Transcutaneous oxygen tension as a potential predictor of cardiovascular events in type 2 diabetes: comparison with ankle-brachial index

The risk factors in diabetic foot ulcers and predictive value of prognosis of wound tissue vascular endothelium growth factor

Diabetic foot ulcer (DFU) is a leading cause of high-level amputation in DM patients, with a low wound healing rate and a high incidence of infection. Vascular endothelial growth factor (VEGF) plays an important role in diabetes mellitus (DM) related complications. This study aims to explore the VEGF expression and its predictive value for prognosis in DFU, in order to provide basis for the prevention of DFU related adverse events. We analyzed 502 patients, with 328 in healing group and 174 in non-healing/recurrent group. The general clinical data and laboratory indicators of patients were compared through Spearman correlation analysis, ROC analysis and logistic regression analysis. Finally, the independent risk factors for adverse prognosis in DFU patients were confirmed. Spearman analysis reveals a positive correlation between the DFU healing rate and ABI, VEGF in wound tissue, and positive rate of VEGF expression, and a negative correlation with DM duration, FPG, HbA1c, TC, Scr, BUN, and serum VEGF. Further logistic regression analysis finds that the DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for adverse prognosis in DFU (p < 0.05). DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for prognosis in DFU patients. Patients with these risk factors should be screened in time, which is of great significance to prevent DFU related adverse events and improve outcomes.

Diabetic foot ulcer is associated with cardiovascular-related mortality and morbidity - a systematic review and meta-analysis of 8062 patients

OBJECTIVES

To conduct a systematic review and meta-analysis of prevalence of cardiovascular-related morbidity and mortality in patients with diabetic foot ulcers (DFU), as well as compare risks of cardiovascular-related morbidity and mortality between diabetic patients with and without DFU.

METHODS

A systematic search was conducted on Medline, Embase, and Cochrane databases for randomized controlled trials and observational studies which explored the association between DFU and cardiovascular-related morbidity & mortality, or compared differences in hazard ratios of cardiovascular diseases between diabetics with and without DFU. Frequentist, pairwise meta-analysis was performed on studies with two comparator arms, whereas single-arm studies reporting pooled incidences of cardiovascular-related mortality and morbidity were calculated based on exact binomial distributions. A random-effect meta-analysis model was used with heterogenicity of studies assessed using I2, τ2, and χ2 statistics.

RESULTS

10 studies were identified and included in the systematic review & meta-analysis of 8602 patients. DFU was consistently found to have significant association with cardiovascular-related morbidity and mortality, with pooled prevalences of all cause cardiovascular-related morbidity (37.1%), IHD (44.7%), CHF (25.1%), CAD (11.7%), and CVA (10.9%), and all cause cardiovascular-related mortality (14.6%), fatal IHD (6.2%), fatal CHF (3.67%), fatal CAD (7.92%), and fatal CVA (1.99%). Diabetic patients with DFU were found to have significantly increased risk of IHD (RR 1.25), CVA (RR 2.03), and all-cause cardiovascular-related mortality (RR 2.59) compared to those without DFU.

CONCLUSIONS

The presence of DFU is associated with major adverse cardiac events. The alarming rates of cardiovascular-related morbidity and mortality in DFU patients highlight its potential role as a marker of cardiovascular complications and should prompt early clinical investigation and management.

Therapeutic patient education and treatment intensification of diabetes and hypertension in subjects with newly diagnosed type 2 diabetes mellitus: a longitudinal study

PURPOSE

The aim of this study is to prospectively evaluate whether individual and group Therapeutic Patient Education (TPE) can reduce the need to intensify treatment of diabetes and hypertension in newly diagnosed type 2 diabetic patients.

METHODS

A total of 937 patients were recruited and followed-up for 42.7 ± 21.5 months. TPE was a structured comprehensive education delivered by trained nurses: 322 patients received individual TPE (ITPE), 291 underwent group TPE (GTPE), and 324 were in Usual Care (UC). The primary endpoints were intensification of diabetes treatment and intensification of hypertension treatment.

RESULTS

The rate of diabetes treatment intensification was 40.1% in patients receiving ITPE, 47.8% in patients undergoing GTPE, and 64.2% in patients in UC (p < 0.001). The rate of hypertension treatment intensification was 24.2% in patients following ITPE, 31.3% in patients receiving GTPE, and 41.0% in patients in UC (p < 0.001). Multivariate analysis showed that both ITPE and GTPE were associated with reduced intensification of diabetes (ITPE: HR:0.51; 95% IC:0.40-0.64; p < 0.001 - GTPE: HR:0.46; 95% IC:0.44-0.70; p < 0.001) and hypertension medication (ITPE: HR:0.45; 95% IC:0.34-0.61; p < 0.001 - GTPE: HR:0.49; 95% IC:0.38-0.65; p < 0.001). The association was independent of age, sex, BMI, HbA1c, and presence of hypertension at baseline.

CONCLUSIONS

TPE, delivered as both individual and group sessions, represents an effective tool to reduce the need to intensify treatment of both diabetes and hypertension. Therefore, it can ensure better control of diabetes and hypertension with fewer medications. This could reduce adverse effects and costs and improve quality of life and medication taking in patients with type 2 diabetes.

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Effects of Blood Flow Restriction Resistance Training on Autonomic and Endothelial Function in Persons with Parkinson's Disease

Background

Autonomic dysfunction precedes endothelial dysfunction in Parkinson's disease (PD) and causes blood pressure and circulation abnormalities that are highly disruptive to one's quality of life. While exercise interventions have proven helpful for motor symptoms of PD, improving associated non-motor symptoms is limited. Low-intensity resistance training with blood flow restriction (LIRT-BFR) improves autonomic dysfunction in non-PD patients and high-intensity resistance training (HIRT) is recommended for motor symptom improvements for people with PD (PwPD).

Objective

To determine the effects of LIRT-BFR and HIRT on homocysteine and autonomic and endothelial function in PwPD and to determine the hemodynamic loads during LIRT-BFR and HIRT in PwPD using a novel exercise protocol.

Methods

Thirty-eight PwPD were assigned LIRT-BFR, HIRT or to a control (CNTRL) group. The LIRT-BFR and HIRT groups exercised three days per week for four weeks. The LIRT-BFR protocol used 60% limb occlusion pressure (LOP) and performed three sets of 20 repetitions at 20% of the one-repetition maximum (1RM). The HIRT group performed three sets of eight repetitions at 80% 1RM. The CNTRL group was asked to continue their normal daily routines.

Results

LIRT-BFR significantly improved orthostatic hypotension (p = 0.026), homocysteine levels (p < 0.001), peripheral circulation (p = 0.003), supine blood pressure (p = 0.028) and heart rate variability (p = 0.041); LIRT-BFR improved homocysteine levels (p < 0.018), peripheral circulation (p = 0.005), supine blood pressure (p = 0.007) and heart rate variability (p = 0.047) more than HIRT; and hemodynamic loads for LIRT-BFR and HIRT were similar.

Conclusions

LIRT-BFR may be more effective than HIRT for autonomic and endothelial function improvements in PwPD and hemodynamic loads may be lessened in LIRT-BFR protocols using single-joint exercises with intermittent blood flow restriction. Further research is needed to determine if non-motor symptoms improve over time and if results are sustainable.

Does the advantage of transcutaneous oximetry measurements in diabetic foot ulcer apply equally to free flap reconstruction?

BACKGROUND

Transcutaneous oxygen pressure (TcpO₂) is a precise method for determining oxygen perfusion in wounded tissues. The device uses either electrochemical or optical sensors.

AIM

To evaluate the usefulness of TcpO₂ measurements on free flaps (FFs) in diabetic foot ulcers (DFUs).

METHODS

TcpO₂ was measured in 17 patients with DFUs who underwent anterolateral thigh (ALT)-FF surgery and compared with 30 patients with DFU without FF surgery.

RESULTS

Significant differences were observed in the ankle-brachial index; duration of diabetes; and haemoglobin, creatinine, and C-reactive protein levels between the two groups. TcpO₂ values were similar between two groups except on postoperative days 30 and 60 when the values in the ALT-FF group remained < 30 mmHg and did not increase > 50 mmHg.

CONCLUSION

Even if the flap is clinically stable, sympathectomy due to adventitia stripping during anastomosis and arteriovenous shunt progression due to diabetic polyneuropathy could lead to low TcpO₂ values in the ALT-FF owing to its thick fat tissues, which is supported by the slow recovery of the sympathetic tone following FF. Therefore, TcpO₂ measurements in patients with DFU who underwent FF reconstruction may be less accurate than in those who did not.

Autologous Bone Marrow Stem Cells in Patients With Critical Limb Ischaemia not Eligible for Revascularization: A Single Centre Experience

We evaluated the use of autologus bone marrow stem cells transplantation in patients with critical limb ischaemia (CLI) not eligible for revascularization. Eighty consecutive patients candidate to amputation were enrolled in a single-centre retrospective study. The primary endpoint was defined as the amputation-free rate from stem cells transplantation. Secondary endpoints were the evaluation of transcutaneous oximetry and its predictive potential for probability of amputation and the evaluation of rest pain. Ankle brachial index, transcutaneous oxygen (TcpO2) and radiological imaging were performed at the enrolment and during the follow-up times. All patients were treated with auto transplant of bone marrow stem cells. Two patients died due to acute renal and acute respiratory failures. 19 patients were amputated from the thigh or leg. In total, 59 of 80 patients intended to thigh amputation saved the limb, preserving the plantar support. TcpO2 was found a predictive metric with an AUC equal to .763, and a threshold for a risk of amputation of 10% and 5% at the values ≤22.7 and ≤26.9 mmHg, respectively. Auto transplant of bone marrow stem cells seems to be a safe and an efficient option for CLI not eligible to revascularizzation.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Correlation of ACR and TcPO2 in diabetic kidney disease patients: A pilot study

OBJECTIVE

Transcutaneous oxygen pressure (TcPO2) is used to assess microcirculation clinically; however, it is not widely available especially in rural hospital. The study was designed to explore potential alternatively biomarkers to assess microcirculation in diabetic kidney disease (DKD).

METHODS

A total of 404 patients from Xuzhou first hospital were recruited according to the case records system. Patients were grouped via the ratio of albuminuria and creatinine (ACR; <30 mg/g, 30-300 mg/g, >300 mg/g). Biomarkers in different ACR groups were compared by analysis of variance. Correlation analysis was determined by Pearson or Spearman analysis and binary logistic regression. The receiver operating characteristics (ROC) curve was performed to elucidate the prediction effect of ACR on TcPO2.

RESULTS

A total of 404 diabetic patients were recruited with 248 patients diagnosed as DKD and 156 non-DKDs. Age and cystatin C were significantly higher in the ACR3 group compared with those in the ACR1 group, whereas glomerular filtration rate, low-density lipoprotein cholesterol, and TcPO2 were markedly decreased in the ACR3 group (p < .05). Frequency of low TcPO2 (<40 mm Hg) was markedly increased as increment of ACR stages with 30.2% in the ACR3 group (p < .01). There was a negative correlation between TcPO2 and age, ACR, chronic kidney disease (CKD), fast blood glucose, diabetes mellitus (DM) duration, and diabetic neuropathy. Further, binary logistic regression showed ACR was an independent influence factor for low TcPO2. After adjusting for age, gender, hypertension, DM duration, body mass index, glycated hemoglobin, diabetic neuropathy, and CKD, ACR was still an independent influence factor for TcPO2 (odds ratio = 2.464, p < .01). The area under the ROC curve was 0.768 (95% confidence interval: 0.700-0.836, p < .001) for ACR. The analysis of ROC curves revealed a best cutoff for ACR was 75.25 mg/g and yielded a sensitivity of 71.7% and a specificity of 71.7%.

CONCLUSIONS

ACR could be used as an alternative biomarker for assessing microcirculation in DKD patients.

Impact of microvascular complications on the outcomes of diabetic foot in type 2 diabetic patients with documented peripheral artery disease

PURPOSE

Microvascular disease (MVD) is associated with amputation linked to peripheral artery disease (PAD) in the general population. No study evaluated the impact of diabetic microvascular complications on the outcomes of vascular diabetic foot ulcers (DFU). The aim of the study was to investigate whether retinopathy, nephropathy, and polyneuropathy can predict the outcomes of DFU in type 2 diabetic patients with PAD.

METHODS

Three hundred and thirty-one consecutive patients with vascular DFU were enrolled and followed up for 44.1 ± 23.9 months.

RESULTS

The prevalence of retinopathy was significantly higher in subjects with ulcer persistence (45.2%; p < 0.01), minor amputation (48.9%; p < 0.001), and major amputation (57.9%; p < 0.001) than in healed patients (23.3%), and in non-survivors than in survivors (64.9 versus 20.5%; p < 0.001). The prevalence of nephropathy was significantly greater in subjects with ulcer persistence (83.9%; p < 0.01), minor amputation (86.7%; p < 0.001), and major amputation (94.7%; p < 0.001) than in those with healed DFU (64.4%), and in non-survivors than in survivors (88.3 versus 65.7%; p < 0.001). The prevalence of polyneuropathy was significantly higher in non-survivors than in survivors (76.6 versus 61.0%; p = 0.012). Multivariate analysis showed that absence of retinopathy (OR: 0.451; 95% CI: 0.250-0.815; p < 0.001) and nephropathy (OR: 0.450; 95% CI: 0.212-0.951; p = 0.036) were independently associated with healing. Moreover, retinopathy was a predictor both of minor amputation (OR: 2.291; 95% CI: 1.061-4.949; p = 0.034) and mortality (OR: 5.274; 95% CI: 2.524-11.020; p < 0.001). Polyneuropathy never entered the regression model.

CONCLUSIONS

Diabetic microvascular complications, in particular retinopathy, may predict the outcomes of vascular DFU. Longitudinal studies should confirm this finding.

Comparison of resting/postexercise ankle-brachial index and transcutaneous partial pressure of oxygen for noninvasive diagnosis of peripheral artery disease in type 2 diabetes mellitus

Background Type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a strong risk factor for peripheral artery disease (PAD) and PAD diagnosis in T2DM may indicate coexisting coronary artery disease as well. Postexercise ankle brachial index (ABI) and transcutaneous partial pressure of oxygen (TcPO2) have not been evaluated for PAD diagnosis among Indian T2DM patients. This study aimed to evaluate the performance of resting + postexercise(R + PE) ABI and R + PE-TcPO2 for PAD diagnosis among T2DM patients at increased PAD risk, using colour duplex ultrasound (CDU) as reference standard.

Methods

This prospectively conducted diagnostic accuracy study involved T2DM patients at increased PAD risk. R-ABI≤0.9 or PE-ABI decline >20% from resting value in those with R-ABI between 0.91 and 1.4, R-TcPO2 <30 mm Hg or PE decline of TcPO2 to <30 mm Hg in those with R-TcPO2 ≥30 mm Hg, CDU showing >50% stenosis or complete occlusion of lower extremity arteries constituted PAD.

Results

Among 168 patients enrolled, R + PE-ABI diagnosed PAD in 19(11.3%), R + PE-TcPO2 in 61 (36.3%) and 17 (≈10%) had PAD finally confirmed by CDU. Sensitivity, specificity, PPV and NPV of R + PE-ABI for PAD diagnosis were 82.3%, 96.7%, 73.7% and 98% and that of R + PE-TcPO2 were 76.5%, 68.2%, 21.3% and 96.2%, respectively. PE-ABI increased the sensitivity of ABI by ≈ 18% and had 100% PPV for PAD. When both ABI and TcPO2 (R + PE tests) were normal, PAD could be safely excluded in 88% of patients.

Conclusion

PE-ABI should be routinely employed and TcPO2(R/PE) is unreliable as a stand-alone test for PAD detection among moderate to high risk T2DM patients.

Association of erectile dysfunction with diabetic foot and its outcomes in type 2 diabetic men

PURPOSE

Erectile dysfunction (ED) and diabetic foot (DF) are common complications in patients with diabetes. However, the relationship between ED and DF has been little studied. In particular, no study has evaluated whether ED is associated with the outcomes of DF. The aim of this retrospective cohort study was to investigate whether ED is a predictor of the outcomes of DF in a large population of men with DF.

METHODS

Three hundred and twenty-six consecutive men with type 2 diabetes and a recent and single DF ulcer were recruited and followed up for 41.7 ± 22.7 months.

RESULTS

Among men with DF, 56.1% had ED (ED group) and 43.9% did not (NO ED group). Wound healing rate was significantly higher in the NO ED than in the ED group (90.2 versus 73.3%; p = 0.0001). Minor amputation rate (13.7 versus 4.8%; p = 0.007) and mortality (25.7 versus 0.7%; p < 0.001) were significantly greater in the ED than in the NO ED group. Among 263 patients with healed ulcers, recurrence rate was significantly higher in the ED than in the NO ED group (51.5 versus 26.3%; p < 0.001). Multivariate analysis showed that the absence of ED was associated with wound healing (OR: 0.459; 95% CI: 0.213-0.993; p = 0.048), while the presence of ED predicted mortality (OR: 22.644; 95% CI: 2.976-34.271; p = 0.002) and DF recurrence (OR: 3.498; 95% CI: 1.882-6.499; p < 0.001).

CONCLUSIONS

Our data show that among men with DF the prevalence of ED is very high. Moreover, ED may be a strong predictor of wound healing, mortality, and ulcer recurrence.

A Comprehensive Therapeutic Patient Education May Improve Wound Healing and Reduce Ulcer Recurrence and Mortality in Persons With Type 2 Diabetes

OBJECTIVES

The impact of a comprehensive therapeutic patient education (TPE) on the prognosis of diabetic foot ulcer (DFU) has not yet been evaluated in the literature. The purpose of this study was to determine whether TPE is a predictor of outcome in type 2 diabetes patients with DFU.

METHODS

We evaluated 583 consecutive individuals with a recent and single DFU. They were treated and followed for 42.8±23.3 months. Patients were divided into 2 groups. The TPE group included subjects who had been receiving regular sessions of a comprehensive TPE, including a specific foot care education (FCE), for at least 12 months before DFU occurred (n=129). The non-TPE group comprised the remaining subjects (n=454). All 583 patients received intensive FCE during the treatment period.

RESULTS

We identified a significantly higher percentage of healed DFUs (96.0% vs 74.9%; p<0.0001) and a lower percentage of major amputations (0.8% vs 4.4%; p=0.0511), minor amputations (1.6% vs 12.3%; p=0.0003), DFU persistence (1.6% vs 8.4%; p=0.0069) and deaths (1.6% vs 21.4%; p<0.0001) in the TPE group than in the non-TPE group. Among 464 patients with healed ulcers, the proportion of subjects with re-ulceration was greater in the non-TPE group than in the TPE group (48.8% vs 6.5%; p<0.0001). Multivariate analysis showed that TPE can predict healing (odds ratio [OR], 4.202; 95% confidence interval [CI], 1.604 to 11.004; p=0.0035) and may significantly reduce DFU recurrence (OR, 0.093; 95% CI, 0.043 to 0.201; p<0.0001) and mortality (OR, 0.096; 95% CI, 0.022 to 0.410; p=0.0016).

CONCLUSION

A comprehensive TPE may have a positive impact on wound healing, ulcer recurrence and mortality in people with DFU.

Clinical Characteristics of Lower-Limb Ischemia in Japanese Patients with Type 2 Diabetes and Usefulness of the Great Toe Blood Flow as a Predictive Indicator of Leg Arterial Obstruction

Nurses are required to make quantitative, evidence-based observations when implementing diabetic foot care. This study aimed to clarify the characteristics of lower-limb ischemia in patients with type 2 diabetes using subjective and objective symptoms and physiological indicators and whether the physiological characteristics are established as predictive indicators of arterial obstruction. Fifty Japanese patients with type 2 diabetes (100 limbs) were classified into three groups using the ankle–brachial index (ABI). Patients with an ABI of ≤0.69 had subjective and objective symptoms of blood flow disturbance, such as pain at rest, cold sensation, pale skin, and imperceptibility to the dorsalis pedis artery. Blood flow in the first toe was the lowest. Binary logistic regression analysis established hallux perfusion as a predictive model for lower-limb arterial occlusion (odds ratio = 0.979, 95% confidence interval 0.900–0.999). Thus, when nurses perform diabetic foot care, it is necessary to evaluate not only subjective and objective symptoms, but also blood flow at the microcirculatory level of the great toe.

The combined impact of ankle-brachial index and transcutaneous oxygen pressure on mortality in patients with type 2 diabetes and foot ulcers

AIMS

A diabetic foot ulcer (DFU) is associated with increased cardiovascular risk and mortality, independently of ulcer etiology (ischemic, neuro-ischemic or neuropathic). Ankle-brachial index (ABI) is the most commonly used test when diagnosing peripheral macrovascular disease and is a well-known marker for increased cardiovascular risk. Transcutaneous oxygen pressure (TcPO₂) is considered to better evaluate microvascular function and has in previous studies shown correlations with both wound healing and survival. The aim of this study was to evaluate the combined impact of a low TcPO₂ (<30 mmHg) and a pathological ABI (<0.9 or ≥1.4) on three-year mortality in patients with DFU.

METHODS

Type 2 diabetes patients aged <90 years, with at least one DFU who underwent vascular assessment with ABI and TcPO₂ were screened for participation. The primary endpoint was mortality after three years, assessed from the National Death Registry in Sweden.

RESULTS

The study enrolled 235 participants with a median age of 76 years. Individuals with either an abnormally high or low ABI in combination with a low TcPO₂ had the worst survival rates, with three-year mortality of 54%, compared to 42% in those with one abnormal variable (either ABI or TcPO₂), and 21% in those with normal ABI and TcPO₂.

CONCLUSIONS

Combining ABI and TcPO₂ when risk stratifying DFU patients seems to provide additional predictive information, not only concerning ulcer healing and limb salvage, but also on survival.

Predictors of healing, ulcer recurrence and persistence, amputation and mortality in type 2 diabetic patients with diabetic foot: a 10-year retrospective cohort study

PURPOSE

Predictors of outcome of diabetic foot ulcer (DFU) are important to improve the management of patients. Aim of the study was to find these predictors in type 2 diabetic patients with DFU.

METHODS

We recruited 583 patients. They were followed-up by a multidisciplinary team. A holistic and conservative approach was used and all risk factors and co-morbidities were aggressively treated.

RESULTS

During the follow-up period, 79.6% of patients healed in a mean time of 7.6 ± 3.8 months, 6.9% showed DFU persistence, 9.9% had minor amputations, and 3.6% experienced major amputation. Seventeen percent of the patients died. Among patients who healed, 37.1% of them showed DFU recurrence. Impairment of renal function was associated to DFU persistence, amputation, and mortality. Previous cardiovascular disease predicted DFU persistence, DFU recurrence, and mortality. Lower BMI predicted DFU persistence and mortality. Osteomyelitis was a predictor of amputation and death. Markers of peripheral artery disease (PAD) predicted minor amputation and DFU recurrence. Our study shows a relatively low incidence of complications of DFU.

CONCLUSIONS

Some predictors of outcome of DFU were confirmed and new predictors, like BMI and markers of PAD, were found. Our new findings suggest future strategies for nutrition support and revascularization. In addition, a holistic and conservative approach may improve the prognosis.

A paintable phosphorescent bandage for postoperative tissue oxygen assessment in DIEP flap reconstruction

Flaps are common in plastic surgery to reconstruct large tissue defects in cases such as trauma or cancer. However, most tissue oximeters used for monitoring ischemia in postoperative flaps are bulky, wired devices, which hinder direct flap observation. Here, we present the results of a clinical trial using a previously untried paintable transparent phosphorescent bandage to assess the tissue's partial pressure of oxygen (pO2). Statistical analysis revealed a strong relationship (P < 0.0001) between the rates of change of tissue oxygenation measured by the bandage and blood oxygen saturation (%stO2) readings from a standard-of-care ViOptix near-infrared spectroscopy oximeter. In addition, the oxygen-sensing bandage showed no adverse effects, proved easy handling, and yielded bright images across all skin tones with a digital single-lens reflex (DSLR) camera. This demonstrates the feasibility of using phosphorescent materials to monitor flaps postoperatively and lays the groundwork for future exploration in other tissue oxygen sensing applications.

Characteristics and Outcomes of Patients With Diabetes Mellitus Undergoing Peripheral Vascular Intervention for Infrainguinal Symptomatic Peripheral Artery Disease

PURPOSE

Patients with diabetes mellitus (DM) are known to be at higher risk for peripheral artery disease (PAD), amputations, and major adverse cardiovascular events, though it is unclear whether they are at any higher risk for repeat intervention. LIBERTY 360 offered an opportunity to study a real-world cohort of patients who underwent distal superficial femoral artery endovascular revascularizations. We aimed to describe patients with DM, their outcomes following peripheral vascular intervention, and the effect of DM on outcomes in the LIBERTY 360 cohort.

METHODS

LIBERTY 360 is a prospective, multi-center, non-randomized, mono-industry funded observational study of patients undergoing endovascular revascularization. Outcomes included 30-day and 1-year all-cause mortality, major amputation, target vessel/lesion revascularization, and a composite of those events. A multivariable regression model including DM was constructed to examine the effect of DM on outcomes. Multivariable survival estimates were made using Cox proportional hazards models.

RESULTS

A total of 1,204 patients were enrolled, of whom 727 had DM (60.4%). Patients with DM had significantly more comorbidities and a third required insulin for DM management. Patients with DM had more severe disease based on Rutherford classification at baseline. After adjusting for comorbidities and disease severity, DM patients had more frequent major amputations at 1 year (5.2% versus 1.2%; HR 2.71, 95%CI 1.05-6.98, p = 0.040). The 1-year rates of all-cause mortality and target vessel/lesion revascularization were not significantly higher for patients with DM.

CONCLUSIONS

Diabetes mellitus was associated with increased major amputations at 1 year following endovascular revascularization after accounting for demographics, comorbidities, and PAD-related characteristics. Further research is needed to determine which aspects of PAD and DM are most strongly associated with poor outcomes following lower extremity revascularization.

Simultaneous R2, R2' and R2* measurement of skeletal muscle in a rabbit model of unilateral artery embolization

PURPOSE

To demonstrate the feasibility of using a susceptibility-based MRI technique with multi-echo gradient and spin echo (MEGSE) sequence to achieve simultaneous R2, R2' and R2* measurement and assess skeletal muscle oxygenation alternations in a rabbit model of unilateral artery embolization.

MATERIALS AND METHODS

Approved by the local institutional review board for experimental animal studies, nine New Zealand White rabbits were included in this study. The MEGSE sequence consists of embedding a set of gradient echoes around the echo of a single spin-echo sequence using several gradient echoes to collect the magnetization intensity during the formation and attenuation of spin-echo simultaneously after 180° radio frequency pulse. Within-session and between-day tests were conducted to evaluate the reproducibility of this skeletal muscle oxygenation alternations measurement. Furthermore, all the MEGSE scans of skeletal muscle were conducted using a 3-T clinical MRI scanner during resting state (before unilateral artery embolization operation, pre), 1 h after unilateral artery embolization operation (post1) and 2 h after unilateral artery embolization operation (post2) model to verify the feasibility and sensitivity of this method.

RESULTS

The within-session coefficient of variations (CVs) of R2, R2' and R2* measurements were 1.57%, 3.33% and 2.57%, while the between-day CVs of were 1.42%, 5.85% and 2.85%. In all rabbits, the mean R2 decreased significantly from 36.46 ± 1.03 s^-1 (pre) to 30.58 ± 2.11 s^-1 (post1,**P < 0.01, relative to pre) and 28.62 ± 1.53 s^-1 (post2, **P < 0.01, relative to post1), and the mean R2' went up markedly from 9.88 ± 2.14 s^-1 (pre) to 16.10 ± 2.74 s^-1 (post1, **P < 0.01) and 17.33 ± 2.25 s^-1 (post2, **P < 0.05). The mean R2* increased from 43.27 ± 3.75 s^-1 (pre) to 47.90 ± 5.08 s^-1 (post1, *P < 0.05) and to 48.04 ± 4.42 s^-1 (post2, NS, P > 0.05).

CONCLUSION

This study demonstrates the feasibility of simultaneous R2, R2' and R2* measurement method for the evaluation of skeletal muscle ischemia. Besides, this study indicates the sensitivity of the R2 and R2' compared with R2* and especially the necessity of R2 and R2' measurement for the further evaluation of skeletal muscle ischemia which always causes both edema and hypoxia in a rabbit model of unilateral artery embolization.

The association of diabetic microvascular and macrovascular disease with cutaneous circulation in patients with type 2 diabetes mellitus

AIMS

To study the impact of diabetic neuropathy, both peripheral sensorimotor (DPN) and cardiac autonomic neuropathy (CAN), on transcutaneous oxygen tension (TcPO₂) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 163 participants were recruited; 100 with T2DM and 63 healthy individuals. Peripheral arterial disease (PAD) was defined as ankle-brachial index (ABI) values ≤0.90. Diagnosis of DPN was based on neuropathy symptom score and neuropathy disability score (NDS), while diagnosis of CAN on the battery of the cardiovascular autonomic function tests. TcPO₂ was measured using a TCM30 system.

RESULTS

Patients with T2DM had lower TcPO₂ levels when compared with healthy individuals. Among the diabetic cohort, those who had either PAD, DPN or CAN had significantly lower TcPO₂ values than participants without these complications. Multivariate linear regression analysis, after controlling for diabetes duration, diastolic blood pressure, HbA1c, albumin to creatinine ratio and CAN score, demonstrated that TcPO₂ levels were significantly and independently associated with current smoking (p = 0.013), ABI (p = 0.003), and NDS (p = 0.013).

CONCLUSION

Presence of DPN is independently associated with impaired cutaneous perfusion. Low TcPO₂ in subjects with DPN may contribute to delay in healing of diabetic foot ulcers, irrespectively of PAD.

Transmucosal oxygen tension of the clitoris: a new parameter for future investigations of the sexual, metabolic, and cardiovascular health of women

BACKGROUND

Several studies suggested that abnormalities in tissue perfusion of external genitalia and vagina can lead to female sexual dysfunctions (FSDs) and can be associated to metabolic and cardiovascular risk factors. However, there are some technical difficulties in assessing these abnormalities. The measurement of oxygen partial pressure is a noninvasive method to measure oxygen partial pressure (pO₂) at the skin surface to assess tissue perfusion. The aim of this study was to evaluate whether transmucosal oxygen tension (TmPO₂) can be measured at the mucosal surface of clitoris and whether the measurements are reliable.

METHODS

TmPO₂ was measured in six young healthy women by using a device to measure transcutaneous pO₂ on the skin and by choosing a small sensor, usually used for newborns. The identical procedure for the detection of pO₂ at the skin surface was used.

RESULTS

The mean value of TmPO₂ was 42.3 mmHg (range: 24.1-53.4 mmHg). All the trend curves of the TmPO₂ showed the same behavior: after a stabilization time, there was a stable pO₂ (plateau phase) that corresponds to the TmPO₂ of the clitoris. These curves had a similar trend to those recorded at the skin surface.

CONCLUSIONS

TmPO₂ can be easily measured at the mucosal surface of clitoris. Large epidemiological studies in healthy and unhealthy women and in women with FSD are needed to establish both the normal range of TmPO₂ and the meaning that different values of TmPO₂ can have on sexual and general health of the women.

Prognostic impact of the ankle-brachial index on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

AIMS/HYPOTHESIS

The prognostic importance of the ankle-brachial index (ABI) in individuals with diabetes is controversial. We aimed to evaluate the relationship between the ABI and the occurrence of micro- and macrovascular complications in individuals with type 2 diabetes.

METHODS

The ABI was measured at baseline in 668 individuals with type 2 diabetes, and the individuals were followed-up for a median of 10 years. Multivariate Cox analysis was used to examine associations between the ABI and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration and peripheral neuropathy) and macrovascular (total cardiovascular events, major adverse cardiovascular events [MACE] and cardiovascular mortality) complications, and all-cause mortality. The improvement in risk stratification was assessed using the C statistic and the integrated discrimination improvement (IDI) index.

RESULTS

During follow-up, 168 individuals had a cardiovascular event (140 MACE) and 191 individuals died (92 cardiovascular deaths); 156 individuals newly developed or experienced worsening diabetic retinopathy, 194 achieved the renal composite outcome (122 with newly developed microalbuminuria and 93 with deteriorating renal function) and 95 newly developed or experienced worsening peripheral neuropathy. The ABI, either analysed as a continuous or as a categorical variable, was significantly associated with all macrovascular and mortality outcomes, except for non-cardiovascular mortality. Individuals with a baseline ABI of ≤0.90 had a 2.1-fold increased risk of all-cause mortality (95% CI 1.3, 3.5; p = 0.004), a 2.7-fold excess risk of cardiovascular mortality (95% CI 1.4, 5.4; p = 0.004) and a 2.5-fold increased risk of MACE (95% CI 1.5, 4.4; p = 0.001). The ABI improved risk discrimination over classical risk factors, with relative IDIs ranging from 6.3% (for all-cause mortality) to 31% (for cardiovascular mortality). In addition, an ABI of ≤0.90 was associated with the development or worsening of peripheral neuropathy (2.1-fold increased risk [95% CI 1.1, 4.3]; p = 0.033), but not with retinopathy or renal outcomes.

CONCLUSIONS/INTERPRETATION

A low ABI is associated with excess risk of adverse cardiovascular outcomes, mortality and peripheral neuropathy development or worsening, and improves cardiovascular risk stratification. The ABI should therefore be routinely evaluated in individuals with type 2 diabetes.

Transcutaneous oxygen pressure as a predictor for short-term survival in patients with type 2 diabetes and foot ulcers: a comparison with ankle-brachial index and toe blood pressure

AIMS

Ankle-brachial index (ABI) is the most commonly used test when diagnosing peripheral vascular disease and is considered a marker for cardiovascular risk. Transcutaneous oxygen pressure (TcPO₂), a test associated with microvascular function, has in several studies shown better correlation with diabetic foot ulcer (DFU) healing. Whether a low TcPO₂ could be a marker for mortality in the high-risk population of DFU patients has not been evaluated before. The aim of this study was to evaluate the predictive value of TcPO₂ in comparison with ABI and toe blood pressure (TBP) on 1-year mortality in type 2 diabetes patients with DFU.

METHODS

Type 2 diabetes patients aged ≤ 90 years, with one DFU who attended our multidisciplinary DFU-unit during year 2013-2015 and were screened with TcPO₂, ABI and TBP were retrospectively evaluated. One-year mortality was assessed from the national death register in Sweden.

RESULTS

A total of 236 patients (30% women) with a median age of 76 (69-82) years were evaluated in this study. Within 1 year, 14.8% of the patients died. TcPO₂ < 25 mmHg was associated with a higher 1-year mortality compared with TcPO₂ ≥ 25 mmHg (27.7 vs. 11.6%, p = 0.003). TBP and ABI did not significantly influence 1-year mortality. In a Cox regression analysis adjusted for confounders, TcPO₂ was independently predicting 1-year mortality with a hazard ratio for TcPO₂ < 25 mmHg of 2.8 (95% CI 1.34-5.91, p = 0.006).

CONCLUSIONS

This study indicates that a low TcPO₂ is an independent prognostic marker for 1-year mortality among patients with type 2 diabetes and DFU.

Role of structured individual patient education in the prevention of vascular complications in newly diagnosed type 2 diabetes: the INdividual Therapeutic Education in Newly Diagnosed type 2 diabetes (INTEND) randomized controlled trial

OBJECTIVE

Recent studies showed that a structured patient therapeutic education (PTE) may decrease both mortality and the development of diabetes complications. Nevertheless, no data are available in the literature on the impact of individual PTE on the complications in newly diagnosed type 2 diabetic patients. Aim of the present randomized controlled trial is to evaluate the impact of individual PTE on the occurrence of macrovascular complications in newly diagnosed type 2 diabetic patients when compared to usual care (UC) and group PTE.

DESIGN AND METHODS

Six hundred newly diagnosed type 2 diabetic patients will be enrolled. The patients will be randomly assigned to one of these three groups: individual PTE, group PTE and UC. A comprehensive and complete PTE will be delivered to all the patients: PTE will include eleven themes. Primary composite endpoint of the study is occurrence of vascular complications, including cardiovascular death, non fatal coronary disease, non fatal stroke, peripheral artery disease. Secondary endpoints are: foot ulcers, amputations, sexual dysfunction, quality of life, microvascular complications, bone health, intensification of diabetes and hypertension therapy.

RESULTS AND CONCLUSIONS

The present trial can give precious information on the features for the most effective PTE.

The correlation between transcutaneous oxygen tension and microvascular complications in type 2 diabetic patients

AIMS

This study aimed to assess whether transcutaneous oxygen tension (TcPO₂) was associated with the presence of microvascular complications in type 2 diabetic (T2D) patients and whether TcPO₂ could act as an independent risk factor for predicting the occurrence of microvascular events in these patients.

METHODS

We recruited 436 patients with T2D. Based on the presence of diabetic kidney disease, diabetic retinopathy, and/or diabetic peripheral neuropathy, the patients were divided into groups with and without microvascular complications. The differences between these 2 groups were examined using the chi-square test and the t test. The influencing factors of diabetic microangiopathy were studied using a logistic regression analysis.

RESULTS

The results showed that sex, diabetes duration, smoking history, TcPO₂, and HbA1c were independent risk factors for the occurrence of diabetic microvascular events (P<0.05). In particular, the risk of developing microvascular complications was 10.16 times higher in patients with low TcPO₂ than that in those with high TcPO₂ (OR=10.157, 95% CI: 4.602-22.418).

CONCLUSION

This study showed that TcPO₂ was significantly negatively associated with the occurrence of microvascular events in type 2 diabetic patients and that TcPO₂ may be an independent risk factor for predicting the occurrence of microvascular complications in these patients. These results suggest that for type 2 diabetes mellitus with clinically reduced TcPO₂, we should pay close attention to the occurrence of microvascular complications and engage in early prevention.

The role of patient education in the prevention and management of type 2 diabetes: an overview

The management of type 2 diabetes mellitus includes ability and empowerment of the patient to change lifestyle, maintain an adequate diet and physical activity, manage the disease, and follow a specific program of periodic medical checks and education sessions. In addition, the patient should be able to correctly identify and adequately solve problems related to the disease and actively collaborate with the healthcare system. To obtain these goals, therapeutic patient education (TPE) is now considered a crucial element not only in the treatment but also in the prevention of type 2 diabetes. Several trials showed that TPE is able to improve clinical, lifestyle, and psycho-social outcomes. Nevertheless, studies have not clarified the ideal characteristics of a comprehensive patient education program in clinical practice. Other work is needed to answer open questions regarding the type of PTE (individual or group education), themes, frequency and number of education sessions, contact time between educator and patient, background of educators, use of new technologies, and barriers to self-management. The present review discusses these points on the basis of the most recent data of the literature.

Inverse association between serum total bilirubin levels and diabetic peripheral neuropathy in patients with type 2 diabetes

Several studies have suggested that bilirubin, a potent innate antioxidant, plays a protective role against cardiovascular and microvascular disease. This study investigated the association between serum concentrations of total bilirubin (TB) and the presence of diabetic peripheral neuropathy (DPN) in Korean diabetic patients. This cross-sectional study involved 1207 patients aged more than 30 years with type 2 diabetes. DPN was assessed according to clinical symptoms and physical examinations using Michigan Neuropathy Screening Instrument examination score, 10-g monofilament sensation, and current perception threshold. The subjects were stratified into gender-specific tertiles based on TB values, and the relationship between the TB values and DPN was analyzed. Compared with patients within the lowest TB tertile, those with higher TB levels consisted of patients with shorter duration of diabetes, lower HbA1c, better renal function, and less autonomic neuropathy, retinopathy, and albuminuria. Serum TB levels were inversely associated with DPN. In multivariate analysis for the development of DPN after adjusting for potential confounding factors including retinopathy, albuminuria, and autonomic neuropathy, the TB levels were inversely associated with the presence of DPN, both as a continuous variable [odds ratio (OR) per log standard deviation (SD) 0.79; 95% confidence interval (CI) 0.65-0.97; P = 0.022] and when categorized in tertiles (the highest vs. the lowest tertile; OR 0.63; 95% CI 0.40-0.99; P = 0.046). Low serum bilirubin levels are significantly associated with DPN, independently of classic risk factors and other microvascular complications. Further investigation is necessary to determine whether serum bilirubin has a prognostic significance on DPN.

Cilostazol attenuates the severity of peripheral arterial occlusive disease in patients with type 2 diabetes: the role of plasma soluble receptor for advanced glycation end-products

Recent studies have demonstrated that the plasma soluble receptor for advanced glycation end-products (sRAGE) play a major role in developing macrovascular complications of type 2 diabetes, including peripheral arterial occlusion disease (PAOD). Cilostazol is an antiplatelet, antithrombotic agent, which has been used for the treatment of PAOD. We hypothesized that cilostazol attenuates the severity of PAOD in patients with type 2 diabetes through the augmentation of plasma sRAGE. Ninety type 2 diabetic patients with PAOD defined as intermittent claudication with ankle-brachial index (ABI) ≦0.9 were recruited for an open-labeled, placebo-controlled study for 52 weeks with oral cilostazol 100 mg twice daily (n = 45) or placebo (n = 45). Fasting plasma sRAGE, endothelial variables of E-selectin, soluble vascular cell adhesion molecule-1 (sVCAM-1), and inflammatory markers of high-sensitivity C-reactive protein (hsCRP) and tumor necrosis factor-α (TNF-α) were determined. After completely the 52-week treatment program, the ABI values were elevated in cilostazol group (P < 0.001). The plasma sRAGE was significantly increased (P = 0.007), and hsCRP, sVCAM, and E-selectin concentrations were significantly decreased (P = 0.028, <0.001 and <0.001, respectively) with cilostazol treatment. In a partial correlation analysis with adjustments for sex and age, the net change of sRAGE significantly correlated with the change of ABI in the cilostazol group (P = 0.043). In a stepwise multiple regression model, only the change with regards to sRAGE was significantly associated with the change of ABI (P = 0.046). Our results suggest that cilostazol may effectively attenuate the severity of PAOD in patients with type 2 diabetes. Plasma sRAGE plays a role as an independent predictor for improving the index of PAOD.

Transcutaneous oxygen tension measurements following peripheral transluminal angioplasty procedure has more specificity and sensitivity than ankle brachial index

OBJECTIVE

To evaluate the superiority of transcutaneous oxygen pressure (TcPO2) before, during and after peripheral transluminal angioplasty (PTA) in comparison with ankle brachial index (ABI) in patients with diabetes.

METHODS

40 consecutive patients with diabetes treated by PTA where included. This study shows results before, during and after PTA and their progression for 8 weeks.

RESULTS

The TcPO2 increased from 28.11 ± 8.1 to 48.03 ± 8.4 mmHg, 8 weeks after PTA (p < 0.001). The ABI increased from 0.48 ± 0.38 to 0.77 ± 0.39 after PTA (p < 0.001). After PTA, the stenosis of the vessel decreased from 58.33 ± 20.07% to 21.87 ± 13.57% (p < 0.001). TcPO2 was determined in all the patients, but ABI could not be determined in all patients. Furthermore, we determined patients with "false negatives" with an improvement in ABI and "false positives" in 12.5% of patients. Additionally, in this study, we monitored TcPO2 while performing PTA, revealing variations in each phase of the radiological procedure.

CONCLUSION

The increase in TcPO2 measurements following PTA procedure has more specificity and sensitivity than does ABI. The use of TcPO2 may represent a more accurate alternative than traditional methods (ABI) used in assessing PTA results. The TcPO2 also allows the radiologist to assess changes in tissue oxygenation during PTA, allowing changes to the procedure and subsequent treatment.

ADVANCES IN KNOWLEDGE

This is the first time that a graph is shown with TcPO2 results during PTA performance in many patients.

Serum levels of 25-hydroxyvitamin D are associated with cognitive impairment in type 2 diabetic adults

Hypovitaminosis D is highly prevalent in type 2 diabetes. The aim of this study is to determine the serum levels of 25-hydroxyvitamin D [25(OH)D] in type 2 diabetic patients with and without mild cognitive impairment (MCI), and examine the relationship of 25(OH)D and MCI with other clinical factors. One hundred and sixty-five diabetic patients were enrolled in this study. Among whom, 95 patients were considered as MCI [Montreal Cognitive Assessment score (MoCA) < 26] and the other 70 as no MCI (MoCA ≥ 26). Subjects were assessed clinically. Diabetic patients with MCI had a longer duration of DM, fewer years of education, elevated fasting blood glucose (FBG), resistant index (RI) of carotid, and lower levels of 25(OH)D {[17.35 (13.02-25.92) vs 28.00 (19.67-34.30)] ng/ml, P < 0.001}. The MoCA score was positively correlated with log10[25(OH)D], education year, and inversely correlated with duration of DM, history of hypertension, intima-media thickness (IMT), FBG, max-RI, and min-RI. Log10[25(OH)D] was positively correlated with MoCA score, and inversely correlated with IMT, in multivariate regression analysis adjusted for age, sex, and education year, 25(OH)D (β = 0.210, P = 0.003), history of hypertension (β = -0.191, P = 0.007), IMT (β = -0.194, P = 0.007), and FBG (β = -0.157, P = 0.026) independently predicted MoCA score. In conclusion, our results suggest that levels of serum 25(OH)D are inversely associated with the cognitive impairment in diabetic patients. Vitamin D may be a potential protective factor for cognitive impairment in patients with type 2 diabetes.

Cilostazol effectively attenuates deterioration of albuminuria in patients with type 2 diabetes: a randomized, placebo-controlled trial

Cilostazol is an antiplatelet, antithrombotic agent with anti-inflammatory properties. To date, no clinical study has specifically evaluated the efficacy of cilostazol in patients with diabetic nephropathy (DN). We hypothesized that cilostazol might delay renal deterioration in DN patients at high risk of progression. Between April 2008 and April 2010, we screened 156 consecutive patients aged 35-80 years who were first diagnosed with type 2 diabetes after the age of 30 years. Of these, 90 patients with DN, as defined by morning spot urine microalbuminuria (MAU) >20 mg/L or an albumin-to-creatinine ratio (ACR) >30 μg/mg on at least two consecutive occasions within the prior 3 months, were enrolled into a 52-week randomized, single-blinded, placebo-controlled trial of oral cilostazol 100 mg twice daily or placebo (45 subjects in each group). Morning spot urine samples were collected to determine MAU and ACR. Fasting plasma levels of metabolic, endothelial variables, and inflammatory markers were examined. Following 52 weeks of treatment, urinary MAU and ACR were significantly reduced in the cilostazol group compared with the placebo group (P = 0.024 and P = 0.02, respectively). In regression analyses, changes in monocyte chemotactic protein-1, E-selectin, and soluble vascular cell adhesion molecule-1 (sVCAM-1) were significantly associated with changes in MAU and ACR. Net changes of E-selectin (P < 0.001) and sVCAM-1 (P < 0.05) were independent predictors of change in MAU and ACR, respectively. Our results suggest that cilostazol may effectively attenuate deterioration of albuminuria in patients with type 2 diabetes. This effect is likely mediated by an improvement of adhesion molecules.