Screening for Atherosclerotic Cardiovascular Disease in Patients With Type 2 Diabetes Mellitus: Controversies and Guidelines

Predictors of post-healing recurrence in patients with diabetic foot ulcers: A systematic review and meta-analysis

BACKGROUND

Diabetic foot ulcer is one of the most prevalent, serious, and costly consequences of diabetes, often associated with peripheral neuropathy and peripheral arterial disease. These ulcers contribute to high disability and mortality rates in patients and pose a major challenge to clinical management.

OBJECTIVE

To systematically review the risk prediction models for post-healing recurrence in diabetic foot ulcer (DFU) patients, so as to provide a reference for clinical staff to choose appropriate prediction models.

METHODS

The authors searched five databases (Cochrane Library, PubMed, Web of Science, EMBASE, and Chinese Biomedical Database) from their inception to September 23, 2023, for relevant literature. After data extraction, the quality of the literature was evaluated using the Predictive Model Research Bias Risk and Suitability Assessment tool (PROBAST). Meta-analysis was performed using STATA 17.0 software.

RESULTS

A total of 9 studies involving 5956 patients were included. The recurrence rate after DFU healing ranged from 6.2 % to 41.4 %. Nine studies established 15 risk prediction models, and the area under the curve (AUC) ranged from 0.660 to 0.940, of which 12 models had an AUC≥0.7, indicating good prediction performance. The combined AUC value of the 9 validation models was 0.83 (95 % confidence interval: 0.79-0.88). Hosmer-Lemeshow test was performed for 10 models, external validation for 5 models, and internal validation for 6 models. Meta-analysis showed that 14 predictors, such as age and living alone, could predict post-healing recurrence in DFU patients (p < 0.05).

CONCLUSION

To enhance the quality of these risk prediction models, there is potential for future improvements in terms of follow-up duration, model calibration, and validation processes.

Association between obstructive coronary disease and diabetic retinopathy: Cross-sectional study of coronary angiotomography and multimodal retinal imaging

AIMS

To investigate the association between diabetic retinopathy (DR) and coronary artery disease (CAD) using coronary angiotomography (CCTA) and multimodal retinal imaging (MMRI) with ultra-widefield retinography and optical coherence tomography angiography and structural domain.

METHODS

Single-center, cross-sectional, single-blind. Patients with diabetes who had undergone CCTA underwent MMRI. Uni and multivariate analysis were used to assess the association between CAD and DR and to identify variables independently associated with DR.

RESULTS

We included 171 patients, 87 CAD and 84 non-CAD. Most CAD patients were males (74 % vs 38 %, P < 0.01), insulin users (52 % vs 38 %, p < 0.01) and revascularized (64 %). They had a higher prevalence of DR (48 % vs 22 %, p = 0.01), microaneurysms (25 % vs 13 %, p = 0.04), intraretinal cysts (22 % vs 8 %, p = 0.01) and areas of reduced capillary density (46 % vs 20 %, p < 0.01). CAD patients also had lower mean vascular density (MVD) (15.7 % vs 16.5,%, p = 0.049) and foveal avascular zone (FAZ) circularity (0.64 ± 0.1 vs 0.69 ± 0.1, p = 0.04). There were significant and negative correlations between Duke coronary score and MVD (r = -0.189; p = 0.03) and FAZ circularity (r = -0,206; p = 0.02). CAD, DM duration and insulin use independently associated with DR.

CONCLUSIONS

CAD patients had higher prevalence of DR and lower MVD. CAD, DM duration and insulin use were independently associated with DR.

Deep learning-based coronary artery calcium score to predict coronary artery disease in type 2 diabetes mellitus

Background

Coronary artery disease (CAD) in type 2 diabetes mellitus (T2DM) patients often presents diffuse lesions, with extensive calcification, and it is time-consuming to measure coronary artery calcium score (CACS).

Objectives

To explore the predictive ability of deep learning (DL)-based CACS for obstructive CAD and hemodynamically significant CAD in T2DM.

Methods

469 T2DM patients suspected of CAD who accepted CACS scan and coronary CT angiography between January 2013 and December 2020 were enrolled. Obstructive CAD was defined as diameter stenosis ≥50%. Hemodynamically significant CAD was defined as CT-derived fractional flow reserve ≤0.8. CACS was calculated with a fully automated method based on DL algorithm. Logistic regression was applied to determine the independent predictors. The predictive performance was evaluated with area under receiver operating characteristic curve (AUC).

Results

DL-CACS (adjusted odds ratio (OR): 1.005; 95% CI: 1.003-1.006; P ＜ 0.001) was significantly associated with obstructive CAD. DL-CACS (adjusted OR:1.003; 95% CI: 1.002-1.004; P ＜ 0.001) was also an independent predictor for hemodynamically significant CAD. The AUCs, sensitivities, specificities, positive predictive values and negative predictive values of DL-CACS for obstructive CAD and hemodynamically significant CAD were 0.753 (95% CI: 0.712-0.792), 75.9%, 66.5%, 74.8%, 67.8% and 0.769 (95% CI: 0.728-0.806), 80.7%, 62.1%, 59.6% and 82.3% respectively. It took 1.17 min to perform automated measurement of DL-CACS in total, which was significantly less than manual measurement of 1.73 min (P ＜ 0.001).

Conclusions

DL-CACS, with less time-consuming, can accurately and effectively predict obstructive CAD and hemodynamically significant CAD in T2DM.

Radiomics analysis of pericoronary adipose tissue based on plain CT for preliminary screening of coronary artery disease in patients with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with a markedly increased prevalence of coronary artery disease (CAD). Radiomics features of pericoronary adipose tissue (PCAT) were correlated with inflammation, which may have potential value in the prediction of CAD.

PURPOSE

To determine whether radiomics analysis of PCAT captured by plain computed tomography (CT) could predict obstructive CAD in patients with T2DM.

MATERIAL AND METHODS

The study included 155 patients with T2DM with suspected CAD between January 2020 and December 2021. Volumes of right coronary artery of 10-50 mm were delineated in the plain CT to extract radiomics features and PCAT CT attenuation (PCATa). Least absolute shrinkage and selection operator was used to select the useful radiomics features to calculate the radiomics score (Rad-score). Univariate and multivariable logistic regression were applied to select independent predictors. The predictive performance was evaluated by the area under the receiver operating characteristics curve (AUC).

RESULTS

Rad-score (per 0.1 increments: odds ratio [OR] = 1.297; P < 0.001), coronary artery calcium score (CACS) (OR = 1.003; P = 0.037), and sex (OR = 3.245; P = 0.026) were identified as independent predictors for obstructive CAD. Rad-score (AUC = 0.835) outperformed CACS (AUC = 0.780), sex (AUC = 0.665), and PCATa (AUC = 0.550) in predicting obstructive CAD (P = 0.017 and 0.003 for Rad-score vs. sex and PCATa, respectively); however, the improvement between Rad-score and CACS had no statistical significance (P = 0.490).

CONCLUSION

Plain CT-derived Rad-score may be used as a preliminary screening tool for obstructive CAD in patients with T2DM.

Novel Associations of Dyslipidaemia with Vitamin D and Bone Metabolism in Elderly Patients with Diabetes: A Cross-Sectional Study

Objective

Little is known about whether diabetic dyslipidaemia contributes to increased bone fragility in patients with diabetes. This study aimed to explore the potential effects of dyslipidaemia on vitamin D and bone metabolism in elderly subjects with type 2 diabetes (T2D).

Methods

A total of 1479 male patients and 1356 female patients 50 years or older with T2D were included in Shanghai, China. Lipid profiles, 25-hydroxyvitamin D (25(OH)D), serum procollagen type I N-terminal propeptide (P1NP), β-C-terminal telopeptide (β-CTX) and other parameters were measured. Principal component regression (PCR) and mediation analysis were used to estimate the associations of lipid profile, 25(OH)D and bone turnover levels.

Results

Female patients presented with higher blood lipids, lower 25(OH)D, and higher P1NP and β-CTX levels than male patients with T2D. TC was associated with P1NP in males and females (β=0.056, P<0.05; β=0.095, P<0.01, respectively), and 25(OH)D fully mediated the associations in males and mediated approximately 17.89% of the effects in females. LDL-C was associated with P1NP in males and females (β=0.072 and 0.105 respectively, all P<0.01), and 25(OH)D mediated the relationships approximately 20.83% in males and 14.29% in females. TG was negatively associated with P1NP (in males, β= -0.063, P<0.05; in females, β= -0.100, P<0.01) and β-CTX (in males, β= -0.108; in females, β= -0.128, all P<0.01) independent of 25(OH)D, while HDL-C was not associated with P1NP or β-CTX in diabetic patients.

Conclusion

Hypercholesterolemia and hypertriglyceridaemia might affect bone metabolism by distinguishing pathways in diabetes patients. Ameliorating lipid control in elderly diabetes patients, especially female patients, will benefit both vitamin D and bone metabolism.

Non-contrast CT-based radiomics nomogram of pericoronary adipose tissue for predicting haemodynamically significant coronary stenosis in patients with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) patients have a higher incidence of coronary artery disease than the general population. The aim of this study was to develop a radiomics nomogram of pericoronary adipose tissue (PCAT) based on non-contrast CT to predict haemodynamically significant coronary stenosis in T2DM patients.

METHODS

The study enrolled 215 T2DM patients who underwent non-contrast CT and coronary computed tomography angiography (CCTA). CCTA derived fractional flow reserve (FFR_CT) ≤ 0.80 was defined as hemodynamically significant stenosis.1691 radiomics features were extracted from PCAT on non-contrast CT. Minimum redundancy maximum relevance (mRMR) and least absolute shrinkage and selection operator (LASSO) were used to select useful radiomics features to construct Radscore. Logistic regression was applied to select significant factors among Radscore, fat attenuation index (FAI) and coronary artery calcium score (CACS) to construct radiomics nomogram.

RESULTS

Radscore [odds ratio (OR) = 2.84; P < 0.001] and CACS (OR = 1.00; P = 0.023) were identified as independent predictors to construct the radiomics nomogram. The radiomics nomogram showed excellent performance [training cohort: area under the curve (AUC) = 0.81; 95% CI: 0.76-0.86; validation cohort: AUC = 0.83; 95%CI: 0.76-0.90] to predict haemodynamically significant coronary stenosis in patients with T2DM. Decision curve analysis demonstrated high clinical value of the radiomics nomogram.

CONCLUSION

The non-contrast CT-based radiomics nomogram of PCAT could effectively predict haemodynamically significant coronary stenosis in patients with T2DM, which might be a potential noninvasive tool for screening of high-risk patients.

Obstructive coronary artery disease in symptomatic diabetics with zero coronary calcium score: are we missing something?

BACKGROUND

Prevalence and severity of coronary artery disease (CAD) in symptomatic patients with zero coronary artery calcium score (CACS) are unclear, particularly in regard to the diabetic population, which represents, per se, a subgroup at increased cardiovascular risk. The aim of this study was to investigate the prevalence and severity of CAD by coronary computed tomography angiography (CCTA) in a symptomatic diabetic cohort with zero CACS.

METHODS

All consecutive symptomatic diabetics referred for CAD suspicion were included in this study. All subjects underwent a noncontrast coronary artery calcium scan followed by CCTA. CACS was quantified using the Agatston method. CAD was defined as a total plaque score (TPS) greater than zero. Obstructive and severe obstructive CAD were defined respectively as luminal stenosis >50% and >70% in at least one coronary segment.

RESULTS

We identified 1722 symptomatic diabetics (mean age 62.5 ± 12.9 years, 62% men). One hundred and eleven subjects had zero CACS and TPS >0 (mean age was 49.5 ± 14.8, 58% women, 56% Hispanics). Sixty-five patients (58.5%) had one-vessel disease, followed by 30 (27%) with two-vessel disease and 14 (12.6%) with ≥ three-vessel disease. Obstructive CAD was found in 11 subjects and, among these, three were categorized as severe obstructive CAD.

CONCLUSION

In symptomatic diabetic patients with zero CACS, CAD, including obstructive disease, can still occur and is predominant in middle-aged adults, women and Hispanics. In symptomatic diabetics CCTA is a critical step for accurate risk stratification even when CACS would have placed some of these individuals in a lower-risk category.

[18F]FDG and [18F]NaF as PET markers of systemic atherosclerosis progression: A longitudinal descriptive imaging study in patients with type 2 diabetes mellitus

BACKGROUND

While [18F]-fluordeoxyglucose ([18F]FDG) uptake is associated with arterial inflammation, [18F]-sodium fluoride ([18F]NaF) is a marker for arterial micro-calcification. We aimed to investigate the prospective correlation between both PET markers over time and whether they are prospectively ([18F]FDG) and retrospectively ([18F]NaF) related to progression of systemic arterial disease in a longitudinal study in patients with type 2 diabetes mellitus (T2DM).

METHODS

Baseline [18F]FDG PET/Low Dose (LD) Computed Tomography (CT) scans of ten patients with early T2DM without cardiovascular history (70% men, median age 63 years) were compared with five-year follow-up [18F]NaF/LDCT scans. Systemic activity was expressed as mean target-to-background ratio (meanTBR) by dividing the maximal standardized uptake value (SUVmax) of ten arteries by SUVmean of the caval vein. CT-assessed macro-calcifications were scored visually and expressed as calcified plaque (CP) score. Arterial stiffness was assessed with carotid-femoral pulse wave velocity (PWV). Five-year changes were expressed absolutely with delta (Δ) and relatively with %change.

RESULTS

Baseline meanTBR[18F]FDG was strongly correlated with five-year follow-up meanTBR[18F]NaF (r = 0.709, P = .022). meanTBR[18F]NaF correlated positively with ΔCPscore, CPscore at baseline, and follow-up (r = 0.845, P = .002 and r = 0.855, P = .002, respectively), but not with %change in CPscore and PWV.

CONCLUSION

This proof-of-concept study demonstrated that systemic arterial inflammation is an important pathogenetic factor in systemic arterial micro-calcification development.

Nomogram Prediction for the Risk of Diabetic Foot in Patients With Type 2 Diabetes Mellitus

AIMS

To develop and validate a nomogram prediction model for the risk of diabetic foot in patients with type 2 diabetes mellitus (T2DM) and evaluate its clinical application value.

METHODS

We retrospectively collected clinical data from 1,950 patients with T2DM from the Second Affiliated Hospital of Xi'an Jiaotong University between January 2012 and June 2021. The patients were divided into training cohort and validation cohort according to the random number table method at a ratio of 7:3. The independent risk factors for diabetic foot among patients with T2DM were identified by multivariate logistic regression analysis. Then, a nomogram prediction model was developed using the independent risk factors. The model performances were evaluated by the area under the receiver operating characteristic curve (AUC), calibration plot, Hosmer-Lemeshow test, and the decision curve analysis (DCA).

RESULTS

Multivariate logistic regression analysis indicated that age, hemoglobin A1c (HbA1c), low-density lipoprotein (LDL), total cholesterol (TC), smoke, and drink were independent risk factors for diabetic foot among patients with T2DM (P < 0.05). The AUCs of training cohort and validation cohort were 0.806 (95% CI: 0.775∼0.837) and 0.857 (95% CI: 0.814∼0.899), respectively, suggesting good discrimination of the model. Calibration curves of training cohort and validation cohort showed a favorable consistency between the predicted probability and the actual probability. In addition, the P values of Hosmer-Lemeshow test for training cohort and validation cohort were 0.826 and 0.480, respectively, suggesting a high calibration of the model. When the threshold probability was set as 11.6% in the DCA curve, the clinical net benefits of training cohort and validation cohort were 58% and 65%, respectively, indicating good clinical usefulness of the model.

CONCLUSION

We developed and validated a user-friendly nomogram prediction model for the risk of diabetic foot in patients with T2DM. Nomograms may help clinicians early screen and identify patients at high risk of diabetic foot.

Sexual Dysfunction in Men and Women with Diabetes: A Reflection of their Complications?

BACKGROUND

Diabetes mellitus (DM), one of the worldwide leading causes of death, is associated with a plethora of micro- and macro-vascular complications which should be carefully investigated and, in case, treated in order to improve quality of life and reduce the risk of premature mortality.

OBJECTIVE

The study aimed to investigate and report current evidence with regard to the association between sexual dysfunction and diabetes.

METHODS

A detailed analysis of current literature has been performed on PubMed and Scholar in order to retrieve the most relevant findings pertaining to the study topic.

RESULTS

Female and male sexual dysfunction often occurs in diabetes; while cardiovascular complications are clearly involved, psychosexological factors, endocrine complications, and endothelial dysfunction all contribute to the pathogenesis of sexual dysfunctions. Psychological symptoms are seldom investigated, yet they should not be overlooked by the clinician; in fact, an interplay between sexual dysfunctions and depressive symptoms has been reported, and beneficial effects in both conditions might be obtained by adequate psychological support. Sexual dysfunctions can also act as early biomarkers of cardiovascular disease, a phenomenon frequently reported in men, in which erectile dysfunction predicts the development of coronary artery disease. Additionally, drug therapies can act in both directions, with treatments for diabetes possibly improving male sexual function and exerting beneficial effects for cardiovascular health being reported for pro-erectile drugs.

CONCLUSION

Sexual dysfunctions often occur in men and women with diabetes. Investigating micro- and macro-vascular complications might not be enough to prevent the development or worsening of any sexual dysfunction; endocrine and psychological assessments are therefore needed to provide the best chances for adequate treatment.

Glucose-lowering pharmacotherapies in Chinese adults with type 2 diabetes and cardiovascular disease or chronic kidney disease. An expert consensus reported by the Chinese Diabetes Society and the Chinese Society of Endocrinology

Patients with type 2 diabetes mellitus (T2DM) are at risk of developing atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease (CKD), which are important causes of disabling and death in patients with T2DM. For the prevention and management of ASCVD or CKD, cardiovascular risk factors should be systematically evaluated, and ASCVD and CKD should be screened in patients with T2DM. In this consensus, we recommended that metformin should be used as the first-line therapy for patients with T2DM and ASCVD or very high cardiovascular risk, heart failure (HF) or CKD, and should be retained in the treatment regimen unless contraindicated or not tolerated. In patients with T2DM and established ASCVD or very high cardiovascular risk, addition of a glucagon-like peptide 1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter type 2 (SGLT2) inhibitor with proven cardiovascular benefits should be considered independent of individualised glycated haemoglobin (HbA_1C ) targets. In patients with T2DM and HF, an SGLT2 inhibitor should be preferably added regardless of HbA_1C levels. In patients with T2DM and CKD, SGLT2 inhibitors should be preferred for the combination therapy independent of individualised HbA_1C targets, and GLP-1RAs with proven renal benefits would be alternative if SGLT2 inhibitors are contraindicated. Moreover, the prevention of hypoglycaemia and management of multiple risk factors by comprehensive regimen, including lifestyle intervention, antihypertensive therapies, lipid-lowering treatment and antiplatelet therapies, should be kept in mind in treating patients with T2DM and ASCVD, HF or CKD.

Biomolecules and Electrochemical Tools in Chronic Non-Communicable Disease Surveillance: A Systematic Review

Over recent three decades, the electrochemical techniques have become widely used in biological identification and detection, because it presents optimum features for efficient and sensitive molecular detection of organic compounds, being able to trace quantities with a minimum of reagents and sample manipulation. Given these special features, electrochemical techniques are regularly exploited in disease diagnosis and monitoring. Specifically, amperometric electrochemical analysis has proven to be quite suitable for the detection of physiological biomarkers in monitoring health conditions, as well as toward the control of reactive oxygen species released in the course of oxidative burst during inflammatory events. Besides, electrochemical detection techniques involve a simple and swift assessment that provides a low detection-limit for most of the molecules enclosed biological fluids and related to non-transmittable morbidities.