Review of prevalence and outcome of vascular disease in patients with diabetes mellitus

Unsupervised shape-and-texture-based generative adversarial tuning of pre-trained networks for carotid segmentation from 3D ultrasound images

BACKGROUND

Vessel-wall volume and localized three-dimensional ultrasound (3DUS) metrics are sensitive to the change of carotid atherosclerosis in response to medical/dietary interventions. Manual segmentation of the media-adventitia boundary (MAB) and lumen-intima boundary (LIB) required to obtain these metrics is time-consuming and prone to observer variability. Although supervised deep-learning segmentation models have been proposed, training of these models requires a sizeable manually segmented training set, making larger clinical studies prohibitive.

PURPOSE

We aim to develop a method to optimize pre-trained segmentation models without requiring manual segmentation to supervise the fine-tuning process.

METHODS

We developed an adversarial framework called the unsupervised shape-and-texture generative adversarial network (USTGAN) to fine-tune a convolutional neural network (CNN) pre-trained on a source dataset for accurate segmentation of a target dataset. The network integrates a novel texture-based discriminator with a shape-based discriminator, which together provide feedback for the CNN to segment the target images in a similar way as the source images. The texture-based discriminator increases the accuracy of the CNN in locating the artery, thereby lowering the number of failed segmentations. Failed segmentation was further reduced by a self-checking mechanism to flag longitudinal discontinuity of the artery and by self-correction strategies involving surface interpolation followed by a case-specific tuning of the CNN. The U-Net was pre-trained by the source dataset involving 224 3DUS volumes with 136, 44, and 44 volumes in the training, validation and testing sets. The training of USTGAN involved the same training group of 136 volumes in the source dataset and 533 volumes in the target dataset. No segmented boundaries for the target cohort were available for training USTGAN. The validation and testing of USTGAN involved 118 and 104 volumes from the target cohort, respectively. The segmentation accuracy was quantified by Dice Similarity Coefficient (DSC), and incorrect localization rate (ILR). Tukey's Honestly Significant Difference multiple comparison test was employed to quantify the difference of DSCs between models and settings, wherep ≤ 0.05 $p\,\le \,0.05$ was considered statistically significant.

RESULTS

USTGAN attained a DSC of85.7 ± 13.0 $85.7\,\pm \,13.0$ % in LIB and86.2 ± 10.6 ${86.2}\,\pm \,{10.6}$ % in MAB, improving from the baseline performance of74.6 ± 30.7 ${74.6}\,\pm \,{30.7}$ % in LIB (p< 10 - 12 $<10^{-12}$ ) and75.7 ± 28.9 ${75.7}\,\pm \,{28.9}$ % in MAB (p< 10 - 12 $<10^{-12}$ ). Our approach outperformed six state-of-the-art domain-adaptation models (MAB:p ≤ 3.63 × 10 - 7 $p \le 3.63\,\times \,10^{-7}$ , LIB:p ≤ 9.34 × 10 - 8 $p\,\le \,9.34\,\times \,10^{-8}$ ). The proposed USTGAN also had the lowest ILR among the methods compared (LIB: 2.5%, MAB: 1.7%).

CONCLUSION

Our framework improves segmentation generalizability, thereby facilitating efficient carotid disease monitoring in multicenter trials and in clinics with less expertise in 3DUS imaging.

Medical treatments for abdominal aortic aneurysm: an overview of clinical trials

INTRODUCTION

Abdominal aortic aneurysm is a progressive, segmental, abdominal aortic dilation associated with a high mortality rate. Abdominal aortic aneurysms with diameters larger than 55 mm are associated with a high risk of rupture, and the most effective treatment options are surgical repair. Close observation and lifestyle adjustments are recommended for smaller abdominal aortic aneurysms with lower rupture risk. The development of medical therapies that limit or prevent the progression, expansion, and eventual rupture of abdominal aortic aneurysms remains an unmet clinical need.

AREAS COVERED

This review provides an overview of completed and ongoing clinical trials examining the efficacies of various drug classes, including antibiotics, antihypertensive drugs, hypolipidemic drugs, hypoglycemic drugs, and other potential therapies for abdominal aortic aneurysms. A search of PubMed, Web of Science, Clinical Trials, and another six clinical trial registries was conducted in January 2024.

EXPERT OPINION

None of the drugs have enough evidence to indicate that they can effectively inhibit the dilation of abdominal aortic aneurysm. More clinical trial data is required to support the efficacy of propranolol. Future research should also explore different drug delivery mechanisms, such as nanoparticles, to elevate drug concentration at the aneurysm wall.

Non-coronary arterial outcomes in people with type 1 diabetes mellitus: a Swedish retrospective cohort study

Background

Observational studies on long-term trends, risk factor association and importance are scarce for type 1 diabetes mellitus and peripheral arterial outcomes. We set out to investigate trends in non-coronary complications and their relationships with cardiovascular risk factors in persons with type 1 diabetes mellitus compared to matched controls.

Methods

34,263 persons with type 1 diabetes mellitus from the Swedish National Diabetes Register and 164,063 matched controls were included. Incidence rates of extracranial large artery disease, aortic aneurysm, aortic dissection, lower extremity artery disease, and diabetic foot syndrome were analyzed using standardized incidence rates and Cox regression.

Findings

Between 2001 and 2019, type 1 diabetes mellitus incidence rates per 100,000 person-years were as follows: extracranial large artery disease 296.5-84.3, aortic aneurysm 0-9.2, aortic dissection remained at 0, lower extremity artery disease 456.6-311.1, and diabetic foot disease 814.7-77.6. Persons with type 1 diabetes mellitus with cardiometabolic risk factors at target range did not exhibit excess risk of extracranial large artery disease [HR 0.83 (95% CI, 0.20-3.36)] or lower extremity artery disease [HR 0.94 (95% CI, 0.30-2.93)], compared to controls. Persons with type 1 diabetes with all risk factors at baseline, had substantially elevated risk for diabetic foot disease [HR 29.44 (95% CI, 3.83-226.04)], compared to persons with type 1 diabetes with no risk factors. Persons with type 1 diabetes mellitus continued to display a lower risk for aortic aneurysm, even with three cardiovascular risk factors at baseline [HR 0.31 (95% CI, 0.15-0.67)]. Relative importance analyses demonstrated that education, glycated hemoglobin (HbA1c), duration of diabetes and lipids explained 54% of extracranial large artery disease, while HbA1c, smoking and systolic blood pressure explained 50% of lower extremity artery disease and HbA1c alone contributed to 41% of diabetic foot disease. Income, duration of diabetes and body mass index explained 66% of the contribution to aortic aneurysm.

Interpretation

Peripheral arterial complications decreased in persons with type 1 diabetes mellitus, except for aortic aneurysm which remained low. Besides glycemic control, traditional cardiovascular risk factors were associated with incident outcomes. Risk of these outcomes increased with additional risk factors present. Persons with type 1 diabetes mellitus exhibited a lower risk of aortic aneurysm compared to controls, despite presence of cardiovascular risk factors.

Funding

Swedish Governmental and the county support of research and education of doctors, the Swedish Heart and Lung Foundation, Sweden and Åke-Wibergs grant.

Protection of diabetes in aortic abdominal aneurysm: Are antidiabetics the real effectors?

Aortic aneurysms, including abdominal aortic aneurysms (AAAs), is the second most prevalent aortic disease and represents an important cause of death worldwide. AAA is a permanent dilation of the aorta on its infrarenal portion, pathologically associated with oxidative stress, proteolysis, vascular smooth muscle cell loss, immune-inflammation, and extracellular matrix remodeling and degradation. Most epidemiological studies have shown a potential protective role of diabetes mellitus (DM) on the prevalence and incidence of AAA. The effect of DM on AAA might be explained mainly by two factors: hyperglycemia [or other DM-related factors such as insulin resistance (IR)] and/or by the effect of prescribed DM drugs, which may have a direct or indirect effect on the formation and progression of AAAs. However, recent studies further support that the protective role of DM in AAA may be attributable to antidiabetic therapies (i.e.: metformin or SGLT-2 inhibitors). This review summarizes current literature on the relationship between DM and the incidence, progression, and rupture of AAAs, and discusses the potential cellular and molecular pathways that may be involved in its vascular effects. Besides, we provide a summary of current antidiabetic therapies which use could be beneficial for AAA.

Differences in structural connectivity between diabetic and psychological erectile dysfunction revealed by network-based statistic: A diffusion tensor imaging study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) has been found to be associated with abnormalities of the central and peripheral vascular nervous system, which were considered to be involved in the development of cognitive impairments and erectile dysfunction (ED). In addition, altered brain function and structure were identified in patients with ED, especially psychological ED (pED). However, the similarities and the differences of the central neural mechanisms underlying pED and T2DM with ED (DM-ED) remained unclear.

METHODS

Diffusion tensor imaging data were acquired from 30 T2DM, 32 ED, and 31 DM-ED patients and 47 healthy controls (HCs). Then, whole-brain structural networks were constructed, which were mapped by connectivity matrices (90 × 90) representing the white matter between 90 brain regions parcellated by the anatomical automatic labeling template. Finally, the method of network-based statistic (NBS) was applied to assess the group differences of the structural connectivity.

RESULTS

Our NBS analysis demonstrated three subnetworks with reduced structural connectivity in DM, pED, and DM-ED patients when compared to HCs, which were predominantly located in the prefrontal and subcortical areas. Compared with DM patients, DM-ED patients had an impaired subnetwork with increased structural connectivity, which were primarily located in the parietal regions. Compared with pED patients, an altered subnetwork with increased structural connectivity was identified in DM-ED patients, which were mainly located in the prefrontal and cingulate areas.

CONCLUSION

These findings highlighted that the reduced structural connections in the prefrontal and subcortical areas were similar mechanisms to those associated with pED and DM-ED. However, different connectivity patterns were found between pED and DM-ED, and the increased connectivity in the frontal-parietal network might be due to the compensation mechanisms that were devoted to improving erectile function.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

BACKGROUND

Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS.

METHODS

A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up.

RESULTS

There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04).

CONCLUSION

The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

Exploring the Correlation and Protective Role of Diabetes Mellitus in Aortic Aneurysm Disease

Introduction: Diabetes mellitus is recognised as a significant risk factor for cardiovascular and peripheral vascular disease, as the abnormal metabolic state increases the risk for atherosclerosis, occlusive arterial disease and vascular dysfunction. There have been reports of potential association across the literature that illustrates a link between diabetes mellitus and aortic aneurysm, with the former having a protective role on the development of the latter.

Methods: A thorough literature search was performed through electronic databases, to provide a comprehensive review of the study's reporting on the association of diabetes mellitus and aortic aneurysm, discussing the mechanisms that have been reported; furthemore, we reviewed the reports of the impact of oral hypoglycameic agents on aortic aneurysms.

Results: Various proposed mechanisms are involved in this protective process including endothelial dysfunction, chronic hyperglycemia and insulin resistance. The evidence suggests a negative association between these disease process, with prevelance of diabetes mellitus resulting in lower rates of aortic aneurysm, via its protective mechanistic action. The increase in advanced glycation end products, increased arterial stiffness and vascular remodelling seen in diabetes, was found to have a profound impact on aneurysm development, its slow progression and lower rupture rate in these individuals. This review has also highlighted the role of oral hypoglycaemic agents having a protective effect against AA disease.

Conclusion: A decrease in development, progression and mortality from aortic aneurysms as well as reduced rates of dissection, have been observed in those with diabetes. This review has provided a comprehensive insight on the effect of diabetes and its physiological processes, and elements of its con-committant treatment, having a protective role against these aortic diseases.

Nationwide study in France investigating the impact of diabetes on mortality in patients undergoing abdominal aortic aneurysm repair

The aim of this nationwide study was to analyze the impact of diabetes on post-operative mortality in patients undergoing AAA repair in France. This 10-year retrospective, multicenter study based on the French National electronic health data included patients undergoing AAA repair between 2010 and 2019. In-hospital post-operative mortality was analyzed using Kaplan–Meier curve survival and Log-Rank tests. A multivariate regression analysis was performed to calculate Hazard Ratios. Over 79,935 patients who underwent AAA repair, 61,146 patients (76.5%) had at least one hospital-readmission after the AAA repair, for a mean follow-up of 3.5 ± 2.5 years. Total in-hospital mortality over the 10-year study was 16,986 (21.3%) and 4581 deaths (5.8%) occurred during the first hospital stay for AAA repair. Age over 64 years old, the presence of AAA rupture and hospital readmission at 30-day were predictors of post-operative mortality (AdjHR = 1.59 CI 95% 1.51–1.67; AdjHR = 1.49 CI 95% 1.36–1.62 and AdjHR = 1.92, CI 95% 1.84–2.00). The prevalence of diabetes was significantly lower in ruptured AAA compared to unruptured AAA (14.8% vs 20.9%, P < 0.001 for type 2 diabetes and 2.5% vs 4.0%, P < 0.001 for type 1 diabetes). Type 1 diabetes was significantly associated with post-operative mortality (AdjHR = 1.30 CI 95% 1.20–1.40). For type 2 diabetes, the association was not statistically significant (Adj HR = 0.96, CI 95% 0.92–1.01). Older age, AAA rupture and hospital readmission were associated with deaths that occurred after discharge from the first AAA repair. Type 1 diabetes was identified as a risk factor of post-operative mortality. This study highlights the complex association between diabetes and AAA and should encourage institutions to report long-term follow-up after AAA repair to better understand its impact.

The impact of diabetes mellitus on carotid artery stenting: a meta-analysis

Diabetes is considered to be one of the important factors affecting the prognosis of patients undergoing carotid endarterectomy (CEA), but its effect on carotid stenting (CAS) has not been determined. We performed this analysis to evaluate the impact of diabetes mellitus (DM) on carotid stenting. Studies were searched in the MEDLINE, EMBASE, and Cochrane Library databases for all available studies comparing the outcomes of diabetic and nondiabetic patients who underwent CAS. A meta-analysis was performed using the Mantel-Haenszel model to calculate odds ratios (ORs) with RevMan 5.3 software. Five studies with high quality were ultimately included. A total of 3364 patients underwent CAS, including 1042 diabetic patients and 2322 nondiabetic patients. Meta-analysis showed that there was no statistically significant difference in the risk of perioperative stroke(OR,1.20;95%CI,0.74-1.97;P = 0.46;I² = 24%), transient ischemic attack(TIA)(OR,1.46;95%CI,0.80-2.66;P=0.22;I²=37%), myocardial infarction(MI)(OR,1.12;95%CI,0.47-2.67;P=0.80;I²=0%), mortality (OR,1.77;95%CI,0.91-3.42;P = 0.09;I²=0%), and composite of stroke or death (OR,1.26;95%CI,0.87-1.81;P = 0.22;I²=35%) between diabetic and nondiabetic patients receiving CAS. Sensitivity analysis showed that the meta-analysis results of all outcome events were stable. Compared with nondiabetic patients, diabetes did not increase the risk of the following: perioperative stroke, TIA, MI, mortality, and composite of stroke or death in patients receiving CAS. This study may be used to guide carotid artery stenosis patients with diabetes to choose the optimal treatment option. However, due to the limited number of studies and the different technical levels of institutions, the results should be interpreted caution.

Outcomes of Endovascular Repair for Abdominal Aortic Aneurysms: A Nationwide Survey in Japan

OBJECTIVE

To analyze data on patients treated with a bifurcated stent graft for abdominal aortic aneurysm (AAA).

BACKGROUND

The Japan Committee for Stentgraft Management (JACSM) was established in 2007 to manage the safety of endovascular aortic aneurysm repair (EVAR) in Japan. The JACSM registry includes detailed anatomical and clinical data of all patients who undergo stent graft insertion in Japan.

METHODS

Among 51,380 patients treated with bifurcated stent graft for AAA, we identified 38,008 eligible patients (excluding those with rupture or insufficient data). The analyzed factors included age, sex, comorbidities, AAA pathology and etiology, aneurysm and neck diameters, 7 anti-instructions for use (IFU) factors, and endoleaks at hospital discharge. The endpoints were death, adverse events, sac dilatation (≥5 mm), and reintervention.

RESULTS

The rates of intraoperative and in-hospital mortality were 0.08% and 1.07%, respectively. Infectious aneurysm and pseudo-aneurysm were associated with overall survival and reintervention. Older age, large aneurysm diameter, and all types of persistent endoleaks were strong predictors of adverse events, sac dilatation, and reintervention. Comorbid cerebrovascular disease, renal dysfunction, and respiratory disorders were also risk factors. In total, 47.6% of patients violated the IFU; among the anti-IFU factors assessed, poor access and severe neck calcification were strong risk factors for mortality, reintervention, and adverse events. The sac dilatation rate at 5 years was 23.3%.

CONCLUSIONS

Although the analysis included EVAR with poor anatomy, the perioperative mortality rate was acceptable compared with that in previous large population studies.

Diabetes and aortic aneurysm: current state of the art

Aortic aneurysm is a life-threatening disease due to the risk of aortic rupture. The only curative treatment available relies on surgical approaches; drug-based therapies are lacking, highlighting an unmet need for clinical practice. Abdominal aortic aneurysm (AAA) is frequently associated with atherosclerosis and cardiovascular risk factors including male sex, age, smoking, hypertension, and dyslipidaemia. Thoracic aortic aneurysm (TAA) is more often linked to genetic disorders of the extracellular matrix and the contractile apparatus but also share similar cardiovascular risk factors. Intriguingly, a large body of evidence points to an inverse association between diabetes and both AAA and TAA. A better understanding of the mechanisms underlying the negative association between diabetes and aortic aneurysm could help the development of innovative diagnostic and therapeutic approaches to tackle the disease. Here, we summarize current knowledge on the relationship between glycaemic parameters, diabetes, and the development of aortic aneurysm. Cellular and molecular pathways that underlie the protective effect of diabetes itself and its treatment are reviewed and discussed, along with their potential implications for clinical translation.

Association of abdominal aortic aneurysm diameter with insulin resistance index

Introduction

Epidemiological studies have highlighted a negative association between diabetes and abdominal aortic aneurysm (AAA). The aim of this study was to investigate the association between insulin resistance and AAA size.

Materials and methods

This prospective cross sectional monocentric study analysed fasting blood samples from 55 patients with AAA eligible for surgical repair. They were divided into 2 groups according to the median AAA diameter: diameter < 50 mm (N = 28) and diameter > 50 mm (N = 27). The median ages were respectively 73 years (62 - 79) and 72 years (67 - 81). Glucose and fructosamine concentrations were determined by spectrophotometry; insulin and C-peptide using chemiluminescent technology. Homeostasis model assessment 2 calculator was used to estimate insulin resistance index (HOMA2 IR).

Results

There was no significant difference for fasting glucose concentration between the groups (6.1 vs. 5.9 mmol/L, P = 0.825). C-peptide and insulin concentrations, as well as HOMA2 IR index were significantly higher in patients with AAA > 50 mm (0.82 vs. 0.54 nmol/L, P = 0.012; 9 vs. 5 mU/L, P = 0.019 and 1.72 vs. 1.26, P = 0.028, respectively). No linear correlation was identified between AAA diameter and HOMA2 IR. Fructosamine concentration was lower in patients with AAA > 50 mm (225.5 vs. 251 μmol/L, P = 0.005) and negatively correlated with AAA diameter (r = - 0.54, P < 0.001).

Conclusion

This study evidenced an association between AAA diameter and insulin resistance. Further studies are required to determine a causal link between insulin resistance and AAA development.

Is diabetes a marker of higher risk after carotid revascularization? Experience from a single centre

PURPOSE

This single centre study investigates the influence of diabetes mellitus on outcomes following carotid artery endarterectomy or stenting.

METHODS

In total, 752 carotid revascularizations (58.2% carotid artery stenting and 41.8% carotid endarterectomy) were performed in 221 (29.4%) patients with diabetes and 532 (70.6%) patients without diabetes. The study outcomes were death, disabling and non-disabling stroke, transient ischaemic attack and restenosis within 36 months after the procedure.

RESULTS

Patients with diabetes had higher periprocedural risk of any stroke or death (3.6% diabetes vs 0.6% no diabetes; p < 0.05), transient ischaemic attack (1.8% diabetes vs 0.2% no diabetes; p > 0.05) and restenosis (2.7% diabetes vs 0.6% no diabetes; p < 0.05). During long-term follow-up, there were no significant differences in Kaplan-Meier estimates of freedom from death, any stroke and transient ischaemic attack, between people with and without diabetes for each carotid artery stenting and carotid endarterectomy subgroup. Patients with diabetes showed higher rates of restenosis during follow-up than patients without diabetes (36-months estimate risk of restenosis: 21.2% diabetes vs 12.5% no diabetes; p < 0.05).

CONCLUSION

The presence of diabetes was associated with increased periprocedural risk, but no further additional risk emerged during longer term follow-up. Restenosis rates were higher among patients with diabetes.

Investigation of Plasma Inflammatory Profile in Diabetic Patients With Abdominal Aortic Aneurysm: A Pilot Study

INTRODUCTION:

Clinical studies have unraveled a negative association between diabetes and abdominal aortic aneurysm (AAA), but the mechanisms involved are still poorly understood. The aim of this study was to determine whether diabetic patients with AAA had a distinct plasma inflammatory profile compared to nondiabetic patients.

METHODS:

Plasma samples were obtained from 10 diabetic patients with AAA and 10 nondiabetic patients with AAA. The relative protein expression of 92 inflammatory-related human protein biomarkers was assessed by proximity extension assay technology using Proseek Multiplex Inflammation I kit (Olink).

RESULTS:

Clinical characteristics were similar in diabetic patients with AAA compared to nondiabetic patients with AAA, the median ages being 67 and 73 years, respectively ( P = .61). The AAA diameters were, respectively, 50 and 49 mm ( P = .72). Among the 92 markers screened, 67 (72.8%) were detected in all samples. Diabetic patients had significantly lower protein expression of C-C motif chemokine 19 (CCL19) and C-C motif chemokine 23 (CCL23; 542.3 vs 980.3, P = .01 and 1236 vs 1406, P = .04, respectively). They tended to have higher expression of tumor necrosis factor ligand superfamily member 14 (TNFSF14) compared to controls (14.6 vs 10.8, P = .05).

CONCLUSION:

Diabetic patients with AAA differentially expressed CCL19, CCL23 and TNFSF14 in plasma compared to nondiabetic patients with AAA. Further studies are required to determine whether the markers identified could play a role in the negative association between diabetes and AAA pathogenesis.

The association between Solar Lentigines and Type-2 Diabetes

Background

Limited information exists between the associations of diabetes mellitus (DM) and solar lentigo (SL); a benign, common skin lesion characterized by hyperpigmented macules.

Methods

This study was conducted on 90 patients diagnosed with DM and their age and sex matched controls who were referred to the Departments of Endocrinology at Babol University of Medical Science in Northern of Iran from January 2013 to December 2015. All demographic data including age, gender, occupation, family history of DM, estimated average sun exposure and presence of skin lesions were collected and analyzed.

Results

Presence of SL was significantly higher among patients with DM compared to controls (61.9% vs 33.6%, P<0.001). After adjusting for age, sex and sun exposure rate, results indicated that DM was independently associated with the presence of SL (p=0.002). Stratifying patients based on gender, indicated that DM was significantly associated with SL in females (p=0.03), but not in male patients (p=0.06).

Conclusion

The findings of the present study indicate that DM is an independent risk factor for the occurrence of SL lesions. These findings could represent a novel association between DM as a chronic oxidation state and SL as an early sign of aging.

Revascularization Surgery: Its Efficacy for Limb Salvage in Diabetic Foot

The estimated prevalence of diabetes is 9.78% in Taiwan. The lifetime risk for patients with diabetes to have foot ulcers might be as high as 25%. About 15% of these patients require major limb amputation because of ischemia and infection. Peripheral artery disease is still a major problem involved in diabetic foot disease and the cause for major amputation despite an increase in the prevalence of revascularization surgery and new revascularization techniques over the past 20 years. We investigated the major limb amputation rates in patients with diabetic foot and critical limb ischemia who had undergone revascularization surgery in our hospital. The records of 42 patients who had undergone revascularization surgery for diabetic foot were retrospectively reviewed. Nineteen patients (45%) required major limb amputation despite revascularization. The affected limbs of only 15 patients (36%) were salvaged. Four patients died soon after surgery because of comorbidities, and another 4 were lost to follow-up. Two patients died from procedure-related sepsis, and overall perioperative mortality was 4.8%. Ten predictive risk factors (duration of diabetes, history of smoking, coronary artery disease, congestive heart failure, cerebral vascular accident, contralateral amputation, end-stage renal disease, fever episode, wound infection severity score, and arterial obstruction level) were included for analysis. Although none was significant, long-duration diabetes (OR: 1.13), end-stage renal disease (OR: 10.02), wound infection (OR: 1.56), and infrapopliteal lesions (OR: 3.00) tended to be unfavorable predictive risk factors of limb amputation. Revascularization surgery is still potentially beneficial for these patients--eg, it decreases the contralateral limb amputation rate by 7.5%--if done early in high-risk patients.

Abdominal aortic aneurysms and diabetes mellitus

There is accumulating evidence that risk profiles differ between coronary artery disease and abdominal aortic aneurysms (AAAs). However, diabetes mellitus (DM) appears to be negatively associated with AAA formation. The underlying mechanisms for this negative relationship are far from defined, but may include: increased arterial wall matrix formation via advanced glycation end products; suppression of plasmin and reduction of levels and activity of matrix metalloproteinases (MMP)-2 and 9; diminished aortic wall macrophage infiltration, elastolysis and neovascularization. In addition, the effect of pharmacological agents used for the treatment of patients with DM on AAA formation has been studied with rather controversial results. Statins, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, fenofibrate, antibiotics and some hypoglycemic agents are beginning to be appreciated for a potential modest protection from AAAs, but further studies are needed.

Abdominal Aortic Diameter and the Risk for Asymptomatic Peripheral Arterial Disease in Patients with Type 2 Diabetes

Peripheral arterial disease (PAD) is common among older people because it often results from atherosclerosis, which becomes more common with age. The disease is particularly common among people who have diabetes. Little information is available on the relation between abdominal aortic diameter and PAD in elderly patients with diabetes. This article studies the relationships between abdominal aortic diameter, PAD, and the cardiovascular risk factors in asymptomatic elderly patients suffering from type 2 diabetes mellitus. A case-control study was conducted on 90 participants aged 60 years and older divided into 60 cases (30 males and 30 females) and 30 age-matched healthy controls (15 males and 15 females). The relationships between the size of the abdominal aorta and ankle-brachial index (ABI), plasma cholesterol, triglycerides (TG), and high-sensitivity C-reactive protein were examined. Approximately, 15% of patients with diabetes had asymptomatic PAD. The patients with diabetes with PAD were of older age (70.4 ± 3.6 vs. 63.4 ± 3.9 years; p = 0.000), had larger abdominal aortic diameter (22.4 ± 3.08 vs. 18.7 ± 2 mm; p = 0.000), and higher CRP levels (8.3 ± 1.1 vs. 5.8 ± 2.2 mg/L; p = 0.002), while other variables revealed no significant difference. Abdominal aortic diameter correlated well with ABI measured by Doppler method in diabetic patients (r =  - 0.471, p = 0.000). Older age and larger abdominal aorta are independent risk factors for asymptomatic PAD in the elderly with type 2 diabetes mellitus.

Angelica sinensis polysaccharide regulates glucose and lipid metabolism disorder in prediabetic and streptozotocin-induced diabetic mice through the elevation of glycogen levels and reduction of inflammatory factors

Hypoglycemic and hypolipidemic effects of ASP in prediabetic and T2DM mice.

A longitudinal comparison of hemodynamics and intraluminal thrombus deposition in abdominal aortic aneurysms

Abdominal aortic aneurysm (AAA) is often accompanied by in traluminal thrombus (ILT), which complicates AAA progression and risk of rupture. Patient-specific computational fluid dynamics modeling of 10 small human AAA was performed to investigate relations between hemodynamics and ILT progression. The patients were imaged using magnetic resonance twice in a 2- to 3-yr interval. Wall content data were obtained by a planar T1-weighted fast spin echo black-blood scan, which enabled quantification of thrombus thickness at midaneurysm location during baseline and followup. Computational simulations with patient-specific geometry and boundary conditions were performed to quantify the hemodynamic parameters of time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and mean exposure time at baseline. Spatially resolved quantifications of the change in ILT thickness were compared with the different hemodynamic parameters. Regions of low OSI had the strongest correlation with ILT growth and demonstrated a statistically significant correlation coefficient. Prominent regions of high OSI (>0.4) and low TAWSS (<1 dyn/cm(2)) did not appear to coincide with locations of thrombus deposition.

Nuclear factor (erythroid-derived 2)-like 2 (NFE2L2) is a novel therapeutic target for diabetic complications

Diabetes is a leading cause of death and disability. In 2004, 3.4 million people worldwide died of symptoms relating to high blood sugar. Diabetic complications are caused by organ damage resulting from long-term exposure to high blood sugar, and include diseases such as heart failure, kidney failure, vision loss and neuropathy. The transcription factor nuclear factor (erythroid-derived 2)-like 2 (NFE2L2, also known as NRF2) is an important component of the intracellular antioxidant machinery and a target for treatment of diabetic complications. This article reviews the role of NFE2L2 in diabetic complications with a focus on diabetic nephropathy, cardiomyopathy, neuropathy and retinopathy. Activation of NFE2L2 protects against oxidative stress in vitro and in vivo, and represents an important target for prophylaxis and treatment of diabetic complications. NFE2L2 has potential clinical applications for diabetic patients in the near future.

Contemporary evaluation and management of the diabetic foot

Foot problems in patients with diabetes remain a major public health issue and are the commonest reason for hospitalization of patients with diabetes with prevalence as high as 25%. Ulcers are breaks in the dermal barrier with subsequent erosion of underlying subcutaneous tissue that may extend to muscle and bone, and superimposed infection is a frequent and costly complication. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Early recognition of the etiology of these foot lesions is essential for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs are the mainstays of therapy. Even when properly managed, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents, and negative pressure wound therapy. While these, increasingly expensive, therapies have shown promising results in clinical trials, the results have yet to be translated into widespread clinical practice leaving a huge scope for further research in this field.

Inverse association between the existence of coronary artery disease and progression of abdominal aortic aneurysm

OBJECTIVES

A strong degree of co-existence between coronary artery disease (CAD) and abdominal aortic aneurysm (AAA) is widely acknowledged, however, it remains to be elucidated whether the existence of CAD is associated with an accelerated expansion rate of AAA. Also, the relationship between preoperative CAD and postoperative major adverse cardiovascular events (MACE) has not been examined in Japanese patients. The aim of this study was to investigate the deleterious effects of CAD on the progression of AAA and the onset of postoperative MACE after elective AAA repair.

METHODS AND RESULTS

A retrospective cohort study of 665 consecutive Japanese patients who underwent elective surgical repair for infrarenal AAA at 2 high-volume Tokyo hospitals from 2003 through 2010 was performed. Preoperative CAD was shown to be a significant determinant of postoperative MACE (HR 2.29; 95%CI, 1.12-4.66; p=0.02). In the analysis of 510 patients for whom there were at least 2 follow-up CT scans of the size of their AAA before repair, the existence of CAD was shown to be inversely associated with the accelerated expansion rate of AAA.

CONCLUSION

This study on the patients undergone elective repair for infrarenal AAA identified an inverse association between the existence of CAD and progression of AAA as well as the significant impact of preoperative CAD on the occurrence of postoperative MACE after elective AAA repair.

Socioeconomic position, comorbidity, and mortality in aortic aneurysms: a 13-year prospective cohort study

BACKGROUND

To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register.

METHODS

We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA.

RESULTS

We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA.

CONCLUSIONS

Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA.

Carotid intima media thickness as a measure of cardiovascular disease burden in nigerian africans with hypertension and diabetes mellitus

As part of a larger study of cardiovascular risk factors in nonhypertensive type 2 diabetes patients, we subjected a cohort of diabetics to B mode ultrasonography of the carotid artery to measure the intima media thickness (IMT) and compared it with values in hypertensives and apparently normal controls matched reasonably for gender and age. All groups were comparable in terms of age and gender representation. The mean (SD) of carotid IMT right and left was 0.94 mm (0.12), 0.94 mm (0.16); 0.93 mm (0.21), 0.93 mm (0.15); 0.91 mm (0.17), 0.91 mm (0.13) for diabetic, hypertensive, and normal groups, respectively. There was a nonsignificant tendency to raised IMT for the disease groups from the normal ones. Diabetic and hypertensive Nigerians are equally burdened by cardiovascular disease risk factors. Apparently normal subjects have a reasonable degree of burden suggesting the need to evaluate them for other traditional and emerging risk factors.

High Leg Salvage Rate after Infrainguinal Bypass Surgery for Ischemic Tissue Loss (Fontaine IV) is Compromised by the Short Life Expectancy

Background and Aims:

Most studies analysing the prognosis of infrainguinal bypass surgery (IBS) in patients with critical leg ischemia (CLI) have combined the outcome of patients with rest pain and tissue loss. The aim of the present study was to evaluate amputation-free survival (AFS) after IBS in patients with the most advanced form of peripheral arterial disease, CLI with tissue loss (Fontaine IV), and to analyse the risk factors for an adverse outcome.

Patients and Methods:

636 patients with CLI and tissue loss who underwent unilateral IBS between January 2000 and December 2006 at our institution were included in this retrospective study.

Results:

At one year, the leg salvage, survival and amputation-free survival rates were 83%, 71% and 55%, respectively, and at five years 76%, 38% and 30%, respectively. In univariate analysis, diabetes was associated with decreased AFS. In multivariate analysis, age, coronary artery disease, chronic pulmonary disease, gangrene and renal insufficiency were independent risk factors for decreased AFS.

Conclusion:

Infrainguinal bypass grafting results in a high rate of leg salvage. Amputation-free survival was low during the follow-up due to the high mortality of patients with CLI and tissue loss. Several co-morbidities of the CLI patients were associated with decreased amputation-free survival.

The Influence of Diabetes on Degree of Abdominal Aortic Aneurysm Tissue Inflammation

Abdominal aortic aneurysm (AAA) progression and disease resistance are related to transmural degenerative processes and an inflammatory infiltration (INF). Diabetes is associated with low prevalence and growth rate of AAA. We sought to characterize INF in established AAA (INFAAA), in diabetic patients. From 89 male patients aged 52 to 83 years, aneurysm specimens obtained at open asymptomatic nonruptured AAA repair were graded for INF and immunostained using antibodies against T-lymphocytes (CD3) and macrophages (CD68). Diabetic patients had an odds ratio (OR) 3.8, 95% confidence interval ([CI] 1.14-12.96), P = .03, of experiencing above-median INFAAA. These associations were affected by serum glucose (SG) levels (OR 3.6, 95% CI [0.72-18.77]; P = .1). Macrophage subpopulations higher in diabetic patients (1.44 ± 0.78 versus 0.98 ± 0.76; P = .02) were correlated with SG (r = .21, P = .044). Abdominal aortic aneurysms in diabetic patients are associated with higher INF. Macrophage densities are correlated with SG.

Pharmacological significance of triazole scaffold

The triazole nucleus is one of the most important and well known heterocycles which is a common and integral feature of a variety of natural products and medicinal agents. Triazole nucleus is present as a core structural component in an array of drug categories such as antimicrobial, anti-inflammatory, analgesic, antiepileptic, antiviral, antineoplastic, antihypertensive, antimalarial, local anaesthetic, antianxiety, antidepressant, antihistaminic, antioxidant, antitubercular, anti-Parkinson's, antidiabetic, antiobesity and immunomodulatory agents, etc. The broad and potent activity of triazole and their derivatives has established them as pharmacologically significant scaffolds. The basic heterocyclic rings present in the various medicinal agents are 1,2,3-triazole and 1,2,4-triazole. A large volume of research has been carried out on triazole and their derivatives, which has proved the pharmacological importance of this heterocyclic nucleus. The present paper is an attempt to review the pharmacological activities reported for triazole derivatives in the current literature with an update of recent research findings on this nuclei.

On the sensitivity of ASL MRI in detecting regional differences in cerebral blood flow

Arterial-spin-labeling (ASL) magnetic resonance imaging (MRI) provides a noninvasive tool to measure cerebral blood flow (CBF) and is increasingly used as a surrogate for baseline neural activity. However, the power of ASL MRI in detecting CBF differences between patient and control subjects is hampered by inter-subject variations in global CBF, which are associated with non-neural factors and may contribute to the noise in the across-group comparison. Here, we investigated the sensitivity of this technique and proposed a normalization strategy to better detect such a difference. A "model" situation was employed in which two visual stimuli (i.e. cross fixation and flashing checkerboard) were presented to two groups of subjects to mimic "control" and "patient" groups (N=7 for each group), respectively. It was found that absolute CBF (aCBF) in the occipital lobe in the checkerboard group was 26.0% greater compared to the fixation group, but the level of significance was modest (P=.03). In contrast, when normalizing the CBF with whole-brain CBF or CBF in a reference region [termed relative CBF (rCBF)], the statistical significance was improved considerably (P<.003). For voxel-based analysis, the rCBF indices correctly detected CBF differences in the occipital lobe in the across-group comparison, while aCBF failed to detect any significant cluster using the same statistical threshold. We also performed Monte Carlo simulation to confirm the experimental findings and found that the power improvement was most pronounced when signal-to-noise-ratio is moderate and the underlying CBF difference was small. The simulation also showed that, with the proposed normalization, a detection power of 80% can be achieved using a sample size of about 20. In summary, rCBF is a more sensitive index to detect small differences in CBF, rather than the much-sought-after aCBF, since it reduces data noise caused by inter-subject variations in global CBF.

Prognostic value of dobutamine stress echocardiography in diabetic patients

CAD is the main cause of morbidity and mortality in diabetic patients; we need reliable clinical parameters to stratify cardiovascular risk in these patients. We thus assessed prognostic value of clinical parameters, rest and stress echocardiographic data in diabetic patients, with known or suspected CAD. We studied 322 type 2 diabetic patients, who underwent dobutamine stress echocardiography (DSE) for known or suspected CAD; for prognostic assessment, end-points were all-cause mortality and hard cardiac events (cardiac death and non fatal myocardial infarction). During DSE, viability and inducible ischemia developed in 65 (20%) and 192 (60%) subjects, respectively; a severe ischemia (an asynergic area including more than 40% of all segments combined with a rate pressure product < 17,000) appeared in 88 (27%). Presence of a diabetic treatment or microvascular diabetic complications didn't influence prognosis, while a longer diabetes duration was associated with a higher all-cause mortality at univariate analysis. At multivariate analysis, an advanced age (RR = 1.108, CI: 1.039-1.182, P = 0.002), a lower left ventricular ejection fraction (RR = 0.956, CI: 0.919-0.994, P = 0.025) and, tendentially, peripheral vascular disease (RR = 2.942, CI: 0.985-8.785, P = 0.053) independently determined an increased all-cause mortality. New hard cardiac events occurred more frequently in presence of peripheral vascular disease (RR = 2.975, CI: 1.339-6.608, P = 0.007), viability (RR = 3.427, CI: 1.400-8.390, P = 0.007) and severe ischemia (RR = 3.245, CI: 1.503-7.005, P = 0.003). In diabetic patients with known or suspected CAD, presence of viability and severe ischemia during DSE are independently associated with higher occurrence of hard cardiac events.

Anal pressure in experimental diabetes

PURPOSE

Diabetes mellitus is a metabolic endocrine disorder that affects many systems, the gastrointestinal system often being among the affected systems. This experimental study work was designed to demonstrate altered anal sphincter pressures in an experimental model of diabetes mellitus (DM).

MATERIALS AND METHODS

Male Wistar rats (mean weight = 250 g) were used and randomized in two groups (n = 10): CO = control and DM. DM was induced by administering a single dose of streptozotocin. Glycemic levels were measured at the start (time = 0) and end (time = 60) of the experiment and anorectal manometry at the end.

RESULTS

DM rats presented a significant increase in glycemia at day 60 (DM = 407.14 +/- 73.76) as compared to the control group (time 0 = 175.7 +/- 18.62 and time 60 = 198.04 +/- 28.66). Anorectal manometry showed a significant decrease in anal pressure in the DM group at day 60 (DM = 34.2 +/- 4.97) as compared to the CO group at the same time (CO = 67.4 +/- 2.06), with P < 0.01 and P < 0.001 (Student's t test).

CONCLUSIONS

The results suggest that DM, due to the high glycemic levels, lead to alterations such as anal sphincter hypotony, which may cause complications such as fecal incontinence.

On the assessment of cerebrovascular reactivity using hypercapnia BOLD MRI

Cerebrovascular reactivity (CVR) reflects the capacity of blood vessels to dilate and is an important marker for brain vascular reserve. It may provide a useful addition to the traditional baseline blood flow measurement when assessing vascular factors in brain disorders. Blood-oxygenation-level-dependent MRI under CO(2) inhalation offers a non-invasive and quantitative means to estimate CVR in humans. In this study, we investigated several important methodological aspects of this technique with the goal of optimizing the experimental and data processing strategies for clinical use. Comparing 4 min of 5% CO(2) inhalation (less comfortable) to a 1 min inhalation (more comfortable) duration, it was found that the CVR values were 0.31 +/- 0.05%/mmHg (N = 11) and 0.31 +/- 0.08%/mmHg (N = 9), respectively, showing no significant differences between the two breathing paradigms. Therefore, the 1 min paradigm is recommended for future application studies for patient comfort and tolerability. Furthermore, we have found that end-tidal CO(2) recording was useful for accurate quantification of CVR because it provided both timing and amplitude information regarding the input function to the brain vascular system, which can be subject-dependent. Finally, we show that inter-subject variations in CVR are of physiologic origin and affect the whole brain in a similar fashion. Based on this, it is proposed that relative CVR (normalized against the CVR of the whole brain or a reference tissue) may be a more sensitive biomarker than absolute CVR in clinical applications as it minimizes inter-subject variations. With these technological optimizations, CVR mapping may become a useful method for studies of neurological and psychiatric diseases.

Identifying abdominal aortic aneurysm risk factors in postmenopausal women

Evaluation of: Lederle FA, Larson JC, Margolis KL et al.: Abdominal aortic aneurysm events in the Women's Health Initiative: cohort study. Br. Med. J. 337, A1724 (2008). A linked cohort study of 161,808 postmenopausal women aged 50-79 years enrolled in the Women's Health Initiative was conducted during which participants were followed for the incidence of abdominal aortic aneurysm repair or rupture. This study evaluated the association between potential risk factors and subsequent abdominal aortic aneurysm events in women. A total of 467 women reported a diagnosis of abdominal aortic aneurysm before entering the study or during participation, with 184 aneurysm-related events identified. Abdominal aortic aneurysm events were strongly associated with age and smoking and negatively associated with diabetes and baseline use of postmenopausal hormone supplementation. Previous studies investigating abdominal aortic aneurysm have focused primarily on men, with little reliable information available on women. This study contributes a large female cohort to provide better insight into gender-specific abdominal aortic aneurysm risks and disease associations.

Abdominal aortic aneurysm events in the women's health initiative: cohort study

OBJECTIVE

To assess the association between potential risk factors and subsequent clinically important abdominal aortic aneurysm events (repairs and ruptures) in women.

DESIGN

Large prospective observational cohort study with mean follow-up of 7.8 years.

SETTING

40 clinical centres across the United States.

PARTICIPANTS

161 808 postmenopausal women aged 50-79 enrolled in the women's health initiative.

MAIN OUTCOME MEASURES

Association of self reported or measured baseline variables with confirmed abdominal aortic aneurysm events assessed with multiple logistic regression.

RESULTS

Events occurred in 184 women and were strongly associated with age and smoking. Ever smoking, current smoking, and amount smoked all contributed independent risk. Diabetes showed a negative association (odds ratio 0.29, 95% confidence interval 0.13, 0.68), as did postmenopausal hormone therapy. Positive associations were also seen for height, hypertension, cholesterol lowering treatment, and coronary and peripheral artery disease.

CONCLUSIONS

Our findings confirm the strong positive associations of clinically important abdominal aortic aneurysm with age and smoking in women and the negative association with diabetes previously reported in men.