Mortality in persons with undetected and diagnosed hypertension, type 2 diabetes, and hypothyroidism, compared with persons without corresponding disease - a prospective cohort study; The HUNT Study, Norway

Sodium accumulation in the skin is associated with higher density of skin lymphatic vessels in patients with arterial hypertension

PURPOSE

Recent studies, conducted mainly on the rodent model, have demonstrated that regulatory pathway in the skin provided by glycosaminoglycans, nuclear factor of activated T cells 5 (NFAT5), vascular endothelial growth factor C (VEGF-C) and process of lymphangiogenesis may play an important role in extrarenal regulation of sodium (Na+) balance, body water volume, and blood pressure. We aimed to investigate the concentrations and relations among the main factors of this pathway in human skin to confirm that this regulatory axis also exists in humans.

PATIENTS AND METHODS

Skin specimens from patients diagnosed with arterial hypertension and from control group were histologically and molecularly examined.

RESULTS

The primary hypertensive and control groups did not differ in Na+ ​concentrations in the skin. However, the patients with hypertension and higher skin Na+ concentration had significantly greater density of skin lymphatic vessels. Higher skin Na+concentration was associated with higher skin water content. In turn, skin water content correlated with factors associated with lymphangiogenesis, i.e. NFAT5, VEGF-C, and podoplanin (PDPN) mRNA expression in the skin. The strong mutual pairwise correlations of the expressions of NFAT5, VEGF-C, vascular endothelial growth factor D (VEGF-D) and PDPN mRNA were noted in the skin in all of the studied groups.

CONCLUSIONS

Our study confirms that skin interstitium and the lymphatic system may be important players in the pathophysiology of arterial hypertension in humans. Based on the results of our study and existing literature in this field, we propose the hypothetical model which might explain the phenomenon of salt-sensitivity.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and concurrent pathologies]

Introduction

Type 2 diabetes mellitus is a highly prevalent disease worldwide, generating an increasing clinical and economic burden due to its micro- and macrovascular complications. Frequently, people with diabetes are hospitalized for various pathologies. These patients generally have higher risk of complications, prolonged hospitalizations and mortality. An additional factor that worsens the prognosis in these patients is the concurrence of malnutrition, especially in elderly people. All this makes the management of these patients challenging and requires a specific nutritional approach, whose purpose is to cover the nutritional requirements while always maintaining glycemic control. The purpose of this work is to provide, based on the evidence available in the literature and clinical experience, consensus recommendations by eighteen experts in Endocrinology and Nutrition on the nutritional approach of hospitalized patients with diabetes/ hyperglycemia and compare the optimal management, based on these recommendations with bedside usual care according to a panel of Spanish doctors surveyed about their daily clinical practice. This first article of this extraordinary issue of the journal Nutrición Hospitalaria describes the methodology of the study and the results obtained regarding common issues for all pathologies.

Trends in Cardiometabolic and Cancer Multimorbidity Prevalence and Its Risk With All-Cause and Cause-Specific Mortality in U.S. Adults: Prospective Cohort Study

Several prospective cohort studies have assessed the association between multimorbidity and all-cause mortality, but the findings have been inconsistent. In addition, limited studies have assessed the association between multimorbidity and cause-specific mortality. In this study, we used the population based cohort study of National Health Interview Survey (1997–2014) with linkage to the National Death Index records to 31 December 2015 to examine the trends in prevalence of multimorbidity from 1997 to 2014, and its association with the risk of all-cause and cause-specific mortality in the U.S. population. A total of 372,566 adults aged 30–84 years were included in this study. From 1997 to 2014, the age-standardized prevalence of specific chronic condition and multimorbidity increased significantly (P < 0.0001). During a median follow-up of 9.0 years, 50,309 of 372,566 participants died from all causes, of which 11,132 (22.1%) died from CVD and 13,170 (26.2%) died from cancer. Compared with participants without the above-mentioned chronic conditions, those with 1, 2, 3, and ≥4 of chronic conditions had 1.41 (1.37–1.45), 1.94 (1.88–2.00), 2.64 (2.54–2.75), and 3.68 (3.46–3.91) higher risk of all-cause mortality after adjustment for important covariates. Similarly, a higher risk of CVD-specific and cancer-specific mortality was observed as the number of chronic conditions increased, with the observed risk stronger for CVD-mortality compared with cancer-specific mortality. Given the prevalence of multimorbidity tended to increase from 1997 to 2014, our data suggest effective prevention and intervention programs are necessary to limit the increased mortality risk associated with multimorbidity.

Serum Uric Acid Is a Weak Independent Predictor of Overall Survival in Older Adults

Hyperuricemia accompanies many pathologies that contribute to overall death rate. The population-based multifaceted study of older adults in Poland made it possible to assess the effect of serum uric acid (SUA) on overall mortality. The PolSenior study performed between 2007–2011 included 3926 participants aged 65 years or above (mean age 79 ± 9 years) not treated with xanthin oxidase inhibitors (XOI) who were stratified by sex and SUA concentration into six subgroups increasing by 1 mg/dL. In 2019, survival data were retrieved from the population register. The crude risk of death was significantly higher in men and women with SUA ≥ 7 mg/dL. After adjustment to statistically significant factors, SUA remained a risk factor of death in men with SUA ≥ 8 mg/dL only, potentially due to the limited number of women with high SUA levels. Furthermore, age, heart failure, diabetes, and activities of daily living ≤ 4 pts were identified as factors increasing mortality risk regardless of sex. The risk of death increased also with smoking, past stroke, COPD/asthma, and hs-CRP > 3 mg/dL for men; and eGFR < 45 mL/min/1.73 m², mini nutritional assessment ≤ 7 pts, and loop diuretics use for women. Mild hyperuricemia is a significant health status marker and an independent risk factor for overall mortality in older Caucasians not receiving XOI. Increased mortality is mostly limited to subjects with SUA levels ≥ 8 mg/dL.

Epidemiology of thyroid disorders in the Lifelines Cohort Study (the Netherlands)

BACKGROUND

Thyroid hormone plays a pivotal role in human metabolism. In epidemiologic studies, adequate registration of thyroid disorders is warranted. We examined the prevalence of thyroid disorders, reported thyroid medication use, thyroid hormone levels, and validity of thyroid data obtained from questionnaires in the Lifelines Cohort Study.

METHODS

We evaluated baseline data of all 152180 subjects (aged 18-93 years) of the Lifelines Cohort Study. At baseline, participants were asked about previous thyroid surgery and current and previous thyroid hormone use. At follow-up (n = 136776, after median 43 months), incident thyroid disorders could be reported in an open, non-structured question. Data on baseline thyroid hormone measurements (TSH, FT4 and FT3) were available in a subset of 39935 participants.

RESULTS

Of the 152180 participants, mean (±SD) age was 44.6±13.1 years and 58.5% were female. Thyroid medication was used by 4790 participants (3.1%); the majority (98.2%) used levothyroxine, and 88% were females. 59.3% of levothyroxine users had normal TSH levels. The prevalence of abnormal TSH levels in those not using thyroid medication was 10.8%; 9.4% had a mildly elevated (4.01-10.0 mIU/L), 0.7% had suppressed (<0.40 mIU/L), while 0.7% had elevated (>10.0 mIU/L) TSH levels. Over 98% of subjects with TSH between 4 and 10 mIU/L had normal FT4. Open text questions allowing to report previous thyroid surgery and incident thyroid disorders proved not to be reliable and severely underestimated the true incidence and prevalence of thyroid disorders.

CONCLUSIONS

Undetected thyroid disorders were prevalent in the general population, whereas the prevalence of thyroid medication use was 3.1%. Less than 60% of individuals using levothyroxine had a normal TSH level. The large group of individuals with subclinical hypothyroidism (9.4%) offers an excellent possibility to prospectively follow the natural course of this disorder. Both structured questions as well as linking to G.P.'s and pharmacists' data are necessary to improve the completeness and reliability of Lifelines' data on thyroid disorders.

Association between Low Protein Intake and Mortality in Patients with Type 2 Diabetes

The aim of this study was to investigate the association between protein intake and mortality risk in patients with type 2 diabetes. We analyzed a pooled data of 2494 diabetic patients from two prospective longitudinal studies. Nutritional intake was assessed using a Food Frequency Questionnaire at baseline. Protein intake per body weight (kg) per day was categorized into quartile groups. Adjusted hazard ratios (HRs) and 95% confidence interval (CI) were calculated using Cox regression analysis. During the six-year follow-up, there were 152 incidents of all-cause mortality. The HR for mortality in the lowest quartile of protein intake per body weight compared with the highest quartile was 2.26 (95% CI: 1.34–3.82, p = 0.002) after adjustment for covariates. Subgroup analyses revealed significant associations between low protein intake and mortality in patients aged over 75 years or under 65 years. After further adjustment of the total energy intake, a significant association between protein intake and mortality remained in patients aged ≥ 75 years, whereas the association was attenuated in those aged < 65 years. Our results suggest that adequate protein intake is necessary in older diabetic patients over 75 years, whereas with diabetes, whereas whole optimal total energy intake is required in younger patients with type 2 diabetes.

Incidence of cancer and mortality among heavy alcoholics

BACKGROUND AND AIMS

Cancer risk is increased in alcoholics. Heavy ethanol consumption is also associated with other potentially lethal conditions such as cirrhosis, diabetes, hypertension, dyslipidemia or malnutrition, that increase mortality. The aim of the present study is to analyze the impact on mortality of new cancer development in a cohort of heavy alcoholics.

METHODS

Three hundred and thirty nine heavy alcoholics (about 200 g ethanol/daily during more than 15 years), initially admitted for organic problems to our service (reference hospital) were prospectively followed up for a maximum period of 120 months (median = 26, interquartile range = 12-60 months), either as outpatients or during successive admissions. Clinical and laboratory evaluation including incidence of new cancer and drinking habits were recorded at each appointment, as well as mortality.

RESULTS

During the study period 57 patients developed cancer and 151 died. Only 75 did not relapse in alcohol drinking. Mortality was related to deranged liver function, relapse of alcohol drinking, and malnutrition, whereas age, the development of new cancer, or the presence of diabetes, dyslipidemia or hypertension did not influence on mortality, especially in cirrhotics and among those who did not quit drinking. Cancer was related to mortality only among non-cirrhotics, together with ethanol abstention and age.

CONCLUSIONS

Heavy drinking is associated with high mortality among alcoholic patients admitted to the hospital. If a patient is already cirrhotic or if there is drinking relapse, the development of a new cancer, the concurrent presence of diabetes, hypertension, dyslipidemia, or advanced age have no impact on survival. Mortality is only related to deranged liver function, relapse of alcohol drinking, and malnutrition.

Randomized trial results of alerting primary clinicians to severe weight loss among older adults in the Low Indexes of Metabolism Intervention Trial part A

AIM

To test whether alerting clinicians to severe weight loss in older patients leads to higher dietitian visit rates, to higher body mass index (BMI) levels and, mainly, to lower annual death risk.

METHODS

The randomized controlled trial included patients aged ≥75 years, with BMI ≤23 kg/m² that decreased ≥2 kg/m² during the previous 2 years. All participants received usual care. Additionally, an email alert was sent only to clinicians of participants assigned to the email alert group. The follow-up period was 12 months.

RESULTS

Among 706 participants (mean age 83 ± 6 years; mean baseline BMI 20.5 kg/m² ), the BMI record was updated in 541 (77%) participants, and 123 participants died. Dietitian visits were reported for 22 patients (6%) in the email group (n = 362) and 14 patients (4%) in the control group (n = 344; OR 1.5, 95% CI 0.8-2.9; P = 0.24). Measured BMI were raised by a mean of 0.69 (95% CI 0.43-0.95) kg/m² versus 0.79 (95% CI 0.48-1.1) kg/m² (P = 0.63). A total of 77 patients (21%) died in the intervention group versus 47 (14%) in the control group (P = 0.008; number needed to harm = 13; 95% CI 7-43).

CONCLUSIONS

In this trial, alerting clinical staff to severe weight loss in patients aged ≥75 years was not associated with higher visit rates to a dietitian or change in BMI, but was associated with a significantly higher death rate than usual clinical care. Geriatr Gerontol Int 2020; 20: 329-335.

Phenotyping individuals with newly-diagnosed type 2 diabetes at risk for all-cause mortality: a single centre observational, prospective study

BACKGROUND

Type 2 diabetes (T2D) shows a high mortality rate, dependent on disease duration, comorbidities and glucose control over time. Data on patients with short disease duration are scanty.

METHODS

We prospectively followed a cohort of newly-diagnosed T2D patients referring to a single diabetes centre, treated according to the international guidelines and checked every 6-12 months. All-cause mortality and major cardiovascular (CV) events were registered.

RESULTS

289 patients out of 3019 consecutive first attendances matched inclusion criteria and were included in the observation. Mean follow-up was 51.2 months. At 31 December 2018, 253 patients were alive and 36 deceased. At baseline, deceased individuals were older, with lower eGFR and lower uric acid, higher prevalence of atrial fibrillation. During the follow-up, 18 non-fatal CV events were adjudicated; patients with incident CV disease (CVD) differed at baseline for sex, previous history of CVD and retinopathy, higher use of secretagogues and lower use of metformin. At multivariate analysis, age and previous CVD were the only independent determinants of all-cause mortality and incident CVD, respectively. In deceased individuals, eGFR slope was markedly unstable and ΔeGFR at the end of the follow-up was higher (p < 0.001), and predicted mortality.

CONCLUSION

Newly-diagnosed T2D patients followed according to the best clinical practice show a mortality rate similar to that reported in more complicated patients with longer disease duration; none of the clinical and biochemical variables commonly measured at baseline can predict mortality or incident CVD; early metformin use seems to be associated with no risk of prevalent or incident retinopathy.