Woodlands, Texas, USA
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209
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Farvid MS, Homayouni F, Kashkalani F, Shirzadeh L, Valipour G, Farahnak Z. The associations between oxygen radical absorbance capacity of dietary intake and hypertension in type 2 diabetic patients. J Hum Hypertens 2012; 27:164-8. [PMID: 22695939 DOI: 10.1038/jhh.2012.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The objective of this study was to investigate the potential associations between oxygen radical absorbance capacity (ORAC) of fruits, vegetables, legumes and nuts, and blood pressure in type 2 diabetic patients in Tehran. In a cross-sectional study of 506 type 2 diabetic patients, aged 28-75 years, usual dietary intakes were assessed by means of a 168-item food-frequency questionnaire. To calculate the estimated hydrophilic-ORAC, total ORAC, and total phenolics (TP) of fruits, vegetables, legumes and nuts for each participant, we used the United States Department of Agriculture Database for ORAC. We examined the associations between total ORAC and TP scores, and hypertension using logistic regression. After adjustment for potential confounders, a higher total ORAC score was associated with lower risk of hypertension. The odds ratios (ORs) of systolic blood pressure (SBP) >140 mm Hg across increasing quartiles of the total ORAC score were 1.0, 0.71, 0.38 and 0.56 (P for trend=0.016). The ORs of diastolic blood pressure (DBP) >90 mm Hg across increasing quartiles of the total ORAC score were 1.0, 0.59, 0.47 and 0.35 (P for trend=0.008). Further adjustment for energy, protein and sodium intakes slightly strengthened these associations. Multivariate ORs of elevated SBP across quartiles of TP score were 1.0, 0.83, 0.41 and 0.63 (P for trend=0.027), and for elevated DBP were 1.0, 0.50, 0.40 and 0.38 (P for trend=0.006). Further adjustment for energy, protein and sodium intakes did not change the results materially. Our findings suggest that total antioxidant capacity of the dietary intake was negatively associated with hypertension in type 2 diabetic patients.
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Affiliation(s)
- M S Farvid
- Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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210
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Cariou B. Harnessing the incretin system beyond glucose control: potential cardiovascular benefits of GLP-1 receptor agonists in type 2 diabetes. DIABETES & METABOLISM 2012; 38:298-308. [PMID: 22672960 DOI: 10.1016/j.diabet.2012.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 04/14/2012] [Accepted: 04/14/2012] [Indexed: 12/25/2022]
Abstract
The management of type 2 diabetes continues to evolve as new data emerge. Although glycaemic control is still important, other risk factors--such as hypertension, dyslipidaemia and obesity--must also be addressed in order to reduce the long-term risks of cardiovascular complications and mortality. In this context, targeting the incretin system, and glucagon-like peptide-1 (GLP-1) in particular, has generated much interest. GLP-1 is released from the gut in response to food ingestion and plays a crucial role in glucose homeostasis. GLP-1 receptors are expressed in the heart and vasculature, prompting evaluation of their physiological role and pharmacological stimulation, both in healthy and disease states. These studies indicate that GLP-1 and GLP-1-based therapies appear to have direct, beneficial effects on the cardiovascular system, in addition to their glucose-lowering properties, such as modulation of blood pressure, endothelial function, and myocardial contractility. Intriguingly, some of these effects appear to be independent of GLP-1 receptor signalling. Data from clinical studies of the GLP-1 receptor agonists, exenatide and liraglutide on cardiovascular risk factors, in patients with type 2 diabetes are also promising and the results from prospective studies to assess cardiovascular outcomes are eagerly awaited.
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Affiliation(s)
- B Cariou
- Université de Nantes, CHU de Nantes, Hôpital Guillaume et René-Laennec, boulevard Jacques-Monod, Saint-Herblain, 44093 Nantes cedex 1, France.
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211
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Hassing H, Mooij H, Guo S, Monia B, Chen K, Kulik W, Dallinga-Thie G, Nieuwdorp M, Stroes E, Williams K. Inhibition of hepatic sulfatase-2 in vivo: a novel strategy to correct diabetic dyslipidemia. Hepatology 2012; 55:1746-53. [PMID: 22234891 PMCID: PMC3345297 DOI: 10.1002/hep.25580] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
UNLABELLED Type 2 diabetes mellitus (T2DM) impairs hepatic clearance of atherogenic postprandial triglyceride-rich lipoproteins (TRLs). We recently reported that livers from T2DM db/db mice markedly overexpress the heparan sulfate glucosamine-6-O-endosulfatase-2 (SULF2), an enzyme that removes 6-O sulfate groups from heparan sulfate proteoglycans (HSPGs) and suppresses uptake of TRLs by cultured hepatocytes. In the present study, we evaluated whether Sulf2 inhibition in T2DM mice in vivo could correct their postprandial dyslipidemia. Selective second-generation antisense oligonucleotides (ASOs) targeting Sulf2 were identified. Db/db mice were treated for 5 weeks with Sulf2 ASO (20 or 50 mg/kg per week), nontarget (NT) ASO, or phosphate-buffered saline (PBS). Administration of Sulf2 ASO to db/db mice suppressed hepatic Sulf2 messenger RNA expression by 70%-80% (i.e., down to levels in nondiabetic db/m mice) and increased the ratio of tri- to disulfated disaccharides in hepatic HSPGs (P < 0.05). Hepatocytes isolated from db/db mice on NT ASO exhibited a significant impairment in very-low-density lipoprotein (VLDL) binding that was entirely corrected in db/db mice on Sulf2 ASO. Sulf2 ASO lowered the random, nonfasting plasma triglyceride (TG) levels by 50%, achieving nondiabetic values. Most important, Sulf2 ASO treatment flattened the plasma TG excursions in db/db mice after corn-oil gavage (iAUC, 1,500 ± 470 mg/dL·h for NT ASO versus 160 ± 40 mg/dL · h for Sulf2 ASO\P < 0.01). CONCLUSIONS Despite extensive metabolic derangements in T2DM mice, inhibition of a single dys-regulated molecule, SULF2, normalizes the VLDL-binding capacity of their hepatocytes and abolishes postprandial hypertriglyceridemia. These findings provide a key proof of concept in vivo to support Sulf2 inhibition as an attractive strategy to improve metabolic dyslipidemia.
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Affiliation(s)
- H.C. Hassing
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - H. Mooij
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - S. Guo
- Department of Antisense Drug Discovery, Isis Pharmaceuticals Inc, Carlsbad, CA USA
| | - B.P. Monia
- Department of Antisense Drug Discovery, Isis Pharmaceuticals Inc, Carlsbad, CA USA
| | - Keyang Chen
- Section of Endocrinology, Diabetes and Metabolism, Temple University School of Medicine, Philadelphia, PA USA
| | - W. Kulik
- Laboratory of Genetic and Metabolic Diseases, Academic Medical Center, Amsterdam, The Netherlands
| | - G.M. Dallinga-Thie
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands,Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M. Nieuwdorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - E.S.G. Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - K.J. Williams
- Section of Endocrinology, Diabetes and Metabolism, Temple University School of Medicine, Philadelphia, PA USA
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212
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Abstract
Coronary heart disease (CHD) is the leading cause of morbidity and mortality in patients with diabetes. Asymptomatic CHD in these patients is elusive and carries a poor prognosis given the fact that an unheralded acute myocardial infarction or sudden cardiac death frequently constitutes its first presentation. Because effective screening for asymptomatic patients with type 2 diabetes for both the presence and severity of CHD is intuitively appealing, we have summarized the utility and prognostic value of various diagnostic modalities (both functionally and anatomically) in enhancing risk stratification and leading to improved and more aggressive management of the risk factors. There exist some evidence and recommendations for screening of asymptomatic persons with diabetes using certain modalities. More research is needed to define potential subsets of patients with diabetes who may benefit from additional testing for asymptomatic CHD.
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Affiliation(s)
- Nima Alipour
- Division of Cardiology, Department of Medicine, University of California-Irvine, 333 City Boulevard West, Orange, CA 92868-3298, USA
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213
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Chew BH, Mastura I, Shariff-Ghazali S, Lee PY, Cheong AT, Ahmad Z, Taher SW, Haniff J, Mustapha FI, Bujang MA. Determinants of uncontrolled hypertension in adult type 2 diabetes mellitus: an analysis of the Malaysian diabetes registry 2009. Cardiovasc Diabetol 2012; 11:54. [PMID: 22607105 PMCID: PMC3434063 DOI: 10.1186/1475-2840-11-54] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 05/07/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Uncontrolled blood pressure (BP) is a significant contributor of morbidity and even mortality in type 2 diabetes (T2D) patients. This study was done to determine the significant determinants of uncontrolled blood pressure in T2D patients in Malaysia. METHODS Between 1st January 2009 to 31st December 2009, data from 70 889 patients with Type 2 diabetes was obtained from the Adult Diabetes Control and Management Registry for analysis; 303 centers participated in the study. Their demographic characteristics, the nature of their diabetes, their state of hypertension, treatment modalities, risk factors, and complications are described. Based on their most recent BP values, subjects were divided into controlled BP and uncontrolled BP and their clinical determinants compared. Independent determinants were identified using multivariate logistic regression. RESULTS The mean age of patients at diagnosis of diabetes was 52.3 ± 11.1 years old. Most were women (59.0 %) and of Malay ethnicity (61.9 %). The mean duration of diabetes was 5.9 ± 5.6 years. A total of 57.4 % were hypertensive. Of the 56 503 blood pressure (BP) measured, 13 280 (23.5 %) patients had BP <130/80 mmHg. Eighteen percent was on > two anti-hypertensive agents. Health clinics without doctor, older age (≥ 50 years old), shorter duration of diabetes (< 5 years), Malay, overweight were determinants for uncontrolled blood pressure (BP ≥130/80 mmHg). Patients who were on anti-hypertensive agent/s were 2.7 times more likely to have BP ≥130/80 mmHg. Type 2 diabetes patients who had ischaemic heart disease or nephropathy were about 20 % and 15 % more likely to have their blood pressure treated to target respectively. CONCLUSIONS Major independent determinants of uncontrolled BP in our group of T2D patients were Malay ethnicity, older age, recent diagnosis of diabetes, overweight and follow-up at health clinics without a doctor and possibly the improper use of anti hypertensive agent. More effort, education and resources, especially in the primary health care centres are needed to improve hypertensive care among our patients with diabetes.
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Affiliation(s)
- Boon How Chew
- Department of Family Medicine, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | | | - Sazlina Shariff-Ghazali
- Department of Family Medicine, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Ping Yein Lee
- Department of Family Medicine, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Ai Theng Cheong
- Department of Family Medicine, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Zaiton Ahmad
- Department of Family Medicine, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | | | - Jamaiyah Haniff
- Clinical Research Centre, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | | | - Mohd Adam Bujang
- Clinical Research Centre, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
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214
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Scheen AJ. Pharmacokinetic evaluation of atorvastatin and sitagliptin in combination for the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2012; 8:745-58. [DOI: 10.1517/17425255.2012.686603] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Final tips in interpreting evidence-based medicine. South Med J 2012; 105:173-80. [PMID: 22392215 DOI: 10.1097/smj.0b013e318249c152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this issue, the Southern Medical Journal presents a series of articles to help students of medicine understand the principles of evidence-based medicine. These articles are not meant to be a comprehensive review, but rather an easy-to-read primer. In this final article, the authors offer suggestions to aid the reader in navigating the ever-expanding amount of information. These tips address a number of points that are commonly encountered in the medical literature, but are not all-inclusive.
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Wong K, Glovaci D, Malik S, Franklin SS, Wygant G, Iloeje U, Kan H, Wong ND. Comparison of demographic factors and cardiovascular risk factor control among U.S. adults with type 2 diabetes by insulin treatment classification. J Diabetes Complications 2012; 26:169-74. [PMID: 22502939 PMCID: PMC3931306 DOI: 10.1016/j.jdiacomp.2012.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 02/22/2012] [Accepted: 03/06/2012] [Indexed: 12/17/2022]
Abstract
AIMS Data on glucose and cardiovascular disease (CVD) risk factor control among persons with type 2 diabetes mellitus (DM) according to insulin treatment status are lacking. We examined DM control, risk factors, and comorbidities among U.S. persons according to insulin treatment status. METHODS In the U.S. National Health and Nutrition Examination Surveys 2003-2006, we examined in 10,637 adults aged ≥30 with type 2 DM the extent of control of A1c, LDL-C, HDL-C, triglycerides, and blood pressure (BP) and composite goal attainment by insulin use status. RESULTS 6.6% (n=889, projected to 14.3 million) had type 2 DM; of these, 22.9% were insulin users and 57.2% were treated only by other diabetes medications. Overall, 58.2% had an A1c<7% (53 mmol/mol) (insulin users 33.1%, non-insulin treated 66.1%, and 77.9% of those not on medication, p<0.0001). Overall, 44.2% were at a BP goal of <130/80 mmHg, 43.8% had an LDL-C<100 mg/dl (2.6 mmol/L), and 13.9% a BMI<25 kg/m(2). Only 10.2% were simultaneously at A1c, LDL, and BP goals (5.4% of those on insulin). CONCLUSIONS U.S. adults with type 2 DM, especially those treated with insulin remain inadequately controlled for A1c and CVD risk factors and have a high prevalence of comorbidities.
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Affiliation(s)
- Kalina Wong
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, CA
| | - Diana Glovaci
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, CA
| | - Shaista Malik
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, CA
| | - Stanley S. Franklin
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, CA
| | - Gail Wygant
- Global Health Economics & Outcomes Research, Bristol-Myers Squibb, Princeton, NJ
| | - Uchenna Iloeje
- Global Health Economics & Outcomes Research, Bristol-Myers Squibb, Princeton, NJ
| | - Hongjun Kan
- Global Health Economics & Outcomes Research, Bristol-Myers Squibb, Princeton, NJ
| | - Nathan D. Wong
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, CA
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Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, Akl EA, Lansberg MG, Guyatt GH, Spencer FA. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e637S-e668S. [PMID: 22315274 DOI: 10.1378/chest.11-2306] [Citation(s) in RCA: 332] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B). CONCLUSIONS Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted.
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Affiliation(s)
- Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services and Department of Medicine, Innlandet Hospital Trust Gjøvik, Gjøvik, Norway
| | - A Michael Lincoff
- Department of Cardiovascular Medicine and Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland Clinic, Cleveland, OH
| | - Joel M Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - Frank A Sonnenberg
- Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Elie A Akl
- Department of Medicine and Department of Clinical Epidemiology and Biostatistics, State University of New York at Buffalo, Buffalo, NY
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Sasaki M, Imaeda K, Okayama N, Mizuno T, Kataoka H, Kamiya T, Kubota E, Ogasawara N, Funaki Y, Mizuno M, Iida A, Goto C, Koikeda S, Kasugai K, Joh T. Effects of transglucosidase on diabetes, cardiovascular risk factors and hepatic biomarkers in patients with type 2 diabetes: a 12-week, randomized, double-blind, placebo-controlled trial. Diabetes Obes Metab 2012; 14:379-82. [PMID: 22098444 DOI: 10.1111/j.1463-1326.2011.01539.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this 12-week, randomized, double-blind, placebo-controlled trial, the efficacy and safety of transglucosidase (TGD) were compared with placebo in patients with type 2 diabetes mellitus (T2DM). At 12 weeks, TGD 300 mg/day and TGD 900 mg/day significantly reduced HbA1c (0.18 and 0.21%) and insulin concentration (19.4 and 25.0 pmol/l), respectively, vs. placebo. TGD 300 mg/day and TGD 900 mg/day also significantly reduced low-density lipoprotein cholesterol (0.22 and 0.17 mmol/l, respectively). TGD 900 mg/day significantly reduced triglyceride by 0.24 mmol/l and diastolic blood pressure by 8 mmHg. Placebo was associated with a significant increase from baseline in body mass index, alanine aminotransferase and aspartate aminotransferase (0.17 kg/m(2) , 3 and 2 U/l, respectively), whereas TGD was not. TGD 300 mg/day significantly increased high-molecular-weight adiponectin by 0.6 µg/ml. Adverse events did not differ significantly between the groups. TGD resulted in lowering of HbA1c and blood insulin level and improvements in metabolic and cardiovascular risk factors in T2DM.
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Affiliation(s)
- M Sasaki
- Department of Gastroenterology, Aichi Medical University School of Medicine, 21 Karimata, Aichi-gun, Aichi, Japan.
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Chaudhuri A, Rosenstock J, DiGenio A, Meneghini L, Hollander P, McGill JB, Dandona P, Ilgenfritz J, Riddle M. Comparing the effects of insulin glargine and thiazolidinediones on plasma lipids in type 2 diabetes: a patient-level pooled analysis. Diabetes Metab Res Rev 2012; 28:258-67. [PMID: 22081557 PMCID: PMC3380564 DOI: 10.1002/dmrr.1305] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The prevalence of dyslipidaemia and the risk of cardiovascular disease are elevated in patients with type 2 diabetes. This analysis compared the effects of insulin glargine versus thiazolidinediones (TZDs) on lipid profiles. METHODS Patient-level data were pooled from two randomized clinical studies. The population included 552 men and women aged >18 years, diagnosed with type 2 diabetes for at least 6 months, on metformin and/or sulphonylurea, and with A(1C) ≥7.5% and <12.0% at screening. Lipid outcome measures included change from baseline in lipid levels [low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), total cholesterol, triglycerides, and free fatty acids] and attainment of lipid goals for LDL-C, non-HDL-C, and triglycerides. RESULTS Both insulin glargine and TZDs improved lipid profiles from baseline values. Compared with TZDs, treatment with insulin glargine led to 7.9% greater reduction in LDL-C (p < 0.0003), 7.5% greater reduction in non-HDL-C (p < 0.0001), and 7.8% greater reduction in total cholesterol (p < 0.0001), whereas the HDL-C increase with TZD was 7.6% greater than that with insulin glargine (p < 0.0001). The percentage of patients attaining the lipid goals was comparable between insulin glargine and pioglitazone, but lower for rosiglitazone. Insulin glargine improved glycaemic control more than TZDs; however, insulin glargine caused more hypoglycaemia. Treatment with TZDs caused more weight gain and peripheral oedema. CONCLUSION These findings suggest that the favourable effects of insulin glargine on plasma lipid profiles should be considered among the advantages of treatment with insulin glargine as they are for TZDs.
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Affiliation(s)
- Ajay Chaudhuri
- State University of New York at Buffalo and Kaleida Health, Buffalo, NY 14209, USA.
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He S, Chen X, Cui K, Peng Y, Liu K, Lv Z, Yang R, Zhou X. Validity evaluation of recently published diabetes risk scoring models in a general Chinese population. Diabetes Res Clin Pract 2012; 95:291-8. [PMID: 22129653 DOI: 10.1016/j.diabres.2011.10.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 10/24/2011] [Accepted: 10/25/2011] [Indexed: 11/21/2022]
Abstract
The study aimed to assess the validity of some recently published diabetes risk scoring models in a general Chinese population. In 2007, there was a re-examination of 711 individuals who were originally examined in 1992. Since 24 individuals had diabetes in 1992, 687 individuals were available for analysis. Validity was assessed with area under the receiver operating characteristic curve (AROC), and we assessed seven prospective and four cross-sectional models. When applied to our population, AROCs tended to be higher in Asian models than in non-Asian models (average AROCs 0.694±0.034 vs. 0.667±0.040, p=0.258), and those tended to be higher in prospective models than in cross-sectional models (average AROCs 0.695±0.028 vs. 0.652±0.042, p=0.072). A prospective model from Taiwan performed best (AROC 0.749; 95% CI 0.691-0.807). In conclusion, diabetes risk scoring models could not always be generalized from one population to another before validation. Asian models might be more suitable for Asian populations than non-Asian models, and prospective models might be more suitable for predicting future diabetes than cross-sectional models. When applied to our population, a prospective model from Taiwan performed best, and widespread application might be considered in the population.
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Affiliation(s)
- Sen He
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
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222
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Manzano-Fernández S, Tello-Montoliu A, Marín F. Primary Prevention With Aspirin in Type 2 Diabetic Patients. Circ J 2012; 76:1333-4. [DOI: 10.1253/circj.cj-12-0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Antonio Tello-Montoliu
- Department of Cardiology, University Hospital Virgen de la Arrixaca, University of Murcia
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Francisco Marín
- Department of Cardiology, University Hospital Virgen de la Arrixaca, University of Murcia
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He S, Wang S, Chen X, Jiang L, Peng Y, Li L, Wan L, Cui K. Higher ratio of triglyceride to high-density lipoprotein cholesterol may predispose to diabetes mellitus: 15-year prospective study in a general population. Metabolism 2012; 61:30-6. [PMID: 21664631 DOI: 10.1016/j.metabol.2011.05.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 05/03/2011] [Accepted: 05/04/2011] [Indexed: 02/05/2023]
Abstract
The aims of the study were to examine whether the triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) could predict future diabetes mellitus (DM) in a general population during a 15-year follow-up. The data were collected in 1992 and then again in 2007 from the same group of 711 individuals. Because 24 of them were found to be diabetic in 1992, our analysis was eventually based on the usable data collected from the remaining 687 individuals (male, 58.1%). During the period 1992-2007, 74 individuals were found to have developed DM (10.8%). After adjusting the associated variables, it was found that TG and TG/HDL-C were independent DM risk factors, with the odds ratios being 1.292 (P = .047) and 1.341 (P = .010), respectively, although they were poor in their DM discriminatory power (area under the receiver operating characteristic curve, 0.662 and 0.672, respectively). Combined with other risk factors (fasting plasma glucose, waist circumference, and family history of DM), the DM discriminatory power of TG and TG/HDL-C was improved (area under the receiver operating characteristic curve, 0.764 and 0.767, respectively). The DM incidence increased with ascending risk score. Single HDL-C seems unable to predict future DM. Triglycerides and TG/HDL-C were independent DM risk factors; and of the two, TG/HDL-C was a stronger risk factor. The DM discriminatory power of TG and TG/HDL-C was poor; therefore, it is recommended that they be used in combination with other risk factors. Diabetes mellitus incidence increased with ascending risk score.
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Affiliation(s)
- Sen He
- Department of Cardiovascular Medicine, West China Hospital, Sichuan University, Chengdu, China
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225
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Assessing the association between receipt of dental care, diabetes control measures and health care utilization. J Am Dent Assoc 2012; 143:20-30. [DOI: 10.14219/jada.archive.2012.0014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Studies have suggested that moderate alcohol consumption is associated with a reduced risk of CVD and premature mortality in individuals with diabetes mellitus. However, history of alcohol consumption has hardly been taken into account. We investigated the association between current alcohol consumption and mortality in men and women with diabetes mellitus accounting for past alcohol consumption. Within the European Prospective Investigation into Cancer and Nutrition (EPIC), a cohort was defined of 4797 participants with a confirmed diagnosis of diabetes mellitus. Men and women were assigned to categories of baseline and past alcohol consumption. Hazard ratios (HR) and 95 % CI for total mortality were estimated with multivariable Cox regression models, using light alcohol consumption (>0-6 g/d) as the reference category. Compared with light alcohol consumption, no relationship was observed between consumption of 6 g/d or more and total mortality. HR for >6-12 g/d was 0·89 (95 % CI 0·61, 1·30) in men and 0·86 (95 % CI 0·46, 1·60) in women. Adjustment for past alcohol consumption did not change the estimates substantially. In individuals who at baseline reported abstaining from alcohol, mortality rates were increased relative to light consumers: HR was 1·52 (95 % CI 0·99, 2·35) in men and 1·81 (95 % CI 1·04, 3·17) in women. The present study in diabetic individuals showed no association between current alcohol consumption >6 g/d and mortality risk compared with light consumption. The increased mortality risk among non-consumers appeared to be affected by their past alcohol consumption rather than their current abstinence.
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The role of Dietary Approaches to Stop Hypertension (DASH) diet food groups in blood pressure in type 2 diabetes. Br J Nutr 2011; 108:155-62. [PMID: 22142820 DOI: 10.1017/s0007114511005381] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The role of each Dietary Approaches to Stop Hypertension (DASH) diet component in blood pressure (BP) of patients with diabetes is still uncertain. The aim of the present study was to evaluate possible associations of the recommended food groups of the DASH diet eating plan with BP values in patients with type 2 diabetes. In the present cross-sectional study, 225 patients with type 2 diabetes (age 61·1 (SD 10·4) years; diabetes duration 13·1 (SD 9·1) years; males 48·4 %; BMI 28·5 (SD 4·3) kg/m(2); HbA1c 7·1 (SD 1·3) %; systolic BP 136·7 (SD 20·0) mmHg; diastolic BP 78·4 (SD 11·8) mmHg) without dietary counselling during the previous 6 months had their dietary intake assessed by 3 d weighed-diet records. Patients were divided into two groups according to BP tertiles: LOW BP (first tertile) and HIGH BP (second plus third tertiles). Multivariate logistic regression models demonstrated that the daily intake of 80 g of fruits per 4184 kJ (1000 kcal) (OR 0·781; 95 % CI 0·617, 0·987; P = 0·039) or 50 g of vegetables per 4184 kJ (1000 kcal) (OR 0·781; 95 % CI 0·618, 0·988; P = 0·040) reduced the chance of the presence of HIGH mean BP (MBP ≥ 92 mmHg) by 22 % each, adjusted for possible confounders. In conclusion, fruit and vegetables were the food groups of the DASH diet associated with reduced BP values in patients with type 2 diabetes, and their consumption might play a protective role against increased BP values.
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228
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Anderson DW, Libonati JR. Physical activity and body mass perception. Clin Nurs Res 2011; 21:252-67. [PMID: 22042909 DOI: 10.1177/1054773811426928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate ethnic perceptual variations in body mass index (BMI) and accrued physical activity. Women (n = 204) from the eastern United States were stratified into the following ethnic groups: White women (WW; n = 97), Black women (BW n = 62) and Others (Hispanic and Asian women, n = 45). Participants completed questionnaires and physiologic variables were determined. BW had increased weight, BMI, waist circumference, and body fat percentage vs. WW (p < .05). Body mass was higher in BW vs. Others (p < .05). There were no differences for perception of BMI or body dissatisfaction. BW were the only group in which perception of BMI was lower than measured BMI. BW engaged in 50% less domestic and total physical activity than WW and Others. Physical activity was not correlated to perception of BMI. CONCLUSION Perception of BMI was similar across ethnic groups and not correlated to physical activity levels in young women.
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Simpson SH, Gamble JM, Mereu L, Chambers T. Effect of aspirin dose on mortality and cardiovascular events in people with diabetes: a meta-analysis. J Gen Intern Med 2011; 26:1336-44. [PMID: 21647746 PMCID: PMC3208465 DOI: 10.1007/s11606-011-1757-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Revised: 03/09/2011] [Accepted: 05/03/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pharmacologic evidence suggests adequate antiplatelet activity in diabetic patients requires >100 mg aspirin daily, yet recent trials have used ≤100 mg daily. This meta-analysis explored the relationship between aspirin dose and prevention of cardiovascular events. DATA SOURCES Six electronic databases were searched using database-appropriate terms for aspirin, diabetes, and comparative study from inception until February 2010. REVIEW METHODS Randomized controlled trials and cohort studies comparing aspirin to no antiplatelet therapy were included if they reported cardiovascular events as pre-specified outcomes, aspirin dose, and number of diabetic patients. Studies were stratified by daily aspirin dose (≤100 mg; 101-325 mg; >325 mg) and pooled risk ratios (RR) were calculated using random effects models. All-cause mortality was the primary outcome of interest. Cardiovascular-related mortality, myocardial infarction, and stroke were secondary outcomes. RESULTS Data for diabetic patients were available from 21 studies (n = 17,522). Overall, 1,172 (15.4%) of 7,592 aspirin users and 1,520 (18.4%) of 8,269 controls died (p = 0.31). The pooled RRs were 0.89 (95% CI: 0.72-1.10; p = 0.27) from 13 studies using ≤100 mg (I(2) = 64%); 0.89 (95% CI: 0.61-1.30; p = 0.55) from four studies using 101-325 mg (I(2) = 83%); and 0.96 (95% CI: 0.85-1.08; p = 0.50) from eight studies using >325 mg (I(2) = 0%). Aspirin use was associated with a significantly lower risk of mortality (RR: 0.82; 95% CI: 0.69-0.98; p = 0.03) in 13 secondary prevention studies (I(2) = 27%), whereas aspirin use in seven primary prevention studies (I(2) = 0%) was not (RR: 1.01; 95% CI 0.85-1.19; p = 0.94). A substantial amount of heterogeneity was observed amongst studies in all outcomes. Although inclusion of cohort studies was a major source of heterogeneity, stratification by study design did not reveal a significant dose-response relationship. CONCLUSIONS/INTERPRETATION This summary of available data does not support an aspirin dose-response effect for prevention of cardiovascular events in diabetic patients. However, the systematic review identified an important gap in randomized controlled trial evidence for using 101-325 mg aspirin daily in diabetes.
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Affiliation(s)
- Scot H. Simpson
- Faculty of Pharmacy & Pharmaceutical Sciences, 3126 Dentistry / Pharmacy Centre, University of Alberta, Edmonton, AB Canada T6G 2N8
| | | | - Laurie Mereu
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada
| | - Thane Chambers
- University of Alberta Library Services, Edmonton, AB Canada
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Lee SH, Kim JH, Kang MJ, Lee YA, Won Yang S, Shin CH. Implications of nocturnal hypertension in children and adolescents with type 1 diabetes. Diabetes Care 2011; 34:2180-5. [PMID: 21911774 PMCID: PMC3177721 DOI: 10.2337/dc11-0830] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes is associated with atherogenic risk factors. Hypertension has a major influence on cardiovascular disease in diabetic patients. Ambulatory blood pressure monitoring (ABPM) is useful for identifying nocturnal hypertension. Carotid intima-media thickness (cIMT) is a good measure for identifying subclinical atherosclerosis. This study aimed to evaluate whether nocturnal hypertension affects atherosclerosis in children and adolescents with type 1 diabetes and to investigate the relationship between atherogenic risk factors and cIMT. RESEARCH DESIGN AND METHODS ABPM and cIMT were measured in 82 diabetic children and adolescents. We reviewed the hemoglobin A(1c) levels, 24-h urine microalbumin excretion, lipid profiles, and duration of diabetes. Nocturnal hypertension was defined as hypertension observed only at night. RESULTS Forty-three (52%) subjects were hypertensive, and 30 subjects were classified as having nocturnal hypertension. cIMT was higher in the nocturnal hypertensive group than in the normotensive group (0.44 ± 0.03 vs. 0.42 ± 0.04 mm, P = 0.026). Among children and adolescents with nonhypertensive blood pressure levels in clinic blood pressure monitoring, cIMT and daytime blood pressure were higher in the nocturnal hypertensive group. All ABPM parameters were significantly related to cIMT in multiple linear regression analysis. CONCLUSIONS This study showed significantly increased cIMT and daytime blood pressure in diabetic children and adolescents with nocturnal hypertension. ABPM may be a useful method for detecting the macrovascular complications of type 1 diabetes. Longitudinal studies are needed to find the causes of nocturnal hypertension and to evaluate the effect of nocturnal hypertension on atherosclerosis in type 1 diabetes.
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Affiliation(s)
- Sun Hee Lee
- Department of Pediatrics, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
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Nobels F, Debacker N, Brotons C, Elisaf M, Hermans MP, Michel G, Muls E. Study rationale and design of OPTIMISE, a randomised controlled trial on the effect of benchmarking on quality of care in type 2 diabetes mellitus. Cardiovasc Diabetol 2011; 10:82. [PMID: 21939502 PMCID: PMC3189404 DOI: 10.1186/1475-2840-10-82] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 09/22/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To investigate the effect of physician- and patient-specific feedback with benchmarking on the quality of care in adults with type 2 diabetes mellitus (T2DM). METHODS Study centres in six European countries were randomised to either a benchmarking or control group. Physicians in both groups received feedback on modifiable outcome indicators (glycated haemoglobin [HbA1c], glycaemia, total cholesterol, high density lipoprotein-cholesterol, low density lipoprotein [LDL]-cholesterol and triglycerides) for each patient at 0, 4, 8 and 12 months, based on the four times yearly control visits recommended by international guidelines. The benchmarking group also received comparative results on three critical quality indicators of vascular risk (HbA1c, LDL-cholesterol and systolic blood pressure [SBP]), checked against the results of their colleagues from the same country, and versus pre-set targets. After 12 months of follow up, the percentage of patients achieving the pre-determined targets for the three critical quality indicators will be assessed in the two groups. RESULTS Recruitment was completed in December 2008 with 3994 evaluable patients. CONCLUSIONS This paper discusses the study rationale and design of OPTIMISE, a randomised controlled study, that will help assess whether benchmarking is a useful clinical tool for improving outcomes in T2DM in primary care. TRIAL REGISTRATION NCT00681850.
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Affiliation(s)
- Frank Nobels
- Endocrinologie, OLV Ziekenhuis, Moorselbaan 164, B-9300 Aalst, Belgium
| | | | - Carlos Brotons
- Research Unit, EAP Sardenya-IIB Sant Pau, Sardenya, 466. 08025, Barcelona, Spain
| | - Moses Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Michel P Hermans
- Endocrinology & Nutrition, Cliniques universitaires St-Luc, DIAB 54.74 Tour Claude Bernard +1 avenue Hippocrate 54, B-1200 Brussels, Belgium
| | - Georges Michel
- Endocrinology, Centre Hospitalier de Luxembourg, 4 rue Barblé, L-1210 Luxembourg
| | - Erik Muls
- Department of Endocrinology, UZ Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
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Vanden Bosch ML, Corser WD, Xie Y, Holmes-Rovner M. Posthospital Heart-Healthy Behaviors in Adults With Comorbid Diabetes. Clin Nurs Res 2011; 21:327-49. [PMID: 21926277 DOI: 10.1177/1054773811422123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The purpose of these secondary analyses was to examine relationships between patient factors and patient-provider decision-making style (PDM) on heart-healthy behavior changes in 142 adults with diabetes after hospitalization for an acute coronary syndrome (ACS). A clinical trial randomized adults to either control or a telephone coaching intervention. Generalized estimating equations were used to analyze the relationship between patient factors and PDM style on longitudinal postdischarge changes in three heart-healthy behaviors, avoiding high fat foods, weight loss, and increased physical activity. Neither PDM style nor telephone coaching intervention affected heart-healthy behaviors in this population. Although adults with diabetes preferred collaborative patient-provider decision-making, present levels of provider engagement were not sufficient to support behavior change. Results suggest the need for sustained and tailored nursing interventions to facilitate heart-healthy behavior changes in adults with diabetes after ACS hospitalization.
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Affiliation(s)
| | - William D. Corser
- College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Yan Xie
- Center for Statistical Training & Consulting, Michigan State University, East Lansing, MI, USA
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233
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Poor aspirin response in diabetic patients presenting with acute coronary syndromes: Results using a near patient test. Thromb Res 2011; 128:196-9. [DOI: 10.1016/j.thromres.2011.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/26/2011] [Accepted: 04/02/2011] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Dyslipidemia is an important risk factor for cardiovascular complications in persons with diabetes. Low-density lipoprotein-cholesterol (LDL-C) is the 'cornerstone' for assessment of lipoprotein-associated risk. However, LDL-C levels do not reflect the classic 'diabetic dyslipidemia' of hypertriglyceridemia and low high-density lipoprotein-cholesterol (HDL-C). Measurements of plasma apolipoprotein B100 concentrations and non-HDL-C may improve the definition of dyslipidemia. Statins, nicotinic acid and fibrates have roles in treating dyslipidemia in diabetes. Residual risk (i.e. risk that persists after correction of 'conventional' plasma lipoprotein abnormalities) is a new concept in the role of dyslipidemia in the pathogenesis of diabetic vascular complications. For example, regardless of plasma levels, lipoprotein extravasation through a leaking retinal blood barrier and subsequent modification may be crucial in the development of diabetic retinopathy. The current approach to the management of dyslipidemia in diabetes is briefly summarized, followed by a discussion of new concepts of residual risk and emerging lipoprotein-related mechanisms for vascular disease in diabetes. CONCLUSIONS Effective treatments must correct adverse quantitative plasma lipoprotein levels and a spectrum of qualitative abnormalities in plasma and tissue, as well as the processes by which lipoproteins and cells interact at the sites of disease.
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Affiliation(s)
- Mingyuan Wu
- Harold Hamm Oklahoma Diabetes Center and Section of Endocrinology and Diabetes, University of Oklahoma Health Sciences Center, Oklahoma City, Okla., USA
| | - Timothy J. Lyons
- *Timothy J. Lyons, MD, FRCP, Harold Hamm Oklahoma Diabetes Center, University of Oklahoma Health Sciences Center, Department of Endocrinology and Diabetes, 920 Stanton L. Yound Blvd., WP-1345, Oklahoma City, OK 73104 (USA), Tel. +1 405 271 3616, E-Mail
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Sluik D, Boeing H, Montonen J, Pischon T, Kaaks R, Teucher B, Tjønneland A, Halkjaer J, Berentzen TL, Overvad K, Arriola L, Ardanaz E, Bendinelli B, Grioni S, Tumino R, Sacerdote C, Mattiello A, Spijkerman AMW, van der A DL, Beulens JW, van der Schouw YT, Nilsson PM, Hedblad B, Rolandsson O, Franks PW, Nöthlings U. Associations between general and abdominal adiposity and mortality in individuals with diabetes mellitus. Am J Epidemiol 2011; 174:22-34. [PMID: 21616928 DOI: 10.1093/aje/kwr048] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Individuals with diabetes mellitus are advised to achieve a healthy weight to prevent complications. However, fat mass distribution has hardly been investigated as a risk factor for diabetes complications. The authors studied associations between body mass index, waist circumference, waist/hip ratio, and waist/height ratio and mortality among individuals with diabetes mellitus. Within the European Prospective Investigation into Cancer and Nutrition, a subcohort was defined as 5,435 individuals with a confirmed self-report of diabetes mellitus at baseline in 1992-2000. Participants were aged 57.3 (standard deviation, 6.3) years, 54% were men, the median diabetes duration was 4.6 (interquartile range, 2.0-9.8) years, and 22% of the participants used insulin. Body mass index, as indicator of general obesity, was not associated with higher mortality, whereas all measurements of abdominal obesity showed a positive association. Associations generally were slightly weaker in women. The strongest association was observed for waist/height ratio: In the fifth quintile, the hazard rate ratio was 1.88 (95% confidence interval: 1.33, 2.65) for men and 2.46 (95% confidence interval: 1.46, 4.14) for women. Measurements of abdominal, but not general, adiposity were associated with higher mortality in diabetic individuals. The waist/height ratio showed the strongest association. Respective indicators might be investigated in risk prediction models.
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Affiliation(s)
- Diewertje Sluik
- Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrucke, Arthur-Scheunert-Allee 114–116, 14558 Nuthetal, Germany.
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Giannini C, Mohn A, Chiarelli F, Kelnar CJH. Macrovascular angiopathy in children and adolescents with type 1 diabetes. Diabetes Metab Res Rev 2011; 27:436-60. [PMID: 21433262 DOI: 10.1002/dmrr.1195] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes represents one of the most common diseases globally. Worryingly, the worldwide incidence of type 1 diabetes (T1D) is rising by 3% per year. Despite the rapid increase in diabetes incidence, recent advances in diabetes treatment have been successful in decreasing morbidity and mortality from diabetes-related retinopathy, nephropathy, and neuropathy. In contrast, there is clear evidence for the lack of improvement in mortality for cardiovascular diseases (CVDs). This emphasizes the importance of focusing childhood diabetes care strategies for the prevention of CVD in adulthood. Furthermore, although most work on diabetes and macrovascular disease relates to type 2 diabetes, it has been shown that the age-adjusted relative risk of CVD in T1D far exceeds that in type 2 diabetes. As T1D appears predominantly during childhood, those with T1D are at greater risk for coronary events early in life and require lifelong medical attention. Because of the important health effects of CVDs in children and adolescents with T1D, patients, family members, and care providers should understand the interaction of T1D and cardiovascular risk. In addition, optimal cardiac care for the patient with diabetes should focus on aggressive management of traditional cardiovascular risk factors to optimize those well-recognized as well as new specific risk factors which are becoming available. Therefore, a complete characterization of the molecular mechanisms involved in the development and progression of macrovascular angiopathy is needed. Furthermore, as vascular abnormalities begin as early as in childhood, potentially modifiable risk factors should be identified at an early stage of vascular disease development.
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Affiliation(s)
- Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy.
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237
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Diabetes mellitus and cardiovascular prevention: the role and the limitations of currently available antiplatelet drugs. Int J Vasc Med 2011; 2011:250518. [PMID: 21761004 PMCID: PMC3134090 DOI: 10.1155/2011/250518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 05/03/2011] [Indexed: 11/25/2022] Open
Abstract
Diabetes mellitus (DM) is associated with macrovascular and microvascular complications. Platelets have a “key role” in atherogenesis and its thrombotic complications in subjects with DM. Moreover, the concomitant presence of multiple “classical” cardiovascular risk factors in diabetic subjects contributes to enhanced atherothrombotic risk.
Antiplatelet agents are effective in primary and secondary prevention of arterial thrombosis (cardiovascular events, ischaemic stroke, and peripheral arterial occlusive disease). The role of chronic administration of antiplatelet drugs in primary prevention of arterial vascular events is known to be less clear than in secondary prevention, and, also in diabetic patients, the decision to give primary prophylaxis should be taken on an individual-patient basis, after a careful evaluation of the balance between the expected benefits and the risk of major bleedings.
Although, currently, treatment has proven useful in reducing vascular events, diabetic patients continue to have a higher risk of adverse cardiovascular events compared with those in nondiabetic patients.
This paper reviews the role of currently available antiplatelet drugs in primary and secondary prevention of vascular events in diabetic patients and the limitations of these drugs, and it discusses the role of novel and more potent antiplatelets and of new agents currently under clinical development.
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238
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Schrauwen-Hinderling VB, Meex RCR, Hesselink MKC, van de Weijer T, Leiner T, Schär M, Lamb HJ, Wildberger JE, Glatz JFC, Schrauwen P, Kooi ME. Cardiac lipid content is unresponsive to a physical activity training intervention in type 2 diabetic patients, despite improved ejection fraction. Cardiovasc Diabetol 2011; 10:47. [PMID: 21615922 PMCID: PMC3127755 DOI: 10.1186/1475-2840-10-47] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 05/26/2011] [Indexed: 02/06/2023] Open
Abstract
Background Increased cardiac lipid content has been associated with diabetic cardiomyopathy. We recently showed that cardiac lipid content is reduced after 12 weeks of physical activity training in healthy overweight subjects. The beneficial effect of exercise training on cardiovascular risk is well established and the decrease in cardiac lipid content with exercise training in healthy overweight subjects was accompanied by improved ejection fraction. It is yet unclear whether diabetic patients respond similarly to physical activity training and whether a lowered lipid content in the heart is necessary for improvements in cardiac function. Here, we investigated whether exercise training is able to lower cardiac lipid content and improve cardiac function in type 2 diabetic patients. Methods Eleven overweight-to-obese male patients with type 2 diabetes mellitus (age: 58.4 ± 0.9 years, BMI: 29.9 ± 0.01 kg/m2) followed a 12-week training program (combination endurance/strength training, three sessions/week). Before and after training, maximal whole body oxygen uptake (VO2max) and insulin sensitivity (by hyperinsulinemic, euglycemic clamp) was determined. Systolic function was determined under resting conditions by CINE-MRI and cardiac lipid content in the septum of the heart by Proton Magnetic Resonance Spectroscopy. Results VO2max increased (from 27.1 ± 1.5 to 30.1 ± 1.6 ml/min/kg, p = 0.001) and insulin sensitivity improved upon training (insulin stimulated glucose disposal (delta Rd of glucose) improved from 5.8 ± 1.9 to 10.3 ± 2.0 μmol/kg/min, p = 0.02. Left-ventricular ejection fraction improved after training (from 50.5 ± 2.0 to 55.6 ± 1.5%, p = 0.01) as well as cardiac index and cardiac output. Unexpectedly, cardiac lipid content in the septum remained unchanged (from 0.80 ± 0.22% to 0.95 ± 0.21%, p = 0.15). Conclusions Twelve weeks of progressive endurance/strength training was effective in improving VO2max, insulin sensitivity and cardiac function in patients with type 2 diabetes mellitus. However, cardiac lipid content remained unchanged. These data suggest that a decrease in cardiac lipid content in type 2 diabetic patients is not a prerequisite for improvements in cardiac function. Trial registration ISRCTN: ISRCTN43780395
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Affiliation(s)
- Vera B Schrauwen-Hinderling
- NUTRIM, School of Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands.
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239
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Sturek M. Tuning in to the ‘right’ calcium channel regulation in experimental models of diabetes. Br J Pharmacol 2011; 161:1455-7. [PMID: 20726982 DOI: 10.1111/j.1476-5381.2010.00997.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Elucidation of cellular and molecular mechanisms underlying vascular disease is of fundamental importance to the development of pharmacological agents to target these pathways. Pinho et al. in this issue of the BJP provide highly compelling evidence that the δ isoform of phosphatidyl inositol 3-kinase (PI3K δ) was upregulated and accounted for the increase in L-type, voltage-gated, Ca channel current in aortic vascular smooth muscle (VSM) cells of a mouse model of type 1 diabetes. There are several key issues of broad fundamental significance to this work. Firstly, what is the ‘right’ answer about calcium channel regulation in diabetes? Conflicting reports of increased and decreased Ca channel current may be due to specificity of the vascular bed and species. Then, the time course of diabetic vasculopathy may influence the expression of contractile versus proliferative phenotypes of VSM. Also the metabolic characterization of diabetes may enlighten or confound any study of diabetic vascular disease. These issues need attention to move forward work in this area.
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Affiliation(s)
- M Sturek
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana 46202-5120, USA.
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240
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Gonzalez AB, Salas D, Umpierrez GE. Special considerations on the management of Latino patients with type 2 diabetes mellitus. Curr Med Res Opin 2011; 27:969-79. [PMID: 21385020 DOI: 10.1185/03007995.2011.563505] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Latinos are the largest minority population in the United States, and are characterized by higher rates of obesity and diabetes compared to Whites. The prevalence of diagnosed diabetes in Latinos is two-fold higher than in Caucasians, and Latinos suffer from higher rates of diabetic complications and mortality. As the diabetes epidemic continues to expand and exert greater socioeconomic strain on national healthcare systems, the success of global and national healthcare initiatives for diabetes prevention and improvement of care will depend upon strategies targeted specifically toward this population. Essential to such strategies is an understanding of success factors unique to the Latino population for diabetes prevention and achievement of optimal treatment outcomes. METHODS A PubMed search was conducted for literature describing type 2 diabetes and its complications in Latinos. Specifically, we sought data describing epidemiology, disparities, management considerations, and success factors in this population. RESULTS The title search yielded more than 2000 articles, 80 of which were deemed directly relevant to this review. The inherent limitations of this subjective selection process are acknowledged. CONCLUSIONS A number of studies have highlighted various ethnic disparities in Latinos with diabetes including higher HbA1c levels, greater rates of obesity and metabolic syndrome, and a larger proportion of individuals with inadequate access to care. While relatively fewer studies describe success factors for redressing cultural disparities in diabetes, the current body of literature supports primary care strategies aimed at effective provider-patient relationships and culturally tailored education and lifestyle modification regimens. Further research demonstrating effective, culturally tailored practices that are suitable to the primary care setting would be of value to providers treating Latinos with diabetes.
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241
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Stoma size critical to 12-month outcomes in endoscopic suturing for gastric bypass repair. Surg Obes Relat Dis 2011; 8:282-7. [PMID: 21640665 DOI: 10.1016/j.soard.2011.03.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 01/18/2011] [Accepted: 03/15/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most frequently performed bariatric procedure. However, weight regain after RYGB is common and often associated with pouch and stoma dilation. Historically, revision surgery has a greater risk of morbidity and mortality than the primary procedure. Endoscopic repair appears to be a safer option; however, current knowledge is limited regarding the longer term outcomes. Our objective was to prospectively collect the 12-month post-RYGB outcomes data after repair of dilated gastric tissue with an incisionless tissue approximation system in an open-label, single-group study at 9 U.S. sites. METHODS Adults ≥ 2 years after RYGB, with weight regain and pouch and/or stoma dilation underwent tissue plication with an endolumenal anchoring system to tighten dilated gastric tissue. The outcomes were captured, with statistical modeling used to identify the predictors of success. RESULTS Of the 116 subjects, 112 (97%) had anchors successfully placed (mean 5.9 anchors/subject). The mean stoma diameter and pouch length after the procedure was 11.5 mm (50% reduction) and 3.3 cm (44% reduction), respectively. At 12 months after repair (n = 73), the mean weight loss and percentage of excess weight loss was 5.9 ± 1.1 kg and 14.5% ± 3.1%, respectively. Anchor presence was confirmed endoscopically in 61 (92%) of 66 patients at 1 year. Those with a dilated stoma (>12 mm) who had a postrepair diameter of <10 mm (n = 22, 30% of 66) had more than double the excess weight loss compared with the rest of the cohort (24% versus 10%, P = .03). No serious adverse events occurred. CONCLUSION The 12-month outcomes have demonstrated the safety and durability of this method of gastric bypass repair. Aggressive reduction of stoma dilation was associated with superior weight loss.
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242
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Gonçalves LH, Dusse LMS, Fernandes AP, Gomes KB, Sóter MO, Alves MT, Rodrigues KF, Freitas FR, Komatsuzaki F, Sousa MO, Bosco AA, Pianett GA, Carvalho MDG. Urinary 11-dehydro thromboxane B₂ levels in type 2 diabetic patients before and during aspirin intake. Clin Chim Acta 2011; 412:1366-70. [PMID: 21510926 DOI: 10.1016/j.cca.2011.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 04/06/2011] [Accepted: 04/07/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diabetic patients commonly present an increased risk for cardiovascular events, for which aspirin is the most frequently used medication for primary prevention. Urinary 11-dehydro thromboxane (11-dhTXB₂) concentrations assess the effect of aspirin on platelets and identify patients who are at risk of cardiovascular events. The present study investigated whether or not type 2 diabetic patients who took a daily dose of 100mg of aspirin had a significant reduction in urinary 11-dhTXB₂ concentrations and whether these results were associated with clinical and laboratory variables. METHODS Eighty-one type 2 diabetic patients were enrolled in the study. Laboratory tests included the determination of lipidic profile, glycated hemoglobin, platelets count, molecular analysis for both GPIIbIIIa and COX-1 polymorphisms, and urinary 11-dhTXB₂. RESULTS Patients' median value for urinary 11-dhTXB₂ before aspirin intake was 179 pg/mg of creatinine. After 15days taking aspirin, the patients presented median of 51 pg/mg of creatinine, thus revealing a significant difference between medians (p=0.00). A reduction of 95% in urinary 11-dhTXB₂ concentrations could only be identified in 4 patients (5%). A BMI of ≥ 26 presented a significant association with a reduction of urinary 11-dhTXB₂ concentrations (p=0.010), as shown by the multiple logistic regression model. Other clinical and laboratory variables showed no association. CONCLUSIONS Regardless of the mechanisms related to aspirin non-responsiveness, most patients enrolled in the present study also presented a reduced or minimal response to low-dose aspirin therapy, thereby indicating a clear variability related to aspirin effectiveness. Moreover, BMI appears to be independently associated to the reduction of urinary 11-dhTXB₂ concentrations in type 2 diabetic patients taking aspirin.
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Affiliation(s)
- Lillian Harboe Gonçalves
- Department of Clinical and Toxicological Analysis-Faculty of Pharmacy-Federal University of Minas Gerais, Belo Horizonte, Brazil
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243
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Nan WQ, Shan TQ, Qian X, Ping W, Bing GA, Ying LL. PPARα agonist prevented the apoptosis induced by glucose and fatty acid in neonatal cardiomyocytes. J Endocrinol Invest 2011; 34:271-5. [PMID: 20354356 DOI: 10.1007/bf03347084] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We investigated the effect of peroxisome proliferator activator receptors α (PPARα) on cardiomyocyte apoptosis induced by glucose and fatty acid, and if high glucose levels could increase fatty acid-induced apoptosis. METHODS Cardiomyocytes were maintained in Dulbecco's Modified Eagle Medium and divided into 5 groups: Group N (control Group); Group G (exposed to 25.5 mmol/l glucose); Group L (exposed to 5 mmol/l glucose, fatty acid); Group H (exposed to 25.5 mmol/l glucose and fatty acid); Group I (exposed to 25.5 mmol/l glucose, fatty acid and Wy14643). Apoptosis was detected by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling. Immunocytochemistry staining detected PPARα's expressing, and western blotting detected PPARα and nuclear factor κB's (NF-κB) protein level. RESULTS Exposure to fatty acid resulted in a significant increase of cardiomyocytes apoptosis, with the extension of NF-κB formation, whereas exposure to 25.5 mmol/l glucose had no influence on the apoptosis rate. However, combination with fatty acid and high glucose concentration had induced more apoptosis with the up-regulation of NF-κB formation. The fatty acid and glucose-induced effects were improved by Wy14643, with down-regulation of NF-κB formation. CONCLUSION These results suggested that in neonatal cardiomyocytes, fatty acid and glucose in combination with fatty acid induced apoptosis via NF-κB formation and activation of apoptosis pathways; glucose in combination with fatty acid induce more apoptosis rate for the more NF- κB formation, activation of the PPARα can reverse such apoptosis effect. The results also suggest that gluco-lipotoxicity may play a central role in the development of diabetic cardiomyopathy, and PPARα-agonist may be an effective drug in treating the diabetic cardiomyopathy.
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Affiliation(s)
- W Q Nan
- Department of Gerontology, First Affiliated Hospital of ChongQing Medical University, Chongqing City, China
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Ratner R, Han J, Nicewarner D, Yushmanova I, Hoogwerf BJ, Shen L. Cardiovascular safety of exenatide BID: an integrated analysis from controlled clinical trials in participants with type 2 diabetes. Cardiovasc Diabetol 2011; 10:22. [PMID: 21410975 PMCID: PMC3070629 DOI: 10.1186/1475-2840-10-22] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 03/16/2011] [Indexed: 12/22/2022] Open
Abstract
It is important for patients that treatments for diabetes not increase cardiovascular (CV) risk. The objective of this analysis was to examine retrospectively the CV safety of exenatide BID, a GLP-1 receptor agonist approved for treating hyperglycemia in patients with type 2 diabetes not adequately controlled with diet and exercise. Individual participant data was pooled to assess the relative risk (RR) of CV events with exenatide BID versus a pooled comparator (PC) group treated with either placebo or insulin from 12 controlled, randomized, clinical trials ranging from 12-52 weeks. Mean baseline values for HbA1c (8.33-8.38%), BMI (31.3-31.5 kg/m2), and duration of diabetes (8 y) were similar between groups. Trials included patients with histories of microvascular and/or macrovascular disease. Customized primary major adverse CV events (MACE) included stroke, myocardial infarction, cardiac mortality, acute coronary syndrome, and revascularization procedures. The Primary MACE RR (0.7; 95% CI 0.38, 1.31), calculated by the Mantel-Haenszel method (stratified by study), suggested that exenatide use (vs. PC) did not increase CV risk; this result was consistent across multiple analytic methods. Because the trials were not designed to assess CV outcomes, events were identified retrospectively from a list of preferred terms by physicians blinded to treatment. Other limitations included the low number of CV events, the short duration of trials (≤1 y), and a single active comparator (insulin). The results of these analyses are consistent with those of a recent retrospective analysis of a large insurance database that found that patients treated with exenatide twice daily were less likely to have a CV event than were patients treated with other glucose-lowering therapies. Keywords: GLP-1 receptor agonist, diabetes, cardiovascular safety
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Affiliation(s)
- Robert Ratner
- MedStar Health Research Institute, Hyattsville, MD, USA
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245
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Boyko EJ, Meigs JB. Does diabetes always confer coronary heart disease risk equivalent to a prior myocardial infarction?: implications for prevention. Diabetes Care 2011; 34:782-4. [PMID: 21357366 PMCID: PMC3041226 DOI: 10.2337/dc10-1958] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Edward J. Boyko
- From the Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington; the
- Department of Medicine, University of Washington, Seattle, Washington; and the
| | - James B. Meigs
- General Medicine Division, Harvard Medical School, Boston, Massachusetts
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Kengne AP, Patel A, Marre M, Travert F, Lievre M, Zoungas S, Chalmers J, Colagiuri S, Grobbee DE, Hamet P, Heller S, Neal B, Woodward M. Contemporary model for cardiovascular risk prediction in people with type 2 diabetes. ACTA ACUST UNITED AC 2011; 18:393-8. [PMID: 21450612 DOI: 10.1177/1741826710394270] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Existing cardiovascular risk prediction equations perform non-optimally in different populations with diabetes. Thus, there is a continuing need to develop new equations that will reliably estimate cardiovascular disease (CVD) risk and offer flexibility for adaptation in various settings. This report presents a contemporary model for predicting cardiovascular risk in people with type 2 diabetes mellitus. DESIGN AND METHODS A 4.5-year follow-up of the Action in Diabetes and Vascular disease: preterax and diamicron-MR controlled evaluation (ADVANCE) cohort was used to estimate coefficients for significant predictors of CVD using Cox models. Similar Cox models were used to fit the 4-year risk of CVD in 7168 participants without previous CVD. The model's applicability was tested on the same sample and another dataset. RESULTS A total of 473 major cardiovascular events were recorded during follow-up. Age at diagnosis, known duration of diabetes, sex, pulse pressure, treated hypertension, atrial fibrillation, retinopathy, HbA1c, urinary albumin/creatinine ratio and non-HDL cholesterol at baseline were significant predictors of cardiovascular events. The model developed using these predictors displayed an acceptable discrimination (c-statistic: 0.70) and good calibration during internal validation. The external applicability of the model was tested on an independent cohort of individuals with type 2 diabetes, where similar discrimination was demonstrated (c-statistic: 0.69). CONCLUSIONS Major cardiovascular events in contemporary populations with type 2 diabetes can be predicted on the basis of routinely measured clinical and biological variables. The model presented here can be used to quantify risk and guide the intensity of treatment in people with diabetes.
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Affiliation(s)
- Andre Pascal Kengne
- The George Institute for International Health, The University of Sydney, Australia
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Rodríguez A, Reviriego J, Karamanos V, del Cañizo FJ, Vlachogiannis N, Drossinos V. Management of cardiovascular risk factors with pioglitazone combination therapies in type 2 diabetes: an observational cohort study. Cardiovasc Diabetol 2011; 10:18. [PMID: 21314919 PMCID: PMC3042924 DOI: 10.1186/1475-2840-10-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 02/11/2011] [Indexed: 11/15/2022] Open
Abstract
Background Type 2 diabetes (T2D) is strongly associated with cardiovascular risk and requires medications that improve glycemic control and other cardiovascular risk factors. The authors aimed to assess the relative effectiveness of pioglitazone (Pio), metformin (Met) and any sulfonylurea (SU) combinations in non-insulin-treated T2D patients who were failing previous hypoglycemic therapy. Methods Over a 1-year period, two multicenter, open-labeled, controlled, 1-year, prospective, observational studies evaluated patients with T2D (n = 4585) from routine clinical practice in Spain and Greece with the same protocol. Patients were eligible if they had been prescribed Pio + SU, Pio + Met or SU + Met serving as a control cohort, once they had failed with previous therapy. Anthropometric measurements, lipid and glycemic profiles, blood pressure, and the proportions of patients at microvascular and macrovascular risk were assessed. Results All study treatment combinations rendered progressive 6-month and 12-month lipid, glycemic, and blood pressure improvements. Pio combinations, especially Pio + Met, were associated with increases in HDL-cholesterol and decreases in triglycerides and in the atherogenic index of plasma. The proportion of patients at high risk decreased after 12 months in all study cohorts. Minor weight changes (gain or loss) and no treatment-related fractures occurred during the study. The safety profile was good and proved similar among treatments, except for more hypoglycemic episodes in patients receiving SU and for the occurrence of edema in patients using Pio combinations. Serious cardiovascular events were rarely reported. Conclusions In patients with T2D failing prior hypoglycemic therapies, Pio combinations with SU or Met (especially Pio + Met) improved blood lipid and glycemic profiles, decreasing the proportion of patients with a high microvascular or macrovascular risk. The combination of Pio with SU or Met may therefore be recommended for T2D second-line therapy in the routine clinical practice, particularly in patients with dyslipidemia.
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Kruger DF, Bode B, Spollett GR. Understanding GLP-1 analogs and enhancing patients success. DIABETES EDUCATOR 2011; 36 Suppl 3:44S-72S; quiz 73S-74S. [PMID: 20736387 DOI: 10.1177/0145721710374370] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Recent research into the mechanisms of type 2 diabetes reveals intricate interactions among many hormonal processes. Ultimately, these pathways lead to hyperglycemia, pancreatic beta-cell failure, and the emergence of type 2 diabetes. The incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are now known to play major roles in endogenous glucose control, including regulation of insulin, glucagon, and hepatic glucose metabolism. Investigation of the incretin system has led to development of drugs that mimic or enhance the endogenous hormones, including GLP-1 receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors. This supplement describes the role of incretin hormones in the pathophysiology of type 2 diabetes and their potential as therapeutic targets for disease management. In addition, safety and efficacy profiles of the GLP-1 receptor agonists are reviewed, and the advantages and limitations of these medications are discussed from the perspective of promoting their successful implementation in individualized treatment regimens. As understanding of the underlying pathophysiology and pathogenesis of type 2 diabetes advances, the number of new therapeutic approaches expands. GLP-1 receptor agonists address several aspects of the pathophysiology of type 2 diabetes. A large body of data reveals the efficacy, safety, and tolerability of these drugs. A clear understanding of the evidence base for these drugs will translate into improved education of patients regarding their options to improve glycemic control and, ultimately, to better patient care.
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Affiliation(s)
- Davida F Kruger
- The Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, Michigan
| | - Bruce Bode
- The Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, Michigan
| | - Geralyn R Spollett
- The Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, Michigan
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Lipids, lipid-lowering therapy and diabetes complications. DIABETES & METABOLISM 2011; 37:15-24. [DOI: 10.1016/j.diabet.2010.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 09/30/2010] [Accepted: 10/01/2010] [Indexed: 01/23/2023]
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Abstract
Sibutramine is a combined norepinephrine and serotonin reuptake inhibitor used as an antiobesity agent to reduce appetite and promote weight loss in combination with diet and exercise. At a daily dose of 10-20 mg, it was initially considered to have a good safety profile, as it does not induce primary pulmonary hypertension or adverse effects on cardiac valves, in contrast to previous reports relating to some other antiobesity agents. However, it exerts disparate effects on cardiovascular risk factors. On the one hand, sibutramine may have antiatherogenic activities, as it improves insulin resistance, glucose metabolism, dyslipidemia, and inflammatory markers, with most of these effects resulting from weight loss rather than from an intrinsic effect of the drug. On the other hand, because of its specific mode of action, sibutramine exerts a peripheral sympathomimetic effect, which induces a moderate increase in heart rate and attenuates the reduction in BP attributable to weight loss or even slightly increases BP. It may also prolong the QT interval, an effect that could induce arrhythmias. Because of these complex effects, it is difficult to conclude what the final impact of sibutramine on cardiovascular outcomes might be. Sibutramine has been shown to exert favorable effects on some surrogate cardiovascular endpoints such as reduction of left ventricular hypertrophy and improvement of endothelial dysfunction. A good cardiovascular safety profile was demonstrated in numerous 1- to 2-year controlled trials, in both diabetic and nondiabetic well selected patients, as well as in several observational studies. However, since 2002, several cardiovascular adverse events (hypertension, tachycardia, arrhythmias, and myocardial infarction) have been reported in sibutramine-treated patients. This led to a contraindication of the use of this antiobesity agent in patients with established coronary heart disease, previous stroke, heart failure, or cardiac arrhythmias. SCOUT (Sibutramine Cardiovascular and Diabetes Outcome Study) was designed to prospectively evaluate the efficacy/safety ratio of sibutramine in a high-risk population. The efficacy/safety results of the first 6-week lead-in open period of treatment with sibutramine 10 mg/day were reassuring in 10 742 overweight/obese high-risk subjects (97% had cardiovascular disease, 88% had hypertension, and 84% had type 2 diabetes mellitus). However, the final results of SCOUT showed that long-term (5 years') treatment with sibutramine (10-15 mg/day) exposed subjects with pre-existing cardiovascular disease to a significantly increased risk for nonfatal myocardial infarction and nonfatal stroke, but not cardiovascular death or all-cause mortality. Because the benefit of sibutramine as a weight-loss aid seems not to outweigh the cardiovascular risks, the European Medicines Agency recommended the suspension of marketing authorizations for sibutramine across the EU. The US FDA stated that the drug should carry a 'black box' warning due to an increased risk of stroke and heart attack in patients with a history of cardiovascular disease. In conclusion, concern still persists about the safety profile of sibutramine regarding cardiovascular outcomes, and the drug should not be prescribed for overweight/obese patients with a high cardiovascular risk profile.
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Affiliation(s)
- A J Scheen
- University of Liège, Department of Medicine, CHU Liège, Liège, Belgium.
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