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Gelaw NB, Muche AA, Alem AZ, Gebi NB, Chekol YM, Tesfie TK, Tebeje TM. Development and validation of risk prediction model for diabetic neuropathy among diabetes mellitus patients at selected referral hospitals, in Amhara regional state Northwest Ethiopia, 2005-2021. PLoS One 2023; 18:e0276472. [PMID: 37643198 PMCID: PMC10465000 DOI: 10.1371/journal.pone.0276472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/23/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Diabetic neuropathy is the most common complication in both Type-1 and Type-2 DM patients with more than one half of all patients developing nerve dysfunction in their lifetime. Although, risk prediction model was developed for diabetic neuropathy in developed countries, It is not applicable in clinical practice, due to poor data, methodological problems, inappropriately analyzed and reported. To date, no risk prediction model developed for diabetic neuropathy among DM in Ethiopia, Therefore, this study aimed prediction the risk of diabetic neuropathy among DM patients, used for guiding in clinical decision making for clinicians. OBJECTIVE Development and validation of risk prediction model for diabetic neuropathy among diabetes mellitus patients at selected referral hospitals, in Amhara regional state Northwest Ethiopia, 2005-2021. METHODS A retrospective follow up study was conducted with a total of 808 DM patients were enrolled from January 1,2005 to December 30,2021 at two selected referral hospitals in Amhara regional state. Multi-stage sampling techniques were used and the data was collected by checklist from medical records by Kobo collect and exported to STATA version-17 for analysis. Lasso method were used to select predictors and entered to multivariable logistic regression with P-value<0.05 was used for nomogram development. Model performance was assessed by AUC and calibration plot. Internal validation was done through bootstrapping method and decision curve analysis was performed to evaluate net benefit of model. RESULTS The incidence proportion of diabetic neuropathy among DM patients was 21.29% (95% CI; 18.59, 24.25). In multivariable logistic regression glycemic control, other comorbidities, physical activity, hypertension, alcohol drinking, type of treatment, white blood cells and red blood cells count were statistically significant. Nomogram was developed, has discriminating power AUC; 73.2% (95% CI; 69.0%, 77.3%) and calibration test (P-value = 0.45). It was internally validated by bootstrapping method with discrimination performance 71.7 (95% CI; 67.2%, 75.9%). It had less optimism coefficient (0.015). To make nomogram accessible, mobile based tool were developed. In machine learning, classification and regression tree has discriminating performance of 70.2% (95% CI; 65.8%, 74.6%). The model had high net benefit at different threshold probabilities in both nomogram and classification and regression tree. CONCLUSION The developed nomogram and decision tree, has good level of accuracy and well calibration, easily individualized prediction of diabetic neuropathy. Both models had added net benefit in clinical practice and to be clinically applicable mobile based tool were developed.
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Affiliation(s)
- Negalgn Byadgie Gelaw
- Department of Public Health, Mizan Aman College of Health Sciences, Mizan-Aman, Ethiopia
| | - Achenef Asmamaw Muche
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Adugnaw Zeleke Alem
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nebiyu Bekele Gebi
- Department of Internal Medicine, School of Medicine, University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia
| | - Yazachew Moges Chekol
- Department of Health Information Technology, Mizan Aman College of Health Sciences, Mizan-Aman, Ethiopia
| | - Tigabu Kidie Tesfie
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Tsion Mulat Tebeje
- Unit of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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Gad H, Elgassim E, Mohammed I, Yaser Alhaddad A, Ahmed Hussein Zaky Aly H, Cabibihan JJ, Al-Ali A, Kumar Sadasivuni K, Petropoulos IN, Ponirakis G, Abuhelaiqa W, Jayyousi A, AlMohanadi D, Baagar K, Malik RA. Cardiovascular autonomic neuropathy is associated with increased glycemic variability driven by hyperglycemia rather than hypoglycemia in patients with diabetes. Diabetes Res Clin Pract 2023; 200:110670. [PMID: 37169307 DOI: 10.1016/j.diabres.2023.110670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023]
Abstract
AIM Cardiac autonomic neuropathy (CAN) has been suggested to be associated with hypoglycemia and impaired hypoglycemia unawareness. We have assessed the relationship between CAN and extensive measures of glucose variability (GV) in patients with type 1 and type 2 diabetes. METHODS Participants with diabetes underwent continuous glucose monitoring (CGM) to obtain measures of GV and the extent of hyperglycemia and hypoglycemia and cardiovascular autonomic reflex testing. RESULTS Of the 40 participants (20 T1DM and 20 T2DM) (aged 40.70±13.73 years, diabetes duration 14.43±7.35 years, HbA1c 8.85±1.70%), 23 (57.5%) had CAN. Despite a lower coefficient of variation (CV) (31.26±11.87 vs. 40.33±11.03, P=0.018), they had a higher CONGA (8.42±2.58 vs. 6.68±1.88, P=0.024) with a lower median LBGI (1.60 (range: 0.20-3.50) vs. 4.90 (range: 3.20-7.40), P=0.010) and percentage median time spent in hypoglycemia (4 (range:4-13) vs. 1 (range:0-5), P=0.008), compared to those without CAN. The percentage GRADEEuglycemia (3.30±2.78 vs. 5.69±3.09, P=0.017) and GRADEHypoglycemia (0.3 (range: 0 - 3.80) vs. 1.8 (range: 0.9-6.5), P=0.036) were significantly lower, while the percentage median GRADEHyperglycemia (95.45 (range:93-98) vs. 91.6 (82.8-95.1), P=0.013) was significantly higher in participants with CAN compared to those without CAN. CONCLUSION CAN was associated with increased glycemic variability with less time in euglycemia attributed to a greater time in hyperglycemia but not hypoglycemia.
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Affiliation(s)
- Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Einas Elgassim
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Mohammed
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Internal Medicine, Albany Medical Center Hospital, Albany, New York, USA
| | - Ahmad Yaser Alhaddad
- Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
| | | | - John-John Cabibihan
- Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
| | - Abdulaziz Al-Ali
- KINDI Center for computing research, Qatar University, Doha, Qatar
| | | | | | | | | | - Amin Jayyousi
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Dabia AlMohanadi
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Khaled Baagar
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK.
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de Azevedo Vieira ARS, Porto-Dantas LB, do Prado Romani FA, Carvalho PS, Pop-Busui R, Pedrosa HC. Autonomic neuropathic symptoms in patients with diabetes: practical tools for screening in daily routine. Diabetol Metab Syndr 2023; 15:83. [PMID: 37101234 PMCID: PMC10130803 DOI: 10.1186/s13098-023-01036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Diabetic autonomic neuropathy (DAN) is a frequent complication in people with diabetes whose screening is often neglected. This study aimed to evaluate DAN through practical tools in people with diabetes in a referral center for diabetes treatment. METHODS DAN symptoms and severity were assessed using the Survey of Autonomic Symptoms (SAS) via digital application (app) in patients attended from June 1, 2021, to November 12, 2021. SAS scoring for DAN was performed using established validated cutoffs. The adhesive with cobalt salt color indicator (Neuropad™) was used as a measure of sudomotor dysfunction. Demographical and clinical data were also collected. RESULTS Data from 109 participants, 66.9% T2DM, 73.4% female, with a median age of 54.00 (± 20.00) years, were analyzed. Symptomatic DAN was present in 69.7% of participants and was associated with older age (p = 0.002), higher HbA1c (p = 0.043), higher abdominal circumference (p = 0.019), higher BMI (p = 0.013), more likely to have metabolic syndrome (MS) with a 10-fold increased risk, and more frequent association with diabetic peripheral neuropathy (p = 0.005). Sudomotor dysfunction was found in 65 participants with positive Neuropad™ detected in 63.1% of them. CONCLUSION The use of SAS through an app proved to be a practical and easy-to-use instrument to document symptoms of DAN in busy clinical practice. The high frequency of symptoms draws attention to the importance of screening this underdiagnosed diabetes complication. The risk factors and comorbidities associated with symptomatic DAN highlight the patients' phenotypes linked to MS that should be targeted for DAN evaluations in larger samples in the community.
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Affiliation(s)
- Ana Raquel Souza de Azevedo Vieira
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Lara Benigno Porto-Dantas
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil.
| | - Flaviene Alves do Prado Romani
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Patrícia Souza Carvalho
- Unit of Endocrinology of the Regional Hospital of Taguatinga and Research Center of the Foundation for Education and Research in Health Sciences, Secretariat of Health of the Federal District, Brasilia, Brazil
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hermelinda Cordeiro Pedrosa
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Cardiac Autonomic Neuropathy in Type 1 and 2 Diabetes: Epidemiology, Pathophysiology, and Management. Clin Ther 2022; 44:1394-1416. [DOI: 10.1016/j.clinthera.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 07/23/2022] [Accepted: 09/06/2022] [Indexed: 11/21/2022]
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Menduni M, D'Amato C, Leoni M, Izzo V, Staltari M, Greco C, Abbatepassero A, Seminara G, D'Ippolito I, Lauro D, Spallone V. Clinical scoring systems for the risk of cardiovascular autonomic neuropathy in type 1 and type 2 diabetes: a simple tool. J Peripher Nerv Syst 2022; 27:259-270. [PMID: 36029134 DOI: 10.1111/jns.12510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/01/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS This study was aimed at developing a clinical risk score for cardiovascular autonomic neuropathy (CAN) for type 1 and type 2 diabetes. METHODS In a retrospective cross-sectional one-centre study in an unselected population, 115 participants with type 1 diabetes (age 41.1±12.2 years), and 161 with type 2 diabetes (age 63.1±8.9 years), well-characterised for clinical variables, underwent standard cardiovascular reflex tests (CARTs). Strength of associations of confirmed CAN (based on 2 abnormal CARTs) with clinical variables was used to build a CAN risk score. RESULTS CAN risk score was based on resting heart rate, HbA1c, retinopathy, nephropathy, cardiovascular disease in both type 1 and type 2 diabetes, and on HDL cholesterol, systolic blood pressure, and smoking in type 1 diabetes or insulin treatment and physical activity in type 2 diabetes (range 0-10). In type 1 diabetes, CAN risk score showed an area under the ROC curve (AUC) of 0.890±0.034, and at cut-off of 4 sensitivity of 88%, specificity of 74.4%, and negative predictive value (NPV) of 95.7% for confirmed CAN. In type 2 diabetes, CAN risk score showed an AUC of 0.830±0.051 and at the cut-off of 4 sensitivity and specificity of 78.6% and 73.5%, respectively, and NPV of 97.3% for confirmed CAN. INTERPRETATION These newly developed CAN risk scores are accessible in clinical practice and, if confirmed in a validation study, they might identify asymptomatic individuals with diabetes at greater risk of CAN to be referred to CARTs, thus limiting the burden of a universal screening. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marika Menduni
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia D'Amato
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Martina Leoni
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Mariateresa Staltari
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Carla Greco
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Abbatepassero
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Seminara
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Ilenia D'Ippolito
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
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Gateva A, Kamenov Z. Cardiac Autonomic Neuropathy in Patients with Newly Diagnosed Carbohydrate Disturbances. Horm Metab Res 2022; 54:308-315. [PMID: 35325930 DOI: 10.1055/a-1775-8251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cardiac autonomic neuropathy (CAN) is a serious complication of diabetes mellitus that can predispose patients to higher risk for cardiovascular death. The aim of the present study was to evaluate the presence of cardiac autonomic neuropathy and sudomotor dysfunction in patients with newly diagnosed carbohydrate disturbances (prediabetes or diabetes) and to assess their relationship to metabolic disturbances and cardiovascular risk. In the present study, we included 160 patients -78 with obesity without carbohydrate disturbances, 52 with prediabetes, and 30 with newly diagnosed diabetes. CAN was diagnosed using cardiovascular reflex tests and sudomotor function was evaluated by SUDOSCAN. Cardiovascular risk was calculated using SCORE and FRMINGHAM risk scores. The prevalence of cardiac autonomic neuropathy was significantly higher in patients with newly diagnosed diabetes. Independently of their glycemic status, the patients who had blood glucose on the 60th-minute of OGTT>8.5 mmol/l had significantly higher prevalence of cardiac autonomic neuropathy (30.2% vs 15.6%, р=0.044). Patients with high cardiovascular risk according to FRAMINGHAM and SCORE had worse heart rate variability scores. Autonomic neuropathy risk assessed by SUDOSCAN was a good predictor for the presence of CAN. In conclusion, CAN has a higher prevalence on patients with newly diagnosed diabetes compared to prediabetic and normoglycemic subjects, while the patients with blood glucose>8.5 mmol/l on the 60th-minute of OGTT have higher prevalence of CAN independently of their glycemic status. SUDOSCAN testing can be used to assess the risk of CAN and to select patients that should undergo further testing.
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Affiliation(s)
- Antoaneta Gateva
- Department of Internal Medicine, Medical University, Sofia, Bulgaria
| | - Zdravko Kamenov
- Department of Internal Medicine, Medical University, Sofia, Bulgaria
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Bönhof GJ, Herder C, Ziegler D. Diagnostic Tools, Biomarkers, and Treatments in Diabetic polyneuropathy and Cardiovascular Autonomic Neuropathy. Curr Diabetes Rev 2022; 18:e120421192781. [PMID: 33845748 DOI: 10.2174/1573399817666210412123740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Abstract
The various manifestations of diabetic neuropathy, including distal symmetric sensorimotor polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN), are among the most prevalent chronic complications of diabetes. Major clinical complications of diabetic neuropathies, such as neuropathic pain, chronic foot ulcers, and orthostatic hypotension, are associated with considerable morbidity, increased mortality, and diminished quality of life. Despite the substantial individual and socioeconomic burden, the strategies to diagnose and treat diabetic neuropathies remain insufficient. This review provides an overview of the current clinical aspects and recent advances in exploring local and systemic biomarkers of both DSPN and CAN assessed in human studies (such as biomarkers of inflammation and oxidative stress) for better understanding of the underlying pathophysiology and for improving early detection. Current therapeutic options for DSPN are (I) causal treatment, including lifestyle modification, optimal glycemic control, and multifactorial risk intervention, (II) pharmacotherapy derived from pathogenetic concepts, and (III) analgesic treatment against neuropathic pain. Recent advances in each category are discussed, including non-pharmacological approaches, such as electrical stimulation. Finally, the current therapeutic options for cardiovascular autonomic complications are provided. These insights should contribute to a broader understanding of the various manifestations of diabetic neuropathies from both the research and clinical perspectives.
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Affiliation(s)
- Gidon J Bönhof
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Christian Herder
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
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Lin YK, Gao B, Liu L, Ang L, Mizokami-Stout K, Pop-Busui R, Zhang L. The Prevalence of Diabetic Microvascular Complications in China and the USA. Curr Diab Rep 2021; 21:16. [PMID: 33835284 DOI: 10.1007/s11892-021-01387-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Diabetes can lead to development of devastating microvascular complications, such as nephropathy, retinopathy, and peripheral sensory and autonomic neuropathy. While China and the USA both face the threat of this major public health challenge, the literature is limited in describing similarities and differences in the prevalence, and risk factors for the development, of diabetic microvascular complications between these two countries. RECENT FINDINGS The current review discusses the following: (1) the most recent evidence on prevalence of diabetic microvascular complications in China and the USA (including downtrends of diabetes retinopathy and neuropathy in the USA); (2) differences in patient risk factors of these complications; (3) challenges and current knowledge gaps (such as lacking national epidemiological data of diabetic complications in China); and (4) potential future clinical and research opportunities (including needs in diabetes evaluation and management in remote areas and standardization of methods in evaluating diabetic complications across countries). Diabetic microvascular complications remain to be health threats in both China and the USA. Further investigations are needed for comprehensive understanding and effect prevention and management of these complications.
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Affiliation(s)
- Yu Kuei Lin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Brehm Tower 5119, 1000 Wall Street, Ann Arbor, MI, USA.
| | - Bixia Gao
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Lili Liu
- Department of Medicine, Peking University First Hospital, Beijing, China
| | - Lynn Ang
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Rodica Pop-Busui
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
- Key Laboratory of Renal Disease, National Health Commission of the People's Republic of China, Beijing, China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.
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Eleftheriadou A, Williams S, Nevitt S, Brown E, Roylance R, Wilding JPH, Cuthbertson DJ, Alam U. The prevalence of cardiac autonomic neuropathy in prediabetes: a systematic review. Diabetologia 2021; 64:288-303. [PMID: 33164108 PMCID: PMC7801295 DOI: 10.1007/s00125-020-05316-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS Cardiac autonomic neuropathy (CAN) is independently associated with silent myocardial ischaemia, major cardiovascular events, myocardial dysfunction and cardiovascular mortality. Several studies have highlighted the increased prevalence of CAN in prediabetes (impaired glucose tolerance and/or impaired fasting glucose). Considering the exponential rise of prediabetes, we aimed to determine the prevalence of CAN through a systematic literature review. METHODS This systematic review was registered with PROSPERO (CRD42019125447). An electronic literature search was performed using MEDLINE, EMBASE, PubMed, Web of Science, Scopus and Cochrane databases. Published full text, English language articles that provide CAN prevalence data of studies in individuals with prediabetes and aged over 18 years were included. Prevalence data for normal glucose tolerance and diabetes were also extracted from the selected articles, if present. All articles were screened by two independent reviewers using a priori criteria. Methodological quality and risk of bias were evaluated using a critical appraisal tool. RESULTS Database searches found 4500 articles; subsequently, 199 full text articles were screened, 11 of which fulfilled the inclusion criteria (4431 total participants, 1730 people with prediabetes, 1999 people with normal glucose tolerance [NGT] and 702 people with predominantly type 2 diabetes). Six of the selected studies reported definite CAN prevalence data (9-39%). Only a single large population-based study by Ziegler et al (KORA S4 study, 1332 participants) determined definite CAN based on two or more positive autonomic function tests (AFTs), with a mean prevalence of 9% in all prediabetes groups (isolated impaired glucose tolerance 5.9%; isolated impaired fasting glucose 8.1%; impaired fasting glucose plus impaired glucose tolerance 11.4%), which was higher than NGT (4.5%). This study is most likely to provide a reliable population-specific estimate of CAN in prediabetes. There was a higher than expected prevalence of CAN in prediabetes (9-38%) when compared with normal glucose tolerance (0-18%) within the same studies (n = 8). There was a wide prevalence of possible CAN based on one positive AFT (n = 5). There was heterogeneity between the studies with variations in the definition of CAN, methodology and characteristics of the populations, which likely contributed to the diversity of prevalence estimates. The overall risk of bias was low. CONCLUSIONS/INTERPRETATION There is a higher than expected prevalence of CAN in prediabetes. Early detection of CAN in prediabetes through population screening needs careful consideration in view of the excess morbidity and mortality risk associated with this condition. Graphical abstract.
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Affiliation(s)
- Aikaterini Eleftheriadou
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Scott Williams
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Sarah Nevitt
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Emily Brown
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Rebecca Roylance
- Edge Hill University Library, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - John P H Wilding
- Obesity and Endocrinology Research, Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Daniel J Cuthbertson
- Obesity and Endocrinology Research, Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Uazman Alam
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK.
- Pain Research Institute and Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
- Department of Diabetes and Endocrinology, Liverpool University Hospital NHS Trust, Liverpool, UK.
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Williams SM, Eleftheriadou A, Alam U, Cuthbertson DJ, Wilding JPH. Cardiac Autonomic Neuropathy in Obesity, the Metabolic Syndrome and Prediabetes: A Narrative Review. Diabetes Ther 2019; 10:1995-2021. [PMID: 31552598 PMCID: PMC6848658 DOI: 10.1007/s13300-019-00693-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 12/19/2022] Open
Abstract
Cardiac autonomic neuropathy (CAN) is a major complication of type 1 and type 2 diabetes mellitus (T1DM and T2DM). The increased morbidity, cardiovascular and all-cause mortality associated with CAN is established from numerous epidemiological studies. However, CAN is increasingly recognised in people with prediabetes (pre-DM) and the metabolic syndrome (MetS) with a reported prevalence up to 11% and 24% respectively. CAN is associated with components of MetS including hypertension and obesity, predating hyperglycaemia. The aetiology of CAN is multifactorial and there is a reciprocal relationship with insulin resistance and MetS. Obstructive sleep apnoea (OSA) is also associated with CAN possibly through MetS and an independent mechanism. An estimated global prevalence of the impaired glucose tolerance (IGT) form of pre-DM of 587 million people by 2045 means CAN will become a major clinical problem. CAN is independently associated with silent myocardial ischaemia, major cardiovascular events, myocardial dysfunction and cardiovascular mortality. Screening for CAN in pre-DM using risk scores with analysis of heart rate variability (HRV) or Sudoscan is important to allow earlier treatment at a reversible stage. The link between obesity and CAN highlights the therapeutic potential of lifestyle interventions including diet and physical activity to reverse MetS and prevent CAN. Weight loss achieved using these dietary and exercise lifestyle interventions improves the sympathetic and parasympathetic HRV indices of cardiac autonomic function. Further research is needed to identify high-risk populations of people with pre-DM or obesity that might benefit from targeted pharmacotherapy including metformin, sodium/glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) analogues. Bariatric surgery also improves HRV through weight loss which might also prevent CAN in severe obesity. This article reviews the literature on CAN in obesity, pre-DM and MetS, to help determine a rationale for screening, early intervention treatment and formulate future research questions in this highly prevalent condition.
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Affiliation(s)
| | | | - Uazman Alam
- Diabetes and Neuropathy Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
- Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
| | - Daniel J Cuthbertson
- Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - John P H Wilding
- Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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Spallone V. Update on the Impact, Diagnosis and Management of Cardiovascular Autonomic Neuropathy in Diabetes: What Is Defined, What Is New, and What Is Unmet. Diabetes Metab J 2019; 43:3-30. [PMID: 30793549 PMCID: PMC6387879 DOI: 10.4093/dmj.2018.0259] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/01/2019] [Indexed: 12/15/2022] Open
Abstract
The burden of diabetic cardiovascular autonomic neuropathy (CAN) is expected to increase due to the diabetes epidemic and its early and widespread appearance. CAN has a definite prognostic role for mortality and cardiovascular morbidity. Putative mechanisms for this are tachycardia, QT interval prolongation, orthostatic hypotension, reverse dipping, and impaired heart rate variability, while emerging mechanisms like inflammation support the pervasiveness of autonomic dysfunction. Efforts to overcome CAN under-diagnosis are on the table: by promoting screening for symptoms and signs; by simplifying cardiovascular reflex tests; and by selecting the candidates for screening. CAN assessment allows for treatment of its manifestations, cardiovascular risk stratification, and tailoring therapeutic targets. Risk factors for CAN are mainly glycaemic control in type 1 diabetes mellitus (T1DM) and, in addition, hypertension, dyslipidaemia, and obesity in type 2 diabetes mellitus (T2DM), while preliminary data regard glycaemic variability, vitamin B12 and D changes, oxidative stress, inflammation, and genetic biomarkers. Glycaemic control prevents CAN in T1DM, whereas multifactorial intervention might be effective in T2DM. Lifestyle intervention improves autonomic function mostly in pre-diabetes. While there is no conclusive evidence for a disease-modifying therapy, treatment of CAN manifestations is available. The modulation of autonomic function by SGLT2i represents a promising research field with possible clinical relevance.
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Affiliation(s)
- Vincenza Spallone
- Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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Jiang L, Wu G, Fang P, Xu Z, Tang Z. Development of clinical risk models for diabetic cardiovascular autonomic neuropathy in a Chinese population using logistic regression analysis. TRADITIONAL MEDICINE AND MODERN MEDICINE 2018. [DOI: 10.1142/s2575900018500076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: We developed clinical risk models for predicting diabetic cardiovascular autonomic neuropathy (DCAN) in Chinese diabetic patients. Methods: A Chinese cohort of 455 diabetic participants underwent a short heart rate variability (HRV) test which was recruited between 2011 and 2013. Clinical risk models were developed that included independent and significant risk factors by using multiple variable stepwise regressions. These clinical risk models were tested in another independent cohort of Chinese individuals. Results: The clinical risk models included age, fasting plasma glucose, 2-h plasma blood glucose, triglycerides, resting HRs, and duration of diabetes mellitus. The area under the receiver-operating characteristic (ROC) curve of the study group was 0.794. In the model with the continuous variables, the area under the ROC curve was 0.810. A cutoff score of 12.54 which produced the optimal sensitivity (68.20%) and specificity (76.80%) and identified the percentage (35.77%) of the population that required subsequent testing. Conclusions: The clinical risk models showed high sensitivity and specificity for the prediction of DCAN in Chinese diabetic patients.
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Affiliation(s)
- Lin Jiang
- Health Management Center, Huashan Hospital, Fudan University, Shanghai, P. R. China
| | - Genlong Wu
- Qingpu Hospital of Traditional Chinese Medicine, Shanghai, P. R. China
| | - Ping Fang
- Department of Endocrinology and Metabolism, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Zhensheng Xu
- Health Management Center, Huashan Hospital, Fudan University, Shanghai, P. R. China
| | - Zihui Tang
- Department of Endocrinology and Metabolism, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, P. R. China
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13
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Xue Y, Lv Y, Tang Z, Dong J. Analysis of a Screening System for Diabetic Cardiovascular Autonomic Neuropathy in China. Med Sci Monit 2017; 23:5354-5362. [PMID: 29125834 PMCID: PMC5694192 DOI: 10.12659/msm.905240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background The aim of this study was to create a screening system for diabetic cardiovascular autonomic neuropathy (DCAN) in diabetic patients. Material/Methods A Chinese cohort of 455 diabetic participants was recruited between 2011 and 2013. Short-term heart rate variability testing was used to evaluate cardiovascular autonomic function. A simple model was developed using multiple variable regression to include only significant risk factors that were simple and easily assessed. A DCAN score was determined based on the coefficients of the multiple variable model. This score was tested on the entire cohort of 455 diabetic patients and another independent, external cohort of 115 diabetic patients. Results The screening system consisted of age, body mass index, duration of diabetes mellitus, and resting heart rate, and these factors were significantly (P<0.05) associated with DCAN. Receiver operating characteristic (ROC) curve analysis was done. The areas under the ROC curve were 0.798, 0.756, and 0.729 for the total sample, validation cohort, and external set, respectively. A cutoff DCAN score of 12 out of 25 produced optimal results for sensitivity (80.36%), specificity (58.27%), and percentage of patients that needed subsequent testing (43.55%) for the validation set. Conclusions The study concludes that a simple and practical DCAN screening can be applied for early intervention to delay or prevent the disease in the Chinese population.
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Affiliation(s)
- Ying Xue
- Department of Integrative Medicine, Huashan Hospital, Fudan University, Shanghai, China (mainland).,Department of Endocrinology and Metabolism, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yubao Lv
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, China (mainland).,Institutes of Integrative Medicine, Fudan University, Shanghai, China (mainland)
| | - Zihui Tang
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, China (mainland).,Institutes of Integrative Medicine, Fudan University, Shanghai, China (mainland)
| | - Jingcheng Dong
- Department of Integrative Medicine, Huashan Hospital of Fudan University, Shanghai, China (mainland).,Institutes of Integrative Medicine, Fudan University, Shanghai, China (mainland)
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14
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Ziegler D, Voss A, Rathmann W, Strom A, Perz S, Roden M, Peters A, Meisinger C. Increased prevalence of cardiac autonomic dysfunction at different degrees of glucose intolerance in the general population: the KORA S4 survey. Diabetologia 2015; 58:1118-28. [PMID: 25724570 DOI: 10.1007/s00125-015-3534-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/30/2015] [Indexed: 02/08/2023]
Abstract
AIMS/HYPOTHESIS Cardiac autonomic nervous dysfunction (CAND) raises the risk of mortality, but the glycaemic threshold at which it develops is unclear. We aimed to determine the prevalence of, risk factors for and impact of CAND in glucose intolerance and diabetes. METHODS Among 1,332 eligible participants aged 55-74 years in the population-based cross-sectional KORA S4 study, 130 had known diabetes mellitus (k-DM), and the remaining 1,202 underwent an OGTT. Heart rate variability (HRV) and QT variability were computed from supine 5 min ECGs. RESULTS In all, 565 individuals had normal glucose tolerance (NGT), 336 had isolated impaired fasting glucose (i-IFG), 72 had isolated impaired glucose tolerance (i-IGT), 151 had combined IFG-IGT (IFG-IGT) and 78 had newly detected diabetes mellitus (n-DM). Adjusted normal HRV limits were defined in the NGT population (5th and 95th percentiles). Three HRV measures were more frequently abnormal in those with k-DM, n-DM, IFG-IGT and i-IFG than in those with NGT (p < 0.05). The rates of CAND (≥2 of 4 HRV indices abnormal) were: NGT, 4.5%; i-IFG, 8.1%; i-IGT, 5.9%; IFG-IGT, 11.4%; n-DM, 11.7%; and k-DM, 17.5% (p < 0.05 vs NGT, except for i-IGT). Reduced HRV was associated with cardiovascular risk factors used to construct a simple screening score for CAND. Mortality was higher in participants with reduced HRV (p < 0.05 vs normal HRV). CONCLUSIONS/INTERPRETATION In the general population aged 55-74 years, the prevalence of CAND is increased not only in individuals with diabetes, but also in those with IFG-IGT and, to a lesser degree, in those with i-IFG. It is associated with mortality and modifiable cardiovascular risk factors which may be used to screen for diminished HRV in clinical practice.
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Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center at Heinrich Heine University, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany,
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15
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Balcıoğlu AS, Müderrisoğlu H. Diabetes and cardiac autonomic neuropathy: Clinical manifestations, cardiovascular consequences, diagnosis and treatment. World J Diabetes 2015; 6:80-91. [PMID: 25685280 PMCID: PMC4317320 DOI: 10.4239/wjd.v6.i1.80] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/24/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
Cardiac autonomic neuropathy (CAN) is a frequent chronic complication of diabetes mellitus with potentially life-threatening outcomes. CAN is caused by the impairment of the autonomic nerve fibers regulating heart rate, cardiac output, myocardial contractility, cardiac electrophysiology and blood vessel constriction and dilatation. It causes a wide range of cardiac disorders, including resting tachycardia, arrhythmias, intraoperative cardiovascular instability, asymptomatic myocardial ischemia and infarction and increased rate of mortality after myocardial infarction. Etiological factors associated with autonomic neuropathy include insufficient glycemic control, a longer period since the onset of diabetes, increased age, female sex and greater body mass index. The most commonly used methods for the diagnosis of CAN are based upon the assessment of heart rate variability (the physiological variation in the time interval between heartbeats), as it is one of the first findings in both clinically asymptomatic and symptomatic patients. Clinical symptoms associated with CAN generally occur late in the disease process and include early fatigue and exhaustion during exercise, orthostatic hypotension, dizziness, presyncope and syncope. Treatment is based on early diagnosis, life style changes, optimization of glycemic control and management of cardiovascular risk factors. Medical therapies, including aldose reductase inhibitors, angiotensin-converting enzyme inhibitors, prostoglandin analogs and alpha-lipoic acid, have been found to be effective in randomized controlled trials. The following article includes the epidemiology, clinical findings and cardiovascular consequences, diagnosis, and approaches to prevention and treatment of CAN.
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Zhou J, Yan Y, Guo L, Ou H, Hai J, Zhang C, Wu Z, Tang L. Distinct outcomes in patients with different molecular subtypes of inflammatory breast cancer. Saudi Med J 2014; 35:1324-30. [PMID: 25399208 PMCID: PMC4362150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVES To determine the outcome of patients with luminal A, luminal B, human epidermal growth factor receptor-2 (HER-2) positive, and triple negative molecular subtypes of inflammatory breast cancer (IBC) using a retrospective analysis. METHODS This study was conducted between February 2004 and February 2010 in 3 different hospitals in China. The clinical outcomes, pathological features, and treatment strategies were analyzed in 67 cases of IBC without distant metastases. A chi-square test and one-way ANOVA were used to assess outcomes between different subtypes. Overall survival (OS) was analyzed using the Kaplan-Meier method and multivariate analysis was conducted using the Cox regression model. RESULTS The 2-year OS rate was 55% for the entire cohort. Median OS time among patients with luminal A was 35 months, luminal B was 30 months, HER-2 positive was 24 months, and triple negative subtypes was 20 months, and were significantly different from each other (p=0.001). Using multivariate analysis, luminal A had 76% (p=0.037), luminal B had 54% (p=0.048), and HER-2 positive subtypes had 47% (p=0.032) decreased risk of death compared with the triple negative subtype. Furthermore, elevated Ki-67 labeling was associated with increased risk of death, while the surgical treatment significantly improved patient survival. CONCLUSION Breast cancer subtypes are associated with distinct outcomes in IBC patients. Patients that presented with triple negative IBC had poorer outcome than luminal A, luminal B, and HER-2 subtypes. These results indicate that IBC is a heterogeneous disease similar to the conventional breast cancer.
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Affiliation(s)
- Jingyu Zhou
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.
| | - Yi Yan
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.
| | - Lei Guo
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.
| | | | - Jian Hai
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.
| | - Chaojie Zhang
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.
| | - Zhaoyun Wu
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.
| | - Lili Tang
- From the Departments of Breast Surgery (Zhou, Guo, Ou, Hai, Tang), and Urology (Yan), Xiangya Hospital, Central South University, and the Department of Breast and Thyroid Surgery (Zhang), Hunan Provincial People's Hospital, and the Department of Breast Surgery (Wu), Hunan Provincial Tumor Hospital, Changsha, Hunan, China.,Address correspondence and reprint request to: Prof. Lili Tang, Department of Breast Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China. Tel. +86 (371) 89753516. Fax. +86 (134) 67508520. E-mail: /
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