Predictors of stroke in middle-aged patients with non-insulin-dependent diabetes

Association of longitudinal trajectories of fasting plasma glucose with all-cause and cardiovascular mortality among a Chinese older population: a retrospective cohort study

The association between fasting plasma glucose (FPG), an important indicator of overall glycemic status, and the risk of cardiovascular mortality has been well investigated. The longitudinal study can repeatedly collect measured results for the variables to be studied and then consider the potential effects of intraindividual changes in measurement. This study aimed to identify long-term FPG trajectories and investigate the association between trajectory groups and cardiovascular and all-cause mortality. A latent class growth mixture modeling (LCGMM) was used to identify FPG trajectories. Cox proportional hazard models were used to estimate associations between FPG trajectories and the risk of all-cause and cardiovascular mortality. A U-shaped relationship between FPG and all-cause and cardiovascular mortality was observed in the restricted cubic spline regression models. Two FPG longitudinal trajectories of low-level (mean FPG = 5.12mmol/L) and high-level (mean FPG = 6.74mmol/L) were identified by LCGMM. After being adjusted for potential confounders, compared with the low-level category, the hazard ratios (HRs) for all-cause and cardiovascular mortality were 1.23(1.16-1.30) and 1.25(1.16-1.35), respectively, for the high-level group. Long-term FPG trajectories are significantly associated with and potentially impact the risk of all-cause and cardiovascular mortality.

Diurnal Variations in Serum Uric Acid, Xanthine, and Xanthine Oxidoreductase Activity in Male Patients with Coronary Artery Disease

Hyperuricemia is influenced by diet and can cause gout. Whether it is a potential risk factor for cardiovascular disease (CVD) remains controversial, and the mechanism is unclear. Similar to CVDs, gout attacks occur more frequently in the morning and at night. A possible reason for this is the diurnal variation in uric acid (UA), However, scientific data regarding this variation in patients with CVD are not available. Thus, we aimed to investigate diurnal variations in serum levels of UA and plasma levels of xanthine, hypoxanthine, and xanthine oxidoreductase (XOR) activity, which were measured at 18:00, 6:00, and 12:00 in male patients with coronary artery disease. Thirty eligible patients participated in the study. UA and xanthine levels significantly increased from 18:00 to 6:00 but significantly decreased from 6:00 to 12:00. By contrast, XOR activity significantly increased both from 18:00 to 6:00 and 6:00 to 12:00. Furthermore, the rates of increase in UA and xanthine levels from night to morning were significantly and positively correlated. In conclusion, UA and xanthine showed similar diurnal variations, whereas XOR activity showed different diurnal variations. The morning UA surge could be due to UA production. The mechanism involved XOR activity, but other factors were also considered.

Characteristics of Postoperative Patients with Breast Cancer Aged 65 Years and Older

Objective: This study aimed to compare postoperative patients with breast cancer aged ≥65 years with those aged <65 years and clarify the characteristics of postoperative patients with breast cancer aged ≥65. Methods: In total, 376 patients in whom we were able to evaluate survey items one month after surgery were included in the study. Comorbidity, including diabetes mellitus and hypertension, shoulder range of motion (ROM), upper-limb function, and psychological problems, was evaluated. Results: Hypertension and diabetes mellitus were significantly higher in patients aged ≥65 years (the elderly group) than in those aged <65 years (the non-elderly group) (p < 0.05). Preoperative shoulder flexion ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). Preoperative shoulder abduction ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). At one month after surgery, upper-limb function was more impaired in the non-elderly group than in the elderly group (p < 0.05). In both groups, both ROM and upper-limb function were significantly impaired one month after surgery compared with before surgery (p < 0.05). Conclusions: Postoperative patients with breast cancer aged ≥65 years should be careful about risk management and intervention during rehabilitation. Preoperative evaluation of shoulder ROM should be performed because patients aged ≥65 years have limited ROM before surgery.

Efficacy and safety of intensive versus conventional glucose targets in people with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

The aim of study is to re-evaluate the risk-benefits of intensive glycemic control in the context of multi-factorial intervention in adults with T2D.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane, and CINHAL for randomized control trials comparing standard glucose targets to intensive glucose targets with pre-specified HbA_1clevels. Subgroup analysis was also performed to account for the inclusion of glucose only versus multi-factorial intervention trials. Results are reported as risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Fifty-seven publications including 19 trials were included. Compared to conventional glycemic control, intensive glycemic control decreased the risk of non-fatal myocardial infarction (0.8, 0.7-0.91), macroalbuminuria (0.72, 0.5--0.87), microalbuminuria (0.67, 0.52-0.85), major amputation (0.6, 0.38-0.96), retinopathy (0.75 ,0.63-0.9), and nephropathy (0.78, 0.63-0.97). The risk of hypoglycemia increased with intensive glycemic control than conventional treatment (2.04, 1.34-3.1). No reduction in all-cause or cardiovascular mortality was observed. However, in the context of multifactorial intervention, intensive glucose control was associated with a significant reduction in all-cause mortality (0.74, 0.57-0.95).

CONCLUSION

Targeting HbA_1c levels should be individualized based on the clinical status, balancing risks and benefits and potential risk for developing these complications among people with T2D.

Atrial fibrillation in cancer patients who develop stroke

Background

Acute ischemic stroke (Stroke) and transient ischemic attacks (TIA) are known complications in cancer patients and those with atrial fibrillation (AF). The role AF plays in Stroke/TIA in the setting of cancer is unclear. The purpose of this study was to assess the relationship between AF and Stroke/TIA in cancer patients.

Methods

We conducted a case-control study comparing all patients who developed Stroke/TIA from 2014 to 2019 following a cancer diagnosis at King Hussein Cancer Center (KHCC), matched to Stroke/TIA-free controls based on age, gender, and cancer site.

Results

Two hundred seventy-two patients were included (136 per group). The mean age was 63.95 ± 13.06 and 57% were females. The Stroke/TIA group had more AF at the time of event (14% vs. 4%, OR: 4.25, 95%-CI: 1.39 - 17.36) and had a larger proportion of death on study conclusion (OR: 9.4, 95%-CI: 3.74 - 23.64). On conditional logistic regression, patients in the Stroke/TIA group had higher odds of: AF (OR: 7.93, 95%-CI: 1.6 – 39.18), ischemic stroke before cancer diagnosis (OR: 9.18, 95%-CI: 2.66 – 31.74), being on active cancer treatment (OR: 3.11, 95%-CI: 1.46 – 6.62), dyslipidemia (OR: 3.78, 95%-CI: 1.32 – 10.82), and renal disease (OR: 4.25, 95%-CI: 1.55 – 11.63). On another conditional logistic regression model built to assess the role of the CHA2DS2-VASc score, a score of >=2 in males and >=3 in females significantly increased the risk of developing Stroke/TIA in cancer patients (OR: 2.45, 95%-CI: 1.08 - 5.58).

Conclusion

AF, previous ischemic stroke, active cancer treatment, dyslipidemia, and renal disease are independent risk factors for Stroke/TIA and a higher CHA2DS2-VASc score significantly increases the risk in cancer patients regardless of AF.

Efficacy and safety of carbohydrate counting versus other forms of dietary advice in patients with type 1 diabetes mellitus: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND AND AIMS

Diabetes mellitus (DM) is one of the most prevalent chronic non-communicable diseases globally, and the only way to reduce its complications is good glycemic control. Insulin remains the only approved treatment for type 1 DM (T1DM) and is used by many with Type 2 DM (T2DM). Carbohydrate counting is considered the ideal way to calculate meal-related insulin doses since it allows greater flexibility in diet and could, in some people, reduce the burden of the disease. This systematic review's primary objective was to assess carbohydrate counting efficacy in reducing glycated hemoglobin (HbA_1c ) and safety by not increasing hypoglycemia risk, inducing an increase in body weight or blood lipids, and reducing the quality of life of people with T1DM.

METHODS

We included randomized controlled clinical trials with a parallel-group design comparing any carbohydrate counting forms with standard care or other forms of dietary advice or insulin dose calculation in people with T1DM with a follow up period of at least three months and with no restrictions in language, age, or settings. As a primary outcome, we consider the change of HbA_1c within at least three months. Secondary outcomes were hypoglycemia events, body weight changes, blood lipids levels, and the total daily insulin dose. We also evaluated health-related quality of life changes and diabetes treatment satisfaction questionnaires.

RESULTS

Data from 11 studies with 899 patients were retrieved with a mean follow of 52 ± 35.5 weeks. Carbohydrate counting is not better in reducing HbA_1c , SMD - 0.24% (95%CI -0.68 to 0.21) than all dietary advice forms. However, this finding was highly heterogeneous. We identified three studies that account for most of the heterogeneity using clustering algorithms. A second analysis excluding these studies shows a meaningful HbA_1c reduction, SMD - 0.52% (95%CI -0.82 to -0.23) with low heterogeneity. In the subgroup analysis, carbohydrate counting significantly reduces HbA_1c compared to usual diabetes education. Carbohydrate counting doesn't relate to any substantial change in blood lipids, body weight, hypoglycemia risk, or daily insulin dose. Finally, we analyzed the effect of trial duration with HbA_1c reduction and found no significant change related to time.

CONCLUSIONS

Carbohydrate counting is an efficacious technique to safely reduce HbA_1c in adults and children compared to standard diabetes education. And its effect doesn't seem to change with prolonged time. Standardization in reporting important outcomes like hypoglycemia and quality of life is vital to produce comparable evidence in carbohydrate counting clinical trials. This SR was registered in PROSPERO under code: CRD42020218499. This article is protected by copyright. All rights reserved.

Factors related to the risk of stroke in the population with type 2 diabetes: A protocol for systematic review and meta-analysis

BACKGROUND

Type 2 diabetes is an independent risk factor for stroke. The main role of the current study is to study the mechanism of stroke induced by diabetes, but there is no systematic summary of daily management and stroke prevention for patients with type 2 diabetes. In order to provide a more detailed stroke prevention program for patients with type 2 diabetes, we included in the study and looked forward to analyzing the risk factors that were more in line with the clinical characteristics of type 2 diabetes.

METHODS

We will search the following Chinese and English databases: PubMed, Web of science, Cochrane Library, Medline, and China National Knowledge Infrastructure database. All of the above electronic databases will be searched from inception to June 30, 2021. In addition, we will manually search for conference papers, ongoing experiments, and internal reports to supplement the studies retrieved via electronic search. We will use the STATA 16.0 provided by Cochrane Collaboration Network for statistical analysis.

RESULTS

The study will prove a collective view on the relationship between related factors and stroke in the type 2 diabetes population.

CONCLUSION

We plan to submit this systematic review to a peer-reviewed journal.INPLASY registration number: INPLASY2021100046.

Uncontrolled hypertension in patients with type 2 diabetes: What are the correlates?

Suboptimal blood pressure (BP) control in patients with type 2 diabetes is associated with adverse micro‐ and macrovascular complications. This study aimed to investigate the predictors of uncontrolled hypertension in an Iranian population with type 2 diabetes. This is a cross‐sectional study of 2612 patients with type 2 diabetes, including 944 patients with hypertension. Controlled and uncontrolled hypertension were assessed. Multivariate logistic regression modeling was used to determined independent predictors of uncontrolled hypertension. Of 2612 patients with type 2 diabetes, 944 (36.1%) patients had hypertension. Of all patients with hypertension, 580 (61.4%) were still on monotherapy. Uncontrolled hypertension was detected in 536 participants (56.8%). Patients with uncontrolled hypertension had significantly higher body mass index (BMI) (29.8±4.8 vs. 28.6±4.6), waist circumference (99.11±10.95 vs. 96.68±10.92), pulse pressure (67.3±17.3 vs. 48.4±10.7), total cholesterol (177.1±45.5 vs. 164.3±40.5), non‐HDL cholesterol (133.0±43.5 vs. 120.1±38.7), triglycerides (175.7±80.3 vs. 157.4±76.7), and Atherogenic Index of Plasma (AIP) (0.57±0.23 vs. 0.52±0.24) (p < .05 for all of them) compared to patients with controlled hypertension. Multivariate logistic regression analysis revealed that uncontrolled hypertension was significantly associated with BMI (p = .001), pulse pressure (p = .001), total cholesterol (p = .006), and non‐HDL cholesterol (p = .009). In patients with triglycerides levels > 200 mg/dl non‐HDL cholesterol had a significant correlation with uncontrolled hypertension (OR = 4.635, CI95%:1.781–12.064, p = .002). In conclusion, BMI, pulse pressure, total cholesterol, and non‐HDL cholesterol are significant predictors of uncontrolled hypertension in patients with type 2 diabetes. Also, ineffective monotherapy, medical inertia and patients’ non‐compliance were other contributors to the uncontrolled hypertension.

Macrovascular Complications of Type 2 Diabetes Mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) has emerged as a pandemic. It has different complications, both microvascular and macrovascular.

OBJECTIVE

The purpose of this review is to summarize the different types of macrovascular complications associated with T2DM.

METHODS

A comprehensive review of the literature was performed to identify clinical studies, which determine the macrovascular complications associated with T2DM.

RESULTS

Macrovascular complications of T2DM include coronary heart disease, cardiomyopathy, arrhythmias and sudden death, cerebrovascular disease and peripheral artery disease. Cardiovascular disease is the primary cause of death in diabetic patients. Many clinical studies have shown a connection between T2DM and vascular disease, but almost always other risk factors are present in diabetic patients, such as hypertension, obesity and dyslipidaemia.

CONCLUSION

T2DM causes a variety of macrovascular complications through different pathogenetic pathways that include hyperglycaemia and insulin resistance. The association between T2DM and cardiovascular disease is clear, but we need more clinical studies in order to identify the pure effect of T2DM.

Novel Digital Architecture of a "Low Carb Program" for Initiating and Maintaining Long-Term Sustainable Health-Promoting Behavior Change in Patients with Type 2 Diabetes

Globally, the burden of noncommunicable diseases such as type 2 diabetes is crippling health care systems. Type 2 diabetes, a disease linked with obesity, affects 1 in every 30 people today and is expected to affect 1 in 10 people by 2030. Current provisions are struggling to manage the trajectory of type 2 diabetes prevalence. Offline, face-to-face education for patients with type 2 diabetes has shown to lack long-term impact or the capacity for widespread democratized adoption. Digitally delivered interventions have been developed for patients with type 2 diabetes, and the evidence shows that some interventions provide the capacity to support hyperpersonalization and real-time continuous support to patients, which can result in significant engagement and health outcomes. However, digital health app engagement is notoriously difficult to achieve. This paper reviews the digital behavior change architecture of the Low Carb Program and the application of health behavioral theory underpinning its development and use in scaling novel methods of engaging the population with type 2 diabetes and supporting long-term behavior change.

Predicting the risk of stroke among patients with type 2 diabetes: a systematic review and meta-analysis of C-statistics

OBJECTIVE

Stroke is a major cause of disability and death worldwide. People with diabetes are at a twofold to fivefold increased risk for stroke compared with people without diabetes. This study systematically reviews the literature on available stroke prediction models specifically developed or validated in patients with diabetes and assesses their predictive performance through meta-analysis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A detailed search was performed in MEDLINE, PubMed and EMBASE (from inception to 22 April 2019) to identify studies describing stroke prediction models.

ELIGIBILITY CRITERIA

All studies that developed stroke prediction models in populations with diabetes were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently identified eligible articles and extracted data. Random effects meta-analysis was used to obtain a pooled C-statistic.

RESULTS

Our search retrieved 26 202 relevant papers and finally yielded 38 stroke prediction models, of which 34 were specifically developed for patients with diabetes and 4 were developed in general populations but validated in patients with diabetes. Among the models developed in those with diabetes, 9 reported their outcome as stroke, 23 reported their outcome as composite cardiovascular disease (CVD) where stroke was a component of the outcome and 2 did not report stroke initially as their outcome but later were validated for stroke as the outcome in other studies. C-statistics varied from 0.60 to 0.92 with a median C-statistic of 0.71 (for stroke as the outcome) and 0.70 (for stroke as part of a composite CVD outcome). Seventeen models were externally validated in diabetes populations with a pooled C-statistic of 0.68.

CONCLUSIONS

Overall, the performance of these diabetes-specific stroke prediction models was not satisfactory. Research is needed to identify and incorporate new risk factors into the model to improve models' predictive ability and further external validation of the existing models in diverse population to improve generalisability.

Cause-Specific Risk Factors of Death in Individuals with Diabetes: A Competing Risks Modeling

BACKGROUND

Diabetes is on the rise worldwide.

OBJECTIVES

This study aimed to evaluate the risk factors of various causes of death in people with type 2 diabetes (T2D).

METHODS

In this cohort study on 2638 people with T2D, we applied cause-specific and sub-distribution hazards models to assess the impact of various factors on the risk of death. Moreover, we plotted a cumulative incidence curve to summarize cumulative failure rates over time.

RESULTS

About 75% of individuals with T2D died from cardiovascular disease (CVD) and cerebrovascular accidents (CVA). Death from CVD was associated with the increased risk of hypertension (hazard ratio (HR) = 1.83, 95% CI: 1.37 - 2.46), hypercholesterolemia (HR = 1.58, 95% CI: 1.17 - 2.14), and diabetes duration. The risk of death from CVA was related to hypertension (HR = 2.76, 95% CI: 1.67 - 4.55) and hyperglycemia (HR = 4.34, 95% CI: 1.75 - 10.79). The CVA risk in patients with diabetes duration of 10 - 20 years was higher than the risk in patients with diabetes duration > 20 years (diabetes duration of ≤ 10 years as the reference category). Diabetes duration of longer than 20 years was associated with a higher risk of death from cancer (HR = 2.65, 95% CI: 1.05 - 6.68). The risk of death from foot infection and diabetic nephropathy increased in patients with longer diabetes duration after adjustment for sex, age, and body mass index.

CONCLUSIONS

Regardless of the cause, death rates in people with T2D increase over time and risk factors have different impacts on death from each cause. This should be acknowledged in risk management in individuals with T2D.

The Diabetes Unmet Need with Basal Insulin Evaluation (DUNE) study in type 2 diabetes: Achieving HbA1c targets with basal insulin in a real-world setting

AIMS

To describe in a real-world setting the achievement of physician-selected individualized HbA1c targets in individuals with type 2 diabetes, newly or recently initiated with basal insulin, and the association of hypoglycaemia with target achievement.

MATERIALS AND METHODS

A 12-week, prospective, single-arm, observational study of adults with type 2 diabetes, either newly initiated with any basal insulin or start on basal insulin within the preceding 12 months. At enrollment, eligible participants from 28 countries were treated with or without oral antihyperglycaemic drugs and/or GLP-1 receptor agonists.

RESULTS

Individualized targets for almost all of the 3139 evaluable participants (99.7%) had been set by their physicians, with 57% of participants having HbA1c targets between 7.0% and <7.5% (53 and <58 mmol/mol). By week 12, 28% and 27% of newly and previously initiated participants, respectively, achieved individualized HbA1c targets with modest average increases in daily insulin dose of 9 and 5 U (0.10 and 0.06 U/kg), respectively, from baseline (14 and 23 U [0.17 and 0.29 U/kg], respectively). Overall, 16% of participants experienced at least one episode of hypoglycaemia. Both the incidence and frequency of hypoglycaemia, but not the severity, were positively associated with a higher likelihood of achieving individualized HbA1c targets (P < 0.05).

CONCLUSIONS

In this prospective real-world study, most participants using basal insulin did not achieve the individualized HbA1c targets set by their physicians. Participants who experienced symptomatic hypoglycaemia were more likely to achieve HbA1c targets than those who did not.

Impaired nocturnal blood pressure dipping in patients with type 2 diabetes mellitus

Hypertension is a common comorbidity of type 2 diabetes mellitus (T2DM). Both conditions are associated with an increased cardiovascular risk, which is reduced by tight blood pressure (BP) and glycemic control. However, nondipping BP status continues to be an enduring cardiovascular risk factor in T2DM. Cardiovascular autonomic neuropathy and endothelial dysfunction have been proposed as potential mechanisms. This study tested the hypothesis that microvascular disease rather than cardiovascular autonomic neuropathy interferes with the physiological nocturnal BP reduction. Cardiovascular autonomic function and baroreflex sensitivity were determined in 22 type 2 diabetic patients with (DM+) and 23 diabetic patients without (DM-) manifest microvascular disease. BP dipping status was assessed from 24-hour ambulatory BP measurements. Sixteen nondiabetic subjects served as controls (CTRL). Cardiovascular autonomic function was normal in all subjects. Baroreflex sensitivity was lower in DM- compared with CTRL (7.7 ± 3.3 vs. 12.3 ± 8.3 ms·mm Hg^-1; P < 0.05) and was further reduced in DM + (4.6 ± 2.0 ms·mm Hg^-1; P < 0.01 vs. DM- and CTRL). The nocturnal decline in systolic and diastolic BP was blunted in DM- (12% and 14% vs. 17% and 19% in CTRL; P < 0.05) and even more so in DM+ (8% and 11%; P < 0.05 vs. DM- and P < 0.001 vs. CTRL). A nocturnal reduction in pulse pressure was observed in CTRL and DM- but not in DM+ (P < 0.05 vs. DM- and P < 0.01 vs. CTRL). In T2DM, progression of microvascular disease interferes with the normal nocturnal BP decline and coincides with a persistently increased pulse pressure and reduced baroreflex sensitivity, contributing to their increased cardiovascular risk.

Relationship Between Glycated Hemoglobin and Stroke Risk: A Systematic Review and Meta-Analysis

BACKGROUND

Diabetes mellitus is a major risk factor for ischemic stroke. Rising hemoglobin A_1c (HbA_1c) levels are associated with microvascular diabetes mellitus complication development; however, this relationship has not been established for stroke risk, a macrovascular complication.

METHODS AND RESULTS

We conducted a systematic review and meta-analysis of observational cohort and nested case-control cohort studies assessing the association between rising HbA_1c levels and stroke risk in adults (≥18 years old) with and without type 1 or type 2 diabetes mellitus. Random-effects model meta-analyses were used to calculate pooled adjusted hazard ratios (HRs) and their precision. The systematic review yielded 36 articles, of which 29 articles (comprising n=532 779 participants) were included in our meta-analysis. Compared to non-diabetes mellitus range HbA_1c (<5.7%), diabetes mellitus range HbA_1c (≥6.5%) was associated with an increased risk of first-ever stroke with average HR (95% confidence interval) of 2.15 (1.76, 2.63), whereas pre-diabetes mellitus range HbA_1c (5.7-6.5%) was not (average HR [95% confidence interval], 1.19 [0.87, 1.62]). For every 1% HbA_1c increment (or equivalent), the average HR (95% confidence interval) for first-ever stroke was 1.12 (0.91, 1.39) in non-diabetes mellitus cohorts and 1.17 (1.09, 1.25) in diabetes mellitus cohorts. For every 1% HbA_1c increment, both non-diabetes mellitus and diabetes mellitus cohorts had a higher associated risk of first-ever ischemic stroke with average HR (95% confidence interval) of 1.49 (1.32, 1.69) and 1.24 (1.11, 1.39), respectively.

CONCLUSIONS

A rising HbA_1c level is associated with increased first-ever stroke risk in cohorts with a diabetes mellitus diagnosis and increased risk of first-ever ischemic stroke in non-diabetes mellitus cohorts. These findings suggest that more intensive HbA_1c glycemic control targets may be required for optimal ischemic stroke prevention.

Burden of high blood pressure as a contributing factor to stroke in the Japanese community-based diabetic population

Diabetes mellitus is characterized by alterations in blood glucose (BG) metabolism, and glycated hemoglobin (HbA₁c) has been widely used as a marker of the BG concentration. Diabetes often coexists with high blood pressure (BP). High BP and hyperglycemia are well-known risk factors of stroke. We examined the extent to which the increased risk of stroke in diabetic individuals is attributable to BP and BG using prospectively collected data from the Japanese general population. During an average 8.3 ± 2.2 years of follow-up, out 1606 diabetic individuals aged ≥40 years who were free of cardiovascular disease, 119 participants (7.4%) developed stroke. In multivariable analysis, a significant difference in the risk of incident stroke was noted among the BP categories, including normotension (BP1), prehypertension (BP2), and hypertension (BP3; P for trend = 0.001). By contrast, no difference was noted among the BG categories, including HbA₁c levels <7.0% (HB1), 7.0–7.9% (HB2), and ≥8.0% (HB3; P for trend = 0.430). Compared with the category that included both BP1 and HB1, the population-attributable fraction (PAF) for stroke incidence was 52.0% from the BP2 and BP3 categories and 24.1% from the HB2 and HB3 categories, and the increased incidence from the HB2 and HB3 categories was mostly caused from coexistent BP2 and BP3 categories. In conclusion, in the Japanese community-based diabetic population, concomitant BP elevation largely contributes to the increased incidence of stroke and links BG elevation, as indicated by HbA₁c, to the increased risk of stroke.

Trends in the incidence of use of noninsulin glucose-lowering drugs between 2006 and 2013 in France

This study aimed at describing trends in the incidence of use of noninsulin glucose-lowering drugs (NIGLDs) between 2006 and 2013 in France. Repeated cross-sectional studies on NIGLD new users were performed annually from 2006 to 2013 within the Echantillon Généraliste des Bénéficiaires (EGB) database, a 1/97th representative sample of the population covered by the French healthcare insurance system. NIGLD included metformin, sulfonylureas, α-glucosidase inhibitors, thiazolidinediones, dipeptidylpeptidase-4 (DPP-4) inhibitors, glinides and glucagon-like peptide-1 analogues. New users were defined as patients with no delivery of any NIGLD (first-line new users) or no delivery of a NIGLD of the same class (add-on/switch new users) in the preceding year. Incidence rates of use and corresponding 95% confidence intervals (95% CI) were estimated per 1000 persons. Among the 507 043 persons included in the EGB in 2006, 2036 were identified as NIGLD first-line new users and 2192 as add-on/switch new users, which corresponded to an incidence of use of 4.0‰ (95%CI 3.8-4.2) and 4.3‰ (4.1-4.5), respectively. First-line incidence increased to 5.3‰ (5.1-5.5) in 2010 and then decreased to 4.2‰ (4.0-4.4) in 2013; add-on/switch incidence increased to 8.0‰ (7.8-8.2) in 2010 and then decreased to 5.3‰ (5.1-5.5) in 2013. This reduction was mainly related to DPP-4 inhibitors, whose use as add-on/switch NIGLDs was roughly halved between 2010 and 2013. Concomitantly, the use of sulfonylureas and glinides increased. In conclusion, after reaching a peak in 2010, the incidence of use of NIGLDs has markedly decreased in France. Since then, prescribers seem to have reverted to older and well-known therapies.

Poststroke glycemic variability increased recurrent cardiovascular events in diabetic patients

BACKGROUND AND PURPOSE

The association between blood glucose fluctuation and poststroke cardiovascular outcome has been largely unknown. This study attempted to evaluate whether initial glycemic variability increases cardiovascular events and mortality in diabetic patients with acute ischemic stroke.

METHODS

We recruited consecutive patients with acute ischemic stroke or transient ischemic attack from March 2005 to December 2014. A total of 674 patients with diabetes within 72 hours from stroke onset were included. The serum glucose levels were checked 4 times per day during the initial 3 hospital days. J-index, coefficients of variation and standard deviation were calculated for glycemic variability. Composite outcome (nonfatal stroke, nonfatal myocardial infarction, cardiovascular death) and all-cause mortality at 3 months were prospectively captured. Multivariable logistic regression analyses were done adjusting for covariates which can influence on cardiovascular outcomes.

RESULTS

Cardiovascular composite outcomes at 3 months were identified in 71 (10.5%): 11 (6.5%), 15 (8.9%), 18 (10.7%) and 27 (16.0%) in each J-index quartiles (P = .035). The highest quartile of J-index had significantly higher cardiovascular death (4.2%, 3.6%, 6.5% and 11.8%; P = .008). In multivariable logistic regression, age (odds ratio [OR] 1.045; 95% confidence interval [CI] 1.006-1.084), P = .021), NIH stroke scale (OR 1.078; 95% CI 1.024-1.134, P = .004), and the highest J-index (OR 12.058; 95% 1.890-76.912, P = .008) were significantly associated with 3-month cardiovascular composite outcome. Increased cardiovascular outcomes in highest J-index quartile were similar in both euglycemic and hyperglycemic groups.

CONCLUSION

The initial glycemic variability might increase cardiovascular events in acute ischemic stroke patients with diabetes.

Identification of type 2 diabetes subgroups through topological analysis of patient similarity

Type 2 diabetes (T2D) is a heterogeneous complex disease affecting more than 29 million Americans alone with a rising prevalence trending toward steady increases in the coming decades. Thus, there is a pressing clinical need to improve early prevention and clinical management of T2D and its complications. Clinicians have understood that patients who carry the T2D diagnosis have a variety of phenotypes and susceptibilities to diabetes-related complications. We used a precision medicine approach to characterize the complexity of T2D patient populations based on high-dimensional electronic medical records (EMRs) and genotype data from 11,210 individuals. We successfully identified three distinct subgroups of T2D from topology-based patient-patient networks. Subtype 1 was characterized by T2D complications diabetic nephropathy and diabetic retinopathy; subtype 2 was enriched for cancer malignancy and cardiovascular diseases; and subtype 3 was associated most strongly with cardiovascular diseases, neurological diseases, allergies, and HIV infections. We performed a genetic association analysis of the emergent T2D subtypes to identify subtype-specific genetic markers and identified 1279, 1227, and 1338 single-nucleotide polymorphisms (SNPs) that mapped to 425, 322, and 437 unique genes specific to subtypes 1, 2, and 3, respectively. By assessing the human disease-SNP association for each subtype, the enriched phenotypes and biological functions at the gene level for each subtype matched with the disease comorbidities and clinical differences that we identified through EMRs. Our approach demonstrates the utility of applying the precision medicine paradigm in T2D and the promise of extending the approach to the study of other complex, multifactorial diseases.

Vascular Function and Uric Acid-Lowering in Stage 3 CKD

Hyperuricemia may contribute to endothelial dysfunction in CKD. We evaluated whether lowering serum uric acid levels with allopurinol improves endothelial dysfunction in 80 participants ≥18 years of age with stage 3 CKD and asymptomatic hyperuricemia (≥7 mg/dl in men and ≥6 mg/dl in women) randomized in a double-blinded manner to receive placebo or allopurinol for 12 weeks. Randomization was stratified according to presence or absence of diabetes mellitus. We measured vascular endothelial function by brachial artery flow-mediated dilation. No significant differences existed between groups at baseline; 61% of the participants had diabetes mellitus in both groups. The placebo and the allopurinol groups had baseline serum uric acid levels (SDs) of 8.7 (1.6) mg/dl and 8.3 (1.4) mg/dl, respectively, and baseline flow-mediated dilation values (SDs) of 6.0% (5.0%) and 4.8% (5.0%), respectively. Compared with placebo, allopurinol lowered serum uric acid significantly but did not improve endothelial function. In participants without diabetes mellitus, allopurinol associated with a trend toward improved flow-mediated dilation (+1.4% [3.9%] versus -0.7% [4.1%] with placebo), but this was not statistically significant (P=0.26). Furthermore, we did not detect significant differences between groups in BP or serum levels of markers of inflammation and oxidative stress. In conclusion, allopurinol effectively and safely lowered serum uric acid levels in adults with stage 3 CKD and asymptomatic hyperuricemia but did not improve endothelial function in this sample of patients.

Prevalence, awareness, treatment, control of type 2 diabetes mellitus and risk factors in Chinese rural population: the RuralDiab study

The study aimed to investigate prevalence, awareness, treatment and control of type 2 diabetes mellitus (T2DM), and to explore potential risk factors in rural areas of China. A total of 16413 individuals aged 18–74 years in rural districts were recruited from the Rural Diabetes, Obesity and Lifestyle (RuralDiab) study for the epidemiological research. Meanwhile, a meta-analysis including 7 published studies was conducted to validate the result of the cross-sectional study. The rates of crude and age-standardized prevalence, awareness, treatment and control of T2DM were 12.19%, 67.00%, 62.35%, 22.20% and 6.98%, 60.11%, 54.85%, 18.77%, respectively. The prevalence, awareness, treatment and control of T2DM displayed increased trends with age (P_trend < 0.01) and were strongly associated with education, drinking, more vegetable and fruit intake, physical activity, family history of diabetes, body mass index (BMI). The results of this meta-analysis showed that the pooled prevalence, awareness, treatment and control of T2DM in China countryside were 7.3% (5.3–9.4%), 57.3% (36.9–77.6%), 48.4% (32.4–64.5%) and 21.0% (9.9–32.1%), respectively. The prevalence of T2DM was high with inadequate awareness, treatment and control of T2DM in China rural areas. Healthy lifestyles should be advocated to reduce prevalence and improve awareness, treatment, and control of T2DM in Chinese rural residents.

Meta-analysis of dipeptidyl peptidase-4 inhibitors use and cardiovascular risk in patients with type 2 diabetes mellitus

AIMS

Some meta-analyses have shown that dipeptidyl peptidase-4 (DPP-4) inhibitors decrease the risk of major adverse cardiovascular events (MACE) compared to placebo. However, this association has not been confirmed in large placebo-controlled clinical trials with cardiovascular events as a primary endpoint. The aim of the present meta-analysis is to assess the association between DPP-4 inhibitors use and cardiovascular risk using uniform definition of MACE.

METHODS

Relevant studies through 31 December 2014 were searched in the electronic databases, and we identified all eligible trials comparing DPP-4 inhibitors with active drugs or placebo. Summary odds ratio (OR) with 95% confidence interval (CI) for MACE was calculated using random-effects model.

RESULTS

In 69 trials included in our study, 36,488 patients were treated with DPP-4 inhibitors and 31,290 with other comparators. Treatment with DPP-4 inhibitors was associated with a lower risk of MACE (OR [95% CI]=0.52 [0.36,0.76]) compared to sulfonylureas, while showed a trend toward increased risk (OR [95% CI]=1.89 [0.60,5.93]) compared to sodium-glucose cotransporter 2 (SGLT2) inhibitors. The difference was not statistically significant when compared to placebo (OR [95% CI]=1.04 [0.92,1.18]), and this tendency was similar in both subgroup analyses conducted with a general type 2 diabetes population as well as the population at high cardiovascular risk.

CONCLUSIONS

There is no significant difference in the risk of MACE between DPP-4 inhibitors and placebo groups. DPP-4 inhibitors show significantly lower risk of MACE when compared to sulfonylureas, while SGLT2 inhibitors might have lower risk compared to DPP-4 inhibitors.

Ischemic Stroke and Its Risk Factors in a Registry-Based Large Cross-Sectional Diabetic Cohort in a Country Facing a Diabetes Epidemic

The main aim of this study is to determine the prevalence and risk factors of ischemic stroke among diabetic patients registered in the Saudi National Diabetes Registry (SNDR) database. A cross-sectional sample of 62,681 diabetic patients aged ≥25 years was used to calculate ischemic stroke prevalence and its risk factors. Univariate and multivariate logistic regression analyses were used to assess the roles of different risk factors. The prevalence of ischemic stroke was 4.42% and was higher in the older age group with longer diabetes duration. Poor glycemic control and the presence of chronic diabetes complications were associated with a high risk of ischemic stroke. History of smoking and type 2 diabetes were more frequent among stroke patients. Obesity significantly decreased the risk for ischemic stroke. Regression analysis for ischemic stroke risk factors proved that age ≥45 years, male gender, hypertension, coronary artery disease (CAD), diabetes duration ≥10 years, insulin use, and hyperlipidemia were significant independent risk factors for ischemic stroke. We conclude that ischemic stroke is prevalent among diabetic individuals, particularly among those with type 2 diabetes. Good glycemic, hypertension, and hyperlipidemia control, in addition to smoking cessation, are the cornerstones to achieve a significant reduction in ischemic stroke risk.

Circulating cell-free mitochondrial DNA as the probable inducer of early endothelial dysfunction in the prediabetic patient

Recent evidence has shown that 346million people in the world have diabetes mellitus (DM); this number will increase to 439million by 2030. In addition, current data indicate an increase in DM cases in the population between 40 and 59years of age. Diabetes is associated with the development of micro- and macro-vascular complications, derived from chronic hyperglycemia on the endothelium. Some reports demonstrate that people in a prediabetic state have a major risk of developing early endothelial dysfunction (ED). Today, it is accepted that individuals considered as prediabetic patients are in a pro-inflammatory state associated with endothelial and mitochondrial dysfunction. It is important to mention that impaired mitochondrial functionality has been linked to endothelial apoptosis and release of mitochondrial DNA (mtDNA) in patients with sepsis, cardiac disease, or atherosclerosis. This free mtDNA could promote ED, as well as other side effects on the vascular system through the activation of the toll-like receptor 9 (TLR9). TLR9 is expressed in different cell types (e.g., T or B lymphocytes, mastocytes, and epithelial and endothelial cells). It is localized intracellularly and recognizes non-methylated dinucleotides of viral, bacterial, and mitochondrial DNA. Recently, it has been reported that TLR9 is associated with the pathogenesis of lupus erythematosus, rheumatoid arthritis, and autoimmune diabetes. In this work, it is hypothesized that the increase in the levels of circulating mtDNA is the trigger of early ED in the prediabetic patient, and later on in the older patient with diabetes, through activation of the TLR9 present in the endothelium.

Complications of intravitreal injections in patients with diabetes

Intravitreal injections for the treatment of retinal disorders and intraocular infection have become a common ophthalmic procedure, and injections of anti-vascular endothelial growth factor agents or steroids are frequently performed for the treatment of diabetic macular edema or other diabetic vascular pathology. Diabetic patients may be at higher risk of adverse events than non-diabetic individuals given frequent systemic co-morbidities, such as cardiovascular and renal disease, susceptibility to infection, and unique ocular pathology that includes fibrovascular proliferation. Fortunately, many associated complications, including endophthalmitis, are related to the injection procedure and can therefore be circumvented by careful attention to injection techniques. This review highlights the safety profile of intravitreal injections in patients with diabetes. Although diabetic patients may theoretically be at higher risk than non-diabetic patients for complications, a comprehensive review of the literature does not demonstrate substantial increased risk of intravitreal injections in patients with diabetes.

The cost of diabetes chronic complications among Iranian people with type 2 diabetes mellitus

Background

To evaluate the cost of diabetes related micro- and macrovascular complications in Iranian people with type 2 diabetes mellitus.

Methods

In routine clinical practice, people with type 2 diabetes mellitus were assessed for 10 years at a diabetes care center. The type of medications and clinical data were extracted from patients’ documents. Mortality rate and the incidence of micro- and macrovascular complications recorded in patients’ documents were analyzed. Cost analysis was comprised of 1) para clinic costs as well as laboratory, medications, clinical visits and nonmedical costs 2) inpatient costs as well as hospital admission costs, disability, and mortality costs.

Results

From 1562 people with type 2 diabetes mellitus, a total of 1000 patients with mean duration disease of 11.2 years, who had completed information in their documents, were studied. All people were free from complications at baseline. Mean cumulative incidence of diabetes-related complications over 10 years were 10.9 ± 3.5%, 8.0 ± 3.1%, 4.6 ± 1.7%, 9.1 ± 3.6% and 2.3 ± 0.9% for peripheral neuropathy and diabetic foot ulcer, nephropathy, ophthalmic complications, cardiovascular disease and death, respectively. People with better glycemic control had less complication and also related expenditures. Average para clinic cost per patient was 393.6 ± 47.8 and average inpatient cost per patient was 1520.7 ± 104.5 USD.

Conclusions

Our findings demonstrate considerable incidence of diabetes chronic complications and also high health care expenditure for related complications among our patients. As the number of people with diabetes continues to rise, early detection of the disease and implementation of timely and appropriate therapeutic strategies could decrease the burden of diabetes chronic complications and also huge related expenditures.

Diabetes and risk of physical disability in adults: a systematic review and meta-analysis

BACKGROUND

According to previous reports, the risk of disability as a result of diabetes varies from none to double. Disability is an important measure of health and an estimate of the risk of disability as a result of diabetes is crucial in view of the global diabetes epidemic. We did a systematic review and meta-analysis to estimate this risk.

METHODS

We searched Ovid, Medline, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature up to Aug 8, 2012. We included studies of adults that compared the risk of disability-as measured by activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility-in people with and without any type of diabetes. We excluded studies of subpopulations with specific illnesses or of people in nursing homes. From the studies, we recorded population characteristics, how diabetes was diagnosed (by doctor or self-reported), domain and definition of disability, and risk estimates for disability. We calculated pooled estimates by disability type and type of risk estimate (odds ratio [OR] or risk ratio [RR]).

RESULTS

Our systematic review returned 3224 results, from which 26 studies were included in our meta-analyses. Diabetes increased the risk of mobility disability (15 studies; OR 1.71, 95% CI 1.53-1.91; RR 1.51, 95% CI 1.38-1.64), of IADL disability (ten studies; OR 1.65, 95% CI 1.55-1.74), and of ADL disability (16 studies; OR 1.82, 95% CI 1.63-2.04; RR 1.82, 95% CI 1.40-2.36).

INTERPRETATION

Diabetes is associated with a strong increase in the risk of physical disability. Efforts to promote healthy ageing should account for this risk through prevention and management of diabetes.

FUNDING

Monash University, Baker IDI Bright Sparks Foundation, Australian Postgraduate Award, VicHealth, National Health and Medical Research Council, Australian Research Council, Victorian Government.

Short-term impact of HbA1c on morbidity and all-cause mortality in people with type 2 diabetes: a Danish population-based observational study

AIMS/HYPOTHESIS

In a population-based setting, we investigated whether diabetes-related morbidity and all-cause mortality within 2 years of HbA(1c) measurement were associated with that HbA(1c) level in individuals with type 2 diabetes. The main objective was to compare outcomes in those with HbA(1c) ≥ and <7% (53 mmol/mol).

METHODS

Individuals with type 2 diabetes from Aarhus County, Denmark, were identified from public data files in a 3 year period (2001-2003). Stratifying the 17,760 individuals by HbA(1c), we estimated HRs for diabetes-related morbidities and all-cause mortality using Cox regression. Results were also stratified by treatment modality.

RESULTS

In total, 1,805 individuals experienced at least one diabetes-related morbidity and 1,859 individuals died. In general, the HRs in adjusted analyses of diabetes-related morbidity and mortality were increased for HbA(1c) ≥ 7% (53 mmol/mol): morbidity, HR 1.48 (95% CI 1.34, 1.63); and mortality, HR 1.26 (95% CI 1.15, 1.39). On grouping individuals according to HbA(1c) <5% (31 mmol/mol), 5.0-5.9% (31-41 mmol/mol), 6.0-6.9% (42-52 mmol/mol), 7.0-7.9% (53-63 mmol/mol), 8.0-8.9% (64-74 mmol/mol) and ≥ 9% (75 mmol/mol), the HRs for mortality formed a U shape, with HbA(1c) 6.0-6.9% (42-52 mmol/mol) at the lowest point. For diabetes-related morbidity, a dose-response pattern appeared (lowest for HbA(1c) < 5% [31 mmol/mol]). Patterns of HR differed with treatment modality.

CONCLUSIONS/INTERPRETATION

An HbA(1c) level ≥ 7% (53 mmol/mol) was associated with increased morbidity and mortality. Both high and very low levels of HbA(1c) were associated with increased mortality. A dose-response pattern appeared for morbidity. The impact of HbA(1c) level on morbidity and mortality depended on treatment modality.

Glycosylated hemoglobin in relationship to cardiovascular outcomes and death in patients with type 2 diabetes: a systematic review and meta-analysis

Background

Chronic hyperglycemia in type 2 diabetes increases the risk of microvascular events. However, there is continuing uncertainty about its effect on macrovascular outcomes and death. We conducted a meta-analysis of prospective studies to estimate the association of glycosylated hemoglobin level with the risk of all-cause mortality and cardiovascular outcomes among patients with type 2 diabetes.

Methodology/Principal Findings

We systematically searched the MEDLINE database through April 2011 by using Medical Subject Heading search terms and a standardized protocol. We included prospective cohort studies that reported data of glycosylated hemoglobin level on the risk of incident cardiovascular events and all-cause mortality. Relative risk estimates (continuous and categorical variables) were derived or abstracted from each cohort study. Twenty six studies were included in this analysis with a mean follow-up rang of 2.2–16 years. The pooled relative risk associated with a 1% increase in glycosylated hemoglobin level among patients with type 2 diabetes was 1.15 (95% CI, 1.11 to 1.20) for all-cause mortality, 1.17 (95% CI, 1.12 to 1.23) for cardiovascular disease, 1.15 (95% CI, 1.10 to 1.20) for coronary heart disease, 1.11 (95% CI, 1.05 to 1.18) for heart failure, 1.11 (95% CI, 1.06 to 1.17) for stroke, and 1.29 (95% CI, 1.18 to 1.40) for peripheral arterial disease, respectively. In addition, a positive dose-response trend existed between glycosylated hemoglobin level and cardiovascular outcomes.

Conclusions/Significance

Chronic hyperglycemia is associated with an increased risk for cardiovascular outcomes and all-cause mortality among patients with type 2 diabetes, likely independently from other conventional risk factors.

[Type 2 diabetes in the elderly, which specific features?]

Type 2 diabetes, whose prevalence has increased among elderly aged over 75 years, has a number of specific features which differ from that in young people: heterogeneous population, association with other cardiovascular risk factors and several comorbidities, different therapeutic constraints and risks, and lower life expectancy. By using a standardized geriatric assessment it is possible to determine therapeutic and glycemic goals for each patient. In the elderly, main complications of diabetes are hypoglycemia and foot lesions. In order to avoid malnutrition, lifestyle and dietary rules should not be too strict. Recommendations for the prescription of oral antidiabetic agents are the same for both elderly and young subjects, but with increased monitoring in the elderly because of the high risk of complications including iatrogenic hypoglycemia. Insulin therapy should be preferred.

Duration of diabetes and risk of ischemic stroke: the Northern Manhattan Study

BACKGROUND AND PURPOSE

Diabetes increases stroke risk, but whether diabetes status immediately before stroke improves prediction and whether duration is important are less clear. We hypothesized that diabetes duration independently predicts ischemic stroke.

METHODS

Among 3298 stroke-free participants in the Northern Manhattan Study, baseline diabetes and age at diagnosis were determined. Incident diabetes was assessed annually (median, 9 years). Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% CI for incident ischemic stroke using baseline diabetes, diabetes as a time-dependent covariate, and duration of diabetes as a time-varying covariate; models were adjusted for demographic and cardiovascular risk factors.

RESULTS

Mean age was 69 ± 10 years (52% Hispanic, 21% white, and 24% black); 22% had diabetes at baseline and 10% had development of diabetes. There were 244 ischemic strokes, and both baseline diabetes (HR, 2.5; 95% CI, 1.9-3.3) and diabetes considered as a time-dependent covariate (HR, 2.4; 95% CI, 1.8-3.2) were similarly associated with stroke risk. Duration of diabetes was associated with ischemic stroke (adjusted HR, 1.03 per year with diabetes; 95% CI, 1.02-1.04). Compared to nondiabetic participants, those with diabetes for 0 to 5 years (adjusted HR, 1.7; 95% CI, 1.1-2.7), 5 to 10 years (adjusted HR, 1.8; 95% CI, 1.1-3.0), and ≥ 10 years (adjusted HR, 3.2; 95% CI, 2.4-4.5) were at increased risk.

CONCLUSIONS

Duration of diabetes is independently associated with ischemic stroke risk adjusting for risk factors. The risk increases 3% each year, and triples with diabetes ≥ 10 years.

Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies

BACKGROUND

Numerous studies have demonstrated that both smoking and diabetes are risk factors for mortality and caused-specific cardiovascular events. However, few studies systematically investigated to what extent the excess risk could be attributed to smoking among diabetic patients.

METHODS

Literature references were searched up to April 2011 in MEDLINE and EMBASE, supplemented by manual searches. Inclusion criteria were prospective cohort studies, assessment of the association between smoking and total mortality, cardiovascular death, incidence of coronary heart disease (CHD), stroke and myocardial infarction (MI) in diabetic patients.

RESULTS

Of 3758 studies in the literature searched, 46 were eligible with approximately 130,000 diabetic patients. The relative risk (RR) comparing smokers with nonsmokers was 1.48[95% confidential interval (CI): 1.34-1.64] for total mortality (27 studies), 1.36(1.22-1.52) for cardiovascular mortality (9 studies), 1.54(1.31-1.82) for CHD (13 studies), 1.44(1.28-1.61) for stroke (9 studies) and 1.52(1.25-1.83) for MI (7 studies). Furthermore, the excess risk was observed among former and current smokers with a greater risk in current smokers. Subgroup analysis showed that the increased risk appeared to be consistent regardless of several study characteristics with the RRs ranging from 1.31 to 1.94 for all-cause mortality, 1.37 to 2.28 for CHD, 1.21 to 1.87 for stroke, 1.13 to 1.74 for cardiovascular mortality and 1.15 to 2.01 for MI.

CONCLUSION

Smoking amplified the risk of mortality as well as cardiovascular events and the effect size for CHD appeared to be higher than other events in diabetic patients. Moreover, a trend of decreasing risk was observed among smoking quitters.

Potentiation of aspirin-induced cerebroprotection by minocycline: a therapeutic approach to attenuate exacerbation of transient focal cerebral ischaemia

Cerebrovascular disease is a major cause of mortality and disability in adults. Diabetes mellitus increases the risk of cerebral ischaemia and is associated with worse clinical outcome following an event. Upregulation of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) in diabetes appears to play a role in vascular complications of diabetes. We hypothesised that inhibition of MMP-2 and MMP-9 by minocycline can be potentiated by aspirin through inhibition of cyclooxygenase-2 and tissue plasminogen activator, resulting in amelioration of clinical cerebral ischaemia in diabetes. In the present study, cerebral ischaemia/reperfusion injury was induced in streptozotocin diabetic rats by 1 h middle cerebral artery occlusion and 24 h reperfusion. Infarct volume, cerebral oedema, neurological severity score and blood-brain barrier disruption were significantly increased in diabetic animals compared with the normoglycemic control group. The combination of aspirin and minocycline treatment significantly improved these parameters in diabetic animals. Moreover, this therapy was associated with significantly lower mortality and reduction in MMP-2 and MMP-9 levels. Our data indicate that combination of aspirin and minocycline therapy protects from the consequences of cerebral ischaemia in animal models of diabetes and is associated with inhibition of MMP-2 and MMP-9. Therefore, this combination therapy may represent a novel strategy to reduce the neurological complications of cerebral ischaemia in diabetes.

Incremental value of biochemical and echocardiographic measures in prediction of ischemic stroke: the Strong Heart Study

BACKGROUND AND PURPOSE

American Indians have high rates of stroke. Improved risk stratification could enhance prevention, but the ability of biochemical and echocardiographic markers of preclinical disease to improve stroke prediction is not well-defined.

METHODS

We evaluated such markers as predictors of ischemic stroke in a community-based cohort of American Indians without prevalent cardiovascular or renal disease. Laboratory markers included C-reactive protein, fibrinogen, urine albumin-to-creatinine ratio, and glycohemoglobin (HbA1c), whereas echocardiographic parameters comprised left atrial diameter, left ventricular mass, mitral annular calcification, and the ratio of early to late mitral diastolic velocities. Predictive performance was judged by indices of discrimination, reclassification, and calibration.

RESULTS

After adjustment for standard risk factors, only HbA1c, albuminuria, and left atrial diameter were significantly associated with first ischemic stroke. Addition of HbA1c, although not urine albumin-to-creatinine ratio, to a basic clinical model significantly improved the C-statistic (0.714 versus 0.695; P=0.044), whereas left atrial diameter modestly enhanced integrated discrimination improvement (0.90%; P=0.004), but not the C-statistic (0.701; P=0.528). When combined with HbA1c, left atrial diameter further increased integrated discrimination improvement (1.81%; P<0.001) but not the C-statistic (0.716). No marker achieved significant net reclassification improvement.

CONCLUSIONS

In this cohort at high cardiometabolic risk, HbA1c emerged as the foremost predictor of ischemic stroke when added to traditional risk factors, affording substantially improved discrimination, with a more modest contribution for left atrial diameter. These findings bolster the role of HbA1c in cardiovascular risk assessment among persons with glycometabolic disorders and provide impetus for further study of the incremental value of echocardiography in high-risk populations.

Long-term clinical outcomes of percutaneous coronary intervention for chronic total occlusions in patients with versus without diabetes mellitus

There is a paucity of data on long-term outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) in the high-risk group of patients with diabetes mellitus (DM). The aim of this study was to evaluate long-term clinical outcomes after PCI of CTOs in patients with and without DM. A total of 1,742 patients with known DM status underwent PCI of CTOs at 3 tertiary care centers in the United States, South Korea, and Italy from 1998 to 2007. Five-year clinical outcomes were evaluated in patients with successful versus failed CTO PCI and the use of drug-eluting stents (DES) versus bare-metal stents (BMS) stratified according to DM status. A total of 395 patients (23%) had DM (42% of whom had insulin-dependent DM). Procedural success was similar in patients with versus without DM (69.6% vs 67.9%, p = 0.53). After successful CTO PCI, stents were implanted in 96.4% of patients with DM (BMS in 23.8%, DES in 76.2%) and in 94.0% of patients without DM (BMS in 38.6%, DES in 61.4%). Median follow-up was 3.0 years. In patients with DM, successful CTO PCI was associated with reduced long-term mortality (10.4% vs 13.0%, p <0.05) and a reduced need for coronary artery bypass grafting (2.4% vs 15.7%, p <0.01). The use of DES was associated with a reduction in target vessel revascularization in patients with DM (14.8% vs 54.1%, p <0.01) and in those without DM (17.6% vs 26.5%, p <0.01). Multivariate analysis identified insulin-dependent DM as an independent predictor of mortality in the DM cohort. In conclusion, successful CTO PCI in patients with DM was associated with a reduction in mortality and the need for coronary artery bypass grafting. Compared to non-insulin-dependent DM, patients with insulin-dependent DM had an increased risk for long-term mortality. The use of DES rather than BMS was associated with a reduction in target vessel revascularization in patients with and without DM.

Additive effects of glycaemia and dyslipidaemia on risk of cardiovascular diseases in type 2 diabetes: an observational study from the Swedish National Diabetes Register

AIMS/HYPOTHESIS

The study aimed to assess the relative importance of the control of HbA(1c) and total cholesterol/HDL-cholesterol ratio (TC/HDL) on risk of cardiovascular disease (CVD).

METHODS

In 22,135 participants with type 2 diabetes (age 30-75 years, 15% with previous CVD) followed for 5 years, baseline and annually updated mean HbA(1c) and TC/HDL were analysed and also categorised in combinations of quartiles. Outcomes were fatal/non-fatal CHD, stroke, CVD and total mortality.

RESULTS

In all participants, HRs per 1 SD increase in updated mean HbA(1c) or TC/HDL using Cox regression analysis were 1.13 (95% CI 1.07, 1.19) and 1.31 (1.25, 1.37) for CHD, 1.15 (1.06, 1.24) and 1.25 (1.17, 1.34) for stroke, 1.13 (1.08, 1.18) and 1.29 (1.24, 1.34) for CVD (all p < 0.001), and 1.07 (1.02, 1-13; p = 0.01) and 1.18 (1.12, 1.24; p < 0.001) for total mortality, respectively, adjusted for clinical characteristics and traditional risk factors. The p value for the interaction between HbA(1c) and TC/HDL was 0.02 for CHD, 0.6 for stroke and 0.1 for CVD. Adjusted mean 5-year event rates in a Cox model, in combinations of quartiles of updated mean TC/HDL and HbA(1c) (lowest <3.1 mmol/l and 5.0-6.4% [31-46 mmol/mol]; <3.1 mmol/l and ≥7.8% [≥62 mmol/mol]; ≥4.6 mmol/l and 5.0-6.4% 31-46 mmol/mol; and highest ≥4.6 mmol/l and ≥7.8% [≥62 mmol/mol]), were 4.8%, 7.0%, 9.1% and 14.5% for CHD, and 7.1%, 9.9%, 12.8% and 19.4% for CVD, respectively. Adjusted HRs for highest vs lowest combinations were 2.24 (1.58-3.18) for CHD and 2.43 (1.79-3.29) for CVD (p < 0.001).

CONCLUSIONS/INTERPRETATION

Hyperglycaemia and hyperlipidaemia were less than additive for CHD and additive for other endpoints, with the lowest risk at lowest combination levels and a considerable increase in absolute risk at high combination levels.

Genetic variants, plasma lipoprotein(a) levels, and risk of cardiovascular morbidity and mortality among two prospective cohorts of type 2 diabetes

AIMS

To examine the relations between genetic loci, plasma lipoprotein(a) [Lp(a)] levels, and cardiovascular disease (CVD) risk among diabetic patients and compare with the observations in the general population.

METHODS AND RESULTS

In two prospective cohorts of patients with type 2 diabetes (n= 2308) from the Nurses' Health Study and the Health Professional Follow-Up Study, we performed (i) genome-wide association (GWA) scans for plasma Lp(a); (ii) prospective analysis of plasma Lp(a) for CVD risk and mortality; and (iii) genetic association analysis for CVD risk and mortality. Meta-analysis of the two GWA scans yielded 71 single-nucleotide polymorphisms (SNPs) on chromosome 6q associated with plasma Lp(a) levels at a genome-wide significance level (P< 5 × 10(-8)). The SNP rs10455872 in LPA was most strongly associated with Lp(a) (P= 4.60 × 10(-39)). Forward-selection analysis indicated that rs10455872 and other five SNPs in a region encompassing LPA, PLG, SLC22A3, and LPAL2 genes were independently associated with Lp(a) levels and jointly explained ∼20% of variation in diabetic patients. In prospective analysis, we did not find any significant association between plasma levels and CVD incidence; the relative risk for coronary heart disease (CHD), CVD, and CVD death was 1.05 [95% confidence interval (CI): 0.95-1.15], 1.05 (0.96-1.15), and 1.21 (0.99-1.47) per 1-SD higher log-transformed Lp(a) levels, respectively. Consistently, none of the Lp(a) SNPs were associated with CVD risk or mortality (all P> 0.09). For the best SNP rs10455872 for plasma Lp(a) levels, the OR for CHD, CVD, and CVD death was 0.94 (95% CI: 0.69-1.28), 0.97 (0.72-1.29), and 1.23 (0.79-1.92), respectively. The genetic effect on CHD risk showed a significant heterogeneity between the diabetic and the general populations (P= 0.006).

CONCLUSION

Our data indicate that the effect of Lp(a) on CVD risk among diabetic patients might be different from that in the general population. Diabetes status may attenuate the relation between Lp(a) and cardiovascular risk.

Evaluation of admission characteristics, hospital length of stay and costs for cerebral infarction in a medium-sized city in China

BACKGROUND AND PURPOSE

Stroke is a heavy economic and health burden for the patients and society. This study aimed to evaluate hospital length of stay (LOS) by admission characteristics and costs correlated with medical insurance status for cerebral infarction in a medium-sized city in China.

METHODS

A total of 557 consecutive patients with principal diagnosis of cerebral infarction were enrolled. Admission characteristics, LOS, and costs were retrospectively analyzed.

RESULTS

The mean LOS was 18.5 days (median, 16 days). Our analysis demonstrated that medical insurance status, stroke severity (National Institutes of Health Stroke Scale score, Functional Independence Measure cognitive and motor score, Glasgow coma scale), Oxfordshire Community Stroke Project (OCSP) classification, some comorbidities (coronary heart disease, chronic obstructive pulmonary disease, and hyperlipemia), and raised leukocytes were the main explanatory factors for LOS by stepwise multiple regression model. The mean per patient costs were US $983.0, and mean daily costs US $67.0. Drugs were the most expensive cost subtype, all subtypes costs except non-medical care were significantly higher in patients with state medicine than in those with new cooperative medical scheme (NCMS) (P < 0.001).

CONCLUSION

Stroke severity, OCSP classification, raised leukocytes on admission, some comorbidities, and medical insurance status may help to predict LOS for patients with cerebral infarction. Healthcare expenditures were heavy burdens to inhabitants. State medicine patients could shorten unnecessary LOS to improve the resources allocation and cost-efficiency.

Cortical neurons develop insulin resistance and blunted Akt signaling: a potential mechanism contributing to enhanced ischemic injury in diabetes

Patients with diabetes are at higher risk of stroke and experience increased morbidity and mortality after stroke. We hypothesized that cortical neurons develop insulin resistance, which decreases neuroprotection via circulating insulin and insulin-like growth factor-I (IGF-I). Acute insulin treatment of primary embryonic cortical neurons activated insulin signaling including phosphorylation of the insulin receptor, extracellular signal-regulated kinase (ERK), Akt, p70S6K, and glycogen synthase kinase-3β (GSK-3β). To mimic insulin resistance, cortical neurons were chronically treated with 25 mM glucose, 0.2 mM palmitic acid (PA), or 20 nM insulin before acute exposure to 20 nM insulin. Cortical neurons pretreated with insulin, but not glucose or PA, exhibited blunted phosphorylation of Akt, p70S6K, and GSK-3β with no change detected in ERK. Inhibition of the phosphatidylinositol 3-kinase (PI3-K) pathway during insulin pretreatment restored acute insulin-mediated Akt phosphorylation. Cortical neurons in adult BKS-db/db mice exhibited higher basal Akt phosphorylation than BKS-db(+) mice and did not respond to insulin. Our results indicate that prolonged hyperinsulinemia leads to insulin resistance in cortical neurons. Decreased sensitivity to neuroprotective ligands may explain the increased neuronal damage reported in both experimental models of diabetes and diabetic patients after ischemia-reperfusion injury.

Hypoglycemic effects of intraluminal intestinal electrical stimulation in healthy volunteers

BACKGROUND

Intestinal electrical stimulation (IES) has been shown to delay gastric emptying and reduce nutrient absorption in humans. The aim of this study was to investigate the effect of IES using an intraluminal method on postprandial blood glucose.

METHODS

An oral glucose tolerance test with 150 g of glucose was performed in 10 healthy volunteers with and without IES (13 pulses/min, 300 ms and 5 mA). An intraluminal catheter with a pair of ring electrodes was incubated into the duodenum under endoscopy and used for IES. Gastric emptying was performed simultaneously using an established ultrasonic technique.

RESULTS

(1) IES significantly decreased the postprandial glucose level from 15 min to 90 min after the glucose load. (2) The serum insulin level at 30 min but not other times after the meal was lower in the IES session than that in the control session (p = 0.06). (3) The half-time of gastric emptying with IES was increased from 27 ± 4.8 min in the control session to 36 ± 8.5 min with IES (p < 0.01). (4) The symptoms score of dyspepsia were almost the same between the two sessions except that IES induced a slightly higher nausea symptom score.

CONCLUSIONS

IES decreases postprandial blood glucose possibly by delaying gastric emptying and other unknown mechanisms and the intraluminal method of IES may serve as an excellent screening and research tool for various applications of IES. Further clinical studies are needed to explore therapeutic potentials of IES for diabetes.

Ambulatory blood pressure monitoring in diabetes and obesity-a review

Diabetes mellitus and obesity are both related to the risk of cardiovascular disease and sudden death. In hypertensive guidelines, diabetes and obesity, especially abdominal obesity, are regarded as high-risk factors. Ambulatory blood pressure monitoring (ABPM) is an established method for the management of hypertension. However, ABPM is not a standard tool for the management of hypertension in diabetes and obesity. In this paper, recent data on the use of ABPM in diabetes and obesity will be discussed. In patients with diabetes, the ambulatory BP level has been shown to be better than clinic BP in predicting cardiovascular events. A riser pattern has been associated with increased risk of cardiovascular disease. White-coat hypertension and masked hypertension in diabetics constitute a moderate risk. A nondipping pattern is very common in obese hypertensive patients. In this paper, we will summarize the findings on the use of ABPM in patients with diabetes and obesity.

Prognosis of Ischaemic Stroke is Improving Similarly in Patients with Type 2 Diabetes as in Nondiabetic Patients in Finland

Background

Case fatality of first ischaemic stroke has improved markedly during the past two decades.

Aims

To investigate whether stroke patients with type 2 diabetes have shared this favourable development.

Methods

Nation-wide registers were used to identify all patients with type 2 diabetes in Finland during 1988–2002. All first ischaemic strokes among them and also among all nondiabetic persons were identified from the National Hospital Discharge Register and the Causes of Death Register. Trends over time were calculated, for age-standardised case fatality of first stroke events, separately for two time periods: 0–27 and 28–364 days after the onset of stroke. These trends were compared between patients with type 2 diabetes and nondiabetic patients.

Results

Altogether, 23097 first-ever ischaemic strokes were recorded among 222 940 persons with type 2 diabetes. The 28 day case fatality was 1·1–1·3 times higher, and the one-year case fatality of 28 day survivors was 1·4–2·2 times higher in patients with type 2 diabetes compared with nondiabetic patients. A significant decline in case fatality trends was observed, but the trends did not differ between type 2 diabetes and nondiabetic patients.

Conclusions

The study revealed a positive development in survival after the first stroke event in persons with type 2 diabetes, similar to the development in nondiabetic persons. However, the level of case fatality has remained higher in patients with type 2 diabetes.