Epidemiology and Economic Burden of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus in Spain: A Systematic Review

Barriers and Strategies to Optimize the Use of Glucagon-Like Peptide 1 Receptor Agonists in People with Type 2 Diabetes and High Cardiovascular Risk or Established Cardiovascular Disease: A Delphi Consensus in Spain

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are effective for glycemic control, with many also demonstrating cardiovascular (CV) benefit, in people with type 2 diabetes (T2D). This study aimed to find a consensus on the barriers and strategies for the optimal use of GLP-1 RAs in people with T2D and high CV risk or established cardiovascular disease (CVD) in Spain.

METHODS

A two-round Delphi survey (53 questions) was conducted among members of four national scientific societies in Spain, including physicians experienced in the management of people with T2D. The degree of consensus was evaluated with a 7-point Likert scale, establishing consensus when ≥ 70% of the panelists agreed (6-7) or disagreed (1-2).

RESULTS

A total of 97 physicians participated in the first round (endocrinology: 34%, family and community medicine: 21%, internal medicine: 23%, and cardiology: 23%), and 96 in the second round. The main barriers identified were: therapeutic inertia and late use of GLP-1 RAs; lack of a comprehensive approach to CV risk; lack of knowledge on the usefulness of GLP-1 RAs in CVD prevention and treatment; and economic/administrative barriers. Strategies with a highest consensus included: the need to establish simple protocols that integrate awareness of CV risk monitoring; training professionals and patients; and the use of new technologies.

CONCLUSION

Physicians identified clinical, healthcare, and economic/administrative barriers that limit the use of GLP-1 RAs in people with T2D and high CV risk or established CVD in Spain, highlighting the importance of integrating these therapies according to clinical practice guidelines.

Factors influencing hospitalization or emergency department visits and mortality in type 2 diabetes following the onset of new cardiovascular diagnoses in a population-based study

BACKGROUND

Individuals with type 2 diabetes (T2D) are at increased risk of developing cardiovascular disease (CVD) which necessitates monitoring of risk factors and appropriate pharmacotherapy. This study aimed to identify factors predicting emergency department visits, hospitalizations, and mortality among T2D patients after being newly diagnosed with CVD.

METHODS

In a retrospective observational study conducted in Region Halland, individuals aged > 40 years with T2D diagnosed between 2011 and 2019, and a new diagnosis of CVD between 2016 and 2019, were followed for one year from the date of CVD diagnosis. The first encounter for CVD diagnosis was categorized as inpatient-, outpatient-, primary-, or emergency department care. Follow-up included laboratory tests, blood pressure, pharmacotherapies, and healthcare utilization. Hazard ratios (HR) in two Cox regression analyses determined relative risks for emergency visits/hospitalization and mortality, adjusting for age, sex, glucose regulation, lipid levels, kidney function, blood pressure, pharmacotherapy, and healthcare utilization.

RESULTS

The study included a total of 1759 T2D individuals who received a new CVD diagnosis, with 67% diagnosed during inpatient care. The average hospitalization stay was 6.5 days, and primary care follow-up averaged 10.1 visits. Patients with CVD diagnosed in primary care had a HR 0.52 (confidence interval [CI] 0.35-0.77) for emergency department visits/hospitalization, but age had a HR 1.02 (CI 1.00-1.03). Pharmacotherapy with insulin, DPP4-inhibitors, aldosterone antagonists, and beta-blockers had a raised HR. Highest mortality risk was observed when CVD was diagnosed inpatient care, systolic blood pressure < 100 mm Hg and elevated HbA1c. Age had a HR 1.05 (CI 1.03-1.08), eGFR < 30 ml/min HR 1.46 (CI 1.01-2.11), and LDL-Cholesterol > 2,5 h 1.46 (CI 1.01-2.11) and associated with increased mortality risk. Pharmacotherapy with metformin had a HR 0.41 (CI 0.28-0.62), statins a HR 0.39 (CI 0.27-0.57), and a primary care follow-up < 30 days a HR 0.53 (CI 0.37-0.77) and associated with lower mortality risk.

CONCLUSIONS

T2D individuals who had a new diagnosis of CVD were predominantly diagnosed when hospitalized, while follow-up typically occurred in primary care. Identifying factors that predict risks of mortality and hospitalization should be a focus of follow-up care, underscoring the critical role of primary care in the effective management of T2D and CVD.

Cost-Savings Associated with Multi-Disciplinary Team Approach for Reducing Macrovascular and Microvascular Complications in Patients with Type 2 Diabetes: A Predictive Model

Purpose

This study aims to predict the expected cost savings associated with implementing a multidisciplinary team (MDT) approach to reduce macrovascular and microvascular complications among patients with type 2 diabetes mellitus (T2DM).

Methods

This economic evaluation study was conducted in Riyadh First Health Cluster, Saudi Arabia as a predictive model conceptualized by the authors based on models used in previous studies, particularly the CORE Diabetes Model. Our model was designed based on 1) the level of glycemic control among 24,755 T2DM patients served by MDTs; 2) the expected incidence of diabetes-related complications without intervention; 3) the predicted risk reduction of developing diabetes-related complications with MDTs. Costs of complications and cost savings were then calculated and expressed as mean incremental annual cost savings adjusted for a 1% reduction in HbA1c, and a 10 mmHg reduction in systolic blood pressure (SBP).

Results

Along with the expected reduction in all diabetes-related complications, the average incremental cost savings per diabetic patient is predicted to be ($38,878) with approximately ($11,108) in the year of complication onset and ($27,770) over the subsequent post-index 10-years. On adjustment of cost savings, the average incremental cost savings are predicted to be ($22,869) for each 1% reduction in HbA1c per diabetic patient and ($27,770) for every 10 mmHg reduction in SBP per diabetic patient.

Conclusion

MDT as a model of care is effective in glycemic control among T2DM patients with a predicted significant reduction of all diabetes-related complications and in turn, a predicted significant cost savings.

Temporal trends in cardiovascular outcomes and costs among patients with type 2 diabetes

BACKGROUND

Type 2 diabetes (T2D) is a strong risk factor for cardiovascular (CV) disease. CV outcomes in T2D have generally been improving over time but recent data from the US suggest attenuation of trends in older adults with reversal of trends in younger adults. However, published data are only reported through 2015.

OBJECTIVES

To quantify trends over time in CV outcomes from 2001 to 2018, and describe changes over time in health care costs in T2D.

METHODS

This retrospective cohort study incorporated data from a regional health insurance plan. Study outcomes included acute myocardial infarction (AMI), ischemic stroke, hemorrhagic stroke, heart failure hospitalization (HFH), percutaneous coronary intervention, coronary artery bypass surgery, and all-cause mortality. Poisson regression estimated rate ratios across the entire 17-year study period (RR17).

RESULTS

Among 79,392 T2D members tracked on average 4.1 years, overall trends in AMI (RR17 = 0.69; 95% CI: 0.64, 0.74), HFH (RR17 = 0.82; 0.79, 0.86), and all-cause mortality (RR17 = 0.87; 0.84, 0.91) improved while ischemic stroke (RR17 = 2.36; 2.16, 2.57) worsened. For AMI, HFH, and all-cause mortality, trends in older age groups were significantly better than in younger age groups (interaction P-values < .001). Health care costs related to pharmaceuticals (+15%/year) and emergency department (ED) visits (>15%/year) increased at faster rates than other utilization metrics (+10%/year).

CONCLUSIONS

In T2D, overall trends in most CV outcomes improved but smaller improvements or worsening trends were observed in younger patients. Health care costs accelerated at faster rates for medications and ED visits.

Strong independent association between third-degree AV-block and diabetes mellitus using a large database

BACKGROUND

Recent data suggests an association between DM and third-degree AV- Block. The goal of this study was to evaluate the independent association between diabetes and third-degree AV-Block using a very large database.

METHOD

We used ICD-9 Codes for DM and third-degree AV-block from the Nationwide Inpatient Sample (NIS) database. We randomly selected the 1992 and 2002 databases which are 10 years apart as two independent samples. We used uni- and multi-variate analysis to evaluate this association.

RESULTS

1992 database contained a total of 6,195,744 patients. Diabetes occurred in (0.5 %) of patients with third-degree AV-block vs. (0.2 %) of the control (OR: 2.15, CI 2.06-2.25, p < 0.0001). 2002 database contained a total of 7,853,982 patients. Diabetes occurred in (0.4 %) of patients with third-degree AV-block vs. (0.2 %) of the control (OR: 1.86, CI: 1.80-1.93, p < 0.0001). Using Multivariate analysis adjusting for age, congestive heart failure, and coronary artery disease, DM remained independently associated with third-degree AV block in both databases. (for 1999: OR: 2.54, CI 2.51-2.57, p < 0.0001 and for 2002 OR: 1.56, CI 1.55-1.57, p < 0.0001).

CONCLUSION

DM is independently associated with third-degree AV-block with persistent association over a period of 10 years. The cause of this association warrants further investigation.

Cardiovascular disease and risk factors in adults with diabetes mellitus in Hungary: a population-based study

Introduction

Diabetes mellitus (DM) and cardiovascular disease (CVD) such as acute myocardial infarction, stroke, and coronary artery disease are highly prevalent conditions that are responsible for significant morbidity and mortality, particularly in Hungary. The conditions are attributed to identical risk factors, and individuals with DM are primarily susceptible to cardiovascular complications, which are the leading causes of death and disability in patients with DM. The objective of this study was to estimate the prevalence of CVD in individuals with DM and to investigate the association between potential risk factors and the presence of CVD among individuals with DM in a population-based sample.

Methods

The study was based on data from three waves of the European Health Interview Surveys (EHIS) conducted in Hungary in 2009, 2014, and 2019.

Results

The prevalence of CVD among patients with DM decreased during the study period and that socioeconomic factors, cardiometabolic risk factors including high blood pressure and high cholesterol, and depression are major contributors to CVD burden in patients with DM in Hungary.

Discussion

Our findings suggest the importance of regular check-up for hypertension and hypercholesterolemia, better focus on socioeconomic status, as well as ongoing monitoring of mental health among patients with diabetes. Further research is needed to understand the potential causes behind the observed decrease in CVD prevalence.

Atherosclerotic Cardiovascular Disease in Type 2 Diabetes: A Retrospective, Observational Study of Economic and Clinical Burden in Sweden

INTRODUCTION

Individuals with type 2 diabetes (T2D) are at high risk of experiencing atherosclerotic cardiovascular disease (ASCVD), which is associated with morbidity, mortality and healthcare resource utilisation. Clinical guidelines recommend the use of glucose-lowering medications with cardiovascular benefits in individuals with T2D and cardiovascular disease, but there is evidence that this is not reflected in clinical practice. We used linked national registry data from Sweden to compare outcomes in people with T2D and ASCVD against matched controls with T2D without ASCVD, over 5 years. Direct costs (inpatient, outpatient and selected drug costs), indirect costs resulting from work absence, early retirement, cardiovascular events and mortality were examined.

METHODS

Individuals with T2D who were at least 16 years old and were alive and resident in Sweden on 1 January 2012 were identified in an existing database. In four separate analyses, individuals with a record indicating ASCVD according to a broad definition, peripheral artery disease (PAD), stroke or myocardial infarction (MI) before 1 January 2012 were identified using diagnosis and/or procedure codes and propensity score matched 1:1 to controls with T2D and without ASCVD, using covariates for birth, sex and level of education in 2012. Follow-up continued until death, migration from Sweden or the end of the study period in 2016.

RESULTS

In total, 80,305 individuals with ASCVD, 15,397 individuals with PAD, 17,539 individuals with previous stroke and 25,729 individuals with previous MI were included. Total mean annual costs per person were €14,785 for PAD (2.7 × costs for controls), €11,397 for previous stroke (2.2 × controls), €10,730 for ASCVD (1.9 × controls) and €10,342 for previous MI (1.7 × controls). Indirect costs and costs of inpatient care were the major cost drivers. ASCVD, PAD, stroke and MI were all associated with an increased likelihood of early retirement, cardiovascular events and mortality.

CONCLUSIONS

ASCVD is associated with considerable costs, morbidity and mortality in individuals with T2D. These results support structured assessment of ASCVD risk and broader implementation of guideline-recommended treatments in T2D healthcare.

Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations

AIM

To systematically identify and appraise the international literature on the cost-effectiveness of metabolic surgery for the treatment of comorbid type 2 diabetes (T2D) and obesity.

METHODS

A systematic search was conducted in electronic databases and grey literature sources up to 20 January 2021. Economic evaluations in a T2D population or a subpopulation with T2D were eligible for inclusion. Screening, data extraction, critical appraisal of methodological quality (Consensus Health Economic Criteria list) and assessment of transferability (International Society for Pharmacoeconomics and Outcomes Research questionnaire) were undertaken in duplicate. The incremental cost-effectiveness ratio (ICER) was the main outcome. Costs were reported in 2020 Irish Euro. Cost-effectiveness was interpreted using willingness-to-pay (WTP) thresholds of €20,000 and €45,000/quality-adjusted life year (QALY). Due to heterogeneity arising from various sources, a narrative synthesis was undertaken.

RESULTS

Thirty studies across seventeen jurisdictions met the inclusion criteria; 16 specifically in a T2D population and 14 in a subpopulation with T2D. Overall, metabolic surgery was found to be cost-effective or cost-saving. Where undertaken, the results were robust to sensitivity and scenario analyses. Of the 30 studies included, 15 were considered high quality. Identified limitations included limited long-term follow-up data and uncertainty regarding the utility associated with T2D remission.

CONCLUSION

Published high-quality studies suggest metabolic surgery is a cost-effective or cost-saving intervention. As the prevalence of obesity and obesity-related diseases increases worldwide, significant investment and careful consideration of the resource requirements needed for metabolic surgery programmes will be necessary to ensure that service provision is adequate to meet demand.

GLP-1 RAs in Spain: A Short Narrative Review of Their Use in Real Clinical Practice

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a class of drugs with potent glucose-lowering activity. Additionally, some GLP-1 RAs have demonstrated cardiovascular and renal benefits. Current guidelines recommend their use in patients with type 2 diabetes (T2D) at high risk of or with established cardiovascular disease (CVD), regardless of glycaemic control, with lifestyle modification and metformin. However, several studies have recently highlighted the limited number of patients with T2D benefiting from these medications worldwide. Given the huge burden of CVD among patients with T2D, efforts should be made to bring clinical practice closer to expert guidelines. This review describes the current situation of GLP-1 RA use in Spain and the reasons behind the gap between guidelines and real-world practice and suggests possible solutions. Administrative issues, lack of awareness of the cardiovascular benefits, clinical inertia, rejection of injectable medication and costs could be some of the reasons for the current situation. Possible strategies that could help to close the gap include encouraging a multidisciplinary approach to the treatment of diabetes which involves cardiologists, endocrinologists, nephrologists, primary care providers and pharmacists; improved awareness of comorbidities and earlier evaluation and treatment or risks; and better education of healthcare providers regarding the cardioprotective benefits of these drugs.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and heart failure]

Introduction

Heart failure (HF) is one of the leading causes of morbidity and mortality among older people, making it a major public health problem. Cardiovascular diseases in general, and HF in particular, are common comorbidities in people with type 2 diabetes (DM2). The concurrence of DM2 and HF is associated with more severe clinical symptoms and signs, and poorer quality of life and prognosis. Furthermore, due to the hypercatabolic state and nutrient absorption disorders, malnutrition is present in many HF cases. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with HF.

Cost of cardiovascular diseases and renal complications in people with type 2 diabetes mellitus in the Kingdom of Saudi Arabia: A retrospective analysis of claims database

BACKGROUND

The burden of macro- and microvascular complications in patients with Type 2 diabetes mellitus (T2DM) is substantial in Middle East countries. The current study assessed the healthcare resource utilization (HCRU) and costs related to cardiovascular and renal complications among patients with T2DM.

METHODOLOGY

This non-interventional, longitudinal, retrospective, cohort study collected secondary data from three insurance claims databases across Kingdom of Saudi Arabia (KSA) of patients diagnosed with T2DM. The study included adult patients aged ≥18 years diagnosed with first cardiovascular disease (CVD) during index time period and at least one T2DM claim anytime during the study time period. The primary analyses were conducted per database, stratified by three cohorts; patients with at least one claim every six months during the 1-year pre-index and 1-year post-index period (cohort 1), patients with at least one claim every six months during the 1-year pre-index, and two years post-index period (cohort 2) and patients with at least one claim every six months during the 1-year pre-index and 3-year post-index period (cohort 3). For each Payer database, demographics, CVD subgroups, HCRU, and costs were analysed. Descriptive statistics were used to analyse the data.

RESULTS

The study sample comprised of 72-78% male and 22-28% female T2DM patients with CVD and renal complications. Patients in the age group of 35-65 years or above contributed to the significant disease burden. Nearly 68 to 80% of T2DM patients developed one CVD event, and 19 to 31% of patients developed multiple CVD events during the follow-up period. For most patients with comorbid CVD and renal disease, the average HCRU cost for post‑index periods was higher compared to 1-year pre-index period across the different visit types and activities.

CONCLUSION

The study findings elucidates the need for early initiation of therapies that would reduce the long-term cardiovascular and renal outcomes and the associated costs in patients with T2DM.

Cardiovascular disease in type 2 diabetes mellitus: progress toward personalized management

Cardiovascular diseases (CVDs) are the main cause of death among patients with type 2 diabetes mellitus (T2DM), particularly in low- and middle-income countries. To effectively prevent the development of CVDs in T2DM, considerable effort has been made to explore novel preventive approaches, individualized glycemic control and cardiovascular risk management (strict blood pressure and lipid control), together with recently developed glucose-lowering agents and lipid-lowering drugs. This review mainly addresses the important issues affecting the choice of antidiabetic agents and lipid, blood pressure and antiplatelet treatments considering the cardiovascular status of the patient. Finally, we also discuss the changes in therapy principles underlying CVDs in T2DM.

Serum metabolomic profiles associated with subclinical and clinical cardiovascular phenotypes in people with type 2 diabetes

BACKGROUND

Atherosclerotic cardiovascular diseases (CVD) is the leading cause of death in diabetes, but the full range of biomarkers reflecting atherosclerotic burden and CVD risk in people with diabetes is unknown. Metabolomics may help identify novel biomarkers potentially involved in development of atherosclerosis. We investigated the serum metabolomic profile of subclinical atherosclerosis, measured using ankle brachial index (ABI), in people with type 2 diabetes, compared with the profile for symptomatic CVD in the same population.

METHODS

The Edinburgh Type 2 Diabetes Study is a cohort of 1,066 individuals with type 2 diabetes. ABI was measured at baseline, years 4 and 10, with cardiovascular events assessed at baseline and during 10 years of follow-up. A panel of 228 metabolites was measured at baseline using nuclear magnetic resonance spectrometry, and their association with both ABI and prevalent CVD was explored using univariate regression models and least absolute shrinkage and selection operator (LASSO). Metabolites associated with baseline ABI were further explored for association with follow-up ABI and incident CVD.

RESULTS

Mean (standard deviation, SD) ABI at baseline was 0.97 (0.18, N = 1025), and prevalence of CVD was 35.0%. During 10-year follow-up, mean (SD) change in ABI was + 0.006 (0.178, n = 436), and 257 CVD events occurred. Lactate, glycerol, creatinine and glycoprotein acetyls levels were associated with baseline ABI in both univariate regression [βs (95% confidence interval, CI) ranged from - 0.025 (- 0.036, - 0.015) to - 0.023 (- 0.034, - 0.013), all p < 0.0002] and LASSO analysis. The associations remained nominally significant after adjustment for major vascular risk factors. In prospective analyses, lactate was nominally associated with ABI measured at years 4 and 10 after adjustment for baseline ABI. The four ABI-associated metabolites were all positively associated with prevalent CVD [odds ratios (ORs) ranged from 1.29 (1.13, 1.47) to 1.49 (1.29, 1.74), all p < 0.0002], and they were also positively associated with incident CVD [ORs (95% CI) ranged from 1.19 (1.02, 1.39) to 1.35 (1.17, 1.56), all p < 0.05].

CONCLUSIONS

Serum metabolites relating to glycolysis, fluid balance and inflammation were independently associated with both a marker of subclinical atherosclerosis and with symptomatic CVD in people with type 2 diabetes. Additional investigation is warranted to determine their roles as possible etiological and/or predictive biomarkers for atherosclerotic CVD.

Psychosocial adjustment in young and middle-aged adults after coronary stent implantation: A mixed-method study

BACKGROUND

Currently, the status and principal factors of psychosocial adjustment of young and middle-aged patients after coronary stent implantation (CSI) are understudied.

OBJECTIVE

To investigate the psychosocial adjustment and the life experiences of young and middle-aged patients after CSI and the corresponding support necessary to maintain psychosocial health for this patient population.

METHODS

This is a mixed-method study. Self-reported questionnaires were used to survey 236 patients after CSI from November 2019 to November 2020 in Guangdong, China. Eight of these patients were purposefully invited to participate in semi-structured interviews.

RESULTS

The mean score of psychosocial adjustment were 55.25 (SD=19.96), 55.91 (SD=17.99) for the young and middle-aged patients after CSI respectively. The results of regression analysis showed that resilience, social support, and having diabetes were predictors of psychosocial adjustment of young patients after CSI (R²=0.703, P<0.001). Resilience, social support, current cardiac function, and need to care for parents with chronic diseases were identified as predictors of psychosocial adjustment among middle-aged patients after CSI (R²=0.640, P<0.001). Two themes and six sub-themes related to adjustment challenges and adjustment efforts were identified from the in-depth interviews.

CONCLUSIONS

Psychosocial adjustment of young and middle-aged patients after CSI still needs to be improved. Higher level of social support and resilience would promote patient's psychosocial adjustment after CSI. Diabetes was a negative factor of psychosocial adjustment in young patients, whereas limited cardiac function, need to take care of parents with chronic diseases were negative factors in middle-aged patients. After CSI, both young and middle-aged patients faced various challenges of adjustment.

Cardiovascular Profile of Patients with Type 2 Diabetes in France Based on REWIND CVOT Inclusion Criteria: A Real-World Retrospective Study

INTRODUCTION

The REWIND study demonstrated a cardiovascular (CV) benefit of dulaglutide treatment in patients with type 2 diabetes (T2D) with or without established cardiovascular disease (CVD). The current study aims to describe similarities and differences between characteristics of patients with T2D in France and the REWIND population.

METHODS

A retrospective, observational study was conducted in France using primary care IQVIA electronic medical records. Patients aged ≥ 18 years with at least one clinical visit and/or glucose-lowering agent prescription in 2019 were identified. The percentages of patients aged ≥ 50 years with established CVD, aged ≥ 55 years with subclinical CVD or aged ≥ 60 years with multiple CV risk factors based on REWIND definitions were calculated.

RESULTS

A total of 63,927 patients with T2D were included. Mean age was 67 years, 93% were aged ≥ 50 years and 58% were male. The median time since T2D diagnosis was 5.6 years, mean glycated hemoglobin was 7.1% and mean body mass index was 30.4 kg/m². Of the patients included in the current study, 59.4% fulfilled REWIND CV criteria; 12.4% of patients were ≥ 50 years old with established CVD; 9.7% of patients were aged ≥ 55 years with subclinical vascular disease and 44.7% were aged ≥ 60 years with ≥ 2 CV risk factors.

CONCLUSION

Almost 60% of this primary care French cohort with T2D fulfilled key REWIND CV criteria, with a lower percentage of patients having established CVD than REWIND participants.

Diabetic Heart Failure with Preserved Left Ventricular Ejection Fraction: Review of Current Pharmacotherapy

Diabetes is associated with several diabetic-related abnormalities which increase the risk of onset or worsening of heart failure. Recent studies showed that the majority of diabetic patients present with heart failure with preserved ejection fraction (HFpEF), and the prevalence of HFpEF in diabetics is alarming. Moreover, outcomes in HFpEF are poor and could be compared to those of heart failure with reduced ejection fraction (HFrEF), with 1-year mortality ranging between 10 and 30%. In contrast to HFrEF, there is very limited evidence for pharmacologic therapy in symptomatic patients with preserved ejection fraction, and therefore, the optimal selection of treatment for diabetic HFpEF remains challenging. This narrative review article summarizes the currently available data on the pharmacological treatment of HFpEF in patients with diabetes.

AGEs-Induced and Endoplasmic Reticulum Stress/Inflammation-Mediated Regulation of GLUT4 Expression and Atherogenesis in Diabetes Mellitus

In recent decades, complex and exquisite pathways involved in the endoplasmic reticulum (ER) and inflammatory stress responses have been demonstrated to participate in the development and progression of numerous diseases, among them diabetes mellitus (DM). In those pathways, several players participate in both, reflecting a complicated interplay between ER and inflammatory stress. In DM, ER and inflammatory stress are involved in both the pathogenesis of the loss of glycemic control and the development of degenerative complications. Furthermore, hyperglycemia increases the generation of advanced glycation end products (AGEs), which in turn refeed ER and inflammatory stress, contributing to worsening glycemic homeostasis and to accelerating the development of DM complications. In this review, we present the current knowledge regarding AGEs-induced and ER/inflammation-mediated regulation of the expression of GLUT4 (solute carrier family 2, facilitated glucose transporter member 4), as a marker of glycemic homeostasis and of cardiovascular disease (CVD) development/progression, as a leading cause of morbidity and mortality in DM.

The economic burden of stroke: a systematic review of cost of illness studies

Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.