Association between diabetes complications and leukocyte counts in Iranian patients

Assessment of Erythrocyte Osmotic Fragility and Its Determinants, and Comparison of Hematological Indices Among Type 2 Diabetes Mellitus Patients on Follow-Up at Jimma Medical Center, Southwest Ethiopia

Background

Diabetes Mellitus (DM) is one of the most prevalent non-communicable diseases worldwide. Approximately 9.3% of the general population was estimated to have DM globally in 2019. Erythrocyte osmotic fragility (EOF) in hyperglycemic patients is expected to increase and determine the rate of erythrocyte hemolysis.

Purpose

This study aimed to assess erythrocyte osmotic fragility (EOF) and its determinants and to compare hematological indices among T2DM patients on follow-up at the Jimma Medical Center (JMC), Jimma, Southwest Ethiopia.

Methods

A facility-based cross-sectional study involving 124 participants (each 62) of T2DM patients and controls was conducted from October to November 2020 using a structured questionnaire. 5 mL of venous blood was drawn to assess OF, complete blood count, and blood glucose levels. EOF was investigated using a series hypotonic solution of NaCl. The supernatant of the centrifuged sample was transferred to cuvette test tubes, and the hemolysis stage was read on a spectrophotometer. The collected data were coded and entered into Epi-data Version 3.1. The analysis was performed using SPSS Version 23.

Results

Compared with non-diabetic controls, patients with T2DM had significantly increased EOF. FBG >126mg/dl (AOR=7.741, 95% CI: 1.562-38.360), PPBG >200 mg/dl (AOR=7.576, 95% CI: 1.519-37.791), RDW (AOR=4.558, 95% CI: 1.136-18.284) were significantly associated with abnormal EOF. A statistically significant increase in total white blood cells and absolute neutrophil counts (P < 0.001) were observed in T2DM patients. From RBC indices, red blood cell distribution width (RDW) and mean corpuscular volume (MCV) were significantly increased in T2DM patients (P < 0.001).

Conclusion

This study suggests that EOF was greater in patients with T2DM than in non-diabetic controls and was determined by FBG, PPBG, and RDW. The study also demonstrated that hematological index alterations were higher in T2DM subjects than in non-diabetic controls.

The correlation between peripheral complete blood count parameters and diabetic macular edema in proliferative diabetic retinopathy patients: a cross-sectional study

Background

Numerous studies have demonstrated that retinal chronic inflammation plays a critical role in the pathogenesis of diabetic macular edema (DME). However, studies about the association between peripheral complete blood count, an inexpensive and easily measurable laboratory index, and DME are limited.

Research design and methods

The current study was a hospital-based, cross-sectional study. The participants were inpatients with type 2 diabetes who underwent vitrectomy for PDR, and the contralateral eyes in these PDR patients meeting the criteria were included in the study. Central macular thickness (CMT) was measured automatically and the DME was characterized as CMT ≥ 300 μm.

Results

A total of 239 PDR participants were enrolled. The average age was 55.46 ± 10.08 years old, and the average CMT was 284.23 ± 122.09 μm. In the fully adjusted model, for CMT, the results revealed a significantly negative association between CMT and both white blood cell (WBC) count and neutrophil count (β = -11.95, 95% CI: -22.08, -1.82; p = 0.0218; β = -14.96, 95% CI: -28.02, -1.90; p = 0.0259, respectively); for DME, the results showed an inverse association between DME and WBC count, monocyte count, and eosinophil count (OR = 0.75, 95% CI: 0.59, 0.95; p = 0.0153; OR = 0.07, 95% CI: 0.00, 0.92; p = 0.0431; OR = 0.03, 95% CI: 0.00, 0.88; p = 0.0420, respectively).

Conclusions

In conclusion, our results suggest that WBC and its subtypes in circulation may play an important role in the pathogenesis of DME in PDR patients.

Associations of levels of peripheral blood leukocyte and subtypes with type 2 diabetes: A longitudinal study of Chinese government employees

OBJECTIVES

Available evidence suggests that type 2 diabetes (T2D) may be associated with inflammation and that leukocytes are a topical clinical, biological indicator of inflammation. This study investigates the associations between peripheral blood leukocyte and subtypes levels with T2D.

METHODS

A total of 5,475 individuals were included in the baseline examination from January 2018 to April 2020, with incidence data updated to April 30, 2021, and follow-up to 5,362 individuals. T2D was defined according to the Chinese guidelines for preventing and treating type 2 diabetes. Physiological and biochemical indicators, including leukocyte and subtypes, were obtained from the physical examination results of the tertiary care hospitals relied on at the cohort sites. Covariates such as demographic characteristics and lifestyle were collected by questionnaire. Binary logistic regression and Cox proportional hazard models were used to explore the correlations. Receiver Operating Characteristic (ROC) curves and time-dependent ROC curves were used to estimate the predictive diagnosis of T2D across the subtype of leukocytes.

RESULTS

The mean follow-up time was 12 months, and the cumulative incidence density of T2D was 4.0/1000 person-years. Cross-sectional results at baseline showed that the levels of peripheral blood leukocyte and its subtypes were higher in the T2D group than in the non-T2D group. Total leukocyte count and subtypes levels were grouped by quintile. After adjusting for age, sex, family history of diabetes, lifestyle score, and triglyceride levels, all were compared with the lowest quintile of each group. Logistic regression model results showed that the corrected OR for those with the highest quintile level of leukocyte was 2.01 (95% CI: 1.02-3.98). The longitudinal analysis showed that the adjusted HR was 8.43 (95%CI: 1.06-66.92) for those with the highest quintile level of leukocytes at baseline after controlling for the effects of the above covariates. For those with the highest quintile level of neutrophils at baseline, the adjusted HR was 5.05 (95%CI: 1.01-25.29). The leukocyte and subtypes had predictive values for T2D.

CONCLUSION

Patients with T2D have a higher level of peripheral blood leukocyte and subtypes than those without the disease. Elevated leukocyte and neutrophil counts may link to a higher risk of T2D.

Peripheral Cytopenia and Its Associated Factors in Type 2 Diabetes Mellitus Patients, Northwest Ethiopia

Background

Hematological abnormalities are linked with diabetes mellitus (DM) and play a major role in diabetes-related micro- and macro-vascular complications. Therefore, this study aimed to investigate the magnitude of peripheral cytopenia and associated factors in type 2 diabetes (T2DM) patients.

Methods

A cross-sectional study was conducted from March to May 2021 at the University of Gondar Comprehensive Specialized Hospital. A total of 357 T2DM participants were selected using a simple random sampling technique. A total of 3 mL of venous blood samples were collected using the vacutainer method for the complete blood count (CBC). A univariate and multivariate regression analysis were used to investigate the association between dependent and independent variables. P-value ˂0.05 was considered statistically significant.

Results

The magnitude of cytopenia, bicytopenia, and pancytopenia were 21% (95% CI: 17.1, 25.53), 1.1% (95% CI: 0.44, 2.85), and 0.56% (95% CI: 0.01, 1.12), respectively. Furthermore, the magnitudes of anemia, leucopenia, and thrombocytopenia were 8.7% (95% CI: 6.18, 12.06), 10.9% (95% CI: 8.09, 14.59), and 5.3% (95% CI: 3.43, 8.16), respectively. Being male (AOR: 3.23; 95% CI: 1.43, 7.56), lack of exercise (AOR: 2.70; 95% CI: 1.137, 6.43), and never married (AOR: 3.90; 95% CI: 1.248, 12.18) were all associated with anemia.

Conclusion

This study showed that T2DM causes disturbances in the hematological parameters and leads to a mild level of cytopenia. It is, therefore, suggested that hematological abnormalities, especially cytopenia, should be monitored and controlled on a regular basis in T2DM patients for better prognosis and quality of life.

Hematological abnormalities among adults with type 1 diabetes mellitus at the University of Gondar Comprehensive Specialized Hospital

Objective:

Changes in the blood cell function, metabolism, and the coagulation system were associated with diabetes mellitus. This study aimed to determine the magnitude and associated factors of hematological abnormalities in adults with type 1 diabetes mellitus.

Methods:

A total of 204 medical charts of adults with type 1 diabetes mellitus who registered for follow-up at the University of Gondar Comprehensive Specialized Hospital were reviewed from June to August 2021. Data were collected using a structured data extraction checklist. To identify factors associated with hematological abnormalities, both bivariate and multivariate logistic regression analyses were done. Statistical significance was defined as a p-value of <0.05.

Results:

The overall magnitude of leukocytosis and anemia in adults with type 1 diabetes mellitus was 76.0% (95% confidence interval: 70.07–81.89) and 30.90% (95% confidence interval: 24.49–37.28), respectively. Neutrophilia and lymphocytosis were the common white blood cell abnormalities detected in 53.43% (95% confidence interval: 46.53–60.33) and 43.63% (95% confidence interval: 36.76–50.49) of the patients, respectively. Besides, thrombocytosis and thrombocytopenia were observed in 5.4% (95% confidence interval: 2.27–8.52) and 10.3% (95% confidence interval: 6.09–14.5) of the patients, respectively. Only being male (adjusted odds ratio = 2.28 (95% confidence interval: 1.46–5.29)) and duration of diabetes mellitus (⩾3 years) (adjusted odds ratio = 8.41 (95% confidence interval: 2.49–28.29)) were significantly associated with anemia and leukocytosis, respectively.

Conclusion:

Hematological abnormalities, particularly anemia and leukocytosis, are common in patients with type 1 diabetes mellitus. Therefore, preventive and control strategies for hematological abnormalities are essential in patients with type 1 diabetes mellitus particularly for male and patients with a long duration on diabetes mellitus to reduce the burden and related complications.

Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis

Objectives

To study the clinical profile and risk factors of cerebral edema and acute kidney injury in children with diabetic ketoacidosis.

Design

Retrospective review of medical records.

Patients

Fifty consecutive patients (age <18 years) admitted to our pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 years.

Materials and methods

Retrospective analysis of medical records was done, and data including patients’ age, sex, presenting features, biochemical profile including blood glucose, osmolality, urea, creatinine, and venous blood gas, electrolytes were recorded at admission, at 12 and 24 hours. Treatment details including fluid administration, rate of fall of glucose, time to resolution of diabetic ketoacidosis were noted. Complications such as cerebral edema and acute kidney injury were recorded. Patients with and without cerebral edema and acute kidney injury were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the independent predictors for cerebral edema and acute kidney injury. Odds ratio and 95% confidence interval were calculated using SPSS version 22.

Measurements and main results

Between November 2015 and 2020, 48 patients were admitted for a total of 50 episodes of diabetic ketoacidosis. Two patients had recurrent diabetic ketoacidosis. Median age was 9.5 years (range 1–17). Thirty-one patients (62%) had new-onset type I diabetes mellitus. Twenty-two patients (44%) presented with severe diabetic ketoacidosis. Cerebral edema and acute kidney injury were seen in 11 (22%) and 15 (30%) patients, respectively. On multiple logistic regression analysis, higher blood urea level, lower serum bicarbonate level, and higher corrected sodium levels at admission were identified to be variables independently associated with risk of cerebral edema.

Conclusions

Higher corrected sodium, higher urea level, and lower serum bicarbonate levels at admission are predictive of cerebral edema in patients presenting with diabetic ketoacidosis. The severity of dehydration and acidosis in DKA appears to be a common factor responsible for the development of dysfunction of both brain and kidney.

How to cite this article

Raghunathan V, Jevalikar G, Dhaliwal M, Singh D, Sethi SK, Kaur P, et al. Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian J Crit Care Med 2021;25(12):1446–1451.

The prognostic value of peripheral total and differential leukocyte count in renal progression: A community-based study

Background

Systemic inflammation is related to chronic kidney disease (CKD) patients. Elevated peripheral leukocyte count may be a herald of increased systemic inflammation and subclinical disease. Inflammation plays an important role in renal progression. The pattern of total and differential leukocyte count in CKD is not well understood. Besides, the association between total and differential leukocyte count and renal progression is still uncertain.

Methods

We conducted a community-based cohort study with a follow-up period of two years to evaluate the total and differential leukocyte counts and renal progression association.

Results

In our study population from the community with a total number of 2128, we found 15.7% (335/2128) CKD patients with a mean estimated glomerular filtration rate (eGFR) around 96 ± 26 ml/min/1.73 m². The peripheral total leukocyte count and also differential leukocyte count were significantly negatively correlated with eGFR. A total of 56 patients (3%) experienced a rapid progression of the kidney with the definition of eGFR reduction changes of 30% or greater within two years. Univariate analysis indicated that rapid renal progression was significantly associated with male gender, co-morbidity of diabetes mellitus (DM), higher uric acid levels, higher peripheral neutrophil, monocyte, and eosinophil counts. However, only the peripheral neutrophil count was positively and independently associated with rapid renal progression after multivariate analysis. The ROC curve analysis found that the optimal cutoff value of peripheral neutrophil count for rapid progression was 2760/ mm³, with an area under the curve of 0.813.

Conclusion

Hyperinflammation with higher peripheral total and differential leukocyte count was noted in CKD patients. The peripheral neutrophil count was the only independent factor significantly associated with rapid renal progression. The optimal cutoff point of the peripheral neutrophil count with 2760/mm³ is useful for determining the high-risk population for rapid renal progression with a satisfying sensitivity and specificity.

Anti-Diabetic and Antioxidant Activities of Red Wine Concentrate Enriched with Polyphenol Compounds under Experimental Diabetes in Rats

We obtained red wine concentrate, which was enriched with natural polyphenolic compounds (PC concentrate). The main purpose was to study the hypoglycemic and antioxidant effects of the red wine concentrate, and its impact on key hematological parameters of rats with experimental diabetes mellitus. While administrating the red wine concentrate to rats with diabetes, partial recovering of glucose tolerance was promoted, as well as normalization of glycated hemoglobin level, an increase in the quantity of erythrocytes and hemoglobin concentration. PC concentrate had anti-radical effect, which was determined using 2,2-diphenyl-1-picrylhydrazylradical (DPPH) method and effectively inhibited oxidation of phosphatidylcholine liposomes, induced by 2,2′-azobis(2-amidinopropane) dihydrochloride (AAPH) as a free radical generator. It was also confirmed that PC concentrate had antioxidant properties in vivo. The contents of lipid peroxidation and protein oxidation products, the activity of catalase, and glutathione peroxidase (GPx) were increased in the plasma of rats with diabetes mellitus. At the same time, the activity of superoxide dismutase (SOD) was decreased. The concentrate of red wine had a corrective effect on investigated indicators and caused their normalization in plasma of diabetic animals.

Total Leukocyte Count Depicting the Degree of Inflammation in Acute Appendicitis

Introduction Acute appendicitis (AA) is the most common cause of acute abdomen in young adults. The diagnosis is usually made on various clinical findings. However, a missed case of acute appendicitis is a catastrophe as it later presents with life-threatening complications and results in medicolegal issues. Raised total leukocyte count (TLC) is a frequent finding in patients with acute appendicitis. As a convention, a normal leukocyte count usually rules out the differential diagnosis of acute appendicitis. Recent studies claimed that a substantial proportion of patients with normal TLC also had acute appendicitis and warranted a careful evaluation of such cases before sending them home. However, the reported frequency of acute appendicitis among TLC normal patients varied greatly among studies which necessitated the present study. Aim Our aim was to determine the frequency of acute appendicitis in patients of normal TLC. Materials and methods This descriptive cross-sectional study was conducted at the Department of Surgery, KRL Hospital Islamabad. This study was carried out from 1 July 2019 to 31 December 2019. This study involved 238 patients of both genders aged between 12 and 70 years suspected of acute appendicitis on physical and ultrasound findings but with a normal TLC (4,500-11,000 WBCs/µL). The outcome variable was the frequency of acute appendicitis among such patients which was diagnosed upon surgery (inflamed appendix with free fluid) and histopathology of excised tissue (mucosal inflammation, neutrophil infiltrates, wall necrosis). Frequency of acute appendicitis was compared across various age and gender groups. Written informed consent was obtained from every patient. Results The mean age of the patients was 27.4±15.5 years. Majority (n = 167, 70.2%) of the patients were aged ≤25 years, followed by 40 (16.8%) patients aged ≥46 years and 31 (13.0%) patients aged between 26 and 45 years. There were 135 (56.7%) male and 103 (43.3%) female patients with a male to female ratio of 1.3:1. All of the patients (100.0%) had pain in the right iliac fossa (RIF) while rebound tenderness, anorexia, nausea/vomiting, fever and dysuria were noted in 83.6%, 79.0%, 73.9%, 63.9% and 15.1% patients, respectively. The diagnosis of acute appendicitis was made in 198 (83.2%) patients with normal TLC and suspicion of acute appendicitis on physical findings and ultrasound. When stratified, there was no statistically significant difference in the frequency of acute appendicitis across various age (p-value = 0.988) and gender (p-value = 0.913) groups. Conclusion In the present study, contrary to the routine impression that normal TLC rules out the differential diagnosis of acute appendicitis, a substantial proportion of patients with clinical and ultrasound suspicion of acute appendicitis but normal TLC had acute appendicitis which is worrisome as a missed case may later present with complications. The present study thus warrants cautious evaluation of clinically suspected cases with normal TLC count to avoid a missed appendicitis and improve the outcome in future surgical practice.

Clinical and therapeutic features of acute cholecystitis in diabetic patients

The present study aimed to compare the clinical, paraclinical, intraoperative findings, and postoperative complications in acute cholecystitis in diabetic patients vs. non-diabetic patients. A 2-year retrospective study was performed on the patients who underwent emergency cholecystectomy for acute cholecystitis between 2017 and 2019 at the 4th Department of Surgery, Emergency University Hospital Bucharest. The diabetic subgroup numbered 46 eligible patients and the non-diabetic one 287 patients. Demographics, the severity of the clinical forms, biological variables (including white cell count, urea, creatinine, coagulation and liver function tests) comorbidity status, surgical approach, postoperative complications, and hospital stay were analyzed. Statistical analyses were performed to assess comparative results between the aforementioned data (SPSS V 13.0). The CCI and ASA risk classes were increased in the diabetic group, with 34.78% of patients having 3 or more associated comorbidities. No statistically significant associations were demonstrated between diabetes and the severity of the cholecystitis and risk for conversion. Postoperatively both minor complications such as surgical site infections and major cardiovascular events were more common in the diabetic subgroup (P=0.0254), well associated with the preoperative status and baseline cardiovascular comorbidities. Laparoscopic cholecystectomy is a safe procedure for diabetic patients, which can provide the best outcomes, by decreasing the risks of surgical wounds. Attentive perioperative care and good glycemic control must be provided to minimize the risk of complications.

Association Between Neutrophil-Lymphocyte Ratio and Gestational Diabetes-A Systematic Review and Meta-Analysis

A growing body of evidence shows that the neutrophil-lymphocyte ratio (NLR) is a surrogate index of systemic inflammation in several chronic diseases. Conflicting associations between NLR and gestational diabetes mellitus (GDM) have been reported in individual studies. This meta-analysis sought to investigate the association between NLR and GDM. The PubMed, EMBASE, and Google Scholar databases were searched to identify relevant articles. The pooled standardized mean difference with 95% CI was calculated using a random-effects model. Subgroup and meta-regression analysis were carried out to control for the effects of GDM diagnostic criteria, ethnicity, body mass index (BMI), and age. Eleven eligible articles were included, containing 1271 participants with GDM and 1504 controls. Pooled outcomes indicated a higher NLR in GDM pregnancies than in normoglycemic controls (SMD = 0.584; 95% CI, 0.339–0.830; P < .001), although extensive heterogeneity between studies was noted. Subgroup analysis revealed that the higher pooled estimate in GDM was not affected by diagnostic criteria, ethnicity, or BMI, although matching for BMI reduced heterogeneity between studies. This meta-analysis supports the higher NLR in GDM described by some individual studies.

Dysregulation of Leukocyte Trafficking in Type 2 Diabetes: Mechanisms and Potential Therapeutic Avenues

Type 2 Diabetes Mellitus (T2DM) is a chronic inflammatory disorder that is characterized by chronic hyperglycemia and impaired insulin signaling which in addition to be caused by common metabolic dysregulations, have also been associated to changes in various immune cell number, function and activation phenotype. Obesity plays a central role in the development of T2DM. The inflammation originating from obese adipose tissue develops systemically and contributes to insulin resistance, beta cell dysfunction and hyperglycemia. Hyperglycemia can also contribute to chronic, low-grade inflammation resulting in compromised immune function. In this review, we explore how the trafficking of innate and adaptive immune cells under inflammatory condition is dysregulated in T2DM. We particularly highlight the obesity-related accumulation of leukocytes in the adipose tissue leading to insulin resistance and beta-cell dysfunction and resulting in hyperglycemia and consequent changes of adhesion and migratory behavior of leukocytes in different vascular beds. Thus, here we discuss how potential therapeutic targeting of leukocyte trafficking could be an efficient way to control inflammation as well as diabetes and its vascular complications.

Hydroethanolic Extract from Bridelia atroviridis Müll. Arg. Bark Improves Haematological and Biochemical Parameters in Nicotinamide-/Streptozotocin-Induced Diabetic Rats

Bridelia atroviridis Müll. Arg. (B. atroviridis) is a plant used in Cameroonian traditional medicine to manage diabetes. The effects of hydroethanolic barks extract from B. atroviridis were evaluated on diabetes disorders including hematology, inflammatory, and oxidative stress parameters. The in vitro antioxidant capacity of the hydroethanolic bark extract (70 : 30) was evaluated. Nicotinamide-/streptozotocin-induced diabetic rats were daily treated with the B. atroviridis extract for fifteen days. Glycemia were evaluated every 5 days, insulin sensibility test was performed, and haematological, inflammatory, and oxidative stress parameters were analysed. Histomorphometry of the pancreas was realized. The extract was able to scavenge free radicals in vitro and decrease significantly the blood glucose levels. The treatment resulted in a significant alleviation of insulin resistance, anemia, leukocytopenia, and thrombocytopenia observed in untreated diabetic rats. The extract significantly decreased proinflammatory cytokines TNF-α, IL-1β, and IL-10. The rate of reduced glutathione was increased in the pancreas, whereas the catalase activity and nitrite concentration were decreased. Diabetic control showed a reduced size of Langerhans islet, whereas the size of islets was large in treated groups. The hydroethanolic extract of B. atroviridis was able to improve glycemia and alleviate haematological and inflammatory parameters disorders observed in diabetic conditions, probably due to its antidiabetic, anti-inflammatory, and antioxidant capacities.

Association Between Random Glucose Level and Leukocytes Count in Female Cancer Patients

Leukocytosis is common among patients suffering from cancer when leukocytes count exceeds 11,000 cells per mm³. This is a usual immune response toward infection and foreign elements. This leads to the release of inflammatory mediators at the targeted site. Studies have found leukocytes count increase in diabetes mellitus patients. Random glucose level indicates the patient is at risk of developing diabetes mellitus. In this study, the association between random glucose level and leukocytes count in female cancer patients is evaluated. About 210 cancer patients included in this study and the results have indicated a positive association between high glucose level and high leukocyte count. This indicates poor prognosis of the patients as high glucose levels increase tumor cell proliferation and high leukocytes count can induce inflammation leading to the progression of cancer and increase mortality rate.

Overall adjustment acupuncture for postmenopausal osteoporosis (PMOP): a study protocol for a randomized sham-controlled trial

BACKGROUND

Osteoporosis is becoming more prevalent in aging societies worldwide, and the economic burden attributable to osteoporotic fractures is substantial. The medications presently available to treat osteoporosis have side effects. Acupuncture is widely used for treating osteoporotic postmenopausal women because it is non-invasive and has fewer side effects, but the powerful clinical evidence for its efficacy remains insufficient. Our study intends to explore the effect of overall adjustment acupuncture (OA) in the treatment of postmenopausal osteoporosis (PMOP).

METHODS/DESIGN

This study is a randomized, sham-controlled, patient- and assessor-blinded trial and aims to evaluate the effect of OA in women with PMOP. We will recruit 104 women aged 45-70 years with a diagnosis of PMOP. Participants will be randomly allocated in a 1:1 ratio to the OA group and the sham acupuncture (SA) group. Both groups will receive real herbal medicine treatment as a basic treatment twice a day for 3 months, the OA group receives real acupuncture treatment and the SA group receives placebo acupuncture treatment (non-penetrating, sham skin-needle therapy, sham cupping). All patients will receive acupuncture treatment twice per week for 3 months. The primary outcome is bone mineral density (BMD) and the secondary outcomes include estradiol (E2), follicle-stimulating hormone (FSH), bone gla protein (BGP), bone alkaline phosphatase (BALP), total antioxidant capacity (TAC), advanced oxidation protein products (AOPP), PPARγ, β-catenin, FoxO3a levels, visual analog pain scale score (VAS), Traditional Chinese medicine (TCM) syndrome scores and quality of daily life score (QOL). Outcome measures will be collected at baseline, middle of the treatment (1.5 months), the end of treatment (3 months). The present protocol followed the SPIRIT guidelines and fulfills the SPIRIT Checklist.

CONCLUSION

This study will be conducted to compare the efficacy of OA versus SA. This trial should help to evaluate whether OA can effectively prevent and treat PMOP by improving the estrogen levels of postmenopausal women. The mechanism is to improve the imbalance of osteogenic differentiation and lipogenesis of bone-marrow cells under oxidative stress.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR1800017581. Registered on 5 August 2018. URL: http://www.chictr.org.cn.

Modulation of Hematological Indices of Normal and Alloxan-Induced Diabetic Rabbits by Aqueous Extract of Pleurotus tuberregium Sclerotia

OBJECTIVE

The ability of an aqueous extract of the sclerotia of Pleurotus tuberregium to modulate hematological parameters was investigated in normal and alloxan treated rabbits.

METHODS

The extract was subjected to atomic absorption spectrophotometric and flame ionization detector-coupled-gas chromatographic (GC-FID) analysis. Diabetes mellitus was induced by a 120 mg/kg body weight intravenous injection of alloxan. Metformin was orally administered at 50 mg/kg, while the extract was administered (both to normal and diabetic rabbits) at 100, 200 and 300 mg/kg.

RESULTS

Analysis of the extract showed that it had high contents of calcium, magnesium, manganese and potassium. Eleven known glycosides were detected, comprising mainly of amygdalin (37.7%), digoxin (14.4%), dhurrin (14.0%), linamarin (13.6%), prunasin (10.8%) and digitoxin (8.4%). Also detected were twelve known saponins, consisting mainly of sapogenin (40.3%) and neochlorogenin (21.8%); and twelve known lignans, consisting mainly of matairesinol (59.7%), secoisolariciresinol (20.9%) and lariciresinol (14.9%). Compared to the Diabetic control, the hematocrit, hemoglobin concentration, mean cell hemoglobin, mean cell hemoglobin concentration, mean corpuscular volume, red cell distribution width; and red cell, total white cell, lymphocytes, granulocytes and platelet counts of the treated groups were significantly (p<0.05) higher.

CONCLUSION

The above result showed that the extract had a positive effect on the hemopoietic system of the treated animals, at least at the doses at which it was administered in this study.

Stress Hormone and Oxidative Stress Biomarkers Link Obesity and Diabetes with Reduced Fertility Potential

Objective

Tilting the balance in favor of antioxidant agents could increase infertility problems in obese and diabetic individuals. The aim of this study was to evaluate oxidative stress status in semen of men with type 2 diabetes and obesity to investigate whether excessive amounts of oxidative stress, as a result of diabetes and obesity, influence infertility potential.

Materials and Methods

A case-control study was conducted in men (n=150) attending the Infertility Center of Royan Institute between December 2016 and February 2017. Participants were categorized into four groups; normal weight (BMI<25 kg/m²) and non-type-2 diabetic (control=40), obese and non- type-2 diabetic (obese=40), non-obese and type- 2 diabetic (Nob-DM=35), and obese and type-2 diabetic (Ob-DM=35). The semen analysis was performed according to the World Health Organization criteria. Oxidative stress, DNA fragmentation, sperm apoptosis, and total antioxidant capacity (TAC) were evaluated in semen samples of men. Serum glucose, HbA1c, cortisol, and testosterone levels were determined using the enzyme-linked immunosorbent assay (ELISA) method.

Results

Compared with the control group, sperm motility, progressive motility, and normal morphology were significantly decreased in the obese, Nob-DM, and Ob-DM groups (P<0.01). The obese, Nob-DM, and Ob-DM groups showed significantly lower levels of TAC and higher amounts of oxidative stress, early apoptotic sperm, and the percentage of DNA fragmentation as compared with the control group (P<0.05). Testosterone concentration was decreased in the obese, Nob-DM, and Ob-DM groups when compared with healthy individuals (P<0.05), whereas the cortisol level was significantly increased in the Nob-DM and Ob-DM groups in comparison to the obese and control group (P<0.01).

Conclusion

Increased amount of reactive oxygen species (ROS) levels and DNA fragmentation in men affected by either diabetes or obesity could be considered prognostic factors in sub-fertile patients, alerting physicians to an early screen of male patients to avoid the development of infertility in prone patients.

Immunophenotypic profile of leukocytes in hyperandrogenemic female rat an animal model of polycystic ovary syndrome

The immune etiology of polycystic ovary syndrome (PCOS) is an intriguing area. However, whether there is alteration in the leukocyte populations in different tissues remain ambiguous.

AIM

To characterize the leukocyte populations of hyperandrogenemic female (HAF) rat tissues.

METHODS

Female Sprague Dawley rats at 3 weeks of age were implanted subcutaneously with dihydrotestosterone (DHT) or placebo pellets. The rats were aged to 14-15 weeks and tissues were collected.

RESULTS

Peripheral blood (PB) and renal CD4⁺ (P < 0.03, P < 0.007), Th17 (P < 0.05, P < 0.002), and CD4⁺CD28^null (P < 0.04, P < 0.001) were significantly increased in HAF rats compared to placebo, respectively, in spite of their lower percentage in the spleen. Although, the percentage of Treg T lymphocytes were significantly higher in the PB (P < 0.001) of HAF rats, the splenic (P < 0.01) and renal Treg cells (P < 0.03) were found to be significantly lower. Remarkably, HAF rats had higher renal mast cells (P < 0.00009) despite lower splenic (P < 0.002). The number of PB, renal, and splenic CD8⁺ T cells and IgM⁺-B cells in HAF rats remained unchanged.

CONCLUSION

Results from this study 1) provide the first evidence of significant alteration of T lymphocyte subsets and different leukocyte populations profile in a rat model of polycystic ovary syndrome, 2) demonstrate alteration of the immunological niche of blood, spleen, and kidney tissues in Hyperandrogenemia state in female rats, 3) imply potential immune system dysregulation in HAF rats which may suggest a link between excess androgen, chronic inflammation, and immune-mediated diseases in polycystic ovary syndrome patients.

Correlation Between White Blood Cell Count and Insulin Resistance in Type 2 Diabetes

BACKGROUND

The role of chronic inflammation in insulin resistance states and the pathogenesis of metabolic syndrome, cardiovascular disease and diabetes have been reported earlier. White Blood Cell (WBC) count is an easy marker for estimation of systemic inflammation.

OBJECTIVE

This study is to clarify whether WBC count is associated with insulin resistance in type 2 diabetic patients.

METHODS

This cross sectional study was conducted in 283 patients with type 2 diabetes and in 283 healthy non diabetic subjects as control group. Data including: age, gender, blood pressure, height and weight, history of smoking were collected for each patient. Fasting blood sugar, HbA1C, insulin, lipid profiles, creatinine, Urine albumin to creatinine ratio, high sensitive C- reactive protein (HCRP) and WBC was measured for all patients. WBC count was measured in control group. Two groups were compared in WBC count. Insulin resistance was calculated with HOMA-IR formula. Association of WBC count with insulin resistance and metabolic parameters was assessed in diabetic patients.

RESULTS

WBC count was significantly associated with body mass index, hypertension, and triglyceride level. There was not significant association between WBC count and glycemic index and insulin resistance.

CONCLUSION

An elevated WBC count (even in the normal range) is closely related to various components of metabolic syndrome but not related to insulin resistance in type 2 diabetes.

Design and Development of a Context-Aware Knowledge-Based Module for Identifying Relevant Information and Information Gaps in Patients With Type 1 Diabetes Self-Collected Health Data

Background

Patients with diabetes use an increasing number of self-management tools in their daily life. However, health institutions rarely use the data generated by these services mainly due to (1) the lack of data reliability, and (2) medical workers spending too much time extracting relevant information from the vast amount of data produced. This work is part of the FullFlow project, which focuses on self-collected health data sharing directly between patients’ tools and EHRs.

Objective

The main objective is to design and implement a prototype for extracting relevant information and documenting information gaps from self-collected health data by patients with type 1 diabetes using a context-aware approach. The module should permit (1) clinicians to assess the reliability of the data and to identify issues to discuss with their patients, and (2) patients to understand the implication their lifestyle has on their disease.

Methods

The identification of context and the design of the system relied on (1) 2 workshops in which the main author participated, 1 patient with type 1 diabetes, and 1 clinician, and (2) a co-design session involving 5 patients with type 1 diabetes and 4 clinicians including 2 endocrinologists and 2 diabetes nurses. The software implementation followed a hybrid agile and waterfall approach. The testing relied on load, and black and white box methods.

Results

We created a context-aware knowledge-based module able to (1) detect potential errors, and information gaps from the self-collected health data, (2) pinpoint relevant data and potential causes of noticeable medical events, and (3) recommend actions to follow to improve the reliability of the data issues and medical issues to be discussed with clinicians. The module uses a reasoning engine following a hypothesize-and-test strategy built on a knowledge base and using contextual information. The knowledge base contains hypotheses, rules, and plans we defined with the input of medical experts. We identified a large set of contextual information: emotional state (eg, preferences, mood) of patients and medical workers, their relationship, their metadata (eg, age, medical specialty), the time and location of usage of the system, patient-collected data (eg, blood glucose, basal-bolus insulin), patients’ goals and medical standards (eg, insulin sensitivity factor, in range values). Demonstrating the usage of the system revealed that (1) participants perceived the system as useful and relevant for consultation, and (2) the system uses less than 30 milliseconds to treat new cases.

Conclusions

Using a knowledge-based system to identify anomalies concerning the reliability of patients’ self-collected health data to provide information on potential information gaps and to propose relevant medical subjects to discuss or actions to follow could ease the introduction of self-collected health data into consultation. Combining this reasoning engine and the system of the FullFlow project could improve the diagnostic process in health care.

The effect of consumption of garlic tablet on proteins oxidation biomarkers in postmenopausal osteoporotic women: A randomized clinical trial

Background

Osteoporosis (OP) is one of the most prevalent metabolic bone diseases at higher ages, especially in postmenopausal women.

Objective

To determine the effect of consumption of garlic tablet on proteins oxidation biomarkers in postmenopausal osteoporotic women.

Methods

The present study was a double-blind randomized controlled clinical trial that included 42 postmenopausal women in Yazd during 2014–2015. Osteoporotic women were randomly assigned into two groups: the garlic group (GG) and the placebo group (PG). Participants in GG took two garlic tablets daily for 1 month and the participants in PG took placebo tablets in the same manner. After 30 days, the plasma level of carbonyl groups (PCO), total antioxidant capacity (TAC), and advanced oxidation protein products (AOPPs) were assessed by spectrophotometric assays. Also, Malondialdehyde (MDA) content was measured according to the procedure of Thiobarbituric Acid (TBA). Data were analyzed by SPSS version 18, using paired-samples t-test, independent-samples t-test, Wilcoxon, and Mann-Whitney U test.

Results

This study showed that garlic tablets had decreased PCO plasma levels (47.37±5.98 vs. 19.62±3.40 nM, p≤0.001, before and after the study, respectively), AOPPs (738.95±151.86 vs. 585.12±209.99 μM, p≤0.008, before and after the study, respectively), and increased TAC (11.34±10.80 vs. 47.93±17.80, p≤0.001, before and after the study, respectively). The parameters in placebo groups showed no significant differences before and after the study, respectively. The levels of MDA before taking the drug in comparison to before Garlic group was also reduced (1.30±1.04 vs. 0.92±0.81 μM, p=0.01, before and after the study, respectively).

Conclusion

The role of oxidative stress in the pathophysiology of many diseases such as osteoporosis has been demonstrated. The present study showed that garlic consumption can reduce the oxidative stress.

Trial registration

The protocol of trial was registered at the Iranian clinical trial register (www.irct.ir) with ID: IRCT138811183273N1.

Funding

This study funded by Shahid Sadoughi University of Medical Sciences (Yazd, Iran).

Association of hematological indices with prediabetes: A cross-sectional study

BACKGROUND

Prediabetes is a condition that occurs when blood glucose levels are higher than normal, but not high enough to be classified as diabetes. Prediabetic people have an increased risk of developing type 2 diabetes and cardiovascular disease. Moreover Hyperglycemia has multiple effects on the hematological parameters.

OBJECTIVE

To examine the association between hematological indices and anthropometric measurement, with prediabetes.

METHODS

This cross-sectional study was conducted on 125 diabetics and 259 prediabetics in the 20-70 age range. They were selected by a convenience sampling method at the Taban Diabetes Center in 2015. An oral glucose tolerance test was performed for each participant who had never been diagnosed with diabetes. Participants were characterized as having prediabetes or diabetes according to American Diabetes Association criteria. The hematologic parameters were measured by using Sysmex-KX 21N analyzers. Data were analyzed by IBM-SPSS version 22 using independent-samples t-test, Mann-Whitney U test, and Pearson's correlation coefficient at p<0.05.

RESULTS

There was significant difference in mean corpuscular hemoglobin concentration (MCVH) (33.81±0.92 g/dL vs. 34.06±1.05 g/dL) between prediabetes patients and diabetes. There was not a statistically significant difference in the prediabetics' hematological parameters, compared with the diabetics. In the prediabetic group, only the mean corpuscular hemoglobin concentration was found to be negatively correlated with diastolic blood pressure (p=0.013) and FBS (p=0.026).

CONCLUSION

Hematological indices are important markers for the assessment of variations in size, number, and maturity of different blood cells. Hematological indices could be utile indicators of vascular complication and glycemic control in type 2 DM patients. Thus, they are important for the evaluation and early management of patients with per diabetes.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios: are they useful for predicting gestational diabetes mellitus during pregnancy?

OBJECTIVE

We aimed to investigate whether the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) could be utilized to screen for gestational diabetes mellitus (GDM).

SUBJECTS AND METHODS

NLR and PLR were assessed by retrospective analysis of 762 healthy and pregnant women with GDM. The patients were stratified into four groups, as follows: GDM (n=144), impaired glucose tolerance (n=76), only screen positive (n=238), and control (n=304).

RESULTS

The leukocyte, neutrophil, and lymphocyte counts were significantly higher in the study groups compared with the control group (P=0.001; P<0.01). There were no statistically significant differences between the groups with respect to the NLR and PLR (P>0.05).

CONCLUSION

We do not recommend that blood NLR and PLR can be used to screen for GDM. However, increase in the leukocyte count is an important marker for GDM as it provides evidence of subclinical inflammation.

Hematological indices and their correlation with fasting blood glucose level and anthropometric measurements in type 2 diabetes mellitus patients in Gondar, Northwest Ethiopia

BACKGROUND

Diabetes mellitus is (DM) a global public health problem and a complex disease characterized by chronic hyperglycemia that leads to long-term macrovascular and microvascular complications. Recent studies have reported the role of hematological indices in contributing to the vascular injury in diabetic patients. Thus, the aim of this study was to determine hematological indices and their correlation with fasting blood glucose level and anthropometric measurement in type 2 DM patients in comparison with healthy controls.

METHODS

A comparative cross-sectional study was conducted at the chronic illness clinic of Gondar University Hospital from February to April 2015. A total of 296 participants (148 cases and 148 healthy controls) were selected using systematic random sampling technique. Data were collected using a pretested structured questionnaire. Fasting blood glucose levels and hematological indices were determined by using Bio Systems A25 and Sysmex-KX 21N analyzers, respectively. Independent sample t-test, Mann-Whitney U-test, and correlation statistics were used. A P-value <0.05 was considered as statistically significant.

RESULT

There was significant difference in red blood cell distribution width (47.3±2.6 fL vs 45.2±3 fL) between diabetic patients and controls. Total white blood cells in 10(3)/µL (6.59±1.42 vs 5.56±1.38), absolute lymphocyte count in 10(3)/µL (2.60±0.70 vs 2.04±0.63), and absolute neutrophil count in 10(3)/µL (3.57±1.46 vs 3.11±1.04) increased significantly in diabetic patients compared with controls, respectively. Among platelet indices, mean platelet volume (10.4±1.1 fL vs 9.9±1.1 fL) and platelet distribution width (14.5±2.1 fL vs 13.4 ±2.1 fL) were found to be significantly increased in the diabetic patients (P<0.05). Anthropometric measurements significantly correlated with white blood cell and platelet indices.

CONCLUSION

The study showed statistically significant difference in some hematological parameters of diabetic patients compared to controls. Thus, hematological indices could be useful indicators of vascular complication and glycemic control in type 2 DM patients.

The effect of self-care education program on reducing HbA1c levels in patients with type 2 diabetes

BACKGROUND

Diabetes as the most common diseases caused by metabolic disorders is an important global challenge. This is a disease that requires lifelong self-care because self-care and improved quality of life is cost effective. This study is aimed to determine the impact of self-care education program on reducing HbA1c, type 2 diabetic patients and was conducted in Zahedan.

MATERIALS AND METHODS

This is an experimental study done on 138 diabetic female patients in Zahedan city, in 2011 (1390). This sampling method of patients was based on inclusion and exclusion criteria of the Diabetes Center, at Hazrat Ali Asghar Hospital (AS) in Zahedan. Samples were divided randomly in to two groups: 69 cases and 69 controls. Data collected included validity and reliability confirmed questionnaire. Checklist was based on patients 'performance of reporting and (HbA1c) testing. Before the educational intervention, the checklist of questions for recording the (HbA1c) test for both the groups were completed, and study samples received 5 sessions of education (with the group discussion and film show) for a month. However, the control group received only routine training. Three months after the educational intervention, both groups completed the questionnaire and the check list and data using SPSS software and the appropriate tests were analyzed.

RESULTS

Findings showed that the mean domain scores of area of knowledge, attitude and practice educational groups, were recorded as (46.6 ± 8.57, 46.5 ± 0.86 and 29.06 ± 10.02), respectively. And after education scores of knowledge, attitude and practice were recorded as (52.80 ± 2.20, 12.98 ± 1.02 and 39.69 ± 4.74), respectively, and in study group significant difference (P < 0/001) was seen.

CONCLUSION

Self-care training in striation leads to improve knowledge, attitude and self-care performance of the study samples and also improves the average (HbA1c). Because it seems to increase the active participation of learners in their care that they have experienced with this training method and their motivation enhanced them to learn better self-care. So this type of care education should be given to the attention of nurses and healthcare's staff.

Is there a link between neutrophil-lymphocyte ratio and microvascular complications in geriatric diabetic patients?

BACKGROUND

Chronic inflammation plays an important role on development and progression of Type 2 diabetes (T2DM) through immunologic inflammatory mechanisms. Neutrophil to lymphocyte ratio (NLR) is a new, simple and cheap marker of subclinical inflammation. NLR has recently been used as a systemic inflammation marker in chronic diseases as well as a predictor of prognosis in cardiovascular diseases and malignancies.

AIM

The objective of the present study was to investigate the relationship between NLR and microvascular complications of diabetes mellitus (DM) in elderly population.

SUBJECTS AND METHODS

Two hundred and forty-two patients with DM (145 diabetic patients with complications, 97 diabetic patients without complications) and 218 control subjects were enrolled in this study. NLR and microvascular complications because of DM were evaluated and compared with other inflammatory markers.

RESULTS

NLR was higher in the diabetic group (2.21±1.14) than in the controls (2.18±0.76). Furthermore, there was a statistically significant difference between NLR levels in diabetic patients with and without complications (2.46±1.26 vs 2.04±0.51, respectively; p<0.001). The results of themultiple logistic regression analysis depicted that NLR is also an independent predictor for microvascular complications (odds ratio 2.217; 95%confidence interval 1.086-4.526, p=0.029). Receiver operating curve analysis suggested that the optimum NLR cutoff point for microvascular complication was 2.89 with 96.72% specificity, 94.4% positive predictive value.

CONCLUSION

Increased NLR levels may be associated with microvascular complications of DM in the elderly population.

Correlation between peripheral white blood cell counts and hyperglycemic emergencies

OBJECTIVE

To determine the correlation between differential leukocyte counts and hyperglycemic emergencies.

METHODS

Fifty patients with diabetic ketoacidosis (DKA), 50 patients with diabetic ketosis (DK), 50 non-DK diabetic patients with stable glycemic control, and 50 normal controls were enrolled. Their total and differential leukocyte counts were measured and evaluated at admission and after treatment.

RESULTS

The patients with DKA and DK had higher plasma glucose levels (20.84±6.73 mmol/L, 15.55±2.6 mmol/L, respectively) and more median leukocytes (13325/mm(3) and 6595/mm(3), respectively) and median neutrophils (11124 /mm(3) and 4125/mm(3), respectively) but fewer median eosinophils (28/mm(3) and 72/mm(3), respectively) compared to non-DK and control groups (all p < 0.05). Acute infection increased the elevating extent. The median leukocyte counts in DK and non-DK patients (6595/mm(3) and 6008/mm(3), respectively) were within the normal range. The counts of total leukocytes and neutrophils were significantly higher but eosinophils lower in severe DKA cases than in mild/moderate cases (p < 0.05). When the DKA and DK and infection resolved, total leukocytes and neutrophils fell, but eosinophils increased. The counts of total leukocytes, neutrophils, and monocytes were negatively correlated with arterial pH levels (r = -0.515, r = -0.510, r = -0.517, all p < 0.001, respectively) and positively correlated with plasma glucose levels (r = 0.722, r = 0.733, r = 0.632, all p < 0.05, respectively) in DKA patients. The arterial pH level was the most significant factor affecting total leukocytes in DKA (β = 0.467, p = 0.003). The diagnosis analysis showed that higher total leukocyte and neutrophil counts and lower eosinophil counts had a significant ability to reflect the presence of hyperglycemic emergencies.

CONCLUSION

More total leukocytes and neutrophils but fewer eosinophils was significantly correlated with DKA and DK. Leukocyte counts can add valuable information to reflect the presence of hyperglycemic crisis and acute infection.

Neutrophil-lymphocyte ratio as a predictor of major adverse cardiac events among diabetic population: a 4-year follow-up study

The neutrophil-lymphocyte ratio (NLR) is an inflammatory marker of major adverse cardiac events (MACEs) in both acute coronary syndromes and stable coronary artery disease. The use of NLR as a predictive tool for MACEs among diabetic patients has not been elucidated. An observational study included 338 diabetic patients followed at our clinic between 2007 and 2011. Patients were arranged into equal tertiles according to the 2007 NLR. The MACEs included acute myocardial infarction, coronary revascularization, and mortality. The lowest NLR tertile (NLR < 1.6) had fewer MACEs compared with the highest NLR tertile (NLR > 2.36; MACEs were 6 of 113 patients vs 24 of 112 patients, respectively; P < .0001). In a multivariate model, the adjusted hazard ratio of third NLR tertile compared with first NLR tertile was 2.8 (95% confidence interval 1.12-6.98, P = .027). The NLR is a significant independent predictor of MACEs in diabetic patients. Further studies with larger numbers are needed.

White blood cell count and endothelin-1 vasoconstrictor tone in middle-aged and older adults

BACKGROUND

Higher white blood cell (WBC) count is associated with impaired endothelium-dependent vasodilation. However, the influence of higher WBC count on endothelin (ET)-1 vasoconstrictor activity is currently unknown. We tested the hypothesis that adults with elevated WBC count demonstrate enhanced ET-1 system activity.

METHODS

Thirty-four healthy adults were studied: 17 with WBC count < 5.0 × 10⁹ cells/L (lower WBC; 9M/8F; age: 53 ± 2 yr) and 17 with WBC count > 5.0 × 10⁹ cells/L (higher WBC; 10M/7F; 54 ± 3 yr). Forearm blood flow (FBF) responses to intra-brachial infusion of ET-1 (5 pmol/min for 20 min) and selective ET_A receptor blockade (BQ-123; 100 nmol/min for 60 min) were measured by venous occlusion plethysmography.

RESULTS

The vasoconstrictor response to ET-1 was significantly blunted (∼60%) in the higher WBC group versus the lower WBC group. The FBF responses to selective ET_A receptor blockade were also significantly different (P < 0.05) between the groups. In the lower WBC group, resting FBF increased marginally (∼5%) to BQ-123, whereas the increase in FBF to BQ-123 was significantly greater (∼15%) in higher WBC group. Furthermore, there was a significant relation between WBC count and FBF response to ET-1 (r = -0.43) and BQ-123 (r = 0.41).

CONCLUSIONS

Relative elevations in WBC count in middle-aged and older adults, independent of adiposity and other cardiometabolic risk factors, are associated with enhanced ET-1-mediated vasoconstrictor tone. Elevated ET-1 system activity may be a mechanism linking higher WBC count with increased cardiovascular risk.