Proteinuria is an independent risk factor for ischemic stroke in non-insulin-dependent diabetes mellitus

Microalbuminuria and mortality in individuals with coronary heart disease: A meta-analysis of a prospective study

AIM

Microalbuminuria has been elevated as an outcome predictor in cardiovascular medicine. However, due to the small number of studies investigating the association of microalbuminuria and mortality in the coronary heart disease (CHD) population, the prognosis value of microalbuminuria in CHD remains under debate. The objective of this meta-analysis was to investigate the relationship between microalbuminuria and mortality in individuals with CHD.

METHOD

A comprehensive literature search was performed using Pubmed, EuroPMC, Science Direct, and Google Scholar from 2000 to September 2022. Only prospective studies investigating microalbuminuria and mortality in CHD patients were selected. The pooled effect estimate was reported as risk ratio (RR).

RESULTS

5176 patients from eight prospective observational studies were included in this meta-analysis. Individuals with CHD have a greater overall risk of all-cause mortality (ACM) [rR = 2.07 (95% CI = 1.70-2.44); p = 0.0003; I2 = 0.0%] as well as cardiovascular mortality (CVM) [rR = 3.23 (95% CI = 2.06-4.39), p < 0.0001; I2 = 0.0%]. Subgroup analysis based on follow-up duration and a subset of CHD patients were similarly associated with an increased risk of ACM.

CONCLUSION

This meta-analysis indicates that microalbuminuria is associated with a higher risk of mortality in individuals with CHD. Microalbuminuria can serve as a predictor of poor outcomes in CHD patients.

Association between diabetes duration and 1-year prognosis of stroke: A national registry study

BACKGROUND AND PURPOSE

Diabetes mellitus is a strong independent risk factor for stroke recurrence. However, the association between diabetes duration and the prognosis of stroke remains uncertain. We aimed to characterize whether an association exists between diabetes duration and stroke outcomes in patients with ischemic stroke or transient ischemic attack (TIA).

METHODS

Between 2015 and 2018, 14,674 patients with ischemic stroke or TIA within 7 days and older than 18 years from the Third China National Stroke Registry (CNSR-III) were included in this analysis. Diabetes duration at baseline was collected by face-to-face interviews and further categorized into groups of without diabetes, diabetes < 4, 4 to <8 and ≥8 years. The association between diabetes duration and clinical outcomes, including stroke recurrence, poor function outcome (modified Rankin Scale score of 3-6), and all-cause mortality at the 1-year follow-up after stroke onset, was evaluated by a multivariable Cox proportional hazard regression model, competing risk model and logistic regression model with adjustment for demographic and clinical features.

RESULTS

Among the 14,674 patients included, the average age was 62.0 years, and 68.5% were male. There were 1419 (9.7%) patients who had stroke recurrence, 1912 (13.0%) who had poor function outcome, and 478 (3.3%) who had all-cause mortality at the 1-year follow-up. After adjusting for potential covariates, a diabetes duration ≥8 years was associated with an increased risk of 1-year stroke recurrence (adjusted hazards ratio [HR], 1.31; 95% CI, 1.05-1.64; p = .02) in comparison to those without Diabetes mellitus. Using a competing risk regression model, a diabetes duration ≥8 years was a significant risk factor for stroke recurrence (HR, 1.31; 95% CI, 1.12-1.53). In contrast, there was no significant association between diabetes duration < 4, 4 to <8 years and clinical outcomes.

CONCLUSIONS

Long-term diabetes duration (≥8 years), but not short-term diabetes duration, was associated with an increased risk of 1-year stroke recurrence in patients with ischemic stroke or TIA.

Prevalence and risk factors of stroke in Bangladesh: A nationwide population-based survey

Background

A paucity of high-quality epidemiological survey on stroke in Bangladesh emphasizes the need for a drastic effort at the national level to study the burden of stroke in Bangladesh. Therefore, this community survey was conducted with to estimate the prevalence of stroke and its associated common risk factors among Bangladeshi population.

Methods

This was a population-based cross-sectional study, carried out in 8 administrative divisions and 64 districts to estimate the prevalence of stroke throughout the country. The study adopted a two-stage cluster random sampling approach. The calculated sample size was 25,287. A semi-structured questionnaire was used to identify suspected stroke patients who were subsequently confirmed by consultant neurologists.

Result

In the first stage, a total number of 25,287 respondents were interviewed throughout the country. Interviewers identified 561 respondents as suspected stroke through the Questionnaire for Verifying Stroke Free Status (QVSFS) system in 64 districts. Of the 25,287 respondents 13,878 (54.9%) were male and 11,409 (45.1%) were female. Mean age was 39.9 years. In the second stage, all suspected stroke cases (561) were further examined by neurologists and finally 288 patients were confirmed as stroke which provided a prevalence of 11.39 per 1000 population. The highest stroke prevalence (14.71 per thousand) were found in Mymensingh division and lowest (7.62 per thousand) found in Rajshahi division. The stroke prevalence varied in different age groups. It was 30.10 per thousand in the age group of >60 years and 4.60 in the age group below 40 years. The prevalence of stroke among male was twice that of female (13.62 versus 8.68 per thousand). The prevalence was slightly higher in rural areas (11.85 versus 11.07). About 50.4% respondents had some idea about stroke.

Out of a total of 288 cases, 79.7% (213) patients had an ischemic stroke, 15.7% (42) had hemorrhagic, and 4.6% (12) were diagnosed as subarachnoid hemorrhage. The majority of the stroke patients had hypertension (79.2%), followed by dyslipidemia (38.9%), tobacco use in any form (37.2%), diabetes (28.8%), ischemic heart disease (20.1%).

Conclusion

We have found a stroke prevalence of 11.39 per 1000 population, the highest being in the Mymensingh division. The prevalence was much higher in the elderly and male population. More than three fourth had an ischemic stroke. Hypertension, dyslipidemia, tobacco use, diabetes, ischemic heart disease are the most common risk factors observed among stroke patients.

New Findings•

This is the first-ever nationwide survey in Bangladesh that revealed a stroke prevalence of 11.39 per thousand.

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There was a wide regional variation in stroke prevalence.

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The prevalence was twice among males.

Impact of the study result•

The study result will help the policymakers in deciding and planning regional policy guidelines to tackle the stroke burden.

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It will also help the clinicians to identify common risk factors among stroke patients and take precautionary measures

Diabetes and Ischemic Stroke: An Old and New Relationship an Overview of the Close Interaction between These Diseases

Diabetes mellitus is a comprehensive expression to identify a condition of chronic hyperglycemia whose causes derive from different metabolic disorders characterized by altered insulin secretion or faulty insulin effect on its targets or often both mechanisms. Diabetes and atherosclerosis are, from the point of view of cardio- and cerebrovascular risk, two complementary diseases. Beyond shared aspects such as inflammation and oxidative stress, there are multiple molecular mechanisms by which they feed off each other: chronic hyperglycemia and advanced glycosylation end-products (AGE) promote ‘accelerated atherosclerosis’ through the induction of endothelial damage and cellular dysfunction. These diseases impact the vascular system and, therefore, the risk of developing cardio- and cerebrovascular events is now evident, but the observation of this significant correlation has its roots in past decades. Cerebrovascular complications make diabetic patients 2–6 times more susceptible to a stroke event and this risk is magnified in younger individuals and in patients with hypertension and complications in other vascular beds. In addition, when patients with diabetes and hyperglycemia experience an acute ischemic stroke, they are more likely to die or be severely disabled and less likely to benefit from the one FDA-approved therapy, intravenous tissue plasminogen activator. Experimental stroke models have revealed that chronic hyperglycemia leads to deficits in cerebrovascular structure and function that may explain some of the clinical observations. Increased edema, neovascularization, and protease expression as well as altered vascular reactivity and tone may be involved and point to potential therapeutic targets. Further study is needed to fully understand this complex disease state and the breadth of its manifestation in the cerebrovasculature.

The many faces of diabetes. Is there a need for re-classification? A narrative review

The alarming rise in the worldwide prevalence of obesity and associated type 2 diabetes mellitus (T2DM) have reached epidemic portions. Diabetes in its many forms and T2DM have different physiological backgrounds and are difficult to classify. Bariatric surgery (BS) is considered the most effective treatment for obesity in terms of weight loss and comorbidity resolution, improves diabetes, and has been proven superior to medical management for the treatment of diabetes. The term metabolic surgery (MS) describes bariatric surgical procedures used primarily to treat T2DM and related metabolic conditions. MS is the most effective means of obtaining substantial and durable weight loss in individuals with obesity. Originally, BS was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with T2DM. MS is more effective than lifestyle or medical management in achieving glycaemic control, sustained weight loss, and reducing diabetes comorbidities. New guidelines for T2DM expand the use of MS to patients with a lower body mass index.Evidence has shown that endocrine changes resulting from BS translate into metabolic benefits that improve the comorbid conditions associated with obesity, such as hypertension, dyslipidemia, and T2DM. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect.This review aims to examine the physiological mechanisms in diabetes, risks for complications, the effects of bariatric and metabolic surgery and will shed light on whether diabetes should be reclassified.

Urine Protein Levels Predict Future Development of Cerebral Infarction in Koreans

PURPOSE

Proteinuria is a clinical sign of adverse cardiovascular outcomes, including stroke. We aimed to assess the relationship between proteinuria and the occurrence of cerebral infarction.

MATERIALS AND METHODS

In total, 208854 Koreans who participated in the 2009 medical examination were followed up until 2013 using the database of the National Health Insurance Service. The results of urine dipstick tests were utilized to assess proteinuria as absent, 1+, 2+, or ≥3+. The International Classification of Diseases code 163 was used to document cerebral infarction.

RESULTS

Between 2009 and 2013, 2383 cases (1.14%) of cerebral infarction occurred during 912772.9 person-years of follow-up. Hazard ratios for incident cerebral infarction increased with inceasing amounts of urine protein from 1.53 (1.23-1.90) in group 2 (1+), 1.67 (1.22-2.28) in group 3 (2+), and 2.66 (1.79-3.96) in group 4 (≥3+), compared to the reference group with little to no detectable urine protein (p<0.001, respectively).

CONCLUSION

An increase in urine protein levels was significantly related to the risk of developing cerebral infarction. Our results suggest that proteinuria might be a potential risk factor for cerebral infarction and that urine dipstick test analysis may be clinically useful for predicting stroke.

Targeting Common Signaling Pathways for the Treatment of Stroke and Alzheimer's: a Comprehensive Review

Neurodegenerative diseases such as stroke and Alzheimer's disease (AD) are two inter-related disorders that affect the neurons in the brain and central nervous system. Alzheimer's is a disease by undefined origin and causes. Stroke and its most common type, ischemic stroke (IS), occurs due to the blockade of cerebral blood vessels. As an important feature, both of disorders are associated with irreversible damages to the brain and nervous system. In this regard, finding common signaling pathways and the same molecular origin between these two diseases may be a promising way for their solution. On the basis of literature appraisal, the most common signaling cascades implicated in the pathogenesis of AD and stroke including notch, autophagy, inflammatory, and insulin signaling pathways were reviewed. Furthermore, current therapeutic strategies including natural and synthetic pharmaceuticals aiming modulation of respective signaling factors were scrutinized to ameliorate neural deficits in AD and stroke. Taken together, digging deeper in the common connections and signal targeting can be greatly helpful in understanding and unified treating of these disorders.

Influencing Factors of Recanalization after Intravenous Thrombolysis with Urokinase in Acute Cerebral Infarction Patients

BACKGROUND

Intravenous thrombolysis (IVT) with urokinase is the standard reperfusion therapy for acute cerebral infarction (ACI) in China. Only about 30% patients who use urokinase for IVT can recanalize. Therefore, this study aimed to analyze the influencing factors of recanalization after IVT using urokinase in ACI patients.

METHODS

A total of 391 consecutive patients with a diagnosis of ACI from January 2013 to October 2019 were enrolled and divided into 2 groups: patients without recanalization and patients with recanalization. Related data were collected and analyzed.

RESULTS

Univariate analysis showed that there were significant differences in gender, atrial fibrillation, erythrocyte mean corpuscular volume, platelet large cell ratio (P-LCR), glucose (GLU), and severity of ICAS between patients without recanalization and patients with recanalization (p < 0.05). Multivariate logistic regression analysis indicated that P-LCR (odds ratio [OR] = 0.17, 95% confidence interval [CI] = 0.03-0.89, p = 0.04), GLU (OR = 0.28, 95% CI = 0.11-0.67, p = 0.004), and ICAS severity (OR = 0.48, 95% CI = 0.32-0.76, p = 0.001) were the influencing factors of recanalization.

CONCLUSION

For patients with higher levels of P-LCR, GLU, or ICAS severity, the recanalization rate might decrease after ACI.

Effects of Thiazolidinedione and New Antidiabetic Agents on Stroke

Patients with hyperglycemia are at a high risk of cardio- and cerebrovascular diseases. Diabetes patients also have poor outcomes after cerebrovascular disease development. Several classes of drugs are used for diabetes management in clinical practice. Thiazolidinedione (TZD) was introduced in the late 1990s, and new antidiabetic agents have been introduced since 2000. After issues with rosiglitazone in 2007, the U.S. Food and Drug Administration strongly recommended that trials investigating cardiovascular risk associated with new antidiabetic medications should be conducted before drug approval in the United States, to prove the safety of these new drugs and to determine their superiority to previous medications. Currently, results are available from two studies with TZD focusing on cardiovascular diseases, including stroke, and from 12 cardiovascular outcome trials focusing on major adverse cardiovascular events associated with new antidiabetic agents (four with dipeptidyl peptidase-4 inhibitors, three with sodium-glucose cotransporter-2 inhibitors, and five with glucagon-like peptide-1 analogues). These studies showed different results for primary cardiovascular outcomes and stroke prevention. It is important to determine whether prescription of TZD or new antidiabetic medications compared to conventional treatment, such as sulfonylurea or insulin, is better for stroke management. Furthermore, it is unclear whether drugs in the same class show greater safety and efficacy than other drugs for stroke management.

Effects of blood glucose and glycosylated hemoglobin levels on intravenous thrombolysis in patients with acute cerebral infarction and type 2 diabetes mellitus

Objective

To investigate the effect of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbAlc.) levels on thrombolytic therapy in patients with acute cerebral infarction and type 2 diabetes mellitus.

Methods

A total of 135 patients with acute cerebral infarction were selected for this study. They were divided into study group (n=70, with acute cerebral infarction & type 2 diabetes mellitus) and control group (n=65, with acute cerebral infarction but no type 2 diabetes mellitus). All patients underwent thrombolysis treatment with Alteplase for injection. The patients were evaluated by the national institutes of health stroke scale (NIHSS) score, the modified Rankin scale (MRS) score and the Barthel index score, such indicators in patients as FPG, HbAlc, triglyceride (TG), low density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and high density lipoprotein cholesterol (HDL-C) were determined, the fast blood sugar before thrombolysis and the treatment effect after 24h thrombolysis in the observation group were observed and meanwhile the mortality rate in patients after 5 months thrombolysis was analyzed.

Results

Compared with before thrombolysis, the indexes of the two groups were significantly improved after thrombolysis, and the improvements of FPG, HbAlc, TG and LDL-C in the control group were better than those in the study group (P<0.05). There was no significant difference between the two groups in the levels of TC and HDL-C after thrombolysis (P>0.05). The 24h MBG, SDBG and MAGE in the study group were higher than those in the control group (P<0.05). In the study group, when the blood glucose was less than 6.0mmol/L before thrombolysis, the lowest effective rate after 24h thrombolysis was 33.3%, and when the blood glucose was ranging from 7.0 to 9.0mmol/L, the highest effective rate after 24h thrombolysis was 73.9%, and with the gradual increase of blood glucose, the effective rate after 24h thrombolysis decreased gradually. Also the effective rate after 24h thrombolysis also decreased gradually with the increase of HbAlc value, it reached the highest value of 64.4% at HbAlc <6.0mmol/Lad the lowest value of 25% at HbAlc >7.0mmol/L. Compared with the control group, the MHSS score and MRS score were higher and the Barthel index after thrombolysis was lower in the study group with the difference being statistically significant (P<0.05). The five months mortality rate after thrombolytic therapy was 12.9% (9/70) in the study group and 10.8% (7/65) in the control group, with no significant difference between the two groups (P=0.316). The incidence of intracranial hemorrhage after thrombolytic therapy was higher in the study group than in the control group, but the difference was not statistically significant (P>0.05), however there was significant difference between the two groups in revascularization and prognosis (P<0.05).

Conclusion

The level of HbAlc affected the curative efficacy, the higher the level, the poorer the efficacy and to control the blood glucose within a certain range before thrombolysis was beneficial to enhance the effect of static thrombolysis.

Prevalence and risk factors associated with stroke in middle-aged and older Chinese: A community-based cross-sectional study

Although the prevalence of stroke and its risk factors has been widely reported in some Western countries, information on essential stroke parameters is lacking in China, the most populous nation. A community-based cross-sectional study with 8,018 Chinese adults aged ≥40 years was used to determine the prevalence of stroke and associated risk factors. Within the screened population, the prevalence of stroke was 2.21% for both sexes, 1.60% for females, and 3.18% for males. Prevalence increased with age in both sexes (P < 0.0001). In a multivariable model, factors significantly associated with stroke were increasing age (odds ratio [OR] = 1.87, 95% CI: 1.58-2.24), male gender (OR = 2.03, 95% CI: 1.42-2.90), family history of stroke (OR = 4.33, 95% CI: 2.89-6.49), history of hyperlipidemia (OR = 1.87, 95% CI 1.31-2.68), history of hypertension (OR = 1.47, 95% CI 1.02-2.12), and physical inactivity (OR = 1.74, 95% CI: 1.16-2.59). The findings indicate that stroke prevalence in middle-aged and older Chinese adults is higher in males than in females, and increases with age in both sexes. Population-based public health intervention programs and policies targeting hyperlipidemia and hypertension control and encouragement of physical activity should be highly prioritized for middle-aged and older adults in Shenzhen, China.

Two-Year Changes in Proteinuria and the Risk of Stroke in the Chinese Population: A Prospective Cohort Study

Background

Whether changes in proteinuria are associated with incident stroke in the general population is unclear. This study aimed to investigate the association between changes in proteinuria and incident stroke and its subtypes.

Methods and Results

The current study included 60 940 Chinese participants (mean age, 50.69 years) who were free of stroke at the time of surveys (2006–2007 and 2008–2009). Participants were divided into 4 categories according to 2‐year changes in proteinuria: no proteinuria, remittent proteinuria, incident proteinuria, and persistent proteinuria. Cox proportional hazards models were used to calculate hazard ratios and their 95% CIs for stroke. After a median follow‐up period of 6.92 years, 1769 individuals developed stroke. After adjustment for confounding factors, incident proteinuria and persistent proteinuria were associated with increased risk of stroke (hazard ratio, 1.46 [95% CI, 1.26–1.68] and hazard ratio, 1.71 [95% CI, 1.42–2.06], respectively) compared with no proteinuria, which were higher than proteinuria detected at one single point (hazard ratio, 1.25; 95% CI, 1.09–1.43). The effect size for risk of stroke subtypes including ischemic stroke and hemorrhagic stroke was similar.

Conclusions

Changes in proteinuria exposure, particularly persistent proteinuria, are more likely to reflect the risk of stroke, compared with proteinuria collected at a single time point in the general population.

MC1R is dispensable for the proteinuria reducing and glomerular protective effect of melanocortin therapy

Melanocortin therapy by using adrenocorticotropic hormone (ACTH) or non-steroidogenic melanocortin peptides attenuates proteinuria and glomerular injury in experimental glomerular diseases and induces remission of nephrotic syndrome in patients with diverse glomerulopathies, even those resistant to steroids. The underlying mechanism remains elusive, but the role of melanocortin 1 receptor (MC1R) has been implicated and was examined here. Four patients with congenital red hair color and nephrotic syndrome caused by idiopathic membranous nephropathy or focal segmental glomerulosclerosis were confirmed by gene sequencing to bear dominant-negative MC1R mutations. Despite prior corticosteroid resistance, all patients responded to ACTH monotherapy and ultimately achieved clinical remission, inferring a steroidogenic-independent and MC1R-dispensable anti-proteinuric effect of melanocortin signaling. In confirmatory animal studies, the protective effect of [Nle⁴, D-Phe⁷]-α-melanocyte stimulating hormone (NDP-MSH), a potent non-steroidogenic pan-melanocortin receptor agonist, on the lipopolysaccharide elicited podocytopathy was completely preserved in MC1R-null mice, marked by reduced albuminuria and diminished histologic signs of podocyte injury. Moreover, in complementary in vitro studies, NDP-MSH attenuated the lipopolysaccharide elicited apoptosis, hypermotility and impairment of filtration barrier function equally in primary podocytes derived from MC1R-null and wild-type mice. Collectively, our findings suggest that melanocortin therapy confers a proteinuria reducing and podoprotective effect in proteinuric glomerulopathies via MC1R-independent mechanisms.

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.

Prediction of hemorrhagic transformation in acute ischaemic stroke by micro- and macroalbuminuria after intravenous thrombolysis

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is one of the most problematic complications to arise from intravenous thrombolysis (IVT). This study was conducted to assess whether micro- and macroalbuminuria could be associated with HT after IVT in patients with acute ischaemic stroke, and to investigate whether the value of urinary albumin-to-creatinine ratios would correlate with the degree of HT.

METHODS

This was a retrospective study of stroke patients who had undergone IVT within 3 h of symptom onset. Albuminuria assessment was based on random morning spot urine collection with patients in a fasting state, the first morning after IVT. Multiple logistic regression analysis was used to evaluate whether the presence of micro- and macroalbuminuria might be independent predictors of HT.

RESULTS

One-hundred and fifty-four patients were included in the study. Fifty-one patients had HT. The presence of micro- or macroalbuminuria was associated with HT after adjustment for variables with clinical significance (adjusting for age, atrial fibrillation, platelet counts, baseline National Institutes of Health Stroke Scale score, hypertension and diabetes mellitus; odds ratio, 2.542; 95% confidence interval, 1.106-5.841; P = 0.028). There were significant relationships between the presence of micro- and macroalbuminuria and types of HT.

CONCLUSION

In conclusion, the results of this study suggest that the presence of micro- and macroalbuminuria after IVT could be a predictor of severe HT in patients with acute ischaemic stroke.

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.

Stroke in diabetic patients

Stroke is the leading cause of disability and the second most frequent cause of death worldwide. On the one hand, diabetic patients have a 1.5 to 3-times higher risk of stroke, especially cerebral infarction, than non-diabetic subjects. This excess risk, which is particularly pronounced in younger individuals and women, can be reduced by effective therapeutic strategies aimed at improving glycaemic control and the management of co-morbid conditions such as hypertension and dyslipidaemia. On the other hand, the prevalence of diabetes in stroke patients is between 10 and 20%, and has been increasing over the last 20 years, probably in response to rising rates of overweight and obesity in the general population and other factors such as a sedentary lifestyle. Even though diabetes has long been considered a specific risk factor of lacunar stroke, recent epidemiological studies have demonstrated that this risk factor was in fact not associated with any ischemic stroke subtype. Finally, it has been suggested that diabetic stroke patients have poorer motor and functional outcomes, and are at a higher risk of dementia, recurrent stroke and death.

Albuminuria and the risk of incident stroke and stroke types in older adults

BACKGROUND

The kidney biomarker that best reflects risk of stroke is unknown. We sought to evaluate the association of stroke with 3 kidney biomarkers: albuminuria, cystatin C, and glomerular filtration rate.

METHODS

These 3 biomarkers were determined in 3,287 participants without history of stroke from the Cardiovascular Health Study, a longitudinal cohort study of men and women age 65 years and older from 4 US communities. The biomarkers were albuminuria ascertained using urinary albumin-to-creatinine ratio (UACR) from morning spot urine, creatinine-based estimated glomerular filtration rate (eGFR), and cystatin C. Outcomes were incident stroke (any, ischemic, or hemorrhagic) during follow-up between 1996 and 2006.

RESULTS

A total of 390 participants had an incident stroke: 81% ischemic, 12% hemorrhagic, and 7% unclassified. In adjusted Cox regression models, UACR was more strongly related to any stroke, ischemic stroke, and hemorrhagic stroke than eGFR and cystatin C. The hazard ratio (HR) of any stroke comparing the top to bottom quintile of UACR was 2.10 (95% confidence interval [CI] 1.47-3.00), while HR for eGFR was 1.29 (95% CI 0.91-1.84) and for cystatin C was 1.22 (95% CI 0.85-1.74). When considering clinically relevant categories, elevated UACR was associated with increased hazard of any stroke and ischemic stroke regardless of eGFR or cystatin C categories.

CONCLUSIONS

UACR was the kidney biomarker most strongly associated with risk of incident stroke. Results in this elderly cohort may not be applicable to younger populations. These findings suggest that measures of glomerular filtration and permeability have differential effects on stroke risk.

Diabetes mellitus and cerebrovascular disease: which are the actual data?

Cerebrovascular disease (CeVD) represents a major cause of morbidity and mortality worldwide. Diabetes mellitus (DM) represents an independent risk factor for CeVD. The aim of the present review is to describe the epidemiology of CeVD in patients with DM and to explain how DM and diabetic autonomic neuropathy can increase the risk of CeVD. The prevention and management of CeVD in the diabetic population are also analyzed.

Diabetes-related microvascular and macrovascular diseases in the physical therapy setting

Physical therapists commonly treat people with diabetes for a wide variety of diabetes-associated impairments, including those from diabetes-related vascular disease. Diabetes is associated with both microvascular and macrovascular diseases affecting several organs, including muscle, skin, heart, brain, and kidneys. A common etiology links the different types of diabetes-associated vascular disease. Common risk factors for vascular disease in people with diabetes, specifically type 2 diabetes, include hyperglycemia, insulin resistance, dyslipidemia, hypertension, tobacco use, and obesity. Mechanisms for vascular disease in diabetes include the pathologic effects of advanced glycation end product accumulation, impaired vasodilatory response attributable to nitric oxide inhibition, smooth muscle cell dysfunction, overproduction of endothelial growth factors, chronic inflammation, hemodynamic dysregulation, impaired fibrinolytic ability, and enhanced platelet aggregation. It is becoming increasingly important for physical therapists to be aware of diabetes-related vascular complications as more patients present with insulin resistance and diabetes. The opportunities for effective physical therapy interventions (such as exercise) are significant.

Review: Stroke in type 2 diabetes

Stroke is the second most frequent cause of death worldwide and the most frequent cause of permanent disability. Patients with diabetes are at 1.5 to three times the risk of stroke compared with the general population. Cerebrovascular disease causes 20% of deaths in diabetic patients. Interestingly, there are some striking differences of stroke patterns between diabetic and non-diabetic subjects suffering a stroke. Even more important is the fact that diabetes dramatically increases the risk of stroke in younger subjects as well as women. These data highlight the need for detection and treatment of diabetes particularly in these patient groups. This review summarises several aspects of stroke in type 2 diabetes, focusing on differences from non-diabetic stroke.

Stroke prediction and stroke prevention with atorvastatin in the Collaborative Atorvastatin Diabetes Study (CARDS)

AIMS

Patients with Type 2 diabetes have an elevated risk of stroke. The role of lipid levels and diabetes-specific factors in risk prediction of stroke is unclear, and estimates of efficacy of lipid-lowering therapy vary between trials. We examined predictors of stroke and the effect of atorvastatin on specific stroke subtypes in Type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS) [a trial of 2838 participants with mean low-density lipoprotein cholesterol < 4.14 mmol/l, no history of macrovascular disease and randomized to atorvastatin 10 mg daily or placebo].

METHODS

Median follow-up was 3.9 years. Cox regression models were used to estimate the effect of atorvastatin on stroke rate and risk of stroke associated with baseline risk factors. Risk factors that predicted stroke in univariate models were examined in a multivariable model.

RESULTS

Independent risk factors predicting stroke were age [10-year increments; hazard ratio (HR) 2.3, P < 0.001], microalbuminuria (albumin : creatinine ratio > 2.5 mg/mmol; HR 2.0, P = 0.007) and glycaemic control (HbA(1c) > 10%; HR 2.7, P = 0.007). Women were at lower risk of stroke (HR 0.3, P = 0.004). Lipids did not predict stroke. Of 60 first strokes, 47 were non-haemorrhagic, 13 were indeterminate and none was definitely haemorrhagic. Atorvastatin treatment was associated with 50% reduction in non-haemorrhagic stroke (95% confidence interval 9%-72%P = 0.024), similar to the 48% reduction (11%-69%) for all strokes combined.

CONCLUSIONS

Diabetes-specific risk factors are important predictors of stroke in Type 2 diabetes. Despite the lack of association between baseline lipids and first stroke, there was a reduction of 50% of non-haemorrhagic strokes associated with atorvastatin treatment in the CARDS population.

Association of D-dimer with microalbuminuria in patients with type 2 diabetes mellitus

BACKGROUND

Microalbuminuria has been reported to be related to incidence of cardiovascular complications in diabetes. No consistent findings have been obtained on the relationships of microalbuminuria with blood coagulation and fibrinolysis. The purpose of this study was to determine whether microalbuminuria is associated with blood markers reflecting coagulation and fibrinolysis activities in patients with type 2 diabetes.

METHODS

The relationships of albumin excretion rate (AER) with atherosclerosis-related variables, including blood coagulation and fibrinolysis markers, were investigated in patients with type 2 diabetes who showed normoalbuminuria (AER: less than 20 microg/min) and microalbuminuria (AER: 20 microg/min or higher and less than 200 microg/min).

RESULTS

AER was significantly correlated with body mass index (BMI), maximum intima-media thickness of common carotid arteries, blood HDL cholesterol, uric acid, creatinine and D-dimer. On the other hand, AER showed no significant correlation with blood platelets, fibrinogen, thrombin-antithrombin III complex, plasmin-alpha2 plasmin inhibitor complex and plasminogen activator inhibitor-1. In multiple regression analysis, using age, sex, BMI, pulse pressure, hemoglobin A1c, HDL cholesterol, uric acid, creatinine, D-dimer and history of anti-thrombotic therapy as explanatory variables, only D-dimer showed a significant correlation with AER. The mean level of log-converted D-dimer after adjustment for age and sex was significantly higher in subjects with microalbuminuria than in those with normoalbuminuria.

CONCLUSIONS

D-dimer is associated with microalbuminuria in patients with diabetes and this suggests that glomerular dysfunction is in part mediated by hypercoagulability.

Cerebral Microangiopathy in Patients with Non-insulin-dependent Diabetes Mellitus

Introduction: The aim of the study was to evaluate cerebral microangiopathy in type 2 non-insulin-dependent diabetes mellitus (NIDDM) patients and to establish potentially conducive factors. Materials and Methods: A group of 34 patients with NIDDM and 31 gender- and age-matched normal controls (NC) were assessed by extracranial Doppler ultrasound, in order to evaluate the pulsatility index (PI) and the resistance index (RI) in the internal carotid arteries (ICAs); transcranial Doppler was utilised to assess the same parameters in the middle cerebral arteries (MCAs). All patients underwent screening for favouring factors for cerebral vascular remodelling. Results: Of the 34 NIDDM patients, 21 patients (61.76%) (subgroup A) presented with microangiopathic complications [of these, 19 patients (90.46%) had diabetic nephropathy (DN)] versus 13 NIDDM patients (38.24%) (subgroup B) without complications. In subgroup A, 16 patients (76.19%) had PI >1 and RI >0.7 in the ICAs and MCAs (changes consistent with cerebral microangiopathy) versus 5 patients (35.46%) in subgroup B, and no modifications in NC. Of the 19 patients with DN, 14 patients (73.68 %) had impaired haemodynamic indices. Univariate regression analysis showed the following risk factors for the cerebral haemodynamics changes: fibrinogen (F) (OR = 3.11), C-reactive protein (CRP) (OR = 2.40), duration of DM (OR=2.40), proteinuria (OR = 1.80), serum creatinine (OR = 1.66). Multivariate regression analysis showed as predictors for impaired haemodynamic indices: duration of DM (HR =1.70), proteinuria (HR = 1.70). The haemodynamic indices in the ICAs correlated with duration of DM (r = 0.87, P <0.0001), F (r = 0.86; P <0.0001), CRP (r = 0.80; P <0.0001); in the MCAs with the duration of DM (r = 0.66, P <0.0001), F (r = 0.38; P <0.0001), CRP (r = 0.88; P <0.0001). Conclusion: Cerebral microangiopathy has a high prevalence in NIDDM patients. These cerebral vascular changes correlate with the duration of DM, parameters of inflammation, and proteinuria. Key words: Cerebral microangiopathy, Diabetic nephropathy, Doppler ultrasound, Non-insu-lin-dependent diabetes mellitus, Risk factors

Microalbuminuria is a prognostic predictor in aneurysmal subarachnoid hemorrhage

OBJECTIVE

To determine the prevalence and the prognostic significance of microalbuminuria in patients after aneurysmal subarachnoid hemorrhage (SAH).

DESIGN

Prospective and observational clinical study.

SETTING

Multidisciplinary intensive care unit.

PATIENTS

Fifty-one consecutive patients who underwent aneurysm clipping or endovascular surgery after SAH; 8 patients who underwent surgical clipping for unruptured intracerebral aneurysm served as control.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

General clinical and neurological data were recorded on admission. Urine was collected preoperatively and daily for up to 7 days postoperatively for measuring the urinary microalbumin/creatinine ratio. The Glasgow Coma Scale (GCS) score was also determined on admission and daily for up to 7 days after operation. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at 3 months after stroke. The prevalence rates of microalbuminuria were 74.5% in SAH and 37.5% in the control. Among the 51 patients, 25 had unfavorable neurological outcome (GOS 1-3). The areas under the receiver operator characteristic curves showed that the highest urinary microalbumin/creatinine ratio and the lowest GCS score during the first 8 days were the significant predictors of unfavorable neurological outcome. The threshold value, sensitivity, specificity, and likelihood ratio for the highest urinary microalbumin/creatinine ratio were 200 mg/g, 60% [95% confidence interval (CI) 41-79], 96% (95% CI 88-100), and 15.6 (95% CI 9.1-26.7), respectively.

CONCLUSIONS

This study confirms a high prevalence of microalbuminuria in the SAH patients, and it suggests that the highest urinary microalbumin/creatinine ratio > 200 mg/g during the first 8 days is a significant predictor of unfavorable neurological outcome.

Low-dose lithium combined with captopril prevents stroke and improves survival in salt-loaded, stroke-prone spontaneously hypertensive rats

OBJECTIVE

A number of potential interactions between angiotensin-converting enzyme inhibitors and lithium have been described in the literature. In the present study, we investigated the effects of a low-dose combination treatment with lithium and captopril on survival and stroke prevention in salt-loaded, stroke-prone spontaneously hypertensive rats (SHRSP).

METHODS

Eight-week-old saline-drinking SHRSP (n = 21 per group) were treated with vehicle, LiCl (1 mmol/kg per day), captopril (25 mg/kg per day) and captopril plus LiCl for up to 37 weeks. Body weight, salt water intake blood pressure and mortality were recorded throughout the experimental period. Plasma renin activity, plasma lithium concentration and urinary excretion of albumin, sodium and potassium were measured at different time points.

RESULTS

Captopril treatment doubled the life expectancy when compared with vehicle-treated rats. Lithium alone had minor effects on survival but led to a dramatic increase in survival when added to captopril (mean survival time > 237 versus 147 days, P < 0.001). Systolic blood pressure increased with age in all treatment groups but was comparable in the captopril-treated and the captopril-plus-lithium-treated groups. Plasma renin activity as well as urinary sodium and potassium excretion did not differ between both groups. In the captopril group a striking fivefold increase of albuminuria occurred between 14 and 26 weeks of age, while this progression was completely abolished by the addition of lithium.

CONCLUSIONS

Our results demonstrate that the addition of lithium to captopril dramatically prolong the effects of the angiotensin-converting enzyme inhibitor on survival in salt-loaded SHRSP. This effect was independent of a reduction in blood pressure.

Diabetes mellitus and stroke

The aim of this article was to describe (i) the epidemiology and outcomes of stroke relating to diabetes; (ii) the pathophysiology of diabetes as a risk factor for stroke; (iii) the management of acute stroke in patients with diabetes; (iv) the evidence of primary and secondary prevention of stroke in patients with diabetes; and (v) the risk of new-onset diabetes using older antihypertensive agents. The combination of diabetes and stroke disease is a major cause of morbidity and mortality worldwide. Evidence from large clinical trials performed in patients with diabetes supports the need for aggressive and early intervention to target patients' cardiovascular (CV) risks in order to prevent the onset, recurrence and progression of acute stroke. Identification of at-risk patients with diabetes and metabolic syndrome has also allowed the delivery of early and effective intervention to reduce stroke risks, while active treatment during the acute phase of stroke will reduce long-term neurological and functional deficits. While the ongoing debate on the risk benefits of different antihypertensive, lipid-lowering and antiplatelet agents should not detract clinicians from pursuing aggressive CV risk reduction, the application of evidence-based medicine specifically in patients with diabetes will facilitate the use of appropriate agents to improve clinical outcomes. The overall management of patients with diabetes and acute stroke or at risk of secondary stroke should also include multifactorial intervention that not only targets patient's CV risk but also includes behavioural, lifestyle and, where appropriate, surgical intervention.

What is the evidence that microalbuminuria is a predictor of cardiovascular disease events?

PURPOSE OF REVIEW

This review describes recently published studies evaluating the association between microalbuminuria and the development of cardiovascular disease events either in the presence of diabetes or hypertension, or in the population as a whole.

RECENT FINDINGS

Prospective studies confirm that microalbuminuria is predictive, independently of classical risk factors, of cardiovascular disease events and all-cause mortality within groups of patients with diabetes or hypertension and in the general population. However, these studies suggest that levels of albuminuria below the conventional cutoff point definition of microalbuminuria are significantly associated with cardiovascular morbidity and mortality. The pathophysiological mechanism underyling this association is still uncertain. Data from recent intervention studies suggest that treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, as well as intensive multi-factorial intervention including behaviour modification and targeted pharmacotherapy in patients with microalbuminuria, offers significant reduction in cardiovascular and renal morbidity in people with albuminuria.

SUMMARY

Future absolute risk prediction scores for primary cardiovascular events could include microalbuminuria as a modifiable risk factor. The association between levels of albuminuria and cardiovascular outcomes in individuals within the normoalbuminuric range questions the current categorical definition of microalbuminuria. Intensive multifactorial interventions, including the use of agents that affect the renin-angiotensin pathway, are effective in reducing cardiovascular risk in patients with microalbuminuria and diabetes or hypertension.

Urine albumin excretion in acute ischaemic stroke is related to serum interleukin-6

BACKGROUND AND PURPOSE

Several studies show a link between microalbuminuria and markers of inflammation. Increased urine albumin excretion accompanies acute ischaemic stroke. The mechanisms responsible for microalbuminuria in acute stroke patients remain unclear. The goal of this study was to determine if there is a relationship between urine albumin excretion and interleukin-6, a key mediator of acute phase reaction.

METHODS

Nineteen acute ischaemic stroke patients and 13 controls matched for age, sex and cardiovascular risk factors were included. Serum interleukin-6 level was measured on the 2nd day of stroke at 06:00 am, 10:00 am, 06:00 pm and 10:00 pm using ELISA method. Urine albumin excretion was determined using immunonephelometric method.

RESULTS

Interleukin-6 level and urine albumin excretion were significantly higher in stroke patients than in controls. There was a significant correlation between interleukin-6 level and urine albumin excretion in stroke patients (R = -0.60 at 06:00 am; R = -0.49 at 10:00 am; R = -0.64 at 06:00 pm; R = -0.54 at 10:00 pm) but not in controls.

CONCLUSIONS

Urine albumin excretion in acute ischaemic stroke is related to serum interleukin-6.

Low Well-Being Is an Independent Predictor for Stroke in Elderly Patients with Diabetes Mellitus

OBJECTIVES

To examine whether psychological factors are risk factors for the development of stroke in elderly diabetic patients.

DESIGN

Prospective cohort study.

SETTING

Outpatient clinic.

PARTICIPANTS

Three hundred seventy-six diabetic outpatients free of stroke; mean age 75.

METHODS

Well-being and diabetes-specific burden were assessed at baseline using the Philadelphia Geriatric Center morale scale and the Elderly Diabetes Burden Scale (EDBS), respectively. Symptomatic stroke was defined as a focal neurological deficit with rapid onset that persists for more than 24 hours, supported by brain computed tomography or magnetic resonance imaging.

RESULTS

During the 3-year follow-up period, 25 symptomatic strokes (24 ischemic strokes and 1 cerebral hemorrhage) occurred. Low scores on the morale scale (</=7) were significant predictors for stroke after adjustment for age; sex; body mass index; hemoglobin A1c level; systolic blood pressure; serum levels of total cholesterol, triglycerides, and high-density lipoprotein cholesterol; smoking; and previous ischemic heart disease (IHD) (hazard ratio (HR)=3.0, 95% confidence interval (CI)=1.2-7.3, P=.017). The relationship between low morale scores and future stroke remained significant after adjusting for socioeconomic factors and microalbuminuria. Increased symptom burden and social burden, but not dietary restrictions, worry about diabetes mellitus (DM), treatment satisfaction, and burden by tablets or insulin of EDBS, were also significant predictors for stroke after adjustment for age, sex, duration of DM, previous IHD, and microalbuminuria (HR=2.6, 95% CI=1.1-6.5, P=.039).

CONCLUSION

Low well-being and symptom burden were predictors of stroke in elderly patients with diabetes mellitus (DM), although the causal relationship remains unknown.

Retinopathy as a predictor of other diabetic complications

PURPOSE

Early predictors of diabetic complications may aid in the prevention and/or management of these complications. The aim of this cross-sectional study was to determine the predictive value of retinopathy for the presence of other diabetic complications.

METHODS

The population studied comprised 648 patients with diabetes mellitus assessed by our service. There were 210 patients (32.4%) with insulin-dependent diabetes mellitus (IDDM), and 438 patients (67.6%) with non-insulin-dependent diabetes mellitus (NIDDM).

RESULTS

Univariate analyses revealed that retinopathy significantly predicted the presence of neuropathy (odds ratio [OR] = 2.23; 95% confidence interval [CI] = 1.56-3.18; p < 0.001), nephropathy (OR = 5.68; 95% CI = 3.06-10.62; p < 0.001), and cerebrovascular disease (OR = 6.6; 95% CI = 1.16-67.21; p = 0.0239) in the total group. Similar associations were observed both in subjects with IDDM and NIDDM. The associations between retinopathy severity level and the prevalence rate of nephropathy were significant in the total group (p = 0.0001), in patients with IDDM (p = 0.0113), and in patients with NIDDM (p = 0.01). In patients with mild to moderate non-proliferative retinopathy (NPDR), nephropathy was present in 17.2% of patients with IDDM, and in 11.4% of patients with NIDDM. In patients with severe NPDR, nephropathy was present in 23.3% in patients with IDDM, and in 11.8% of patients with NIDDM. In patients with proliferative retinopathy (PDR), nephropathy was present in 50% in patients with IDDM, and in 45.5% in patients with NIDDM. In multivariate logistic regression analyses, nephropathy was the only significant complication to be independently associated with retinopathy in patients with IDDM (OR = 8.02; 95% CI = 1.95-33), and in patients with NIDDM (OR = 2.48; 95% CI = 1.02-6.03).

CONCLUSIONS

Retinopathy, especially the presence of PDR, is an independent predictor for nephropathy. The predictive value of retinopathy for nephropathy is stronger in patients with IDDM than in those with NIDDM. Ophthalmologists should refer patients with retinopathy for regular medical evaluations.

Stroke: epidemiology, clinical picture, and risk factors--Part I of III

The aim of this review is to present the current knowledge regarding stroke. It will appear in three parts (in part II the pathogenesis, investigations, and prognosis will be presented, while part III will consist of the management and rehabilitation). In the current part (I) the definitions of the clinical picture are presented. These include: amaurosis fugax, vertebrobasilar transient ischemic attack, and stroke (with good recovery, in evolution and complete). The role of the following risk factors is discussed in detail: age, gender, ethnicity, heredity, hypertension, cigarette smoking, hyperlipidemia, diabetes mellitus, obesity, fibrinogen and clotting factors, oral contraceptives, erythrocytosis and hematocrit level, prior cerebrovascular and other diseases, physical inactivity, diet and alcohol consumption, illicit drug use, and genetic predisposition. In particular, regarding the carotid arteries, the following characteristics are analyzed: atheroma, carotid plaque echomorphology, carotid stenosis, presence of ulcer, local variations in surface deformability, pathological characteristics, and dissection. Finally the significance of the cerebral collateral circulation and the conditions predisposing to cardioembolism and to cerebral hemorrhage are presented.

Hyperinsulinemia and abdominal obesity are more prevalent in non-diabetic subjects with family history of type 2 diabetes

BACKGROUND

This study was undertaken in order to identify the relationships between family history of type 2 diabetes and cardiovascular risk factors in non-diabetic Mexican individuals.

METHODS

The design was a cross-sectional, population-based study stratified by age and sex. Participants consisted of 189 non-diabetic volunteers 30-64 years of age, both males and non-pregnant females randomly selected from a middle income neighborhood in Durango, Mexico and distributed into two groups, with and without family history of type 2 diabetes mellitus. Hypertensive subjects were excluded. Body mass index (BMI) and waist-to-hip ratio (WHR) were assessed. Hematocrit, both fasting and 2-h post 75-g glucose load insulin, and glucose levels, lipid profile, serum albumin, and proteinuria were measured.

RESULTS

Ninety-four (49.7%) individuals with family history of type 2 diabetes, and 95 (50.3%) in the control group were included. The prevalence of obesity was greater among women with family history of diabetes, 39 (73.6%) vs. 27 (50.0%) of the control group, p = 0.02. Adiposity tended to be centrally distributed in 86 subjects, of whom 22 (25. 6%) males and 54 (62.8%) females were in the group with family history of diabetes and four (4.6%) males and six (7.0%) females in the control group, p <0.000. Multivariate logistic regression analysis showed a strong relationship between family history of type 2 diabetes with both abdominal obesity (odds ratio [OR] 4.2, CI 95% 1.9-10.1, p <0.05) and fasting hyperinsulinemia (OR 3.1, CI 95% 1. 4-11.2, p <0.05).

CONCLUSION

In the absence of additional risk factors such as diabetes and hypertension, there is a strong relationship between family history of diabetes with hyperinsulinemia and abdominal obesity in middle-aged Mexican individuals.