Cardiovascular complications in diabetes: targets and interventions

Are Nutrition Literacy and Sustainable Dietary Habits Associated with Cardiovascular Disease and Diabetes Developmental Risks?

OBJECTIVE

This study aimed to examine the association of nutritional literacy levels and sustainable nutritional behaviors with the risk of developing cardiovascular diseases and diabetes in the Turkish adult population.

METHODS

Sociodemographic information, disease history, nutritional habits, and physical activity levels of 3146 volunteer individuals (male = 1590, female = 1556) between the ages of 40-75 were collected using a questionnaire form and face-to-face interviews. The sustainable nutritional behaviors of the participants were evaluated using Turkish validated scales for Sustainable and Healthy Eating Behavior (SHE) and nutritional literacy levels with the Evaluation Instrument of Nutrition Literacy on Adults (EINLA). Cardiovascular disease risks of the participants were assessed with the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator program and the Heart Score (SCORE) scale and type-2 diabetes risk with the Finnish Diabetes Risk Score (FINDRISC). Each participant's 24-h food consumption record was obtained using the retrospective recall method.

RESULTS

It was determined that ASCVD and SCORE levels were significantly higher in males compared to females. It was observed that individuals with lower cardiovascular and diabetes risk scores had higher educational levels, and the risks increased significantly with age (p < 0.05). Anthropometric measurements such as body mass index, and waist hip circumference were significantly higher in those with higher cardiovascular and diabetes risk scores. Furthermore, in individuals with higher SCORE and FINDRISC levels, SHE and EINLA scores were significantly lower (p < 0.05). It was also observed that SCORE and diabetes risk scores increased with higher energy and macronutrient intakes.

CONCLUSION

The risk of developing cardiovascular disease and diabetes was associated with sustainable nutritional behaviors and nutritional literacy. It may be suggested that increasing nutritional literacy and encouraging sustainable nutritional behaviors may be effective strategies in the management and reduction of the prevalence of certain chronic diseases. KEY TEACHING POINTSCardiovascular diseases and diabetes are two major chronic conditions that can be managed and treated through proper nutrition.Increased nutritional literacy levels and sustainable dietary habits may result in reduced risk of cardiovascular diseases and diabetes.Nutritionists should assess the patients' nutrition literacy levels and implement sustainable, health-focused nutrition education programs to enhance their understanding of nutrition.

From iPSCs to Pancreatic β Cells: Unveiling Molecular Pathways and Enhancements with Vitamin C and Retinoic Acid in Diabetes Research

Diabetes mellitus, a chronic and non-transmissible disease, triggers a wide range of micro- and macrovascular complications. The differentiation of pancreatic β-like cells (PβLCs) from induced pluripotent stem cells (iPSCs) offers a promising avenue for regenerative medicine aimed at treating diabetes. Current differentiation protocols strive to emulate pancreatic embryonic development by utilizing cytokines and small molecules at specific doses to activate and inhibit distinct molecular signaling pathways, directing the differentiation of iPSCs into pancreatic β cells. Despite significant progress and improved protocols, the full spectrum of molecular signaling pathways governing pancreatic development and the physiological characteristics of the differentiated cells are not yet fully understood. Here, we report a specific combination of cofactors and small molecules that successfully differentiate iPSCs into PβLCs. Our protocol has shown to be effective, with the resulting cells exhibiting key functional properties of pancreatic β cells, including the expression of crucial molecular markers (pdx1, nkx6.1, ngn3) and the capability to secrete insulin in response to glucose. Furthermore, the addition of vitamin C and retinoic acid in the final stages of differentiation led to the overexpression of specific β cell genes.

Evaluation of prescribing pattern, therapeutic adherence, and occurrence of adverse drug reactions in patients with type 2 diabetes mellitus

Background:

Persistent hyperglycemia in diabetes mellitus (DM) is considered as the leading cause of morbidity and mortality associated with both microvascular and macrovascular complications and has a greater economic impact. This study aimed to assess the impact of socioeconomic status, prescribing patterns, and patient compliance in type 2 diabetes mellitus patients.

Method:

This study was carried out in the department of medicine and diabetic clinic of Hakeem Abdul Hameed (HAH) Centenary Hospital at Hamdard University, New Delhi, India. We conducted a prospective observational study on prescribing patterns and monitoring of adverse drug reactions (ADRs) in patients with type 2 DM (T2DM) taking standard care. We enrolled 150 confirmed cases and data was obtained from pre-validated questionnaires and then coded and analyzed to observe the association between variables.

Results:

The glycosylated haemoglobin level in 56 % of cases was between 6.4 to 8.0 and cardiovascular complications were observed as the major comorbidities. 45.33 % of cases were on mono drug therapy and Metformin (23. 52 %) was the drug of choice followed by Glimepiride (23.52 %). Among the dual drug therapies, Sitagliptin with Metformin and in triple-drug therapy, Glimepiride concurrent with Metformin and Voglibose was the most preferred drug in the treatment of T2DM. Sitagliptin was observed to be a major patient burden (46.213 USD). In only 7.33 % of cases, we observed definite ADR in T2DM patients. Underprivileged awareness, mainly due to low literacy, was a major concern in the development of new cases of T2DM.

Conclusion:

We observed better patient compliance and disease awareness program is required to be implemented. The use of oral hypoglycaemic drugs is still dominant in clinical practice and cardiovascular disorders as comorbidities emerge as a greater challenge in terms of patient outcome and cost burden.

Diabetes Mellitus Is a Chronic Disease that Can Benefit from Therapy with Induced Pluripotent Stem Cells

Diabetes mellitus (DM) is one of the main causes of morbidity and mortality, with an increasing incidence worldwide. The impact of DM on public health in developing countries has triggered alarm due to the exaggerated costs of the treatment and monitoring of patients with this disease. Considerable efforts have been made to try to prevent the onset and reduce the complications of DM. However, because insulin-producing pancreatic β-cells progressively deteriorate, many people must receive insulin through subcutaneous injection. Additionally, current therapies do not have consistent results regarding the prevention of chronic complications. Leveraging the approval of real-time continuous glucose monitors and sophisticated algorithms that partially automate insulin infusion pumps has improved glycemic control, decreasing the burden of diabetes management. However, these advances are facing physiologic barriers. New findings in molecular and cellular biology have produced an extraordinary advancement in tissue development for the treatment of DM. Obtaining pancreatic β-cells from somatic cells is a great resource that currently exists for patients with DM. Although this therapeutic option has great prospects for patients, some challenges remain for this therapeutic plan to be used clinically. The purpose of this review is to describe the new techniques in cell biology and regenerative medicine as possible treatments for DM. In particular, this review highlights the origin of induced pluripotent cells (iPSCs) and how they have begun to emerge as a regenerative treatment that may mitigate the pathology of this disease.

Association between Proinflammatory Markers, Leukocyte-Endothelium Interactions, and Carotid Intima-Media Thickness in Type 2 Diabetes: Role of Glycemic Control

Glycated hemoglobin monitorization could be a tool for maintaining type 2 diabetes (T2D) under control and delaying the appearance of cardiovascular events. This cross-sectional study was designed to assess the role of glycemic control in modulating early-stage markers of cardiovascular complications. One hundred and eight healthy controls and 161 type 2 diabetic patients were recruited and distributed according to their glycemic control, setting the threshold at 6.5% (good control). Biochemical and anthropometrical parameters were registered during the initial visit, and peripheral blood was extracted to obtain polymorphonuclear cells and analyze inflammatory markers, adhesion molecules, leukocyte-endothelium interactions, and carotid intima-media thickness. Correlations between these parameters were explored. We found that inflammatory markers and adhesion molecules were augmented in type 2 diabetic subjects with poor glycemic control. Polymorphonuclear leukocytes interacted more with the endothelium in the diabetic population, and even more significantly in the poorly controlled subjects. In parallel, carotid intima-media thickness was also increased in the diabetic population, and the difference was greater among poorly controlled subjects. Finally, correlation measurement revealed that carotid intima-media thickness was related to glycemic control and lipid metabolism in diabetic patients. Our results suggest that glycemic control delays the onset of cardiovascular comorbidities in diabetic subjects.

Type-2 diabetes mellitus in schizophrenia: Increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up

Objective

Physical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.

Methods

During 2000–2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.

Results

The prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.

Conclusion

Schizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.

Growth of Diabetes Research in United Arab Emirates: Current and Future Perspectives

BACKGROUND

Diabetes mellitus (DM) is one of the most prevalent metabolic diseases in the UAE. During the last two decades, the United Arab Emirates (UAE) has experienced tremendous development in all fields including DM research. The present study sheds light on the growth in DM research in UAE and represents a guide for DM researchers to create more focused future directions in DM research.

OBJECTIVES

The main objective of the present study is to investigate and document the changes that occurred in DM research in the UAE over the last two decades.

METHODS

Several research databases were reviewed and all the articles that involved any form of DM research within the UAE were selected. Inclusion criteria were: (i) Research studies related to DM and conducted by institutions based in UAE (ii) Research studies related to DM and conducted in the population of UAE and (iii) Research articles related to DM and the authors (principal investigators or co-investigators) are from UAE.

RESULTS

Between the years of 1996 and 2000, there was an average of 6.4 articles about DM being published per year. This pattern changed dramatically between years 2011 to 2015 where an average of 22.8 articles were being published. In addition, a significant increase was noticed in the year 2015 with 42 articles published per year. It was also found that 46.8% articles involved clinical study, 12.1% were basic research, 17.5% cross-sectional studies, 8.91% reviews, 8.2% were cohort and all the other types of research represented about 5.58%.

CONCLUSION

Significant progress has been noticed in DM research in the UAE during the last two decades. Based on the findings of the present study, more focus should be given to the case reports and clinical trials.

Mechanisms of Protective Effects of SGLT2 Inhibitors in Cardiovascular Disease and Renal Dysfunction

Type 2 diabetes mellitus is one of the most common forms of the disease worldwide. Hyperglycemia and insulin resistance play key roles in type 2 diabetes mellitus. Renal glucose reabsorption is an essential feature in glycaemic control. Kidneys filter 160 g of glucose daily in healthy subjects under euglycaemic conditions. The expanding epidemic of diabetes leads to a prevalence of diabetes-related cardiovascular disorders, in particular, heart failure and renal dysfunction. Cellular glucose uptake is a fundamental process for homeostasis, growth, and metabolism. In humans, three families of glucose transporters have been identified, including the glucose facilitators GLUTs, the sodium-glucose cotransporter SGLTs, and the recently identified SWEETs. Structures of the major isoforms of all three families were studied. Sodium-glucose cotransporter (SGLT2) provides most of the capacity for renal glucose reabsorption in the early proximal tubule. A number of cardiovascular outcome trials in patients with type 2 diabetes have been studied with SGLT2 inhibitors reducing cardiovascular morbidity and mortality. The current review article summarises these aspects and discusses possible mechanisms with SGLT2 inhibitors in protecting heart failure and renal dysfunction in diabetic patients. Through glucosuria, SGLT2 inhibitors reduce body weight and body fat, and shift substrate utilisation from carbohydrates to lipids and, possibly, ketone bodies. These pleiotropic effects of SGLT2 inhibitors are likely to have contributed to the results of the EMPA-REG OUTCOME trial in which the SGLT2 inhibitor, empagliflozin, slowed down the progression of chronic kidney disease and reduced major adverse cardiovascular events in high-risk individuals with type 2 diabetes. This review discusses the role of SGLT2 in the physiology and pathophysiology of renal glucose reabsorption and outlines the unexpected logic of inhibiting SGLT2 in the diabetic kidney.

Thyroidectomy Complications in Patients with Diabetes Mellitus

Objective

To (1) analyze postoperative thyroidectomy outcomes in patients with diabetes mellitus (DM), who are prone to deleterious effects of glucose dysmetabolism, and (2) apply findings to optimize perioperative management of diabetics requiring thyroid surgery.

Study Design

Retrospective database analysis.

Setting

University hospital.

Subjects and Methods

The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedure Coding System (PCS) codes for patients with benign or malignant thyroid disease who underwent thyroid surgery between 2002 and 2013. An analysis of demographics, comorbidities, and postoperative outcomes was conducted between a DM vs non-DM cohort using bivariate and multivariate techniques.

Results

In total, 103,842 cases met inclusion criteria; 14.2% were diabetics. Diabetics had significantly higher rates of baseline comorbid chronic pulmonary disease, hypertension, obesity, and anemia. Following thyroidectomy, patients with DM were more likely to have vocal cord paresis or paralysis compared to non-DM patients (2.0% vs 1.3%; P < .001). However, when adjusting for demographics and comorbidities, there was no significant difference in this complication between the 2 groups. Diabetics had independently higher rates of cardiac, pulmonary, and urinary complications, as well as transfusion, reintubation, and in-hospital mortality. Diabetics had longer hospital stays (2.76 vs 1.97; P < .001) with higher incurred hospital charges (32,921 vs 25,198; P < .001).

Conclusion

Although DM often confers metabolic and ischemic derangements secondary to hyperglycemia such as neuropathy, this comorbidity was not independently associated with higher rates of vocal cord paresis or paralysis following thyroid surgery. However, DM predicted other adverse outcomes, including greater cardiac, pulmonary, and urinary complications, as well as transfusion, reintubation, and in-hospital mortality.

Association between educational level and cardiovascular disease and all-cause mortality in patients with type 2 diabetes: a prospective study in the Joint Asia Diabetes Evaluation Program

Purpose

The aim of this study was to describe the association between educational level and incident cardiovascular disease (CVD) and all-cause mortality in Hong Kong Chinese patients with type 2 diabetes.

Patients and methods

We included 12,634 patients with type 2 diabetes who were enrolled into the Joint Asia Diabetes Evaluation Program between June 1, 2007, and June 30, 2017. We classified patients' educational level into the following three groups: ≤6 years, 6-13 years, and >13 years. Incident CVD events were identified using hospital discharge diagnoses. Death was identified from Hong Kong Death Register. We estimated HRs for incident CVD and all-cause mortality using Cox regression models.

Results

Patients with the highest educational level were younger and had shorter diabetes duration and better glycemic control at enrollment than those with the lowest educational level. During the median follow-up of 6.2 years for CVD and 6.4 years for all-cause mortality, 954 CVD events and 833 deaths were recorded. HRs for CVD and all-cause mortality were 0.73 (95% CI: 0.57, 0.94) and 0.71 (95% CI: 0.54, 0.94) for the highest educational level compared to the lowest educational level, after adjustment for age, sex, diabetes duration, and family history of diabetes.

Conclusion

Educational level is inversely associated with the risk of CVD and all-cause mortality among Hong Kong Chinese patients with type 2 diabetes. Hong Kong Chinese patients with type 2 diabetes and low educational level should be given special attention for the prevention of key complications of diabetes.

Brain-derived neurotrophic factor, insulin like growth factor-1 and inflammatory cytokine responses to continuous and intermittent exercise in patients with type 1 diabetes

AIMS

Type 1 diabetes mellitus (T1DM) is an important risk factor for cognitive decline and motor dysfunction due to progressive muscular atrophy. Chronic hyperglycemia may be responsible for impaired vascular function, loss of muscle mass, and morphological abnormalities in the myocytes. For the proper functioning of the neuromuscular system, two crucial growth factors are necessary: brain-derived neurotrophic factor (BDNF) and insulin-like growth factor-1 (IGF-1), whose reduced expressions have been implicated in progressive neuropathy and muscle atrophy in patients with T1DM. The aim of the study was to compare the effects of two different exercise regimes (continuous and intermittent) on BDNF, IGF-1, blood glucose and inflammatory cytokine responses in young adults with and without Type 1 diabetes.

METHODS

Fourteen patients (aged: 26.9 years) with T1DM and age-matched adults without diabetes participated in a 40 min continuous exercise (ExC, 50% of lactate threshold) and a high intensity intermittent exercise (ExInt, 120% of lactate threshold). During the study the patients performed self-monitoring of blood glucose levels (SMBG) under glycemic control. The effects of ExC and ExInt on BDNF, IGF-1, insulin like growth factor binding protein (IGFBP-3), insulin (INS), vascular endothelial growth factor (VEGF), transforming growth factor beta (TGF-β) and tumor necrosis factor alpha (TNF-α) were analyzed.

RESULTS

BDNF and IGF-1 baseline serum levels were significantly lower in the T1DM patients compared to the healthy controls, but we found that ExInt and ExC significantly increase the secretion of BDNF and IGF-1 levels. Significant increases in BDNF and TGF-β levels, higher blood glucose decline, and a lower incidence of hypoglycaemia in ExInt compared to ExC were observed. Lower IGFBP-3 concentrations were revealed in T1DM patients in response to ExInt compared to ExC, suggesting a positive effect on IGF-1/IGFBP-3 ratio and the bioavailability of IGF-1.

CONCLUSIONS

According to our results physical exercise has beneficial effects on serum BDNF and IGF-1 levels. A high-intensity intermittent exercise may be more effective at reducing the risk of exercise-induced glycaemic disorders in the T1DM patients as compared to continuous exercise.

Association Trends Between Antihypertensive Drug Therapies and Diastolic Hypotension in Emirati Patients with Type 2 Diabetes: A Single-Center Retrospective Longitudinal Study

INTRODUCTION

Diabetes mellitus (DM) is associated with multiple complications, including cardiovascular diseases. Previously, it was believed that the latter are mainly caused by hypertension and increased systolic blood pressure. However, recent studies have challenged this concept, by showing that diastolic dysfunction may also be involved in the cardiovascular events that are associated with DM. Pharmacologic management of hypertension in patients with type 2 DM appears to adversely influence diastolic function.

METHODS

Four hundred and eight medical records of hypertensive and obese Emirati patients with type 2 DM were included in the present retrospective study. The main objectives of the present study were (1) to determine the prevalence of low diastolic blood pressure (DBP) and diastolic hypotension in this group of patients and (2) to investigate the associations, if any, between the use of various antihypertensive medications and low DBP and diastolic hypotension.

RESULTS

The results of the present study showed that low DBP (< 70 mmHg) was experienced by 40% of the hypertensive type 2 DM patients, whereas diastolic hypotension (< 60 mmHg) was reported to occur in about 10% of the patients. Another important factor that has been significantly correlated with diastolic hypotension is age (p < 0.01). Association trends have been reported between low DBP and diastolic hypotension and several antihypertensive therapies, including (1) monotherapies such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), (2) dual therapies such as ACE inhibitors in combination with thiazide-like diuretics (THLDs) or beta blockers, and (3) triple therapy combinations of ACE inhibitors with THLDs and potassium-sparing diuretics.

CONCLUSION

The use of antihypertensive medications, in particular ACE inhibitors and ARBs, appears to be a risk factor for the development of low DBP and diastolic hypotension in obese hypertensive Emirati patients with type 2 DM, whereas calcium channel blockers seem to be a safer option for this group of patients.

Interference effect of oral administration of mulberry branch bark powder on the incidence of type II diabetes in mice induced by streptozotocin

Background

Diabetes is a group of metabolic diseases that has become a global health problem worldwide. Many researchers have found that mulberry branches have a hypoglycemic effect, but there have been few studies or investigations regarding the use of mulberry branches to prevent the incidence of diabetes.

Objective

This study aimed to investigate the potential preventive effect of mulberry branch bark powder (MBBP) from Morus multicaulis L against type II diabetes in mice induced by streptozotocin (STZ).

Design

The normal mice were fed a diet containing 2.5, 5.0, and 10.0%, MBBP, respectively, for 2 weeks. After that, STZ (100 mg/kg) was injected into the caudal vein of these mice. These mice continued to be fed the same diet, and the fasting blood glucose (FBG) levels were monitored on the 17th and 21st days.

Results

Oral administration of MBBP could effectively inhibit weight loss and maintain the FBG level. The incidence of diabetes in mice was almost inhibited by treatment with 10% MBBP. MBBP could also maintain the original antioxidant capacity and regulate the lipid metabolism in mice. An immunohistochemical assay showed that MBBP could prevent the injury of the insulin-secreting islet beta cells induced by STZ. RT-PCR also confirmed that the mRNA expression of the genes PI3K, Pdk1, Akt, and FoxO1, which were involved in the PI3K/Akt signaling pathway, hardly suffered from STZ in the 10% MBBP-dose group.

Conclusions

Our results indicate that powdered mulberry branch bark has a powerful anti-diabetic effect. These results clearly illustrated that MBBP has a potential use as a health food additive in the prevention of diabetes.

Effects of active and passive smoking on the development of cardiovascular disease as assessed by a carotid intima-media thickness examination in patients with type 2 diabetes mellitus

Carotid intima-media thickness has been widely used as a surrogate end-point for cardiovascular disease, myocardial infarction, and stroke. This study aimed to assess the effects of active and passive smoking exposure on the development of cardiovascular disease in patients with type 2 diabetes mellitus. Seven hundred twenty-two patients with type 2 diabetes mellitus were recruited for the study. A standardized questionnaire on smoking status, pack-years of smoking, and the number of years of smoking cessation was provided to the patients, and their responses were collected for analysis. The carotid intima-media thickness, carotid plaque, and the internal diameter of the common carotid artery were determined by high-resolution B-mode ultrasonography. Compared to non-smokers, passive female smokers had a higher risk of cardiovascular disease (odds ratio = 3.50, 95% confidence interval: 1.29-9.49, P = 0.009); they also had a significantly larger common carotid artery (P = 0.041) and risk of carotid plaque (odds ratio = 2.20, 95% confidence interval: 1.1980-4.0505, P = 0.01). Both active and passive male smokers had a significantly greater carotid intima-media thickness than non-smokers (P = 0.003 and P = 0.005, respectively). Male active smokers had a significantly higher risk of carotid plaque (odds ratio = 2.88, 95% confidence interval: 1.4788-5.6094, P = 0.001). In conclusion, cumulative active and passive smoking exposures are significant risk factors for carotid atherosclerosis in patients with type 2 diabetes mellitus. Our results highlight the importance of endorsing a smoke-free environment for patients with type 2 diabetes mellitus.

The clinical application of linagliptin in Asians

Asia has a growing diabetic population. Linagliptin, a member of dipeptidyl peptidase-4 inhibitor class, is unique in its nonlinear pharmacokinetics with the characteristics of rapid attainment of steady state, little accumulation, predominantly nonrenal route of elimination, prolonged terminal half-life, and sustained inhibition of dipeptidyl peptidase-4 enzyme. No clinically relevant difference in pharmacokinetics was observed between Asians and non-Asians. The management of type 2 diabetes is increasingly challenging with the progression of disease, especially with the requirements of minimal hypoglycemia, weight gain, fluid retention, and other adverse effects. Linagliptin was efficacious and well-tolerated in Asian type 2 diabetes patients with or without renal or hepatic dysfunctions, comparable to that in Caucasians. This review will focus on the usage of linagliptin in clinical studies in Asians.

Glycated hemoglobin and its spinoffs: Cardiovascular disease markers or risk factors?

Atherosclerosis is a major complication of diabetes, increasing the risk of cardiovascular related morbidities and mortalities. The hallmark of diabetes is hyperglycemia which duration is best predicted by elevated glycated haemoglobin A_1C (HbA_1C) levels. Diabetic complications are usually attributed to oxidative stress associated with glycation of major structural and functional proteins. This non-enzymatic glycation of long lived proteins such as collagen, albumin, fibrinogen, liver enzymes and globulins result in the formation of early and advanced glycation end products (AGEs) associated with the production of myriads of free radicles and oxidants that have detrimental effects leading to diabetic complications. AGEs have been extensively discussed in the literature as etiological factors in the advancement of atherogenic events. Mechanisms described include the effects of glycation on protein structure and function that lead to defective receptor binding, impairment of immune system and enzyme function and alteration of basement membrane structural integrity. Hemoglobin (Hb) is a major circulating protein susceptible to glycation. Glycated Hb, namely HbA_1C is used as a useful tool in the diagnosis of diabetes progression. Many studies have shown strong positive associations between elevated HbA_1C levels and existing cardiovascular disease and major risk factors. Also, several studies presented HbA_1C as an independent predictor of cardiovascular risk. In spite of extensive reports on positive associations, limited evidence is available considering the role of glycated Hb in the etiology of atherosclerosis. This editorial highlights potential mechanisms by which glycated hemoglobin may contribute, as a causative factor, to the progression of atherosclerosis in diabetics.

Role of multiligand/RAGE axis in platelet activation

In the context of plaque progression, platelet hyperactivity associated with hyperlipidemia contributes to the development of a pro-thrombotic state. In this context, it has been demonstrated that advanced glycation end products (AGEs) significantly increases platelet activation and receptor for AGEs (RAGE) expression at the platelet surface membrane. In addition to AGEs, other ligands (S100, HMGB1 and amyloid β, among others) of RAGE have raised particular attention in platelet activation. Therefore, in this article we describe platelet hyperactivity by AGEs via RAGE-independent and RAGE-dependent pathways.

Physical comorbidity and its relevance on mortality in schizophrenia: a naturalistic 12-year follow-up in general hospital admissions

Schizophrenia is a major psychotic disorder with significant comorbidity and mortality. Patients with schizophrenia are said to suffer more type-2 diabetes mellitus (T2DM) and diabetogenic complications. However, there is little consistent evidence that comorbidity with physical diseases leads to excess mortality in schizophrenic patients. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital mortality differed between patients with and without schizophrenia in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 31 June 2012, 1418 adult patients with schizophrenia were admitted to three General Manchester NHS Hospitals. All comorbid diseases with a prevalemce ≥1% were compared with those of 14,180 age- and gender-matched hospital controls. Risk factors, i.e. comorbid diseases that were predictors for general hospital mortality were identified using multivariate logistic regression analyses. Compared with controls, schizophrenic patients had a higher proportion of emergency admissions (69.8 vs. 43.0%), an extended average length of stay at index hospitalization (8.1 vs. 3.4 days), a higher number of hospital admissions (11.5 vs. 6.3), a shorter length of survival (1895 vs. 2161 days), and a nearly twofold increased mortality rate (18.0 vs. 9.7%). Schizophrenic patients suffered more depression, T2DM, alcohol abuse, asthma, COPD, and twenty-three more diseases, many of them diabetic-related complications or other environmentally influenced conditions. In contrast, hypertension, cataract, angina, and hyperlipidaemia were less prevalent in the schizophrenia population compared to the control population. In deceased schizophrenic patients, T2DM was the most frequently recorded comorbidity, contributing to 31.4% of hospital deaths (only 14.4% of schizophrenic patients with comorbid T2DM survived the study period). Further predictors of general hospital mortality in schizophrenia were found to be alcoholic liver disease (OR = 10.3), parkinsonism (OR = 5.0), T1DM (OR = 3.8), non-specific renal failure (OR = 3.5), ischaemic stroke (OR = 3.3), pneumonia (OR = 3.0), iron-deficiency anaemia (OR = 2.8), COPD (OR = 2.8), and bronchitis (OR = 2.6). There were no significant differences in their impact on hospital mortality compared to control subjects with the same diseases except parkinsonism which was associated with higher mortality in the schizophrenia population compared with the control population. The prevalence of parkinsonism was significantly elevated in the 255 deceased schizophrenic patients (5.5 %) than in those 1,163 surviving the study period (0.8 %, OR = 5.0) and deceased schizophrenic patients had significantly more suffered extrapyramidal symptoms than deceased control subjects (5.5 vs. 1.5 %). Therefore patients with schizophrenia have a higher burden of physical comorbidity that is associated with a worse outcome in a 12-year follow-up of mortality in general hospitals compared with hospital controls. However, schizophrenic patients die of the same physical diseases as their peers without schizophrenia. The most relevant physical risk factors of general hospital mortality are T2DM, COPD and infectious respiratory complications, iron-deficiency anaemia, T1DM, unspecific renal failure, ischaemic stroke, and alcoholic liver disease. Additionally, parkinsonism is a major risk factor for general hospital mortality in schizophrenia. Thus, optimal monitoring and management of acute T2DM and COPD with its infectious respiratory complications, as well as the accurate detection and management of iron-deficiency anaemia, of diabetic-related long-term micro- and macrovascular complications, of alcoholic liver disease, and of extrapyramidal symptoms are of utmost relevance in schizophrenia.

Milk nutritional composition and its role in human health

Dairy and milk consumption are frequently included as important elements in a healthy and balanced diet. It is the first food for mammals and provides all the necessary energy and nutrients to ensure proper growth and development, being crucial in respect to bone mass formation. However, several controversies arise from consumption of dairy and milk products during adulthood, especially because it refers to milk from other species. Despite these controversies, epidemiologic studies confirm the nutritional importance of milk in the human diet and reinforce the possible role of its consumption in preventing several chronic conditions like cardiovascular diseases (CVDs), some forms of cancer, obesity, and diabetes. Lactose malabsorption symptoms and cow milk protein allergy are generally considered to be the adverse reactions to milk consumption. The present article reviews the main aspects of milk nutritional composition and establishes several associations between its nutritious role, health promotion, and disease prevention.

Hyperuricemia as an independent predictor of vascular complications and mortality in type 2 diabetes patients: a meta-analysis

Background

Recent data have suggested that serum uric acid (SUA) level is positively associated with the development of type 2 diabetes (T2DM). Whether SUA is also independently associated with the development of vascular complications and mortality in T2DM is controversial.

Methods

A computerized literature search of MEDLINE, Embase and PubMed database was conducted and the odds ratio (OR) or hazard ratio (HR) for per 0.1mmol/l increase in SUA in each study was calculated. Cochrane’s Q and I² statistics were used to evaluate heterogeneity among studies and pooling OR and HR with 95% confidence intervals (CIs) were calculated using random-effects models and fixed-effects models. The pooled analysis was performed using Stata 10.0.

Results

Our search yielded 9 eligible articles (16 ORs and HRs) including 20,891 T2DM patients. Pooled estimates for the relationship suggested that each 0.1 mmol/l increase in SUA resulted in a 28% increase in the risk of diabetic vascular complications and a 9% increase in the risk of diabetic mortality. In stratification-analysis, the positive relationship between SUA and vascular complications remained significant irrespective of mean age, adjustment for metabolic variables and medications. However, it was inconsistent in different populations (significantly positive in the Asian but not in Australian and Italian population) and sample sizes (significantly positive in the relatively large sample size [≥1000] but non-significant in the small sample size [<1000]).

Conclusions

Results of this meta-analysis supported elevated SUA as an independent predictor of vascular complications and mortality in T2DM patients. SUA-lowering therapies might be helpful for prevention and treatment of vascular complications in this population.

Detectable subclinical myocardial necrosis is associated with cardiovascular risk in stable patients with diabetes

OBJECTIVE

To investigate the relationship between different degrees of subclinical myocardial necrosis, glycemic control, and long-term adverse clinical outcomes within a stable patient population with diabetes mellitus.

RESEARCH DESIGN AND METHODS

We examined 1,275 stable patients with diabetes mellitus undergoing elective diagnostic coronary angiography with cardiac troponin I (cTnI) levels below the diagnostic cut-off for defining myocardial infarction (MI) (<0.03 ng/mL). The relationship of subclinical myocardial necrosis (cTnI 0.009-0.029 ng/mL) with incident major adverse cardiovascular events (MACE; defined as any death, MI, or stroke) over 3 years of follow-up was examined.

RESULTS

Subclinical myocardial necrosis was observed in 22% of patients. A strong association was observed between the magnitude of subclinical myocardial necrosis and risk of 3-year incident MACE (hazard ratio, 1.98; 95% confidence interval, 1.48-2.65; P < 0.001) and remained statistically significant even after adjustment for traditional risk factors, high-sensitivity C-reactive protein, and creatinine clearance. Only a weak correlation was observed between the presence of subclinical myocardial necrosis and either glycemic control (r = 0.06; P = 0.044 for hemoglobin A1c versus cTnI) or insulin resistance (r = 0.04; P = 0.094 for glucose-to-insulin ratio versus cTnI).

CONCLUSIONS

The presence of detectable subclinical myocardial necrosis in stable patients with diabetes mellitus is associated with heightened long-term risk for MACE, independent of traditional risk factors and glycemic control.

The antidiabetic effects of an herbal formula composed of Alnus hirsuta, Rosa davurica, Acanthopanax senticosus and Panax schinseng in the streptozotocin-induced diabetic rats

A folk prescription consisting of Alnus hirsuta, Rosa davurica, Acanthopanax senticosus and Panax schinseng has been used in the treatment of diabetes mellitus. The aim of the present investigation was to evaluate the antidiabetic effects of the herb formula extract (HFE) composed of Alnus hirsuta, Rosa davurica, Acanthopanax senticosus and Panax schinseng in the streptozotocin (STZ)-induced diabetic rats. The HFE was mixed in the food supply of the healthy and STZ-induced diabetic male Sprague-Dawley rats, and its effects on the body weight, water and food intake, hyperglycemia, hypolipidemic and islet structure were studied. The treatment of the rats with STZ for 6 weeks resulted in marasmus, polydipsia, polyphagia, hyperglycemia and hypoinsulinemia. In addition, the diabetic rats showed an apparent decrease in the insulin immunoreactivity and the number of β-cells in the pancreas. The addition of the HFE to the rats' food supply significantly lowered the serum glucose and the serum triglycerides level and preserved the normal histological appearance of the pancreatic islets. These results indicate that the HEF have a strong antidiabetic potential along with the significant hypoglycemic and hypolipidemic effects, which may be applicable in the pharmaceutical industry.

Haemoglobin A1c: Historical overview and current concepts

Since the discovery of the relation between increased concentrations of fast haemoglobin fractions in patients with diabetes mellitus compared to concentrations in subjects without diabetes mellitus by Samuel Rahbar and co-workers in 1969, glycated haemoglobin A1c (HbA1c) has become a "gold standard" for glucose management in patients with diabetes mellitus. Recently, HbA1c has been advocated as a diagnostic marker for diabetes mellitus, which further underlines the importance of HbA1c. There are currently more than 30 methods available on the market with an analytical performance ranging from poor to state of the art. This review describes the biochemistry of HbA1c and the concepts of analytical and biological variation with respect to the measurement of HbA1c. Subsequently, aspects regarding the discovery of HbA1c are described. In addition, an overview is given on the assays methods that are currently available for the measurement of HbA1c. Finally, recommendations for the minimally required analytical performance characteristics of the current HbA1c assays are presented.

[Characteristics of therapy of acute myocardial infarction in diabetes]

Therapy of acute myocardial infarction (STEMI and NSTEMI) in diabetics does not principally differ from that of non-diabetic patients. Due to the higher mortality in diabetics reperfusion measures, such as direct percutaneous coronary intervention (PCI), should be rapidly performed. An intensive drug treatment with thrombocyte aggregation inhibitors, angiotensin-converting enzyme (ACE) inhibitors and beta-receptor blocking agents must be carried out according to the current guidelines. An important factor is the high risk of renal failure due to the contrast dye administered during PCI in the presence of pre-existing diabetic kidney damage which should be limited to 100 ml if possible. Direct PCI should be limited to the infarcted vessel. After stabilization a comprehensive strategy to cure coronary artery disease, whether with PCI or coronary artery bypass graft (CABG) should be finalized. If severe coronary 3-vessel disease is present, CABG should be favored in diabetic patients. After surviving an acute myocardial infarction differentiated metabolic monitoring is mandatory.

What the radiologist needs to know about the diabetic patient

Diabetes mellitus (DM) is recognised as a major health problem. Ninety-nine percent of diabetics suffer from type 2 DM and 10% from type 1 and other types of DM. The number of diabetic patients worldwide is expected to reach 380 millions over the next 15 years. The duration of diabetes is an important factor in the pathogenesis of complications, but other factors frequently coexisting with type 2 DM, such as hypertension, obesity and dyslipidaemia, also contribute to the development of diabetic angiopathy. Microvascular complications include retinopathy, nephropathy and neuropathy. Macroangiopathy mainly affects coronary arteries, carotid arteries and arteries of the lower extremities. Eighty percent of deaths in the diabetic population result from cardiovascular incidents. DM is considered an equivalent of coronary heart disease (CHD). Stroke and peripheral artery disease (PAD) are other main manifestations of diabetic macroangiopathy. Diabetic cardiomyopathy (DC) represents another chronic complication that occurs independently of CHD and hypertension. The greater susceptibility of diabetic patients to infections completes the spectrum of the main consequences of DM. The serious complications of DM make it essential for physicians to be aware of the screening guidelines, allowing for earlier patient diagnosis and treatment.

Fruit consumption is associated with lower carotid intima-media thickness and C-reactive protein levels in patients with type 2 diabetes mellitus

Preliminary evidence in support of fruit intake for the prevention of cardiovascular disease in patients with type 2 diabetes mellitus (T2DM) is still limited. The objective of this study was to evaluate the association between fruit consumption and cardiovascular risk factors such as carotid intima-media thickness (CIMT) and high-sensitive C-reactive protein (hsCRP) in patients with T2DM. In this cross-sectional study, 407 patients with T2DM were recruited from August 2007 to December 2009. Dietary assessment based on 3-day 24-hour recall interviews, hsCRP levels, and CIMT were examined. Participants were categorized into three tertiles based on fruit intake. Comparisons of the participants' clinical characteristics among the three categories were performed using either one-way analysis of variance or analysis of covariance. In patients with type 2 diabetes with CIMT ≥1 mm, the intake of fruit was lower (P=0.001), whereas the serum hsCRP level was higher (P<0.001) compared with patients showing CIMT <1 mm. Results of the multivariable logistic regression analysis showed that the odds ratios of CIMT and hsCRP were 8% and 31% lower, respectively, in participants in the top tertile compared with those in the lowest tertile (P=0.018 and P<0.001, respectively) after adjustment for potential confounders. Hence, a reduction in hsCRP concentration and CIMT were found to be associated with an increase in fruit intake. Sufficient daily intake of fruits should, therefore, be considered as an important component of a medical nutritional therapy strategy for the prevention of cardiovascular diseases in patients with T2DM.

Incidence of subclinical atherosclerosis in asymptomatic type-2 diabetic patients: the potential of multi-slice computed tomography coronary angiography

BACKGROUND AND OBJECTIVES

Type-2 diabetic patients constitute a high-risk population for atherosclerosis. Primary prevention, although recommended, is not well funded. Our aim was to evaluate the degree of subclinical atherosclerosis, in asymptomatic diabetic patients, using coronary multi-slice computed tomography (MSCT) angiography.

METHODS

We prospectively studied 71 diabetic patients without any symptoms or documentation of atherosclerotic disease. Coronary MSCT angiography was performed in all patients and coronary artery calcium score (CACS) was evaluated. The number of diseased coronary segments was determined and classified as obstructive or nonobstructive and fibrolipid or calcified lesions. The mean follow-up was 29.5±6.6 months. Major adverse cardiovascular events were registered.

RESULTS

The mean age was 59±10 years, 48% were female patients. The duration of diabetes was 12.5±8.7 years. CACS ranged from 0 to 1293 Agatston units (153±269.1). Image quality was generally good, allowing satisfactory evaluation of most of the coronary artery segments. CACS was 0 in 28 patients, but in nine patients MSCT angiography showed fibrolipid plaques. Obstructive coronary artery disease was present in 26.7% of the patients (5.6% with multivessel disease). During the follow-up period, six major adverse cardiovascular events were detected in patients, five of whom had a CACS more than 100 Agatston units.

CONCLUSION

This study shows a high prevalence of silent atherosclerotic lesions in type-2 diabetic patients, reinforcing the importance of risk factor modification even when calcified disease is absent. Coronary MSCT angiography can be performed to identify the atherosclerotic burden and may be an important test in selecting the patients who are benefiting the most from primary prevention.

[Cardial target-organ damage in diabetes]

Coronary heart disease and type 2 diabetes mellitus can be considered as a syntropy. Accordingly, cardiologists and diabetologists should organize an interdisciplinary car of the patient with both cardiac disease and diabetes mellitus. Arterial hypertension is frequently present in the diabetic condition and increases further morbidity and mortality rates due to the involvement of the coronary microcirculation. Coronary artery disease is characterized by a rapid progression and a diffuse distribution particularly in the periphery. Consequently in severe diabetic coronary artery disease coronary bypass surgery should be preferred rather than percutaneous coronary stenting, which should be favored in less severe cases. In the antihyperglycemic treatment a reduction in cardiovascular endpoints has only be documented after metformin. Therapy with thiazolidinediones has been terminated due to an increase in coronary morbidity and mortality under rosiglitazone. In as much glucagon-like peptide-I analogues and dipeptidylpeptidase 4 inhibitors will reduce cardiovascular endpoints has to be waited for. Thus an endpoint orientated antihyperglycemic treatment is limited to insulin, metformin and sulfonylureas.

Impaired glucose tolerance plus hyperlipidaemia induced by diet promotes retina microaneurysms in New Zealand rabbits

With the increasing prevalence of diabetes mellitus and metabolic syndrome worldwide, experimental models are required to better understand the pathophysiology and therapeutic approaches to preserve pancreatic beta cells, attenuate atherosclerosis and protect target organs. The aims of this study were to develop an experimental model of impaired glucose tolerance combined with hypercholesterolaemia induced by diet and assess metabolic alterations and target organ lesions. New Zealand male rabbits were fed high-fat/high-sucrose (10/40%) and cholesterol-enriched diet for 24 weeks, when they were sacrificed. Biochemistry, fundus photographs with fluorescein angiography and pathological analyses were performed. Cholesterol-fed and normal animals of same age were compared.

RESULTS

The animals with diet-induced impaired glucose tolerance combined with hypercholesterolaemia gained weight, increased blood glucose, total cholesterol, LDL-C and triglycerides and decreased HDL-C (P < 0.05 vs. baseline). Fructosamine levels and the homeostasis model assessment of insulin resistance (HOMA-IR) index were increased, while there was a reduction in the HOMA-β (P < 0.05 for all vs. baseline). Histomorphologic findings of this model were aortic atherosclerosis, hepatic steatofibrosis and glomerular macrophage infiltration. Early clinical features of diabetic retinopathy with hyperfluorescent dots consistent with presence of retina microaneurysms were seen since week 12, progressing up to the end of the experiment (P < 0.0005 vs. baseline and 12 weeks). Our model reproduced several metabolic characteristics of human diabetes mellitus and promoted early signs of retinopathy. This non-expensive model is suitable for studying mechanistic pathways and allowing novel strategic approaches.

TLR-4+ peripheral blood monocytes and cardiovascular events in patients with chronic kidney disease--a prospective follow-up study

BACKGROUND

Atherosclerosis is an inflammatory process mediated by circulating immune cells, including monocytes. There is accumulating evidence for the involvement of Toll-like receptor 4 (TLR-4) as a mediator of atherogenesis.

METHODS

We evaluated the association between CD14+/TLR-4+ monocytes in peripheral blood (flow cytometry) and future cardiovascular events (CVE), e.g. myocardial infarction, percutaneous transluminal coronary angioplasty (including stenting), aortocoronary bypass, stroke and angiographically verified stenosis of peripheral arteries and cardiovascular (CV) death, in 191 patients with chronic kidney disease Stage V receiving hemodialysis therapy.

RESULTS

At baseline, CD14+/TLR-4+ monocytes correlated significantly with age (r = 0.2; P = 0.007), high-sensitivity C-reactive protein (r = 0.2; P = 0.008) and mean arterial pressure (r = -0.2; P = 0.02), but not with gender (P = 0.5), smoking (P = 0.6) and the presence of diabetes (P = 0.5). During a median follow-up period of 36 [1-54] months, 79 (41%) patients experienced a CVE. A total of 55 patients died during the follow-up period, 25 of those due to a confirmed CV cause. Log-rank test did not reveal statistical significance for TLR-4+ monocytes concerning incident CVE (P = 0.3), CV death (P = 0.85) and overall death (P = 0.8). In a multiple Cox-regression analysis, we identified age (P = 0.003) and smoking (P = 0.001) as the only independent variables associated with incident CVE.

CONCLUSIONS

Unexpectedly, we could not detect an association between CD14+/TLR-4+ monocytes and incident CVE as well as CV death in stable hemodialysis patients. Further studies have to clarify the potential role of this cell population for CV outcome in this population.

Safety and efficacy of linagliptin as add-on therapy to metformin in patients with type 2 diabetes: a randomized, double-blind, placebo-controlled study

AIM

To evaluate the efficacy and safety of the potent and selective dipeptidyl peptidase-4 (DPP-4) inhibitor linagliptin administered as add-on therapy to metformin in patients with type 2 diabetes with inadequate glycaemic control.

METHODS

This 24-week, randomized, placebo-controlled, double-blind, parallel-group study was carried out in 82 centres in 10 countries. Patients with HbA1c levels of 7.0-10.0% on metformin and a maximum of one additional antidiabetes medication, which was discontinued at screening, continued on metformin ≥1500 mg/day for 6 weeks, including a placebo run-in period of 2 weeks, before being randomized to linagliptin 5 mg once daily (n = 524) or placebo (n = 177) add-on. The primary outcome was the change from baseline in HbA1c after 24 weeks of treatment, evaluated with an analysis of covariance (ANCOVA).

RESULTS

Mean baseline HbA1c and fasting plasma glucose (FPG) were 8.1% and 9.4 mmol/l, respectively. Linagliptin showed significant reductions vs. placebo in adjusted mean changes from baseline of HbA1c (-0.49 vs. 0.15%), FPG (-0.59 vs. 0.58 mmol/l) and 2hPPG (-2.7 vs. 1.0 mmol/l); all p < 0.0001. Hypoglycaemia was rare, occurring in three patients (0.6%) treated with linagliptin and five patients (2.8%) in the placebo group. Body weight did not change significantly from baseline in both groups (-0.5 kg placebo, -0.4 kg linagliptin).

CONCLUSIONS

The addition of linagliptin 5 mg once daily in patients with type 2 diabetes inadequately controlled on metformin resulted in a significant and clinically meaningful improvement in glycaemic control without weight gain or increased risk of hypoglycaemia.

Urinary biomarkers involved in type 2 diabetes: a review

Diabetes mellitus is one of the most challenging health concerns of the 21st century. With at least 30% of the diabetic population remaining undiagnosed, effective and early diagnosis is of critical concern. Development of a diagnostic test, more convenient and reliable than those currently used, would therefore be highly beneficial. Urine as a diagnostic medium allows for non-invasive detection of biomarkers, including some associated with type 2 diabetes and its complications. This review provides a synopsis of those urinary biomarkers that potentially may provide a basis for the development of improved diagnostic tests. Three main pathways for the sourcing of potential makers are identified: kidney damage, oxidative stress and low-grade inflammation including atherosclerosis/vascular damage. This review briefly presents each pathway and some of the most relevant urinary biomarkers that may be used to monitor the development or progression of diabetes and its complications. In particular, biomarkers of renal dysfunction such as transferrin, type IV collagen and N-acetyl-beta-D-glucosaminidase might prove to be more sensitive than urinary albumin, the current gold standard, in the detection of incipient nephropathy and risk assessment of cardiovascular disease. Inflammatory markers including orosomucoid, tumour necrosis factor-alpha, transforming growth factor-beta, vascular endothelial growth factor and monocyte chemoattractant protein-1, as well as oxidative stress markers such as 8-hydroxy-2'deoxyguanosine may also be useful biomarkers for diagnosis or monitoring of diabetic complications, particularly kidney disease. However, the sensitivity of these markers compared with albumin requires further investigation.

Modification of vascular and inflammation biomarkers after OGTT in overweight healthy and diabetic subjects

We evaluated the effect of an oral glucose tolerance test (OGTT) on the level of biomarkers of vascular remodelling. We enrolled 256 Caucasian overweight healthy subjects (H) and 274 overweight type 2 diabetic patients (D). All patients underwent basal measurements of blood glucose (BG), nitrites/nitrates, adiponectin (ADP), matrix metalloproteinase-2 (MMP-2), and matrix metalloproteinase-9 (MMP-9) before and after OGTT. Nitrites/nitrates decrease was present after 60, 90, 120, and 180 min in both groups. Nitrite/nitrate levels were decreased at baseline, after 30 and 60 min in D group compared to H group. ADP decrease was present after 90, 120, and 180 min, in both groups. ADP levels were lower in D group than in H group during OGTT. MMP-2 increase was present after 60, 90, and 120 min in H group, while MMP-2 increase was observed after 90, 120, and 180 min in D group. MMP-2 levels were higher in D group than in H group during OGTT. MMP-9 increase was present in H group after 60, 90, 120, and 180 min, while MMP-9 increase was observed after 90, 120, and 180 min in D group. MMP-9 levels were higher in D group than in H group during OGTT. Postprandial glycemia induces an acute increase in biomarkers of vascular remodelling.

Angiotensin II receptor blocker and statins lower elevated levels of osteopontin in essential hypertension--results from the EUTOPIA trial

BACKGROUND

Osteopontin is a pleiotropic cytokine that has been implicated as a key factor in the development of atherosclerosis, a major complication of hypertension. We have earlier shown that olmesartan reduces mediators of vascular inflammation in patients with hypertension and cardiovascular disease. We aimed at studying the effect of olmesartan and/or pravastatin on osteopontin plasma levels, and the association between vascular inflammation markers and osteopontin in hypertensive patients.

METHODS

We assessed a panel of vascular inflammation markers and osteopontin during 12 weeks of therapy with 20mg olmesartan (n=94) or placebo (n=96) in a prospective, double-blind, multi-center study in patients with essential hypertension (re-evaluation of the EUTOPIA trial blood samples). Pravastatin (20mg) was added to the double-blind therapy at week 6 in both arms. The association of demographic variables and inflammation markers with osteopontin has been analyzed as well.

RESULTS

Baseline osteopontin plasma concentrations in the study population were elevated compared to healthy controls (32.85+/-19.04ng/mL vs. 23.82+/-3.69ng/mL, p=0.027). Mono-therapy with olmesartan and co-therapy with pravastatin reduced levels of circulating osteopontin (p<0.001). The addition of pravastatin to the placebo treatment-arm resulted in a reduction of osteopontin levels as well (p<0.01). osteopontin plasma levels correlated with VCAM-1 (r=0.27; p=0.0002), ICAM-1 (r=0.18; p=0.015), IL-6 (r=0.35; p<0.0001) and hsCRP (r=0.22; p=0.0022).

CONCLUSION

We show, for the first time, that olmesartan significantly decreases osteopontin concentrations. Co-therapy with pravastatin also reduces osteopontin levels. Elevated osteopontin levels in hypertensive patients correlate with adhesion molecules and inflammation markers.

Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach

AIM

To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. BACKGROUND. Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management.

DESIGN

Systematic review.

METHOD

The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage).

RESULTS

Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase.

CONCLUSIONS

Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design.

RELEVANCE TO CLINICAL PRACTICE

To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family.

Sex-dependent impairment of cardiac action potential conduction in type 1 diabetic rats

The incidence of diabetes mellitus is increasing. Cardiac dysfunction often develops, resulting in diverse arrhythmias. These arise from ion channel remodeling or from altered speed and pattern of impulse propagation. Few studies have investigated impulse propagation in the diabetic heart. We previously showed a reduced conduction reserve in the diabetic heart, with associated changes in intercellular gap junctions. The present study investigated whether these effects are sex specific. Hearts from control and streptozotocin-diabetic male and female rats were used. Optical mapping was performed with the voltage-sensitive dye di-4-ANEPPS, using Langendorff-perfused hearts. Isolated ventricular cells and tissue sections were used for immunofluorescent labeling of the gap junction protein connexin43 (Cx43). The gap junction uncoupler heptanol (0.75 mM) or elevated K+ (9 mM, to reduce cell excitability) produced significantly greater slowing of propagation in diabetic males than females. In ovariectomized diabetic females, 9 mM K+ slowed conduction significantly more than in nonovariectomized females. The subcellular redistribution (lateralization) of the gap junction protein Cx43 was smaller in diabetic females. Pretreatment of diabetic males with the angiotensin-converting enzyme inhibitor quinapril reduced Cx43 lateralization and the effects of 9 mM K+ on propagation. In conclusion, the slowing of cardiac impulse propagation in type 1 diabetes is smaller in female rats, partly due to the presence of female sex hormones. This difference is (partly) mediated by sex differences in activation of the cardiac renin-angiotensin system.

Gonadal and adrenal androgen deficiencies as independent predictors of increased cardiovascular mortality in men with type II diabetes mellitus and stable coronary artery disease

BACKGROUND

Age-related decline in circulating androgens in men is associated with poor cardiovascular (CV) outcome. Men with type II diabetes mellitus (DM) are prone to develop androgen deficiency.

OBJECTIVES

We studied the prevalence and prognostic consequences of deficiencies in circulating total and free testosterone (TT, FT) and dehydroepiandrosterone sulphate (DHEAS) in type II DM men with coronary artery disease (CAD).

METHODS

We examined 153 diabetic men with stable CAD (age: 65±9 years). Serum levels of FT were estimated (eFT) from TT and sex hormone binding globulin levels.

RESULTS

TT, eFT and DHEAS deficiencies (serum levels≤the 10th percentile of healthy peers) were found in 22%, 33% and 77% of DM men with CAD, being more frequent than in healthy peers (all p<0.001). During follow-up (median: 19 months), there were 43 (28%) CV deaths. We identified 4 independent predictors of CV mortality: testosterone (TT, eFT) and DHEAS deficiencies, high plasma N-terminal pro-B-type natriuretic peptide (≥2661 pg/mL, upper quartile), high serum high sensitivity C-reactive protein (≥6.58 mg/L, upper quartile) (all p<0.01). There was a graded relation between the number of risk factors and increased CV mortality: hazard risk (95% confidence interval) for 1, 2, 3-4 vs. no risk factors, respectively: 5.9 (0.8-45.6), p=0.09, 9.2 (1.2-69.2), 63.0 (8.0-498.7), p<0.0001 (χ(2)=42.23, p<0.0001).

CONCLUSIONS

In diabetic men with stable CAD, testosterone and DHEAS deficiencies are common and related to high CV mortality. Whether an androgen substitution would improve prognosis in androgen deficient men with type II diabetes and stable CAD, requires further studies.