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Jeyaseeli A, R G, Mathivanan D, Prabagaran A. Assessment of Triglyceride Glucose Index in Type 2 Diabetes Mellitus Patients With and Without Cardiac Autonomic Neuropathy. Cureus 2023; 15:e42541. [PMID: 37533622 PMCID: PMC10393284 DOI: 10.7759/cureus.42541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
Background Cardiac autonomic neuropathy (CAN) is a major complication of type 2 diabetes mellitus (T2DM). Hyperglycaemia and hypertriglyceridemia are known risk factors in the development of CAN with T2DM. The triglyceride glucose (TyG) index is calculated using both the fasting blood glucose (FBG) and fasting triglyceride levels (FTG). There is a paucity of literature revealing a direct relationship between the TyG index and CAN in T2DM patients of the south Indian population. Objective To assess the TyG index levels in T2DM with and without CAN. Methods A cross-sectional study was performed, involving 100 T2DM patients (58 males and 42 females) aged between 30 and 60 years, who attended medicine OPD, Sri Venkateswaraa Medical College, Hospital and Research Centre (SVMCH & RC) during the study period. Age, duration of illness, height, weight, waist circumference (WC), hip circumference (HC), body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured. Glycated hemoglobin (HbA1C) and lipid profile values were taken from patients' recent medical records. Ewing autonomic function tests were used to diagnose CAN, which included heart rate response to standing, heart rate response to deep breathing, heart rate response to Valsalva maneuver, blood pressure response to standing and blood pressure response to isometric handgrip. FBG and FTG were measured and the TyG index was calculated from these parameters. Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Version 20.0, Armonk, NY) was used for the statistical analysis and a 'P' value < 0.05 was considered statistically significant. Results In our study, out of 100 T2DM patients, 42 patients were diagnosed with CAN. The mean levels of TyG Index, HbA1C, FBG, FTG, BMI and WC were significantly (p<0.05) higher in T2DM patients with CAN when compared to T2DM without CAN. We couldn't find any significant difference (p<0.05) in age, duration of illness, blood pressure and lipid profile parameters between the groups. Conclusion We found that abdominal obesity, hyperglycemia, and hypertriglyceridemia are the risk factors for developing CAN in T2DM patients. Our study results also showed that the TyG index can be used to predict CAN in T2DM patients.
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Affiliation(s)
- Angeline Jeyaseeli
- Physiology, Sri Venkateswaraa Medical College Hospital and Research Centre, Puducherry, IND
| | - Ganesan R
- Physiology, Sri Venkateswaraa Medical College Hospital and Research Centre, Puducherry, IND
| | - Dhibika Mathivanan
- Microbiology, Indira Gandhi Medical College and Research Institute, Puducherry, IND
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Tung DD, Minh NN, Nguyen HT, Nguyen Thi PN, Nguyen Thi HL, Nguyen DL, Pham DTN, Tran TQ, Nguyen DT, Nguyen LP. Lower Extremity Nerve Conduction Abnormalities in Vietnamese Patients with Type 2 Diabetes: A Cross-Sectional Study on Peripheral Neuropathy and Its Correlation with Glycemic Control and Renal Function. J Pers Med 2023; 13:jpm13040617. [PMID: 37109004 PMCID: PMC10142910 DOI: 10.3390/jpm13040617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/21/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Peripheral neuropathy is a common complication of type 2 diabetes mellitus (T2DM) that results in nerve conduction abnormalities. This study aimed to investigate the parameters of nerve conduction in lower extremities among T2DM patients in Vietnam. A cross-sectional study was conducted on 61 T2DM patients aged 18 years and older, diagnosed according to the American Diabetes Association’s criteria. Data on demographic characteristics, duration of diabetes, hypertension, dyslipidemia, neuropathy symptoms, and biochemical parameters were collected. Nerve conduction parameters were measured in the tibial and peroneal nerves, including peripheral motor potential time, response amplitude M, and motor conduction speed, as well as sensory conduction in the shallow nerve. The study found a high rate of peripheral neuropathy among T2DM patients in Vietnam, with decreased conduction rate, motor response amplitude, and nerve sensation. The incidence of nerve damage was highest in the right peroneal nerve and left peroneal nerve (86.7% for both), followed by the right tibial nerve and left tibial nerve (67.2% and 68.9%, respectively). No significant differences were found in the rate of nerve defects between different age groups, body mass index (BMI) groups, or groups with hypertension or dyslipidemia. However, a statistically significant association was found between the rate of clinical neurological abnormalities and the duration of diabetes (p < 0.05). Patients with poor glucose control and/or decreased renal function also had a higher incidence of nerve defects. The study highlights the high incidence of peripheral neuropathy among T2DM patients in Vietnam and the association between nerve conduction abnormalities and poor glucose control and/or decreased renal function. The findings underscore the importance of early diagnosis and management of neuropathy in T2DM patients to prevent serious complications.
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Affiliation(s)
- Do Dinh Tung
- Saint Paul General Hospital, 12A Chu Van An, Ba Dinh District, Ha Noi 100000, Vietnam
- Vietnam Diabetes Educators Association, 52/A1 Dai Kim Urban Area, Hoang Mai District, Ha Noi 100000, Vietnam
| | - Nui Nguyen Minh
- Department of Joints and Endocrinology, Military Medical University, 160, Phung Hung Street, Hadong District, Ha Noi 100000, Vietnam
| | - Hanh Thi Nguyen
- Department of Joints and Endocrinology, Military Medical University, 160, Phung Hung Street, Hadong District, Ha Noi 100000, Vietnam
| | - Phi Nga Nguyen Thi
- Department of Joints and Endocrinology, Military Medical University, 160, Phung Hung Street, Hadong District, Ha Noi 100000, Vietnam
| | - Huong Lan Nguyen Thi
- Saint Paul General Hospital, 12A Chu Van An, Ba Dinh District, Ha Noi 100000, Vietnam
| | - Duc Long Nguyen
- Saint Paul General Hospital, 12A Chu Van An, Ba Dinh District, Ha Noi 100000, Vietnam
| | - Dung Thuy Nguyen Pham
- NTT Institute of Applied Technology and Sustainable Development, Nguyen Tat Thanh University, Ho Chi Minh City 700000, Vietnam
- Faculty of Environmental and Food Engineering, Nguyen Tat Thanh University, Ho Chi Minh City 700000, Vietnam
| | - Toan Quoc Tran
- Institute of Natural Products Chemistry, Vietnam Academy of Science and Technology (VAST), 18 Hoang Quoc Viet St., Cau Giay Dist., Ha Noi 100000, Vietnam
| | - Duong Thanh Nguyen
- Institute for Tropical Technology, Vietnam Academy of Science and Technology (VAST), 18 Hoang Quoc Viet St., Cau Giay Dist., Ha Noi 100000, Vietnam
| | - Linh Phuong Nguyen
- School of Preventive Medicine and Public Health, Ha Noi Medical University, 1, Ton That Tung Street, Dong Da District, Ha Noi 100000, Vietnam
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Gutiérrez J. Electrophysiological assessment of peripheral and central autonomic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:301-314. [PMID: 37562875 DOI: 10.1016/b978-0-323-98818-6.00015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The autonomic nervous system (ANS) coordinates multiple reflex actions which are essential for life. The tests employed to evaluate the ANS provide valuable information of the functional state of these reflex arcs. The ideal test should be simple to perform, noninvasive, reproducible, sensitive, specific, safe, and appropriate for longitudinal studies. The availability of computer-based techniques has facilitated the electrophysiological assessment of ANS-mediated reflexes. The information provided by autonomic testing must be analyzed in combination with the clinical history and physical examination of the patient, allowing for a hypothesis that can be tested. Properly performed and interpreted, ANS testing can be used to confirm the presence of an ANS disturbance and the involved functional pathways, as well as the extent, intensity, and site of injury. This chapter describes the most important electrophysiological tests used to evaluate the ANS control of cardiovascular reflexes and sweat gland activity.
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Affiliation(s)
- Joel Gutiérrez
- Department of Clinical Neurophysiology, Cuban Institute of Neurology and Neurosurgery, Havana, Cuba; Department of Clinical Neurophysiology, Havana University of Medical Sciences, Havana, Cuba
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Association between Polypharmacy and Cardiovascular Autonomic Function among Elderly Patients in an Urban Municipality Area of Kolkata, India: A Record-Based Cross-Sectional Study. Geriatrics (Basel) 2022; 7:geriatrics7060136. [PMID: 36547272 PMCID: PMC9778147 DOI: 10.3390/geriatrics7060136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
We assessed the association between polypharmacy and cardiovascular autonomic function among community-dwelling elderly patients having chronic diseases. Three hundred and twenty-one patients from an urban municipality area of Kolkata, India were studied in August 2022. The anticholinergic burden and cardiac autonomic function (Valsalva ratio, orthostatic hypotension, change in diastolic blood pressure after an isometric exercise, and heart rate variability during expiration and inspiration) were evaluated. Binary logistic regression analysis was performed to find out the association of polypharmacy and total anticholinergic burden with cardiac autonomic neuropathy. A total of 305 patients (age, 68.9 ± 3.4; 65.9% male) were included. Of these patients, 81 (26.6%) were on polypharmacy. Out of these 81 patients, 42 patients were on ninety-eight potential inappropriate medications. The anticholinergic burden and the proportion of patients with cardiac autonomic neuropathy were significantly higher among patients who were on polypharmacy than those who were not (8.1 ± 2.3 vs. 2.3 ± 0.9; p = 0.03 and 56.8% vs. 44.6%; p = 0.01). The presence of polypharmacy and a total anticholinergic burden of > 3 was significantly associated with cardiac autonomic neuropathy (aOR, 2.66; 95% CI, 0.91−3.98 and aOR, 2.51; 95% CI, 0.99−3.52, respectively). Thus, polypharmacy was significantly associated with cardiac autonomic neuropathy among community-dwelling elderly patients.
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Gavan DE, Gavan A, Bondor CI, Florea B, Bowling FL, Inceu GV, Colobatiu L. SUDOSCAN, an Innovative, Simple and Non-Invasive Medical Device for Assessing Sudomotor Function. SENSORS (BASEL, SWITZERLAND) 2022; 22:7571. [PMID: 36236669 PMCID: PMC9573142 DOI: 10.3390/s22197571] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/29/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
Diabetic autonomic neuropathy is probably the most undiagnosed but serious complication of diabetes. The main objectives were to assess the prevalence of peripheral and autonomic neuropathy in a population of diabetic patients, analyze it in a real-life outpatient unit scenario and determine the feasibility of performing SUDOSCAN tests together with widely used tests for neuropathy. A total of 33 patients were included in the study. Different scoring systems (the Toronto Clinical Neuropathy Score-TCNS; the Neuropathy Disability Score-NDS; and the Neuropathy Symptom Score-NSS) were applied to record diabetic neuropathy (DN), while the SUDOSCAN medical device was used to assess sudomotor function, detect diabetic autonomic neuropathy and screen for cardiac autonomic neuropathy (CAN). Fifteen (45.5%) patients had sudomotor dysfunction. The SUDOSCAN CAN risk score was positively correlated with the hands' electrochemical sweat conductance (ESC), diastolic blood pressure (DBP), the level of the glycated hemoglobin, as well as with the TCNS, NDS and NSS. Performing SUDOSCAN tests together with other tests for DN proved to be a feasible approach that could be used in daily clinical practice in order to screen for DN, as well as for the early screening of CAN, before more complex and time-consuming tests.
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Affiliation(s)
- Dana Elena Gavan
- Clinic of Podiatry, 10 Iuliu Moldovan Street, 400348 Cluj-Napoca, Romania
| | - Alexandru Gavan
- Department of Medical Devices, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 4 Louis Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Cosmina Ioana Bondor
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 6 Louis Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Bogdan Florea
- Clinic of Podiatry, 10 Iuliu Moldovan Street, 400348 Cluj-Napoca, Romania
| | - Frank Lee Bowling
- Faculty of Medicine, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Georgeta Victoria Inceu
- Department of Diabetes, Nutrition and Metabolical Diseases, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 2–4 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Liora Colobatiu
- Department of Medical Devices, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 4 Louis Pasteur Street, 400349 Cluj-Napoca, Romania
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Huang WK, Chung YM, Wang YB, Mandel JE, Wu HT. Airflow recovery from thoracic and abdominal movements using synchrosqueezing transform and locally stationary Gaussian process regression. Comput Stat Data Anal 2022. [DOI: 10.1016/j.csda.2021.107384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Menduni M, D'Amato C, Leoni M, Izzo V, Staltari M, Greco C, Abbatepassero A, Seminara G, D'Ippolito I, Lauro D, Spallone V. Clinical scoring systems for the risk of cardiovascular autonomic neuropathy in type 1 and type 2 diabetes: a simple tool. J Peripher Nerv Syst 2022; 27:259-270. [PMID: 36029134 DOI: 10.1111/jns.12510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/01/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS This study was aimed at developing a clinical risk score for cardiovascular autonomic neuropathy (CAN) for type 1 and type 2 diabetes. METHODS In a retrospective cross-sectional one-centre study in an unselected population, 115 participants with type 1 diabetes (age 41.1±12.2 years), and 161 with type 2 diabetes (age 63.1±8.9 years), well-characterised for clinical variables, underwent standard cardiovascular reflex tests (CARTs). Strength of associations of confirmed CAN (based on 2 abnormal CARTs) with clinical variables was used to build a CAN risk score. RESULTS CAN risk score was based on resting heart rate, HbA1c, retinopathy, nephropathy, cardiovascular disease in both type 1 and type 2 diabetes, and on HDL cholesterol, systolic blood pressure, and smoking in type 1 diabetes or insulin treatment and physical activity in type 2 diabetes (range 0-10). In type 1 diabetes, CAN risk score showed an area under the ROC curve (AUC) of 0.890±0.034, and at cut-off of 4 sensitivity of 88%, specificity of 74.4%, and negative predictive value (NPV) of 95.7% for confirmed CAN. In type 2 diabetes, CAN risk score showed an AUC of 0.830±0.051 and at the cut-off of 4 sensitivity and specificity of 78.6% and 73.5%, respectively, and NPV of 97.3% for confirmed CAN. INTERPRETATION These newly developed CAN risk scores are accessible in clinical practice and, if confirmed in a validation study, they might identify asymptomatic individuals with diabetes at greater risk of CAN to be referred to CARTs, thus limiting the burden of a universal screening. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marika Menduni
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia D'Amato
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Martina Leoni
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Mariateresa Staltari
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Carla Greco
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Abbatepassero
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Seminara
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Ilenia D'Ippolito
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
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Bezen D, Türkmenoğlu Y, İrdem A. Ventricular depolarization and repolarization variability in children with type 1 diabetes mellitus. Pediatr Int 2022; 64:e15290. [PMID: 36257614 DOI: 10.1111/ped.15290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/01/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arrhythmias can be seen as a sign of cardiac autonomic neuropathy in type 1 diabetes mellitus. We aimed to evaluate pulmonary artery pressure, ventricular depolarization and repolarization variability in children with type 1 diabetes mellitus. METHODS We investigated 78 children with type 1 diabetes mellitus (mean age 11.6 ± 3.6 years) and 68 age-gender matched healthy children as control group. All type 1 diabetes mellitus patients were divided into three subgroups according to glycated hemoglobin (HbA1c) levels and the duration of disease. Electrocardiogram and transthoracic echocardiograms were performed on both groups. RESULTS In patients with type 1 diabetes mellitus, there was an elongation in P, Pd, PR, QTc, QTd, QTcd, JT, JTc, JTd, Tp-Te and Tp-Te/QT, Tp-Te/QTc, Tp-Te/JT, Tp-Te/JTc ratios were higher (P < 0.05). In patients with type 1 diabetes mellitus, pulmonary artery pressure was higher than control group (P = 0.001). Prolongation of QTc, thickness of left ventricle end-diastolic diameter and left ventricle posterior wall diameter were higher in the HbA1c ≥9% subgroup. When adjusted for age there was no significant correlation between left ventricle parameters and HbA1c. CONCLUSIONS Atrial conduction delay and impairment of ventricular repolarization were significantly high and there was a predisposition for the development of pulmonary artery hypertension in children with type 1 diabetes mellitus. Poor glycemic control was not a risk factor for propensity of left ventricle hypertrophy and left ventricle dysfunction.
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Affiliation(s)
- Diğdem Bezen
- Department of Pediatrics, Pediatric Endocrinology, University of Health Sciences, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul, Turkey
| | - Yelda Türkmenoğlu
- Department of Pediatrics, University of Health Sciences, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul, Turkey
| | - Ahmet İrdem
- Department of Pediatrics, Pediatric Cardiology, University of Health Sciences, Prof. Dr. Cemil Taşçıoğlu City Hospital, İstanbul, Turkey
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Serdarova M, Dimova R, Chakarova N, Grozeva G, Todorova A, Tankova T. Relationship between cardiac autonomic neuropathy and cardio-metabolic risk profile in adults with type 1 diabetes. Diabetes Res Clin Pract 2021; 174:108721. [PMID: 33640411 DOI: 10.1016/j.diabres.2021.108721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/01/2020] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
AIM The present study aims to determine the prevalence and association of cardiac autonomic neuropathy (CAN) with some traditional cardio-metabolic risk factors in adults with type 1 diabetes (T1D). MATERIAL AND METHODS 235 adults with T1D, divided into three groups according to diabetes duration, were recruited in this cross-sectional study from May 2017 till December 2018. Anthropometric parameters and blood pressure were measured. Lipids, liver enzymes, uric acid, creatinine, HbA1c and high sensitive C-reactive protein (hsCRP) were measured at fasting. Albumin/creatinine ratio (ACR) was measured in a first spot urine sample. Body composition was evaluated using bio-impedance analysis, Inbody720 (Biospace, USA). Advanced glycation end products (AGEs) were assessed by autofluorescence method, AGE Reader (Diagnoptics, The Netherlands). CAN was assessed by ANX-3.0 monitoring technology (ANSAR Medical Technologies, Inc., Philadelphia, PA), applying standard clinical tests. 2005 IDF and 2009 JIS definitions were used to define Metabolic Syndrome (MetS). RESULTS The prevalence of CAN was 23% and increased with diabetes duration. Sympathetic activity was independently related to age, albumin/creatinine ratio (ACR) and total body fat mass, and parasympathetic activity - to age and ACR. Elevated hsCRP, AGEs and body fat, diabetic retinopathy and nephropathy, as well as hypertension, dyslipidemia and metabolic syndrome were found to increase the risk of CAN in T1D. CONCLUSION CAN appears to be a common complication of T1D, especially with longer duration, and is found to be related to diabetic microvascular disease and metabolic syndrome components.
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Affiliation(s)
- M Serdarova
- Department of Endocrinology, Medical University of Sofia, Bulgaria.
| | - R Dimova
- Department of Endocrinology, Medical University of Sofia, Bulgaria
| | - N Chakarova
- Department of Endocrinology, Medical University of Sofia, Bulgaria
| | - G Grozeva
- Department of Endocrinology, Medical University of Sofia, Bulgaria
| | - A Todorova
- Department of Endocrinology, Medical University of Sofia, Bulgaria
| | - T Tankova
- Department of Endocrinology, Medical University of Sofia, Bulgaria
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Braffett BH, Gubitosi-Klug RA, Albers JW, Feldman EL, Martin CL, White NH, Orchard TJ, Lopes-Virella M, Lachin JM, Pop-Busui R. Risk Factors for Diabetic Peripheral Neuropathy and Cardiovascular Autonomic Neuropathy in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study. Diabetes 2020; 69:1000-1010. [PMID: 32051148 PMCID: PMC7171957 DOI: 10.2337/db19-1046] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022]
Abstract
The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study demonstrated that intensive glucose control reduced the risk of developing diabetic peripheral neuropathy (DPN) and cardiovascular autonomic neuropathy (CAN). We evaluated multiple risk factors and phenotypes associated with DPN and CAN in this large, well-characterized cohort of participants with type 1 diabetes, followed for >23 years. DPN was defined by symptoms, signs, and nerve conduction study abnormalities in ≥2 nerves; CAN was assessed using standardized cardiovascular reflex tests. Generalized estimating equation models assessed the association of DPN and CAN with individual risk factors measured repeatedly. During DCCT/EDIC, 33% of participants developed DPN and 44% CAN. Higher mean HbA1c was the most significant risk factor for DPN, followed by older age, longer duration, greater height, macroalbuminuria, higher mean pulse rate, β-blocker use, and sustained albuminuria. The most significant risk factor for CAN was older age, followed by higher mean HbA1c, sustained albuminuria, longer duration of type 1 diabetes, higher mean pulse rate, higher mean systolic blood pressure, β-blocker use, estimated glomerular filtration rate <60 mL/min/1.73 m2, higher most recent pulse rate, and cigarette smoking. These findings identify risk factors and phenotypes of participants with diabetic neuropathy that can be used in the design of new interventional trials and for personalized approaches to neuropathy prevention.
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Affiliation(s)
| | - Rose A Gubitosi-Klug
- Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH
| | | | - Eva L Feldman
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Neil H White
- Washington University School of Medicine in St. Louis, St Louis, MO
| | - Trevor J Orchard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Maria Lopes-Virella
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - John M Lachin
- Biostatistics Center, George Washington University, Rockville, MD
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Ang L, Dillon B, Mizokami-Stout K, Pop-Busui R. Cardiovascular autonomic neuropathy: A silent killer with long reach. Auton Neurosci 2020; 225:102646. [PMID: 32106052 DOI: 10.1016/j.autneu.2020.102646] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/30/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
Cardiovascular autonomic neuropathy (CAN) is a common and deadly complication of diabetes mellitus, which is frequently overlooked in clinical practice due to its characteristic subtle presentation earlier in disease. Yet, timely detection of CAN may help implementation of tailored interventions to prevent its progression and mitigate the risk of associated complications, including cardiovascular disease (CVD), cardiac arrhythmias, myocardial dysfunction leading to congestive heart failure and all-cause mortality. This review highlights current CAN epidemiology trends, novel mechanisms linking CAN with other diabetes complications and current recommendations for diagnosis and management of the disease in the clinical setting.
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Affiliation(s)
- Lynn Ang
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Brendan Dillon
- University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America.
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Ju J, Tomaszewski EL, Orchard TJ, Evans RW, Feingold E, Costacou T. The haptoglobin 2-2 genotype is associated with cardiac autonomic neuropathy in type 1 diabetes: the RETRO HDLc study. Acta Diabetol 2020; 57:271-278. [PMID: 31529337 PMCID: PMC7054154 DOI: 10.1007/s00592-019-01422-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
AIM The haptoglobin (Hp) 2-2 genotype has been shown to increase the risk of coronary artery disease, kidney dysfunction and mortality from cardiovascular and renal causes in type 1 diabetes (T1D). Similar associations, however, have not been observed in those without diabetes. As cardiac autonomic neuropathy (CAN) is a cardiovascular disease risk factor, we assessed the presence of an association between the Hp 2-2 genotype and CAN. METHODS The study included 216 individuals with childhood-onset T1D and 200 individuals with normal glucose tolerance (NGT) of similar age and gender distribution to their counterparts with T1D. CAN was assessed using an electrocardiogram as an abnormal, age-specific, heart rate response to deep breathing. Multivariable logistic regression models were used to assess the association between the Hp 2-2 genotype and CAN. RESULTS Compared with NGT, participants with T1D had a similar proportion of Hp 2-2 carriers (41.5% vs. 32.0%, p = 0.05) but a greater CAN prevalence (28.2% vs. 5.0%, p < 0.0001). In multivariable logistic regression models, those carrying the Hp 2-2 genotype had significantly higher odds of CAN compared with Hp 1-1 or Hp 2-1 carriers (OR = 2.27, p = 0.01). The presence of T1D (OR = 4.20, p = 0.0003), hypertension (OR = 2.08, p = 0.03), eGFR (OR = 0.98, p = 0.01) and WBC count (OR = 1.21, p = 0.02) were also associated with CAN. There was no T1D by Hp interaction (p = 0.92), although in stratified analyses, the Hp-CAN association was significant only in T1D. CONCLUSIONS The Hp 2-2 genotype was independently associated with greater odds of CAN in T1D though no definitive conclusions could be made in NGT.
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Affiliation(s)
- Jinghui Ju
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Erin L Tomaszewski
- Diabetes and Lipid Research Clinic, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Trevor J Orchard
- Diabetes and Lipid Research Clinic, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Rhobert W Evans
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Eleanor Feingold
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Tina Costacou
- Diabetes and Lipid Research Clinic, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 3512 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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Yang D, Yan J, Deng H, Yang X, Luo S, Zheng X, Lv J, Liang W, Hong M, Wu Z, Yao B, Weng J, Xu W. Effects of Metformin Added to Insulin in Adolescents with Type 1 Diabetes: An Exploratory Crossover Randomized Trial. J Diabetes Res 2020; 2020:7419345. [PMID: 33457425 PMCID: PMC7785393 DOI: 10.1155/2020/7419345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To comprehensively assess the effects of metformin added to insulin on metabolic control, insulin sensitivity, and cardiovascular autonomic function in adolescents with type 1 diabetes. MATERIALS AND METHODS This was an exploratory, crossover, randomized trial conducted in adolescents with type 1 diabetes aged 12-18 years old. Participants were randomly received metformin (≤1000 mg/d) added to insulin for 24 weeks followed by insulin monotherapy for a subsequent 24 weeks or vice versa. Blood pressure, body mass index, insulin dose, estimated insulin sensitivity, glycated hemoglobin A1c (HbA1c), and lipid profiles were measured, with a 72-hour continuous glucose monitoring and 24-hour Holter monitoring performed at baseline, 24, and 50 weeks for the assessments of glucose variability and heart rate variability. RESULTS Seventeen patients with mean ± SD age 14.4 ± 2.3 years, body mass index 18.17 ± 1.81 kg/m2, median (IQR) diabetes duration 4.50 (3.58, 6.92) years, and HbA1c 9.0% (8.5%, 9.4%) were enrolled. The between-group difference in HbA1c of 0.28% (95% CI -0.39 to 0.95%) was not significant (P = 0.40). Changes in body mass index, insulin dose, blood pressure, lipid profiles, and estimated insulin sensitivity were similar for metformin add-on vs. insulin monotherapy. Glucose variability also did not differ. Compared with insulin monotherapy, metformin add-on significantly increased multiple heart rate variability parameters. CONCLUSIONS Metformin added to insulin did not improve metabolic control or glucose variability in lean/normal-weight adolescents with type 1 diabetes. However, metformin added to insulin significantly increased heart rate variability, suggesting that metformin might improve cardiovascular autonomic function in this population.
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Affiliation(s)
- Daizhi Yang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
| | - Jinhua Yan
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
| | - Hongrong Deng
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
| | - Xubin Yang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
| | - Sihui Luo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of USTC, Division of Life Sciences of Medicine, University of Science and Technology of China, Anhui 230026, China
| | - Xueying Zheng
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of USTC, Division of Life Sciences of Medicine, University of Science and Technology of China, Anhui 230026, China
| | - Jing Lv
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Wen Liang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Department of Endocrinology and Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, China
| | - Mengjie Hong
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Department of Cardiovascular Medicine, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China
| | - Zekai Wu
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
| | - Bin Yao
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
| | - Jianping Weng
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of USTC, Division of Life Sciences of Medicine, University of Science and Technology of China, Anhui 230026, China
| | - Wen Xu
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou 510630, China
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Riguetto CM, Takano CR, Admoni SN, Parisi MCR, Giannella MLC, Pavin EJ, Moura Neto A. Identification and performance of multiple clinical and laboratorial risk factors for diagnosis of cardiac autonomic neuropathy in type 1 diabetes patients. J Diabetes Metab Disord 2019; 18:565-573. [PMID: 31890683 DOI: 10.1007/s40200-019-00467-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 11/05/2019] [Indexed: 01/05/2023]
Abstract
Purpose The incidence of cardiac autonomic neuropathy (CAN) in patients with type 1 diabetes (T1D) is frequently underestimated. Individuals with T1D and CAN have an increased mortality risk, mainly from cardiovascular causes. The objectives of the present study were to assess the clinical and laboratory characteristics associated with CAN in patients with T1D and verify the ability of multiple clinical factors to help identify patients with this condition. Methods 102 patients with T1D were evaluated for CAN using standardized cardiovascular reflex testing. Clinical characteristics were used to compute a numerical score for CAN diagnosis and a ROC curve elaborated for assessment of the best cutoff to predict CAN. This score was then applied to the second sample of 120 patients. The sensitivity, specificity, and positive and negative predictive values were calculated. Results Prevalence of CAN was around 35% in the first sample of patients and just below 20% in the second sample. Hypertension, total cholesterol, triglycerides, postprandial sweating, diastolic blood pressure, abnormal right and left 10 g monofilament, retinopathy, and nephropathy were considered independent predictors of CAN. The CAN-score cut-off was 16.88. This yielded a sensitivity of 50%, specificity 73.8%, positive predictive value 22.9%, and negative predictive value 90.5%. Conclusion The use of a subset of clinical and laboratory characteristics can be more accessible than the cardiac reflex tests and more accurate than a single isolated characteristic.
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Affiliation(s)
- Cinthia Minatel Riguetto
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Caroline Rigoleto Takano
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Sharon Nina Admoni
- 2Serviço de Endocrinologia e Metabologia do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo Brazil
| | - Maria Candida Ribeiro Parisi
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Maria Lucia Correa Giannella
- 2Serviço de Endocrinologia e Metabologia do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo Brazil
| | - Elizabeth João Pavin
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
| | - Arnaldo Moura Neto
- 1Endocrinology Division, Internal Medicine Department, Faculty of Medical Sciences, University of Campinas, Rua Tessália Vieira de Camargo, 126 Campinas, São Paulo, 13084-971 Brazil
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Kim HY, Jung HW, Lee YA, Shin CH, Yang SW. Cardiac autonomic neuropathy in nonobese young adults with type 1 diabetes. Ann Pediatr Endocrinol Metab 2019; 24:180-186. [PMID: 31607111 PMCID: PMC6790876 DOI: 10.6065/apem.2019.24.3.180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/16/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the prevalence and risk factors for cardiac autonomic neuropathy (CAN) in nonobese nonobese young type 1 diabetes mellitus (T1DM) patients without micro- or macrovascular complications. METHODS CAN was assessed in 95 patients with T1DM, aged 18-29 years, using standard cardiovascular reflex tests - heart rate response to deep breathing, standing, and the Valsalva maneuver and blood pressure response to standing. Furthermore, power spectral analyses of overall heart rate variability (HRV), standard deviation of NN intervals (SDNN), and total power (TP) were tested with DiCAN. CAN was defined as abnormal results for at least 1 of the 4 cardiovascular reflex tests. RESULTS The prevalence of CAN was 12.6%. The frequency of one and 2 abnormal reflex tests was 10.5% and 2.1%, respectively. No significant differences were observed in age, sex, mean hemoglobin A1c (HbA1c) level, and duration of diabetes with respect to presence of CAN. Patients with CAN exhibited lower overall HRV parameters (SDNN and TP) compared with those without CAN even though there was no statistical significance. In multivariable analyses, higher mean HbA1c level was significantly associated with lower overall HRV (β=-44.42, P=0.002 for SDNN and β=-2.82, P<0.001 for TP). CONCLUSION CAN can be detected in 12.6% of young adult T1DM patients even without other micro- or macrovascular complications. Glycemic control is the main determinant to maintain overall HRV and prevent CAN.
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Affiliation(s)
- Hwa Young Kim
- Department of Pediatrics, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Hae Woon Jung
- Department of Pediatrics, Kyung Hee University Medical Center, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea,Address for correspondence: Young Ah Lee, MD, PhD Division of Endocrinology and Metabolism, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-2308 Fax: +82-2-743-3455 E-mail:
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Complexity Sciences. HEALTH SYSTEM REDESIGN 2018. [PMCID: PMC7187952 DOI: 10.1007/978-3-319-64605-3_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Complexity sciences, in plain English, are the sciences of interconnectedness. The aim of complexity sciences is to understand the many different facets of phenomena. Complexity sciences employs a variety of different methodological approaches to describe and to analyse multifaceted phenomena like health, the economy, or environmental systems. Basically, a system consists of a number of parts that are connected to each other. Systems differ depending on the nature of their connectedness. Simple systems have one-to-one relationships and their behaviour is precisely predictable. Complicated systems have one-to-many relationships with mostly predictable behaviours. This book deals with complex adaptive systems with many-to-many relationships. Their many-to-many relationships make their behaviour emergent, hence their outcomes are unpredictable. Complex adaptive systems have a special characteristic, the members of the system can learn from feedback and experiences. The relationships in complex adaptive systems change constantly allowing the system to evolve over time in light of changing demands. However, a system’s overall behaviour, despite its adaptation to changing circumstances, remains relatively stable within boundaries, but occasionally, its behaviour may change abruptly and dramatically for no apparent reason.
One can compare the behaviour of complex adaptive systems to that of a family; most of the time a family stays together despite ups and downs, but occasionally a family can abruptly break apart to the surprise of its members and its surroundings. Another important characteristic of complex adaptive systems is its nonlinear behaviour to change, i.e. the magnitude of change in one member of the system shows a disproportional change in that of others. As experience shows, small changes in the behaviour of a system member often show dramatic changes in the behaviour of the whole system, whereas a major change in the behaviour of that member typically results in little or no change.
Studying complex adaptive systems aims to understand the relationships and the dynamics between the members of the systems. This understanding allows for better responses when the system as a whole is challenged by constraints and/or unfamiliar challenges. A special characteristic of social systems is their “goal-delivering” nature. In organisational terms these are codified by their purpose, goals, and values statements.
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Sohn MW, Epstein N, Huang ES, Huo Z, Emanuele N, Stukenborg G, Guihan M, Li J, Budiman-Mak E. Visit-to-visit systolic blood pressure variability and microvascular complications among patients with diabetes. J Diabetes Complications 2017; 31:195-201. [PMID: 27671535 PMCID: PMC5209256 DOI: 10.1016/j.jdiacomp.2016.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 09/07/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
Abstract
AIMS To examine the relationship between systolic blood pressure (SBP) variability and the risk of microvascular complications in a non-elderly diabetic population. METHODS This is a retrospective cohort study of individuals aged ≤60years treated for diabetes in 2003 in the US Department of Veterans Affairs healthcare system. Individuals were followed for five years for any new diagnosis of diabetic nephropathy, retinopathy, or neuropathy. In each year of follow-up, individuals were classified into quartiles based on their SBP variability. RESULTS We identified 208,338 patients with diabetes without diabetic nephropathy, retinopathy, or neuropathy at baseline. Compared to individuals with the least SBP variability (Quartile 1), those with most variability (Quartile 4) had 81% (OR=1.81; 95% CI, 1.72-1.91), 17% (OR=1.17; 95% CI, 1.13-1.21), 30% (OR=1.30; 95% CI, 1.25-1.35), and 19% (OR=1.19; 95% CI, 1.15-1.23) higher incidence of nephropathy, retinopathy, neuropathy, and any complication, respectively, after adjusting for mean SBP, demographic and clinical factors. CONCLUSIONS We found a significant graded relationship between SBP variability and the incidence of each complication and of any combined endpoint. This is the first study showing a significant association between SBP variability and the risk of diabetic retinopathy and neuropathy.
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Affiliation(s)
- Min-Woong Sohn
- Department of Public Health Sciences, School of Medicine, University of Virginia, PO Box 800717, Charlottesville, VA 22908.
| | - Noam Epstein
- Medical and Research Services, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL 60141
| | - Elbert S Huang
- Department of Medicine, the University of Chicago, 924 East 57th Street, Chicago, IL 60637
| | - Zhiping Huo
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL 60141
| | - Nicholas Emanuele
- Medical and Research Services, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL 60141; Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Avenue, Maywood, IL 60153
| | - George Stukenborg
- Department of Public Health Sciences, School of Medicine, University of Virginia, PO Box 800717, Charlottesville, VA 22908
| | - Marylou Guihan
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL 60141; Department of Physical Medicine and Rehabilitation, Northwestern University, 710 North Lake Shore Drive #1022, Chicago, IL 60611
| | - Junping Li
- Medical and Research Services, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL 60141; Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Avenue, Maywood, IL 60153
| | - Elly Budiman-Mak
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Avenue, Hines, IL 60141; Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Avenue, Maywood, IL 60153
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Dafaalla MD, Nimir MN, Mohammed MI, Ali OA, Hussein A. Risk factors of diabetic cardiac autonomic neuropathy in patients with type 1 diabetes mellitus: a meta-analysis. Open Heart 2016; 3:e000336. [PMID: 27843562 PMCID: PMC5073521 DOI: 10.1136/openhrt-2015-000336] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 04/25/2016] [Accepted: 06/30/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES We aimed to stratify the possible risk factors for diabetic cardiac autonomic neuropathy (CAN). METHODS We did a meta-analysis of risk factors of CAN. We did a web-based search for literature in MEDLINE/PubMed, Scopus database and CENTRAL database up to August 2015. We included clinical trials or cohort studies that provide data about relationship between CAN and variables of interest. Our risk factors of interest were age, sex, duration of diabetes, body mass index (BMI), systolic blood pressure (sBP) and diastolic blood pressure (dBP), glycated haemoglobin (HbA1c), high-density lipoprotein and low-density lipoprotein (HDL and LDL), triglycerides, retinopathy and nephropathy. We generated Forest plots, χ2 test and I2 as tests for heterogeneity, risk ratio (RR), mean difference (MD), CIs and p values by ReVMan V.5.3 software. RESULTS We found a total of 882 related items. We excluded 873 studies from the title and abstract and 4 studies after review of full reports. Four studies were included. Our meta-analysis showed significant association between CAN and age (MD=4.94 (3.46 to 6.42)), duration of diabetes (MD=4.51 (2.51 to 6.52)), HbA1c (MD=0.48 (0.28 to 0.67)), BMI (MD=0.55 (0.08 to 1.01)), serum triglycerides (MD=0.09 (0.01 to 0.17)), proliferative retinopathy (RR=3.69 (1.20 to 11.34)), microalbuminuria (RR=2.47 (1.43 to 4.29)), hypertension (RR=4.18 (2.52 to 6.91)) and sBP (MD=4.10 (2.20 to 6.00)). We neither discovered the absence of significant association between the development of CAN and male sex (RR=1.57 (0.45 to 5.39)), dBP (MD=0.89 (-0.36 to 2.14)), cholesterol level (MD=1.19 (-0.99 to 3.36)), LDL (MD=0.12 (-0.15 to 0.39)), nor HDL level (MD=-0.28 (-0.58 to 0.03)). CONCLUSIONS Age, duration of diabetes, HbA1c, BMI, serum triglycerides, proliferative retinopathy, microalbuminuria, hypertension and sBP are directly related to the risk of development of diabetic CAN.
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Affiliation(s)
- Mohamed D Dafaalla
- Soba Center for Audit and Research (SCAR), University of Khartoum , Khartoum , Sudan
| | | | | | - Omer A Ali
- Daoud Research Group, University of Khartoum , Khartoum , Sudan
| | - Abbashar Hussein
- Faculty of Medicine, Daoud Research Group , University of Khartoum , Khartoum , Sudan
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Abstract
Cardiac autonomic neuropathy (CAN) is the least recognized and understood complication of peripheral neuropathy. However, because of its potential adverse effects including sudden death, CAN is one of the most important forms of autonomic neuropathies. CAN presents with different clinical manifestations including postural hypotension, exercise intolerance, fluctuation of blood pressure and heart rate, arrhythmia, and increased risk of myocardial infarction. In this article, the prevalence, clinical presentations, and management of cardiac involvement in certain peripheral neuropathies, including diabetic neuropathy, Guillain-Barré syndrome, chronic inflammatory polyneuropathy, human immunodeficiency virus-associated neuropathy, hereditary neuropathies, and amyloid neuropathy are examined in detail.
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Affiliation(s)
- Ahmet Z Burakgazi
- *Department of Medicine, MDA/ALS Clinic at Carilion Clinic, Roanoke, VA; Virginia Tech Carilion School of Medicine and Research Institute; and †Department of Medicine, Carilion Clinic Heart Rhythm Services; Virginia Tech Carilion School of Medicine and Research Institute
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Ziegler D, Behler M, Schroers-Teuber M, Roden M. Near-normoglycaemia and development of neuropathy: a 24-year prospective study from diagnosis of type 1 diabetes. BMJ Open 2015; 5:e006559. [PMID: 26109108 PMCID: PMC4479996 DOI: 10.1136/bmjopen-2014-006559] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Complete prevention of diabetic neuropathies has not been previously demonstrated. We sought to determine whether long-term near-normoglycaemia maintained from the diagnosis of type 1 diabetes is associated with polyneuropathy and cardiac autonomic dysfunction. DESIGN Prospective observational study over 24 years. SETTING Ambulatory care. PARTICIPANTS 32 newly diagnosed patients with type 1 diabetes aged 20.3 ± 1.0 years, duration of diabetes 2.7 ± 0.3 weeks. INTERVENTION Insulin therapy according to standards of care. PRIMARY AND SECONDARY OUTCOME MEASURES Motor and sensory nerve conduction velocity (MNCV and SNCV), heart rate variability (HRV), and confirmed clinical polyneuropathy measured at 15 time points over 24 years and quantitative sensory testing (QST) determined over 20-22 years. RESULTS 11 patients were well controlled over 24 years with mean glycated haemoglobin (HbA1c) <7.0% (6.5 ± 0.1%; group 1), whereas 21 patients were poorly controlled (mean HbA1c ≥ 7.0%: 8.3 ± 0.2%; group 2). After 24 years, MNCV was faster in group 1 versus group 2 in the median (55.5 ± 1.6 vs 48.9 ± 1.6 m/s), ulnar (56.5 ± 1.5 vs 49.3 ± 1.7 m/s) and peroneal nerve (44.7 ± 1.6 vs 36.8 ± 2.5 m/s), while SNCV was faster in the median (53.6 ± 1.6 vs 45.5 ± 2.8 m/s), ulnar (54.7 ± 1.8 vs 43.0 ± 3.9 m/s), and sural nerve (44.5 ± 1.8 vs 35.5 ± 2.6 m/s; all p<0.05). The annual decline in peroneal MNCV and sural SNCV in group 1 was sixfold and threefold faster in group 2 than in group 1, respectively. Likewise, impairment in QST and HRV developed at faster rates in group 2. After 24 years, 64% of patients in group 2, but none in group 1, developed confirmed clinical polyneuropathy. CONCLUSIONS Near-normoglycaemia maintained from the diagnosis of type 1 diabetes over 24 years was associated with a complete prevention of the decline in hyperglycaemia-related peripheral and autonomic nerve function, and development of confirmed clinical polyneuropathy.
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Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Margarete Behler
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Maria Schroers-Teuber
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
| | - Michael Roden
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Sturmberg J, Lanham HJ. Understanding health care delivery as a complex system: achieving best possible health outcomes for individuals and communities by focusing on interdependencies. J Eval Clin Pract 2014; 20:1005-9. [PMID: 24797788 DOI: 10.1111/jep.12142] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2014] [Indexed: 12/17/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The concept of emergence offers a new way of thinking about multimorbidity and chronic disease. RESULTS AND CONCLUSIONS Multimorbidity and chronic disease are the end results of ongoing perturbations and interconnected activities of simpler substructures that collectively constitute the complex adaptive superstructure known as us, the person or patient. Medical interventions cause perturbations of many different subsystems within the patient, hence they are not limited to the person's bodily function, but also affect his general health perception and his interactions with his external environments. Changes in these domains inevitably have consequences on body function, and close the feedback loop of illness/disease, recovery and regained health.
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Affiliation(s)
- Joachim Sturmberg
- Departments of General Practice, Newcastle University-Newcastle, Newcastle, NSW, Australia
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Abstract
OBJECTIVE To evaluate heart rate variability by Holter monitoring in type 1 diabetic children compared with a healthy control group and determine the factors modifying heart rate variability. METHODS This was designed as a prospective study comparing 28 patients, diagnosed with type 1 diabetes and under follow-up, with 27 healthy control group subjects. RESULTS The patients were aged 9.9 ± 4.2 years in the diabetic group, including 13 (46.5%) girls and 15 (53.5%) boys. The healthy control group comprised 20 (74%) girls and seven boys (26%) with an average age of 8.6 ± 3.7 years. The search for factors modifying heart rate variability yielded the following correlations: for the time-dependent variables, negative between age and both average and maximal heart rate (r = -0.263 and -0.460, respectively), negative between haemoglobin A1c and percentage of differences between adjacent RR intervals >50 ms, positive between diabetes duration and square root of the mean of the sum of squares of differences between adjacent NN intervals. The average heart rate and percentage of differences between adjacent RR intervals >50 ms was significantly higher in the girls than the boys in all groups. With regard to the frequency-dependent factors affecting heart rate variability, correlations were found between haemoglobin A1c level and both total power and very low frequency (r = -0.751 and -0.644) and between very low frequency and diabetes duration. CONCLUSION A reduction in heart rate variability parameters was observed in type 1 diabetes mellitus patients who had a long disease duration or were poorly controlled, as compared with healthy controls.
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Abstract
Diabetic neuropathies (DNs) differ in clinical course, distribution, fiber involvement (type and size), and pathophysiology, the most typical type being a length-dependent distal symmetric polyneuropathy (DSP) with differing degrees of autonomic involvement. The pathogenesis of diabetic DSP is multifactorial, including increased mitochondrial production of free radicals due to hyperglycemia-induced oxidative stress. Mechanisms that impact neuronal activity, mitochondrial function, membrane permeability, and endothelial function include formation of advanced glycosylation end products, activation of polyol aldose reductase signaling, activation of poly(ADP ribose) polymerase, and altered function of the Na(+)/K(+)-ATPase pump. Hyperglycemia-induced endoplasmic reticulum stress triggers several neuronal apoptotic processes. Additional mechanisms include impaired nerve perfusion, dyslipidemia, altered redox status, low-grade inflammation, and perturbation of calcium balance. Successful therapies require an integrated approach targeting these mechanisms. Intensive glycemic control is essential but is insufficient to prevent onset or progression of DSP, and disease-modifying treatments for DSP have been disappointing. Atypical forms of DN include subacute-onset sensory (symmetric) or motor (asymmetric) predominant conditions that are frequently painful but generally self-limited. DNs are a major cause of disability, associated with reduced quality of life and increased mortality.
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Affiliation(s)
- James W. Albers
- Neuromuscular Section, Department of Neurology, University of Michigan Health System, 1C325 University Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0032, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, 5329 Brehm Tower, 1000 Wall Street, Ann Arbor, MI 48105, USA
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Zanone MM, Raviolo A, Coppo E, Trento M, Trevisan M, Cavallo F, Favaro E, Passera P, Porta M, Camussi G. Association of autoimmunity to autonomic nervous structures with nerve function in patients with type 1 diabetes: a 16-year prospective study. Diabetes Care 2014; 37:1108-15. [PMID: 24550215 DOI: 10.2337/dc13-2274] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We prospectively evaluated the association between autoimmunity to autonomic nervous structures and autonomic neuropathy in type 1 diabetes in relation to clinical variables. RESEARCH DESIGN AND METHODS A cohort of 112 patients with type 1 diabetes was prospectively followed from adolescence (T0) to approximately 4 (T4) and 16 (T16) years later. Standard cardiovascular (CV) tests and neurological examination were performed and related to the presence of circulating antibodies (Ab) to autonomic nervous structures detected at T0 and T4. Quality of life was assessed by a diabetes-specific questionnaire. RESULTS Sixty-six patients (59% of the cohort) were reexamined at T16 (age 31.4 ± 2 years; disease duration 23.4 ± 3.7 years). Nineteen had circulating Ab to autonomic structures. Prevalence of abnormal tests and autonomic symptoms were higher in Ab-positive (68 and 26%, respectively) than Ab-negative (32 and 4%) patients (P < 0.05). Among Ab-positive patients, the relative risk (RR) of having at least one altered CV test was 5.77 (95% CI 1.56-21.33), and an altered deep breathing (DB) test (<15 bpm) was 14.65 (2.48-86.46). Previous glycemic control was the only other predictor (RR 1.06 [1.002-1.13]/mmol/mol HbA1c increase). Presence of Ab carried over a 68% probability of developing an altered CV test; absence of Ab carried a 91% probability of not having an altered DB test and an 89% probability of not having an altered Valsalva ratio. Autonomic neuropathy was independently associated with worse quality of life. CONCLUSIONS Circulating Ab to autonomic structures are associated with the development of autonomic dysfunction in young diabetic patients independent of glycemic control.
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Tang ZH, Zeng F, Li Z, Zhou L. Association and predictive value analysis for resting heart rate and diabetes mellitus on cardiovascular autonomic neuropathy in general population. J Diabetes Res 2014; 2014:215473. [PMID: 24772443 PMCID: PMC3977100 DOI: 10.1155/2014/215473] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 01/11/2014] [Accepted: 01/20/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the predictive value of DM and resting HR on CAN in a large sample derived from a Chinese population. MATERIALS AND METHODS We conducted a large-scale, population-based, cross-sectional study to explore the relationships of CAN with DM and resting HR. A total of 387 subjects were diagnosed with CAN in our dataset. The associations of CAN with DM and resting HR were assessed by a multivariate logistic regression (MLR) analysis (using subjects without CAN as a reference group) after controlling for potential confounding factors. The area under the receiver-operating characteristic curve (AUC) was used to evaluate the predictive performance of resting HR and DM. RESULTS A tendency toward increased CAN prevalence with increasing resting HR was reported (P for trend <0.001). MLR analysis showed that DM and resting HR were very significantly and independently associated with CAN (P < 0.001 for both). Resting HR alone or combined with DM (DM-HR) both strongly predicted CAN (AUC = 0.719, 95% CI 0.690-0.748 for resting HR and AUC = 0.738, 95% CI 0.710-0.766 for DM-HR). CONCLUSION Our findings signify that resting HR and DM-HR have a high value in predicting CAN in the general population.
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Affiliation(s)
- Zi-Hui Tang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, No. 12 Wulumuqi Mid Road, Building No. 0, Jing'an District, Shanghai 200040, China
- *Zi-Hui Tang: and
| | - Fangfang Zeng
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, No. 12 Wulumuqi Mid Road, Building No. 0, Jing'an District, Shanghai 200040, China
| | - Zhongtao Li
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, No. 12 Wulumuqi Mid Road, Building No. 0, Jing'an District, Shanghai 200040, China
| | - Linuo Zhou
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, No. 12 Wulumuqi Mid Road, Building No. 0, Jing'an District, Shanghai 200040, China
- *Linuo Zhou:
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Oxidative Stress and Cardiovascular Disease in Diabetes. OXIDATIVE STRESS IN APPLIED BASIC RESEARCH AND CLINICAL PRACTICE 2014. [DOI: 10.1007/978-1-4899-8035-9_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Stranieri A, Abawajy J, Kelarev A, Huda S, Chowdhury M, Jelinek HF. An approach for Ewing test selection to support the clinical assessment of cardiac autonomic neuropathy. Artif Intell Med 2013; 58:185-93. [PMID: 23768975 DOI: 10.1016/j.artmed.2013.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 02/23/2013] [Accepted: 04/25/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This article addresses the problem of determining optimal sequences of tests for the clinical assessment of cardiac autonomic neuropathy (CAN). We investigate the accuracy of using only one of the recommended Ewing tests to classify CAN and the additional accuracy obtained by adding the remaining tests of the Ewing battery. This is important as not all five Ewing tests can always be applied in each situation in practice. METHODS AND MATERIAL We used new and unique database of the diabetes screening research initiative project, which is more than ten times larger than the data set used by Ewing in his original investigation of CAN. We utilized decision trees and the optimal decision path finder (ODPF) procedure for identifying optimal sequences of tests. RESULTS We present experimental results on the accuracy of using each one of the recommended Ewing tests to classify CAN and the additional accuracy that can be achieved by adding the remaining tests of the Ewing battery. We found the best sequences of tests for cost-function equal to the number of tests. The accuracies achieved by the initial segments of the optimal sequences for 2, 3 and 4 categories of CAN are 80.80, 91.33, 93.97 and 94.14, and respectively, 79.86, 89.29, 91.16 and 91.76, and 78.90, 86.21, 88.15 and 88.93. They show significant improvement compared to the sequence considered previously in the literature and the mathematical expectations of the accuracies of a random sequence of tests. The complete outcomes obtained for all subsets of the Ewing features are required for determining optimal sequences of tests for any cost-function with the use of the ODPF procedure. We have also found two most significant additional features that can increase the accuracy when some of the Ewing attributes cannot be obtained. CONCLUSIONS The outcomes obtained can be used to determine the optimal sequences of tests for each individual cost-function by following the ODPF procedure. The results show that the best single Ewing test for diagnosing CAN is the deep breathing heart rate variation test. Optimal sequences found for the cost-function equal to the number of tests guarantee that the best accuracy is achieved after any number of tests and provide an improvement in comparison with the previous ordering of tests or a random sequence.
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Affiliation(s)
- Andrew Stranieri
- School of Science, Information Technology and Engineering, University of Ballarat, P.O. Box 663, Ballarat, Victoria 3353, Australia.
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Diabetic cardiac autonomic neuropathy: insights from animal models. Auton Neurosci 2013; 177:74-80. [PMID: 23562143 DOI: 10.1016/j.autneu.2013.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 03/01/2013] [Indexed: 12/19/2022]
Abstract
Cardiac autonomic neuropathy (CAN) is a relatively common and often devastating complication of diabetes. The major clinical signs are tachycardia, exercise intolerance, and orthostatic hypotension, but the most severe aspects of this complication are high rates of cardiac events and mortality. One of the earliest manifestations of CAN is reduced heart rate variability, and detection of this, along with abnormal results in postural blood pressure testing and/or the Valsalva maneuver, are central to diagnosis of the disease. The treatment options for CAN, beyond glycemic control, are extremely limited and lack evidence of efficacy. The underlying molecular mechanisms are also poorly understood. Thus, CAN is associated with a poor prognosis and there is a compelling need for research to understand, prevent, and reverse CAN. In this review of the literature we examine the use and usefulness of animal models of CAN in diabetes. Compared to other diabetic complications, the number of animal studies of CAN is very low. The published studies range across a variety of species, methods of inducing diabetes, and timescales examined, leading to high variability in study outcomes. The lack of well-characterized animal models makes it difficult to judge the relevance of these models to the human disease. One major advantage of animal studies is the ability to probe underlying molecular mechanisms, and the limited numbers of mechanistic studies conducted to date are outlined. Thus, while animal models of CAN in diabetes are crucial to better understanding and development of therapies, they are currently under-used.
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Maser RE, Lenhard MJ, Kolm P, Edwards DG. Direct renin inhibition improves parasympathetic function in diabetes. Diabetes Obes Metab 2013; 15:28-34. [PMID: 22834767 PMCID: PMC3524360 DOI: 10.1111/j.1463-1326.2012.01669.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 06/18/2012] [Accepted: 07/23/2012] [Indexed: 11/30/2022]
Abstract
AIM The renin-angiotensin-aldosterone system (RAAS) and autonomic nervous system regulate the cardiovascular system. Blockade of the RAAS may slow the progression of end-organ damage. Direct renin inhibition offers a means for blocking the RAAS. The objective of this study was to examine the effect of direct renin inhibition on cardiovascular autonomic function. METHODS In this double-blind, placebo-controlled trial, 60 individuals with diabetes were randomly assigned to 300 mg of aliskiren or placebo once daily for 6 weeks. The primary end point was a change in tests of cardiovascular autonomic function. Autonomic function was assessed by power spectral analysis and RR-variation during deep breathing [i.e. mean circular resultant (MCR), expiration/inspiration (E/I) ratio]. The MCR and E/I ratio assess parasympathetic function. Secondary measures included change in biochemical parameters [e.g. plasma renin activity, leptin and interleukin-6]. Change in cardiovascular autonomic function and blood analytes were analysed by a mixed effects model for repeated measures. RESULTS Baseline characteristics were similar between treatment groups. In response to aliskiren compared with placebo, blood pressure was reduced as well as plasma renin activity [from 2.4 ± 3.8 (mean ± standard deviation) to 0.5 ± 0.4 µg/l/h, p < 0.001]. There was a significant interaction (aliskiren × visit) for MCR (p = 0.003) and E/I ratio (p = 0.003) indicating improvement in MCR and E/I ratio for those on aliskiren. MCR means, baseline vs. follow-up, were 41.8 ± 19.7 vs. 50.8 ± 26.1 (aliskiren) and 38.2 ± 23.6 vs. 37.5 ± 24.1 (placebo). CONCLUSIONS Parasympathetic function (i.e. MCR and E/I ratio) was enhanced by downregulation of the RAAS.
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Affiliation(s)
- R E Maser
- Department of Medical Laboratory Sciences, University of Delaware, Newark, DE 19716, USA.
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Pop-Busui R. What do we know and we do not know about cardiovascular autonomic neuropathy in diabetes. J Cardiovasc Transl Res 2012; 5:463-78. [PMID: 22644723 DOI: 10.1007/s12265-012-9367-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 04/12/2012] [Indexed: 12/16/2022]
Abstract
Cardiovascular autonomic neuropathy (CAN) in diabetes is generally overlooked in practice, although awareness of its serious consequences is emerging. Challenges in understanding the complex, dynamic changes in the modulation of the sympathetic/parasympathetic systems' tone and their interactions with physiologic mechanisms regulating the control of heart rate, blood pressure, and other cardiovascular functions in the presence of acute hyper-or-hypoglycemic stress, other stressors or medication, and challenges with sensitive evaluations have contributed to lower CAN visibility compared with other diabetes complications. Yet, CAN is a significant cause of morbidity and mortality, due to a high-risk of cardiac arrhythmias, silent myocardial ischemia and sudden death. While striving for aggressive risk factor control in diabetes practice seemed intuitive, recent reports of major clinical trials undermine established thinking concerning glycemic control and cardiovascular risk. This review covers current understanding and gaps in that understanding of the clinical implications of CAN and prevention and treatment of CAN.
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Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Hawthorne KM, Johri AM, Malhotra R, Hung J, Baggish A, Picard MH. Quality Assessment in Dobutamine Stress Echocardiography: What are the Clinical Predictors Associated With a Non-Diagnostic Test? Cardiol Res 2012; 3:73-79. [PMID: 28348675 PMCID: PMC5358144 DOI: 10.4021/cr154w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2012] [Indexed: 11/21/2022] Open
Abstract
Background Non-diagnostic dobutamine stress echocardiography (ndDSE, failure to achieve 85% of maximal predicted heart rate (HR) without evidence of inducible ischemia) is an important limitation affecting quality of DSE testing. The objectives of this study were to identify the clinical variables associated with a non-diagnostic Dobutamine Stress Echocardiogram (ndDSE) and further evaluate the patterns of subsequent testing for myocardial ischemia. Methods Consecutive DSE’s over a 17 month period (January 2008 to June 2009) were studied. Baseline demographics, medical history, and vital signs were collected. Subsequent testing was determined for up to 6 months after the initial DSE. Univariate and multivariate logistic regression analysis was performed to identify clinical factors associated with ndDSE. Results Of 467 total DSE, 314 (67%) were negative for ischemia, 69 (15%) were positive, and 84 (18%) were ndDSE. Of those recommended for further nuclear MPI testing 12 (14%) had an ndDSE compared to 16 (4%) patients with a diagnostic DSE (P = 0.001). Fifty percent of the ndDSE nuclear MPI tests were positive for ischemia. In the univariate analysis, Diabetes Mellitus (DM; P = 0.003), calcium channel antagonist (CCA) use (P = 0.047), Hypertension (HTN; P = 0.06), low baseline HR (P < 0.001), and younger age group (P = 0.02) were predictive of ndDSE. Of these, all except CCA use remained independent predictors of ndDSE in multivariate analysis. A 4 variable model for predicting ndDSE was developed from the multivariate logistic regression displayed in Table 1 (age and baseline HR were categorized and scored 0-2; DM and HTN were scored as 0 (absent) or 1 (present)). Figure 2 demonstrates how risk of ndDSE correlated with a higher score, with each increment having an odds ratio of 2.1 (P < 0.001). Conclusions DM, HTN, younger age, and lower baseline HR affect the quality of DSE testing, resulting in non-diagnostic tests. A model combining these factors can identify patients most likely to have this outcome. Identification of this cohort may improve referral patterns and improve the quality of stress testing.
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Affiliation(s)
- Katie M Hawthorne
- Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA; Authors contributed equally to writing of manuscript
| | - Amer M Johri
- Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA; Authors contributed equally to writing of manuscript
| | - Rajeev Malhotra
- Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA; Authors contributed equally to writing of manuscript
| | - Judy Hung
- Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Aaron Baggish
- Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Michael H Picard
- Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
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Orlov S, Bril V, Orszag A, Perkins BA. Heart rate variability and sensorimotor polyneuropathy in type 1 diabetes. Diabetes Care 2012; 35:809-16. [PMID: 22357183 PMCID: PMC3308280 DOI: 10.2337/dc11-1652] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Reduced heart rate variability (HRV) is classically viewed as an early phenomenon in diabetic sensorimotor polyneuropathy (DSP). We aimed to determine the characteristics of HRV across the spectrum of clinical DSP in type 1 diabetes. RESEARCH DESIGN AND METHODS Eighty-nine diabetic subjects and 60 healthy volunteers underwent assessment of RR interval variation (RR(var)) during deep breathing and clinical and electrophysiological examination. We examined the distribution of age-standardized RR(var) across the spectrum of clinical DSP, identified variables associated with RR(var) in multivariate regression, and compared RR(var) with validated measures of neuropathy. RESULTS Age-standardized RR(var) had a significant, step-wise, inverse relationship with ordinal categories of increasing DSP severity (β = -5.4, P < 0.0001) among subjects with diabetes. Case subjects with DSP had substantially lower age-standardized RR(var) compared with diabetic control subjects without DSP (β = -5.2, P < 0.01), although there was substantial overlap of RR(var) between diabetic case subjects and control subjects and the healthy volunteer cohort. In multivariate analysis, advanced age was independently associated with lower RR(var) in both healthy volunteers and diabetic subjects, whereas higher glycated hemoglobin A(1c) and systolic blood pressure were independently associated with lower RR(var) in diabetic subjects. RR(var) had a significant association with validated measures of large and small fiber neuropathy. CONCLUSIONS HRV may be a biomarker for clinical DSP and is associated cross-sectionally with both early and late measures of neuropathy. The low HRV observed in some control subjects without DSP and in most case subjects with severe DSP may signify that HRV has different prognostic implications in these groups, requiring further longitudinal study.
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Affiliation(s)
- Steven Orlov
- Department of Medicine, Division of Endocrinology and Metabolism, University of Toronto, Toronto, Ontario, Canada
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Giannini C, Mohn A, Chiarelli F, Kelnar CJH. Macrovascular angiopathy in children and adolescents with type 1 diabetes. Diabetes Metab Res Rev 2011; 27:436-60. [PMID: 21433262 DOI: 10.1002/dmrr.1195] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes represents one of the most common diseases globally. Worryingly, the worldwide incidence of type 1 diabetes (T1D) is rising by 3% per year. Despite the rapid increase in diabetes incidence, recent advances in diabetes treatment have been successful in decreasing morbidity and mortality from diabetes-related retinopathy, nephropathy, and neuropathy. In contrast, there is clear evidence for the lack of improvement in mortality for cardiovascular diseases (CVDs). This emphasizes the importance of focusing childhood diabetes care strategies for the prevention of CVD in adulthood. Furthermore, although most work on diabetes and macrovascular disease relates to type 2 diabetes, it has been shown that the age-adjusted relative risk of CVD in T1D far exceeds that in type 2 diabetes. As T1D appears predominantly during childhood, those with T1D are at greater risk for coronary events early in life and require lifelong medical attention. Because of the important health effects of CVDs in children and adolescents with T1D, patients, family members, and care providers should understand the interaction of T1D and cardiovascular risk. In addition, optimal cardiac care for the patient with diabetes should focus on aggressive management of traditional cardiovascular risk factors to optimize those well-recognized as well as new specific risk factors which are becoming available. Therefore, a complete characterization of the molecular mechanisms involved in the development and progression of macrovascular angiopathy is needed. Furthermore, as vascular abnormalities begin as early as in childhood, potentially modifiable risk factors should be identified at an early stage of vascular disease development.
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Affiliation(s)
- Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy.
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Abstract
It has long been recognized that cardiac autonomic neuropathy increases morbidity and mortality in diabetes and may have greater predictive power than traditional risk factors for cardiovascular events. Significant morbidity and mortality can now be attributable to autonomic imbalance between the sympathetic and parasympathetic nervous system regulation of cardiovascular function. New and emerging syndromes include orthostatic tachycardia, orthostatic bradycardia and an inability to use heart rate as a guide to exercise intensity because of the resting tachycardia. Recent studies have shown that autonomic imbalance may be a predictor of risk of sudden death with intensification of glycaemic control. This review examines an association of autonomic dysregulation and the role of inflammatory cytokines and adipocytokines that promote cardiovascular risk. In addition, conditions of autonomic imbalance associated with cardiovascular risk are discussed. Potential treatment for restoration of autonomic balance is outlined.
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Affiliation(s)
- A I Vinik
- Eastern Virginia Medical School, Strelitz Diabetes Research Center and Neuroendocrine Unit, 855 W Brambleton Avenue, Norfolk, VA 23510, USA.
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Conway BN, Aroda VR, Maynard JD, Matter N, Fernandez S, Ratner RE, Orchard TJ. Skin intrinsic fluorescence correlates with autonomic and distal symmetrical polyneuropathy in individuals with type 1 diabetes. Diabetes Care 2011; 34:1000-5. [PMID: 21307380 PMCID: PMC3064012 DOI: 10.2337/dc10-1791] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether skin intrinsic fluorescence (SIF) was associated with autonomic neuropathy and confirmed distal symmetrical polyneuropathy (CDSP) in 111 individuals with type 1 diabetes (mean age 49 years, mean diabetes duration 40 years). RESEARCH DESIGN AND METHODS SIF was measured using the SCOUT DM device. Autonomic neuropathy was defined as an electrocardiographic abnormal heart rate response to deep breathing (expiration-to-inspiration ratio <1.1). CDSP was defined using the Diabetes Control and Complications Trial clinical exam protocol (the presence of two or more of the following: symptoms, sensory and/or motor signs, and/or reduced/absent tendon reflexes consistent with DSP) confirmed by the presence of an abnormal age-specific vibratory threshold (using a Vibratron II tester). RESULTS The prevalence of autonomic neuropathy and CDSP were 61 and 66%, respectively. SIF was higher in those with autonomic neuropathy (P < 0.0001). In multivariable analyses controlling for age and updated mean (18-year average) HbA(1c), and allowing for other univariately and clinically significant correlates of autonomic neuropathy, each SD change in SIF was associated with a 2.6-greater likelihood of autonomic neuropathy (P = 0.006). Receiver operating characteristic (ROC) analyses revealed that SIF and updated mean HbA(1c) accounted for 80 and 57%, respectively, of the area under the curve (AUC) for autonomic neuropathy. SIF also was higher in those with CDSP (P < 0.0001) and remained so in multivariable analyses (odds ratio 2.70; P = 0.005). ROC analyses revealed that SIF and updated mean HbA(1c) accounted for 78 and 59%, respectively, of the AUC for CDSP. CONCLUSIONS SIF, a marker of dermal advanced glycation end products, appears to be more strongly associated with the presence of both CDSP and autonomic neuropathy than mean HbA(1c).
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Affiliation(s)
- Baqiyyah N Conway
- Division of Epidemiology, Vanderbilt University, Nashville, Tennessee, USA
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36
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Affiliation(s)
- Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA.
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Pop-Busui R, Roberts L, Pennathur S, Kretzler M, Brosius FC, Feldman EL. The management of diabetic neuropathy in CKD. Am J Kidney Dis 2010; 55:365-85. [PMID: 20042258 PMCID: PMC4007054 DOI: 10.1053/j.ajkd.2009.10.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 10/29/2009] [Indexed: 02/07/2023]
Abstract
A 64-year-old male with a 15-year history of poorly controlled type 2 diabetes and a 10-year history of hypertension and hyperlipidemia had developed multiple diabetes-related complications within the last 5 years. He first developed albuminuria 5 years ago, and over the next several years experienced fairly rapid decline in kidney function, with eGFR of 55 mL/min/1.73m2 noted 2 years ago. He was diagnosed with proliferative retinopathy 5 years ago and underwent laser photocoagulation. Four years ago, he noted symptoms of peripheral neuropathy manifested as shooting pain and numbness with loss of light touch, thermal and vibratory sensation in a stocking distribution. Last year he developed a non-healing ulcer on the plantar aspect of his left foot which was complicated with gangrene and resulted in a below-the-knee amputation of the left leg one year ago. He now reports a new onset of weakness, lightheadedness and dizziness on standing that affects his daily activities. He reports lancinating pain in his right lower extremity, worse in the evening. Medications include: neutral protamine Hagedorn insulin twice daily and regular insulin on a sliding scale, metoprolol 50 mg/d, lisinopril 40 mg/d, atorvastatin 80 mg/d, furosemide 40 mg/d and aspirin 81 mg/d. Blood pressure is 127/69 mm Hg with a pulse rate of 96 bpm while supine and 94/50 mmHg with a pulse rate of 102 bpm while standing. Strength is normal but with a complete loss of all sensory modalities to the knee in his remaining limb and up to the wrists in both upper extremities, and he is areflexic. Today's laboratory evaluations show a serum creatinine of 2.8 mg/dl, an estimated GFR (eGFR) of 24 ml/min/1.73m2, a hemoglobin A1c (HbA1c) of 7.9 % and 2.1 g of urine protein per gram of creatinine. What would be the most appropriate management for this patient?
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Affiliation(s)
- Rodica Pop-Busui
- University of Michigan Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes
| | | | | | - Mathias Kretzler
- University of Michigan Department of Internal Medicine, Division of Nephrology
| | - Frank C. Brosius
- University of Michigan Department of Internal Medicine, Division of Nephrology
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Nolan RP, Barry-Bianchi SM, Mechetiuc AE, Chen MH. Sex-based differences in the association between duration of type 2 diabetes and heart rate variability. Diab Vasc Dis Res 2009; 6:276-82. [PMID: 20368222 DOI: 10.1177/1479164109339965] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We examined the association between heart rate variability (HRV) and duration of type 2 diabetes among 155 female and 106 male subjects: mean+/-SD for duration=49.6+/-65.6 and 57.3+/-77.1 months, respectively, p=0.38. Among males, duration of diabetes was independently and inversely associated with vagal-heart rate modulation (high frequency (HF) power, 0.15-0.40 Hz, standardised ss = -0.32, p=0.001; root mean square of successive differences between R-R intervals, ss = -0.26, p=0.006) and total R-R variability (standard deviation of normal R-R intervals, ss = -0.36, p=0.001); but not among females (p> or =0.80 for each HRV index). In contrast, HF was inversely associated with age of diabetes diagnosis (ss = -0.16, p=0.04) and 10-year absolute risk for coronary heart disease (ss = -0.16, p=0.04) among female subjects. Longitudinal research is needed to establish whether risk factors for early cardiac autonomic impairment differ among men and women with type 2 diabetes.
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Affiliation(s)
- Robert P Nolan
- Behavioral Cardiology Research Unit, University Health Network, 585 University Ave., Toronto, ON M5G 2N2, Canada.
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Affiliation(s)
- Nishi Chaturvedi
- From the International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College NHS Healthcare Trust, London, United Kingdom
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40
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Affiliation(s)
- Joachim P Sturmberg
- Monash University, Melbourne, and The Newcastle University, Newcastle, Australia.
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Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Clinical review: Prevalence and incidence of endocrine and metabolic disorders in the United States: a comprehensive review. J Clin Endocrinol Metab 2009; 94:1853-78. [PMID: 19494161 PMCID: PMC5393375 DOI: 10.1210/jc.2008-2291] [Citation(s) in RCA: 334] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT There has not been a comprehensive compilation of data regarding the epidemiology of all endocrine and metabolic disorders in the United States. EVIDENCE ACQUISITION We included 54 disorders with clinical and public health significance. We identified population-based studies that provided U.S. prevalence and/or incidence data by searching PubMed in December 2007 for English-language reports, hand-searching reference lists of six textbooks of endocrinology, obtaining additional resources from identified experts in each subspecialty, and searching epidemiological databases and web sites of relevant organizations. When available, we selected articles with data from 1998 or later. Otherwise, we selected the article with the most recent data, broadest geographical coverage, and most stratifications by sex, ethnicity, and/or age. Ultimately, we abstracted data from 70 articles and 40 cohorts. EVIDENCE SYNTHESIS Endocrine disorders with U.S. prevalence estimates of at least 5% in adults included diabetes mellitus, impaired fasting glucose, impaired glucose tolerance, obesity, metabolic syndrome, osteoporosis, osteopenia, mild-moderate hypovitaminosis D, erectile dysfunction, dyslipidemia, and thyroiditis. Erectile dysfunction and osteopenia/osteoporosis had the highest incidence in males and females, respectively. The least prevalent conditions, affecting less than 1% of the U.S. population, were diabetes mellitus in children and pituitary adenoma. Conditions with the lowest incidence were adrenocortical carcinoma, pheochromocytoma, and pituitary adenomas. Certain disorders, such as hyperparathyroidism and thyroid disorders, were more common in females. As expected, the prevalence of diabetes mellitus was highest among ethnic minorities. Sparse data were available on pituitary, adrenal, and gonadal disorders. CONCLUSIONS The current review shows high prevalence and incidence of common endocrine and metabolic disorders. Defining the epidemiology of these conditions will provide clues to risk factors and identify areas to allocate public health and research resources.
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Affiliation(s)
- Sherita H Golden
- Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, 2024 East Monument Street, Suite 2-600, Baltimore, Maryland 21205, USA.
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Pop-Busui R, Low PA, Waberski BH, Martin CL, Albers JW, Feldman EL, Sommer C, Cleary PA, Lachin JM, Herman WH. Effects of prior intensive insulin therapy on cardiac autonomic nervous system function in type 1 diabetes mellitus: the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study (DCCT/EDIC). Circulation 2009; 119:2886-93. [PMID: 19470886 DOI: 10.1161/circulationaha.108.837369] [Citation(s) in RCA: 222] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Epidemiology of Diabetes Interventions and Complications (EDIC) study, a prospective observational follow-up of the Diabetes Control and Complications Trial (DCCT) cohort, reported persistent benefit of prior intensive therapy on retinopathy and nephropathy in type 1 diabetes mellitus. We evaluated the effects of prior intensive insulin therapy on the prevalence and incidence of cardiac autonomic neuropathy (CAN) in former DCCT intensive and conventional therapy subjects 13 to 14 years after DCCT closeout. METHODS AND RESULTS DCCT autonomic measures (R-R variation with paced breathing, Valsalva ratio, postural blood pressure changes, and autonomic symptoms) were repeated in 1226 EDIC subjects in EDIC year 13/14. Logistic regression models were used to calculate the odds of incident CAN by DCCT treatment group after adjustment for DCCT baseline covariates, duration in the DCCT, and quantitative autonomic measures at DCCT closeout. In EDIC year 13/14, the prevalence of CAN using the DCCT composite definition was significantly lower in the former intensive group versus the former conventional group (28.9% versus 35.2%; P=0.018). Adjusted R-R variation was significantly greater in the former DCCT intensive versus the former conventional group (29.9 versus 25.9; P<0.001). Prior DCCT intensive therapy reduced the risks of incident CAN by 31% (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.93) and of incident abnormal R-R variation by 30% (odds ratio, 0.70; 95% confidence interval, 0.51 to 0.96) in EDIC year 13/14. CONCLUSIONS Although CAN prevalence increased in both groups, the incidence was significantly lower in the former intensive group compared with the former conventional group. The benefits of former intensive therapy extend to measures of CAN up to 14 years after DCCT closeout.
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Affiliation(s)
- Rodica Pop-Busui
- University of Michigan, Department of Internal Medicine, Division of Metabolism, Endocrinology, Diabetes, Ann Arbor, MI, USA.
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Kim YK, Lee JE, Kim YG, Kim DJ, Oh HY, Yang CW, Kim KW, Huh W. Cardiac autonomic neuropathy as a predictor of deterioration of the renal function in normoalbuminuric, normotensive patients with type 2 diabetes mellitus. J Korean Med Sci 2009; 24 Suppl:S69-74. [PMID: 19194565 PMCID: PMC2633204 DOI: 10.3346/jkms.2009.24.s1.s69] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 01/12/2009] [Indexed: 01/13/2023] Open
Abstract
Our study was performed to determine whether cardiac autonomic neuropathy can predict deterioration of the renal function in normoalbuminuric, normotensive people with type 2 diabetes mellitus (DM). One hundred and fifty-six normoalbuminuric, normotensive people with type 2 DM were included in our retrospective longitudinal study. We categorized normal patterns, early patterns, and definite or severe patterns according to the results of the cardiac autonomic function test. Of 156 patients included, 54 had normal patterns, 75 had early patterns, 25 had definite or severe patterns, and 2 had atypical patterns. During a median follow-up of nine years, glomerular filtration rates (GFR) remained stable in the normal and early pattern groups (mean changes, 4.50% and 0.77%, respectively) but declined in those with definite or severe patterns (mean change, -10.28%; p=0.047). An abnormal heart response to the deep breathing test of the cardiac autonomic function tests was an independent predictor of GFR decline. Our data suggest that cardiac autonomic neuropathy, especially with a definite or severe pattern, might be associated with a subsequent deterioration in renal function in normoalbuminuric, normotensive people with type 2 DM.
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Affiliation(s)
- Yong Kyun Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Eun Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Goo Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae Joong Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha-Young Oh
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang-Won Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooseong Huh
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Chen SR, Lee YJ, Chiu HW, Jeng C. Impact of physical activity on heart rate variability in children with type 1 diabetes. Childs Nerv Syst 2008; 24:741-7. [PMID: 17901961 DOI: 10.1007/s00381-007-0499-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Revised: 07/19/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Children with type 1 diabetes are usually associated with cardiovascular autonomic neuropathy. The present study explored the influence of physical activity on their autonomic nervous function by measuring the heart rate variability (HRV). MATERIALS AND METHODS A total of 93 type 1 diabetic children and 107 healthy control subjects were enrolled. The Physical Activity Questionnaire for Children (PAQ-C) was adopted to determine the physical activity level as low, moderate, or high activity. HRV was determined by frequency analysis and measured in both resting and active states. RESULTS Children with type 1 diabetes had significantly lower HRV than that of healthy control subjects in resting state but not in active state. The decreased HRV in diabetic children was observed only in subjects with low physical activity. The HRV in diabetic children with moderate to high physical activity, however, was not different from that of their healthy controls. CONCLUSIONS Diabetic children should be encouraged to engage in physical activity with more intensity, which can benefit their autonomic nervous function. Nevertheless, the potential risk of vigorous activity still needs our concern.
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Affiliation(s)
- Su-Ru Chen
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Chen SR, Lee YJ, Chiu HW, Jeng C. Impact of glycemic control, disease duration, and exercise on heart rate variability in children with type 1 diabetes mellitus. J Formos Med Assoc 2008; 106:935-42. [PMID: 18063515 DOI: 10.1016/s0929-6646(08)60064-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND/PURPOSE Type 1 diabetes is commonly associated with autonomic neuropathy. The present study investigated the influences of glycemic control, disease duration (DD), and exercise on autonomic nervous function in children with type 1 diabetes by analysis of their heart rate variability (HRV). METHODS Seventy-nine type 1 diabetic children were recruited and categorized into four groups by HbA1c of 8% and DD of 4.5 years. HRV parameters as determined by separate frequency domain components (low frequency: LnLF, 0.04-0.15 Hz; high frequency: LnHF, 0.15-0.5 Hz; total power: LnTP, 0.04-0.5 Hz) were measured both at rest and during exercise. Pearson's correlation, one-way ANOVA, and multiple regressions with stepwise method were used for statistical analysis. RESULTS While at rest, HbA1c and DD were negatively correlated with all HRV parameters. Both HbA1c and DD were significant predictors in LnTP. However, only HbA1c was a significant predictor in LnLF and LnHF. Type 1 diabetes patients with HbA1c > 8% and DD > 4.5 years had a significantly lower HRV than the other patients. During exercise, HRV reduced significantly and no significant correlation between HbA1c and HRV or between DD and HRV was observed. Also, a significant difference in HRV among the four groups was not demonstrated. The smallest decrement in HRV from resting to exercise were in subjects with HbA1c > 8% and DD > 4.5 years. CONCLUSION HbA1c was a more dominant predictor for LnTP, LnHF and LnLF than DD in children with type 1 diabetes at rest. HRV reduced significantly from resting to exercise. However, the responses of HRV during exercise differ from the responses of HRV at rest.
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Affiliation(s)
- Su-Ru Chen
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Lacigová S, Safránek P, Cechurová D, Krcma M, Vísek J, Jankovec Z, Zourek M, Haladová I, Rusavý Z. Could we predict asymptomatic cardiovascular autonomic neuropathy in type 1 diabetic patients attending out-patients clinics? Wien Klin Wochenschr 2007; 119:303-8. [PMID: 17571235 DOI: 10.1007/s00508-007-0789-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 11/09/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Diabetic cardiovascular autonomic neuropathy (CAN) is associated with increased morbidity and mortality. This complication may be asymptomatic for a long time. The aim of this study was to assess the prevalence, severity and predictors of asymptomatic CAN in patients with type 1 diabetes mellitus (DM1). PATIENTS AND METHODS 107 patients with DM1 were enrolled: 52 men and 55 women aged 39.8 +/- 12.4 years (18-72), duration of DM 16.6 +/- 9.5 years (0.5-43), age at DM manifestation 23.5 +/- 12.8 years (1-54) and BMI 25.1 +/- 3.2 (18.9-33.91). CAN was assessed using standard cardiovascular reflex tests (Ewing battery) and the patients were divided into three groups according to the results: Group 0, without CAN; Group I, 1(st) degree CAN; Group II, 2(nd) degree CAN. We assessed the most frequent relationships between CAN and chronic complications, episodes of severe hypoglycemia, time-related parameters (age of patients, duration of diabetes, age at manifestation), glycosylated hemoglobin (HbA(1)c), BMI, cardiovascular diseases and blood pressure, and determined the predictability of CAN on the basis of these relationships. RESULTS Only 50 of the 107 patients (46%) showed no CAN. We found 1(st) degree CAN in 38 patients (36%) and 2(nd) degree CAN in 19 (18%). CAN correlated more significantly with the duration of diabetes (p < 0.001) than with age (p < 0.05). The relationship between CAN and HbA(1)c was on the borderline of statistical significance (p = 0.053). We found a positive correlation between CAN and the presence of chronic complications [peripheral neuropathy (p < 0.001), retinopathy (p < 0.001), and some markers of nephropathy: creatinine (p < 0.03), albuminuria (p < 0.01)]. Although blood pressure was within the physiological range (124.2/74.5 +/- 11.5/7.8 mmHg) in all patients, a positive correlation with CAN was confirmed (p < 0.05). No relationship with occurrence of severe hypoglycemia was found. CONCLUSIONS According to our results, asymptomatic CAN is very frequent in patients with DM1. By using multifactorial logistic regression (step-wise) analysis we demonstrated that if albuminuria, peripheral neuropathy and elevated systolic BP are present simultaneously, there is a high probability that the patient also has CAN (84.9% of initial group correctly predicted, p < 0.001).
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Affiliation(s)
- Silvie Lacigová
- Medical Department I, Diabetology Center, Charles University, Pilsen, Czech Republic.
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Affiliation(s)
- Trevor J Orchard
- MBBCh, MMedSci, Diabetes and Lipid Research Bldg., 3512 Fifth Ave., Pittsburgh, PA 15213, USA.
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Pambianco G, Costacou T, Ellis D, Becker DJ, Klein R, Orchard TJ. The 30-year natural history of type 1 diabetes complications: the Pittsburgh Epidemiology of Diabetes Complications Study experience. Diabetes 2006; 55:1463-9. [PMID: 16644706 DOI: 10.2337/db05-1423] [Citation(s) in RCA: 341] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Declining incidences in Europe of overt nephropathy, proliferative retinopathy, and mortality in type 1 diabetes have recently been reported. However, comparable data for the U.S. and trend data for neuropathy and macrovascular complications are lacking. These issues are addressed using the prospective observational Pittsburgh Epidemiology of Childhood-Onset Diabetes Complications Study. Participants were stratified into five cohorts by diagnosis year: 1950-1959, 1960-1964, 1965-1969, 1970-1974, and 1975-1980. Mortality, renal failure, and coronary artery disease (CAD) status were determined on the complete cohort (n = 906) at 20, 25, and 30 years. Overt nephropathy, proliferative retinopathy, and neuropathy were assessed at 20 and 25 years on the subset of participants with a clinical examination. There was a decreasing trend by diagnosis year for mortality, renal failure, and neuropathy across all time intervals (P < 0.05), with the 1950-1959 cohort having a fivefold higher mortality at 25 years than the 1970s' cohorts. Proliferative retinopathy and overt nephropathy showed nonsignificant declines at 20 years (P < 0.16 and P < 0.13, respectively) and no change at 25 years. CAD event rates, which were lower than the other complications, also showed no trend. Although some type 1 diabetes complications (mortality, renal failure, and neuropathy) are declining, others (CAD, overt nephropathy, and proliferative retinopathy) show less favorable changes by 30 years.
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Affiliation(s)
- Georgia Pambianco
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Diabetes & Lipid Research Building, 3512 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Stella P, Tabak AG, Zgibor JC, Orchard TJ. Late diabetes complications and non-dipping phenomenon in patients with Type 1 diabetes. Diabetes Res Clin Pract 2006; 71:14-20. [PMID: 15963594 DOI: 10.1016/j.diabres.2005.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Revised: 04/28/2005] [Accepted: 05/05/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular autonomic neuropathy (CAN) has been thought to underlie the loss of normal nocturnal blood pressure dipping, which is associated with a higher risk for nephropathy in Type 1 diabetes. Previous analyses also suggest however that nephropathy is a major predictor of subsequent CAN. OBJECTIVE To investigate links between non-dipping phenomenon (NDP) and complications, particularly CAN and nephropathy. METHODS 24-h ambulatory blood pressure monitoring was performed on 61 consecutively recruited subjects (mean age: 38.5+/-8.1, mean duration: 29.5+/-8.2 years) from the Pittsburgh Epidemiology of Diabetes Complications cohort (658 subjects with childhood onset Type 1 diabetes diagnosed between 1950 and 80). NDP was diagnosed if nocturnal fall of both systolic and diastolic blood pressure was <10% of the average daytime blood pressure. CAN was detected by abnormal (<or=1.1) expiration/inspiration heart rate ratio. Proteinuria was established by abnormal (>20 microg/min) albumin excretion rate (AER) in at least two of three timed urines. RESULTS Non-dippers (n=17) had greater LDLc (p=0.012) and AER (p=0.052) and a higher frequency of nephropathy (OR=3.6, 95% CI=1.0-12.6) and proliferative retinopathy (OR=5.1, 95% CI=1.3-20.3) compared to the 44 dippers. CAN and NDP were not associated. In multivariate analyses, adjusting for CAN, proteinuria was significantly related to NDP (OR=3.6, 95% CI=1.0-12.6), an association that further modeling suggests was related to interactions between nephropathy, LDLc and hypertension. CONCLUSIONS These data suggest a strong link between NDP and proteinuria which is independent of CAN and may be modified by LDLc and hypertension.
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Affiliation(s)
- Peter Stella
- 4th Department of Medicine, St. Imre Hospital, Budapest, Hungary
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Complicaciones crónicas, factores de riesgo cardiovascular y HbA1c en la diabetes mellitus tipo 1 a los 14 años de diagnóstico. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1575-0922(05)71048-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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