Prospective associations of fasting insulin, body fat distribution, and diabetes with risk of ischemic stroke. The Atherosclerosis Risk in Communities (ARIC) Study Investigators

Effect of pioglitazone on vascular events in post-stroke cognitive impairment: Post hoc analysis of the IRIS trial

BACKGROUND

In stroke patients with insulin resistance (IR), post-stroke cognitive impairment (PSCI) is associated with higher risk of recurrent stroke, but the effect of pioglitazone on that risk has not been explored. The goal of this study was to compare the secondary stroke prevention effect of pioglitazone against placebo in patients with versus without PSCI.

METHODS

We studied patients enrolled in the Insulin Resistance Intervention after Stroke (IRIS) trial with a post-stroke modified Mini-Mental State Examination (3MS) cognitive assessment (mean time of assessment: 79 days post-stroke). We considered a baseline score of ⩽ 88 on the 3MS to indicate global PSCI, and domain-specific summary scores in the lowest quartile to indicate attention, language, memory, orientation, and visuospatial impairments.

RESULTS

In n = 3338 patients with IR, the effect of pioglitazone versus placebo on secondary stroke significantly differed by initial post-stroke global (interaction p = 0.0127) and memory impairment status (interaction p = 0.0003). Hazard ratios (HRs) were time-dependent such that, among those with either global or memory impairment, pioglitazone has an increasingly stronger protective effect at later timepoints. There was no statistically significant effect of pioglitazone among those without either global or memory impairment. The effect of pioglitazone versus placebo on myocardial infarction (MI) also significantly differed by global impairment status (interaction p = 0.030). Pioglitazone was protective among those with global impairment (HR = 0.23 [95% CI: 0.08, 0.71]) but not among those without (HR = 0.88 [95% CI: 0.59, 1.31]).

CONCLUSION

These data indicate that pioglitazone treatment may be more effective at reducing risk of recurrent stroke and MI in stroke patients with PSCI. Simple cognitive testing 2-3 months post-stroke may identify patients for whom treatment would be most beneficial.

Antioxidant peptides, the guardian of life from oxidative stress

Reactive oxygen species (ROS) are produced during oxidative metabolism in aerobic organisms. Under normal conditions, ROS production and elimination are in a relatively balanced state. However, under internal or external environmental stress, such as high glucose levels or UV radiation, ROS production can increase significantly, leading to oxidative stress. Excess ROS production not only damages biomolecules but is also closely associated with the pathogenesis of many diseases, such as skin photoaging, diabetes, and cancer. Antioxidant peptides (AOPs) are naturally occurring or artificially designed peptides that can reduce the levels of ROS and other pro-oxidants, thus showing great potential in the treatment of oxidative stress-related diseases. In this review, we discussed ROS production and its role in inducing oxidative stress-related diseases in humans. Additionally, we discussed the sources, mechanism of action, and evaluation methods of AOPs and provided directions for future studies on AOPs.

From diabetic hyperglycemia to cerebrovascular Damage: A narrative review

Diabetes mellitus is a globally significant disease that can lead to systemic complications, particularly vascular damage, including cardiovascular and cerebrovascular diseases of relevance. The physiological changes resulting from the imbalance in blood glucose levels play a crucial role in initiating vascular endothelial damage. Elevated glucose levels can also penetrate the central nervous system, triggering diabetic encephalopathy characterized by oxidative damage to brain components and activation of alternative and neurotoxic pathways. This brain damage increases the risk of ischemic stroke, a leading cause of mortality worldwide and a major cause of disability among surviving patients. The aim of this review is to highlight important pathways related to hyperglycemic damage that extend to the brain and result in vascular dysfunction, ultimately leading to the occurrence of a stroke. Understanding how diabetes mellitus contributes to the development of ischemic stroke and its impact on patient outcomes is crucial for implementing therapeutic strategies that reduce the incidence of diabetes mellitus and its complications, ultimately decreasing morbidity and mortality associated with the disease.

Incidence of Stroke in People With Diabetes Compared to Those Without Diabetes: A Systematic Review

BACKGROUND

One of the goals of the St. Vincent Declaration was to reduce serious complications of diabetes, including strokes. However, it remains uncertain whether this goal has been achieved.

STUDY AIM

To evaluate the incidence of stroke in the diabetic population and its differences regarding sex, ethnicity, age, and region, to compare the incidence rate in people with and without diabetes, and to investigate time trends.

MATERIALS AND METHODS

A systematic review was conducted according to the guidelines for meta-analysis of observational studies in epidemiology (the MOOSE group) and the PRISMA group guidelines.

RESULTS

Nineteen of the 6.470 studies retrieved were included in the analysis. The incidence of stroke in the population with diabetes ranged from 238 per 100,000 person-years in Germany in 2014 to 1191 during the 1990s in the United Kingdom. The relative risk comparing people with diabetes to those without diabetes varied between 1.0 and 2.84 for total stroke, 1.0 and 3.7 for ischemic stroke, and 0.68 and 1.6 for hemorrhagic stroke. Differences between fatal and non-fatal stroke were significant, depending on the time period and the population. We found decreasing time trends in people with diabetes and stable incidence rates of stroke over time in people without diabetes.

CONCLUSION

The considerable differences between results can partly be explained by differences in study designs, statistical methods, definitions of stroke, and methods used to identify patients with diabetes. The lack of evidence arising from these differences ought to be rectified by new studies.

Antioxidant Phytochemicals as Potential Therapy for Diabetic Complications

The global prevalence of diabetes continues to increase partly due to rapid urbanization and an increase in the aging population. Consequently, this is associated with a parallel increase in the prevalence of diabetic vascular complications which significantly worsen the burden of diabetes. For these diabetic vascular complications, there is still an unmet need for safe and effective alternative/adjuvant therapeutic interventions. There is also an increasing urge for therapeutic options to come from natural products such as plants. Hyperglycemia-induced oxidative stress is central to the development of diabetes and diabetic complications. Furthermore, oxidative stress-induced inflammation and insulin resistance are central to endothelial damage and the progression of diabetic complications. Human and animal studies have shown that polyphenols could reduce oxidative stress, hyperglycemia, and prevent diabetic complications including diabetic retinopathy, diabetic nephropathy, and diabetic peripheral neuropathy. Part of the therapeutic effects of polyphenols is attributed to their modulatory effect on endogenous antioxidant systems. This review attempts to summarize the established effects of polyphenols on endogenous antioxidant systems from the literature. Moreover, potential therapeutic strategies for harnessing the potential benefits of polyphenols for diabetic vascular complications are also discussed.

Serum Cystatin-C is linked to increased prevalence of diabetes and higher risk of mortality in diverse middle-aged and older adults

Objective

Type 2 Diabetes Mellitus (henceforth diabetes) affects roughly 35 million individuals in the US and is a major risk factor for cardiovascular and kidney disease. Serum Cystatin-C is used to monitor renal function and detect kidney damage. Recent research has focused on linking Cystatin-C to cardiovascular risk and disease, but most findings focus on small sample sizes and generalize poorly to diverse populations, thus limiting epidemiological inferences. The aim of this manuscript is to study the association between Cystatin-C, diabetes, and mortality and test for possible sex or racial/ethnic background modifications in these relationships.

Methods

We analyzed 8-years of biennial panel data from Health and Retirement Study participants 50-years and older who self-identified as White (unweighted N (uN) = 5,595), Black (uN = 867), or Latino (uN = 565) for a total of uN = 7,027 individuals. We modeled diabetes and death over 8-years as function of baseline Cystatin-C (log transformed) adjusting for covariates and tested modifications in associations by race/ethnic background and sex.

Results

Mean log Cystatin-C at visit 1 was 0.03±0.32 standard deviation. A 10% increase in Cystatin-C levels was associated with 13% increased relative risk of diabetes at baseline (11% and 9% by years 4 and 8). A 10% increase in Cystatin-C was highly associated with increased relative risk of death (28% and 31% by years 4 and 8). These associations were present even after adjusting for possible confounders and were not modified by sex or racial/ethnic background.

Conclusion

Despite differential risks for diabetes and mortality by racial/ethnic groups, Cystatin-C was equally predictive of these outcomes across groups. Cystatin-C dysregulations could be used as a risk indicator for diabetes and as a warning sign for accelerated risk of mortality.

European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack

Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.

Effect of Psyllium husk fiber and lifestyle modification on human body insulin resistance

Insulin resistance is a metabolic disorder that is increasing worldwide and is associated with some of the most common diseases affecting modern societies including diabetes, hypertension, obesity, and coronary heart disease. Changes in diet and physical activity have a profound effect on lowering the risk and cost of managing insulin resistance compared to the pharmacological approach. An interventional study of 16 weeks explored the effect of Psyllium husk fiber in combination with lifestyle modification on insulin resistance among the centrally obese school teachers of district Malakand Khyber Pakhtunkhwa. One Hundred twenty school teachers with central obesity, aged 40-60 years, with no chronic disease history were divided into four subgroups (n = 30) with equal gender bifurcation; a control group, lifestyle modification (LSM) group, psyllium husk fiber (PSH) group, and the combined intervention of LSM & PSH group. Fasting serum was collected to analyze fasting blood glucose, and insulin resistance by using the HOMA-IR method at baseline and post-intervention. A significant effect of the intervention was observed on fasting blood glucose. The combined group of LSM&PSH showed the highest mean change of -7.5 ± 2.6 mg/dl (-9%), followed by the PSH group with a mean change of -6.3 ± 2.1 mg/dl, (-7%). Likewise a significant effect (P < 0.05) on HOMA-IR was observed in the combined group of LSM&PSH with a mean of 1.02 ± 0.14 molar units (-58%), followed by the PSH group with a mean of 1.55 ± 0.14 molar units (-33%). The current study was carried out to assess the effect of regular consumption of Psyllium husk fiber in combination with lifestyle modification on insulin resistance and fasting blood glucose.

Dicarbonyl Stress in Diabetic Vascular Disease

Late vascular complications play a prominent role in the diabetes-induced increase in morbidity and mortality. Diabetes mellitus is recognised as a risk factor driving atherosclerosis and cardiovascular mortality; even after the normalisation of blood glucose concentration, the event risk is amplified—an effect called “glycolytic memory”. The hallmark of this glycolytic memory and diabetic pathology are advanced glycation end products (AGEs) and reactive glucose metabolites such as methylglyoxal (MGO), a highly reactive dicarbonyl compound derived mainly from glycolysis. MGO and AGEs have an impact on vascular and organ structure and function, contributing to organ damage. As MGO is not only associated with hyperglycaemia in diabetes but also with other risk factors for diabetic vascular complications such as obesity, dyslipidaemia and hypertension, MGO is identified as a major player in the development of vascular complications in diabetes both on micro- as well as macrovascular level. In diabetes mellitus, the detoxifying system for MGO, the glyoxalase system, is diminished, accounting for the increased MGO concentration and glycotoxic load. This overview will summarise current knowledge on the effect of MGO and AGEs on vascular function.

Diabetes and Ischemic Stroke: An Old and New Relationship an Overview of the Close Interaction between These Diseases

Diabetes mellitus is a comprehensive expression to identify a condition of chronic hyperglycemia whose causes derive from different metabolic disorders characterized by altered insulin secretion or faulty insulin effect on its targets or often both mechanisms. Diabetes and atherosclerosis are, from the point of view of cardio- and cerebrovascular risk, two complementary diseases. Beyond shared aspects such as inflammation and oxidative stress, there are multiple molecular mechanisms by which they feed off each other: chronic hyperglycemia and advanced glycosylation end-products (AGE) promote ‘accelerated atherosclerosis’ through the induction of endothelial damage and cellular dysfunction. These diseases impact the vascular system and, therefore, the risk of developing cardio- and cerebrovascular events is now evident, but the observation of this significant correlation has its roots in past decades. Cerebrovascular complications make diabetic patients 2–6 times more susceptible to a stroke event and this risk is magnified in younger individuals and in patients with hypertension and complications in other vascular beds. In addition, when patients with diabetes and hyperglycemia experience an acute ischemic stroke, they are more likely to die or be severely disabled and less likely to benefit from the one FDA-approved therapy, intravenous tissue plasminogen activator. Experimental stroke models have revealed that chronic hyperglycemia leads to deficits in cerebrovascular structure and function that may explain some of the clinical observations. Increased edema, neovascularization, and protease expression as well as altered vascular reactivity and tone may be involved and point to potential therapeutic targets. Further study is needed to fully understand this complex disease state and the breadth of its manifestation in the cerebrovasculature.

Factors related to the risk of stroke in the population with type 2 diabetes: A protocol for systematic review and meta-analysis

BACKGROUND

Type 2 diabetes is an independent risk factor for stroke. The main role of the current study is to study the mechanism of stroke induced by diabetes, but there is no systematic summary of daily management and stroke prevention for patients with type 2 diabetes. In order to provide a more detailed stroke prevention program for patients with type 2 diabetes, we included in the study and looked forward to analyzing the risk factors that were more in line with the clinical characteristics of type 2 diabetes.

METHODS

We will search the following Chinese and English databases: PubMed, Web of science, Cochrane Library, Medline, and China National Knowledge Infrastructure database. All of the above electronic databases will be searched from inception to June 30, 2021. In addition, we will manually search for conference papers, ongoing experiments, and internal reports to supplement the studies retrieved via electronic search. We will use the STATA 16.0 provided by Cochrane Collaboration Network for statistical analysis.

RESULTS

The study will prove a collective view on the relationship between related factors and stroke in the type 2 diabetes population.

CONCLUSION

We plan to submit this systematic review to a peer-reviewed journal.INPLASY registration number: INPLASY2021100046.

The Influence of Different Types of Diabetes on Vascular Complications

The final outcome of diabetes is chronic complications, of which vascular complications are the most serious, which is the main cause of death for diabetic patients and the direct cause of the increase in the cost of diabetes. Type 1 and type 2 diabetes are the main types of diabetes, and their pathogenesis is completely different. Type 1 diabetes is caused by genetics and immunity to destroy a large number of β cells, and insulin secretion is absolutely insufficient, which is more prone to microvascular complications. Type 2 diabetes is dominated by insulin resistance, leading to atherosclerosis, which is more likely to progress to macrovascular complications. This article explores the pathogenesis of two types of diabetes, analyzes the pathogenesis of different vascular complications, and tries to explain the different trends in the progression of different types of diabetes to vascular complications, in order to better prevent diabetes and its vascular complications.

Targeting autophagy in ischemic stroke: From molecular mechanisms to clinical therapeutics

Stroke constitutes the second leading cause of death and a major cause of disability worldwide. Stroke is normally classified as either ischemic or hemorrhagic stroke (HS) although 87% of cases belong to ischemic nature. Approximately 700,000 individuals suffer an ischemic stroke (IS) in the US each year. Recent evidence has denoted a rather pivotal role for defective macroautophagy/autophagy in the pathogenesis of IS. Cellular response to stroke includes autophagy as an adaptive mechanism that alleviates cellular stresses by removing long-lived or damaged organelles, protein aggregates, and surplus cellular components via the autophagosome-lysosomal degradation process. In this context, autophagy functions as an essential cellular process to maintain cellular homeostasis and organismal survival. However, unchecked or excessive induction of autophagy has been perceived to be detrimental and its contribution to neuronal cell death remains largely unknown. In this review, we will summarize the role of autophagy in IS, and discuss potential strategies, particularly, employment of natural compounds for IS treatment through manipulation of autophagy.

Blood urea nitrogen, blood urea nitrogen to creatinine ratio and incident stroke: The Dongfeng-Tongji cohort

BACKGROUND AND AIMS

It remains unclear whether extreme levels of blood urea nitrogen (BUN) and BUN to creatinine ratio (BUN/Cr) can increase future risk of stroke. We conducted this study to investigate the associations of BUN and BUN/Cr with incident stroke and its subtypes.

METHODS

A total of 26,835 and 26,379 participants with a mean follow-up of 7.9 years were included to investigate the associations of BUN and BUN/Cr with incident stroke, respectively. Cox proportional hazard models were used to evaluate hazard ratios (HRs) and 95% confidence intervals (CIs) for incident stroke and its subtypes.

RESULTS

Compared with participants in the third quintile of BUN, the adjusted HRs (95% CIs) for participants in the lowest quintile were 1.21 (1.04-1.40), 1.41 (1.18-1.68) and 1.36 (0.97-1.91) for total, ischemic and hemorrhagic stroke, respectively; while for those in the highest quintile, the corresponding HRs (95% CIs) were 1.16 (1.01-1.32), 1.30 (1.11-1.53), and 1.24 (0.90-1.71). The associations remained robust when restricting the analyses to participants within clinically normal range of BUN. For BUN/Cr, compared with participants in the third quintile, participants in the lowest quintile had significant higher risks of stroke (HRs [95% CIs] were 1.19 [1.04-1.37], 1.26 [1.07-1.48], and 1.22 [0.90-1.67] for total, ischemic and hemorrhagic stroke).

CONCLUSIONS

Both high and low levels of BUN were associated with higher risks of total and ischemic stroke. Low level of BUN/Cr was associated with excess risks of total and ischemic stroke.

Deferoxamine Treatment Prevents Post-Stroke Vasoregression and Neurovascular Unit Remodeling Leading to Improved Functional Outcomes in Type 2 Male Diabetic Rats: Role of Endothelial Ferroptosis

It is a clinically well-established fact that patients with diabetes have very poor stroke outcomes. Yet, the underlying mechanisms remain largely unknown. Our previous studies showed that male diabetic animals show greater hemorrhagic transformation (HT), profound loss of cerebral vasculature in the recovery period, and poor sensorimotor and cognitive outcomes after ischemic stroke. This study aimed to determine the impact of iron chelation with deferoxamine (DFX) on (1) cerebral vascularization patterns and (2) functional outcomes after stroke in control and diabetic rats. After 8 weeks of type 2 diabetes induced by a combination of high-fat diet and low-dose streptozotocin, male control and diabetic animals were subjected to thromboembolic middle cerebral artery occlusion (MCAO) and randomized to vehicle, DFX, or tPA/DFX and followed for 14 days with behavioral tests. Vascular indices (vascular volume and surface area), neurovascular remodeling (AQP4 polarity), and microglia activation were measured. Brain microvascular endothelial cells (BMVEC) from control and diabetic animals were evaluated for the impact of DFX on ferroptotic cell death. DFX treatment prevented vasoregression and microglia activation while improving AQP4 polarity as well as blood-brain barrier permeability by day 14 in diabetic rats. These pathological changes were associated with improvement of functional outcomes. In control rats, DFX did not have an effect. Iron increased markers of ferroptosis and lipid reactive oxygen species (ROS) to a greater extent in BMVECs from diabetic animals, and this was prevented by DFX. These results strongly suggest that (1) HT impacts post-stroke vascularization patterns and recovery responses in diabetes, (2) treatment of bleeding with iron chelation has differential effects on outcomes in comorbid disease conditions, and (3) iron chelation and possibly inhibition of ferroptosis may provide a novel disease-modifying therapeutic strategy in the prevention of post-stroke cognitive impairment in diabetes.

Association of the Prognosis of Ankle-brachial Index Improvement One Year Following Endovascular Therapy in Patients with Peripheral Artery Disease: Data from the I-PAD NAGANO Registry

Objective Despite reports on the effects of ankle-brachial index (ABI) improvement following endovascular therapy (EVT) on the limb prognosis, studies evaluating cardiovascular events are limited. We investigated whether or not ABI improvement 1 year following EVT was associated with cardiovascular events. Methods The I-PAD NAGANO registry is an observational multicenter cohort study that enrolled 337 patients with peripheral artery disease (PAD) who underwent EVT between August 2015 and July 2016. From this cohort, we identified 232 patients whose ABI data 1 year following EVT were available, after excluding patients with critical limb ischemia. We divided the patients into two groups according to the degree of ABI improvement 1 year following EVT (ΔABI) - the ΔABI <0.15 group and the ΔABI ≥0.15 group - and compared the outcomes. The primary endpoint was major adverse cardiovascular events (MACEs), including all - cause death, myocardial infarction (MI), and stroke. The secondary endpoints were major adverse limb events (MALEs), defined as a composite of target lesion revascularization and major amputation, all - cause death, MI, and stroke. The median follow-up period was 3.3 years. Results The incidence of MACEs was significantly higher in the ΔABI <0.15 group than in the ΔABI ≥0.15 group (ΔABI <0.15 vs. ΔABI ≥0.15, 25.8% vs. 11.9%, log-rank p=0.036), as was the incidence of stroke (14.1% vs. 2.2%, log-rank p=0.016). A Cox regression analysis revealed that ΔABI ≥0.15 was significantly associated with fewer MACEs (hazard ratio 0.38, 95% confidence interval 0.17-0.83, p=0.016). Conclusion An increase in ABI ≥0.15 at 1 year following EVT was a predictor of reduced MACEs.

Association of Longitudinal Glycemia with Diffusion Weighted Imaging Lesions in Spontaneous Intracerebral Hemorrhage

OBJECTIVES

Higher glycemia on admission has been associated with diffusion weighted imaging (DWI) lesions in patients with spontaneous intracerebral hemorrhage (sICH). However, the influence of longitudinal glycemia after admission and during a patient's hospitalization on DWI lesions in sICH has not been studied. Our aim was to compare longitudinal glycemia in sICH patients with and without DWI lesions.

MATERIAL AND METHODS

Glycemia measurements were abstracted on participants enrolled in a prospective observational study examining predictors for DWI lesions in sICH. Univariate analysis was used to compare mean longitudinal glycemia in sICH patients with and without DWI lesions. Logistical regression was used to determine whether mean longitudinal glycemia was predictive of DWI lesions.

RESULTS

DWI lesions were found in 60 of the 121 (49.6%) participants. Mean time-to-MRI was 99.6 h (SD ± 89). During this time interval, 2,101 glucose measurements were analyzed with a median number of 7 (IQR 12, 1-261) measurements per patient. Mean longitudinal glycemia was higher in the DWI positive group compared to the DWI negative group until time-to-MRI (132 mg/dL vs 122 mg/dL, p = 0.03). Mean longitudinal glycemia was found to be predictive of DWI lesions (OR 1.02, 95% CI 1.005 to 1.035, p = 0.011).

CONCLUSIONS

Mean longitudinal glycemia was higher in sICH patients with DWI lesions compared to those without DWI lesions. Future research into the association between higher glycemia and DWI lesions in sICH may provide insight into a pathophysiologic mechanism.

Fasting blood glucose and risk of Stroke: A Dose-Response meta-analysis

BACKGROUND & PURPOSE

A growing number of studies have shown that fasting blood glucose is related to the risk of stroke, however, the dose-response association between fasting blood glucose and the risk of stroke is still unclear. Accordingly, we conducted a dose-response meta-analysis to evaluate the relationship between fasting blood glucose and the risk of stroke by summarizing cohort studies.

METHODS

PubMed and Embase databases were searched for related studies (until October 2020). Cohort studies examining the influence of fasting blood glucose on stroke risk were summarized. A dose-response relationship was determined using a random-effect model.

RESULTS

Eighteen cohort studies involving 2,555,666 participants were included. The pooled relative risk for the high-versus-low categories was 1.79 (95% CI: 1.68-1.91) in all people, and 1.16 (95% CI: 1.11-1.21) in non-diabetic people. In addition, there was a non-linear relationship between fasting blood glucose and stroke risk. The incidence of stroke was reduced to its lowest point when fasting blood glucose level was 70-100 mg/dL.

CONCLUSION

Fasting blood glucose was positively related to stroke risk, with a non-linear dose-response relationship.

Diet pattern may affect fasting insulin in a large sample of black and white adults

OBJECTIVE

Dietary modification of insulin resistance may be a strategy for reducing chronic disease. For this study, we tested the hypothesis that higher fasting insulin, a marker for insulin resistance, would be related to diet patterns with a high proportion of carbohydrates, those with a high glycemic index, and those characterized by added sugar and processed starches.

STUDY DESIGN

Data were analyzed on 13,528 nondiabetic participants of the REasons for Geographic and Ethnic Differences in Stroke (REGARDS), an observational study of adults aged ≥45 years residing in 1855 counties across the continental USA. Information on habitual diet was collected using the Block 98 Food Frequency Questionnaire. Percent energy from carbohydrate, glycemic index, and glycemic load were determined for each participant, as well as adherence to five established diet patterns. Logistic regression was used to examine associations of baseline diet characteristics with odds for high fasting insulin [quartiles 3 and 4 (median = 98.9 pmol/L) vs. quartile 1], after adjusting for covariates.

RESULT

Greater percent carbohydrate, glycemic index, and glycemic load, and adherence to sweets/fat and southern diet patterns, was associated with greater odds for high insulin (P for trend <0.05 to <0.0001), whereas adherence to the plant-based and alcohol/salad patterns was associated with lower odds for high insulin (P for linear trend <0.0001).

CONCLUSION

In conclusion, diet pattern is associated with fasting insulin. Future studies are needed to determine if diet interventions designed to lower insulin, perhaps based on the patterns identified in this study, can improve risk for chronic disease.

Hyperglycemia, duration of diabetes, and intracranial atherosclerotic stenosis by magnetic resonance angiography: The ARIC-NCS study

AIMS

The association of hyperglycemia and duration of diabetes with intracranial atherosclerotic stenosis (ICAS) in the general population is not well documented. We examined whether elevated glucose and longer diabetes duration is independently associated with ICAS in a community-based sample.

METHODS

We cross-sectionally analyzed 1644 participants (age 67-90 years) of the Atherosclerosis Risk in Communities Study who underwent cerebrovascular magnetic resonance angiography in 2011-13. We applied multivariable ordinal logistic regression to evaluate the association of ICAS category ("no stenosis", "stenosis <50%", or "stenosis ≥50%") with glucose or diabetes duration (<10, 10 to 20, and ≥20 years). We also obtained the corresponding odds ratios applying inverse-probability weighting to account for potential selection bias due to attrition.

RESULTS

Compared to non-diabetic participants in the lowest glucose quartile, the weighted odds ratios (95% confidence interval) of higher ICAS category were 1.88 (1.18, 3.00) and 2.01 (1.08, 3.72) for non-diabetic and diabetic participants in the corresponding highest glucose quartile, respectively. We observed significant positive trends of ICAS across diabetes duration categories in unweighted, but not in weighted, analyses.

CONCLUSIONS

Hyperglycemia and longer duration of diabetes were independently associated with ICAS, suggesting the importance of maintaining glycemic control to prevent stroke.

Association between type 2 diabetes mellitus, especially recently uncontrolled glycemia, and intracranial plaque characteristics: A high-resolution magnetic resonance imaging study

AIMS/INTRODUCTION

Type 2 diabetes mellitus is a specific risk factor for intracranial atherosclerosis. The purpose of this study was to investigate the relationship between type 2 diabetes mellitus, especially uncontrolled glycemia, and intracranial plaque characteristics using high-resolution magnetic resonance imaging.

MATERIALS AND METHODS

A total of 263 patients (182 men; mean age 62.6 ± 11.5 years) with intracranial atherosclerotic plaques detected on high-resolution magnetic resonance imaging from December 2017 to March 2019 were included in this study. Patients were divided into different groups: (i) patients with and without type 2 diabetes mellitus; (ii) diabetes patients with uncontrolled glycemia (glycated hemoglobin level ≥7.0%) and controlled glycemia; and (iii), diabetes patients with diabetes duration of <5, 5-10 and >10 years. Comparisons of plaque features between groups were made, respectively.

RESULTS

Type 2 diabetes mellitus was diagnosed in 118 patients (44.9%). Diabetes patients had a significantly greater prevalence of enhanced plaque, greater maximum plaque length, maximum wall thickness and more severe luminal stenosis than non-diabetes patients. Compared with diabetes patients with controlled glycemia, those with uncontrolled glycemia had a significantly greater prevalence of enhanced plaque and greater maximum plaque length (all P < 0.05). There were no significant differences in plaque features among patients with different durations of type 2 diabetes mellitus. Uncontrolled glycemia was an independent factor for plaque enhancement after adjustment for potential confounding factors (odds ratio 5.690; 95% confidence interval 1.748-18.526; P = 0.004).

CONCLUSIONS

Type 2 diabetes mellitus is closely related to intracranial plaque enhancement and burden. Recently uncontrolled glycemia might play an important role in the development of enhanced plaque.

Diabetes Mellitus and Stroke - A cross Sectional Study of 2.5 Million Adults in the United States

Objectives: The main purpose of this work is to study diabetes mellitus and stroke in the United States during the years 2007-2017 and to find not only statistically significant predictors for diabetes, but also a possible association between diabetes and stroke. Methods: Chi-square test and One-way analysis of variance (ANOVA) were the statistical methods used to derive the results of this work in order to check the statistical significance of diabetes mellitus in relation to patients' socioeconomic factors. In addition, a multivariate logistic regression analysis was used to obtain odds ratio and find statistically significant prognostic factors for both diabetes and stroke. Results: According to multiple logistic regression analysis, the risk for diabetes mellitus is four times higher in widowed men and two times higher in unemployed male subjects who had previously worked. In addition, marital status and employment have been shown to be prognostic risks for stroke. Conclusion: The results describe for the first time the importance of deprivation (of work and partner) as a primary prognostic risk factor for diabetes. Moreover, the same factor was proved to be the primary prognostic risk factor for both stroke and diabetes, which implies a nexus between diabetes mellitus and stroke.

Associations of a metabolic syndrome severity score with coronary heart disease and diabetes in fasting vs. non-fasting individuals

BACKGROUND AND AIMS

Many traditional assessments of risk for coronary heart disease (CHD) and diabetes require laboratory studies performed after an 8-h fast. We assessed whether metabolic-syndrome (MetS) severity would remain linked to future CHD and diabetes even when assessed from non-fasting samples.

METHODS AND RESULTS

Participants in the Atherosclerosis Risk in Communities study were assessed at 4 visits and followed for 20-years of adjudicated CHD outcomes. We used Cox proportional-hazard models (for 20-year CHD outcomes) and logistic regression (for 9-year diabetes outcomes) to compare incident disease risk associated with a race/ethnicity-specific MetS-severity Z-score (MetS-Z) calculated in participants who were fasting (≥8 h) or non-fasting. All analyses were adjusted for sex, race, education, income and smoking. MetS Z-scores were overall similar between participants who were always fasting vs. those non-fasting at Visits 1-3 (all values -0.1 to 0.4), while MetS-Z for participants who were non-fasting at Visit-4 were higher at each visit. Baseline MetS-Z was linked to future CHD when calculated from both fasting and non-fasting measurements, with hazard ratio (HR) for fasting MetS-Z 1.53 (95% confidence interval [CI] 1.42, 1.66) and for non-fasting 1.28 (CI 1.08, 1.51). MetS-Z at Visit-1 also remained linked to future diabetes when measured from non-fasting samples, with odds ratio for fasting MetS-Z 3.10 (CI 2.88, 3.35) and for non-fasting 1.92 (CI 1.05, 3.51).

CONCLUSIONS

MetS-Z remained linked to future CHD and diabetes when assessed from non-fasting samples. A score such as this may allow for identification of at-risk individuals and serve as a motivation toward interventions to reduce risk.

Diabetes drugs and stroke risk: Intensive versus conventional glucose-lowering strategies, and implications of recent cardiovascular outcome trials

People with diabetes mellitus are at higher risk of ischaemic stroke and worse outcomes thereafter. However, whether it is better to prescribe intensive glucose-lowering treatment compared with conventional treatment in people with diabetes to prevent recurrent stroke is debated. It is also crucial to consider whether specific antidiabetic agents are more efficacious and safer than others for prevention of stroke. In this review, we provide an overview of the efficacy of intensive and conventional glucose-lowering treatment in post-stroke management. Our conclusion is that the overall evidence for a beneficial effect of intensive glycaemic control on risk of stroke is limited. We also discuss evidence from recent large clinical trials of thiazolidinediones and new antidiabetic medications, including dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs), and sodium-glucose co-transporter-2 inhibitors. On the basis of the findings of these trials, our conclusion is that pioglitazone and the GLP-1RA class (other than short-acting lixisenatide) are likely to lessen the occurrence of cerebrovascular disease (by mechanisms not dependent on glucose-lowering per se), whereas there is no consistent evidence for other drug classes.

Acute Stroke in Diabetes Mellitus: A Prospective Observational Study Evaluating the Course and Short-Term Outcome in Basrah, Southern Iraq

Introduction Stroke and diabetes mellitus (DM) are distinct conditions with many aspects in common. Both conditions are prevalent and associated with various vascular risk factors such as dyslipidemia and hypertension. This study was conducted to evaluate the association between stroke and DM regarding the course (i.e., type, recurrence, aspirin failure, and degree of disability) of stroke and short-term outcomes in patients with diabetes who suffer an acute stroke. Patients and methods We conducted a prospective observational study of 210 acute stroke patients admitted to the Neurology Unit of Al-Basrah Teaching Hospital in Basrah City in Southern Iraq from May 2014 to September 2015. Our study included 124 men (59%) and 86 (41%) women, and our study population had a mean age of 64 ± 11 years. The study participants were separated into two groups of 105 patients according to their diabetes status, and we evaluated each patient's type of stroke, recurrence, aspirin failure, and degree of neurological disability according to the National Institutes of Health stroke scale. We assessed short-term outcomes (i.e., four weeks' mortality) following acute stroke. Results Ischemic stroke was the primary stroke experienced by patients with diabetes (94.3%), which is highly significant and associated with an increased risk of previous recurrent ischemic stroke (55.2%; P=0.003, <0.001, respectively). We noted a higher rate of loss of antiplatelet activity from aspirin in patients with DM rather than those without DM (p<0.001), and we noted more severe disability in outcomes in patients with DM. In the group of stroke patients with diabetes, 46 patients (59%) died, while 32 patients (41%) without diabetes died (p=0.046). Conclusion DM is associated with a heavier burden for acute stroke along with poorer outcomes than patients without DM. Our findings suggest acute stroke in patients with diabetes may be considered a distinct entity separate from acute stroke in patients without diabetes. The treatment of acute stroke in patients with diabetes warrants further investigation.

Does the Association of Diabetes With Stroke Risk Differ by Age, Race, and Sex? Results From the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

OBJECTIVE

Given temporal changes in diabetes prevalence and stroke incidence, this study investigated age, race, and sex differences in the diabetes-stroke association in a contemporary prospective cohort, the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

RESEARCH DESIGN AND METHODS

We included 23,002 non-Hispanic black and white U.S. adults aged ≥45 years without prevalent stroke at baseline (2003-2007). Diabetes was defined as fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or use of glucose-lowering medication. Incident stroke events were expert adjudicated and available through September 2017.

RESULTS

The prevalence of diabetes was 19.1% at baseline. During follow-up, 1,018 stroke events occurred. Among adults aged <65 years, comparing those with diabetes to those without diabetes, the risk of stroke was increased for white women (hazard ratio [HR] 3.72 [95% CI 2.10-6.57]), black women (HR 1.88 [95% CI 1.22-2.90]), and white men (HR 2.01 [95% CI 1.27-3.27]) but not black men (HR 1.27 [95% CI 0.77-2.10]) after multivariable adjustment. Among those aged ≥65 years, diabetes increased the risk of stroke for white women and black men, but not black women (HR 1.05 [95% CI 0.74-1.48]) or white men (HR 0.86 [95% CI 0.62-1.21]).

CONCLUSIONS

In this contemporary cohort, the diabetes-stroke association varied by age, race, and sex together, with a more pronounced effect observed among adults aged <65 years. With the recent increase in the burden of diabetes complications at younger ages in the U.S., additional efforts are needed earlier in life for stroke prevention among adults with diabetes.

Predicting the risk of stroke among patients with type 2 diabetes: a systematic review and meta-analysis of C-statistics

OBJECTIVE

Stroke is a major cause of disability and death worldwide. People with diabetes are at a twofold to fivefold increased risk for stroke compared with people without diabetes. This study systematically reviews the literature on available stroke prediction models specifically developed or validated in patients with diabetes and assesses their predictive performance through meta-analysis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A detailed search was performed in MEDLINE, PubMed and EMBASE (from inception to 22 April 2019) to identify studies describing stroke prediction models.

ELIGIBILITY CRITERIA

All studies that developed stroke prediction models in populations with diabetes were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently identified eligible articles and extracted data. Random effects meta-analysis was used to obtain a pooled C-statistic.

RESULTS

Our search retrieved 26 202 relevant papers and finally yielded 38 stroke prediction models, of which 34 were specifically developed for patients with diabetes and 4 were developed in general populations but validated in patients with diabetes. Among the models developed in those with diabetes, 9 reported their outcome as stroke, 23 reported their outcome as composite cardiovascular disease (CVD) where stroke was a component of the outcome and 2 did not report stroke initially as their outcome but later were validated for stroke as the outcome in other studies. C-statistics varied from 0.60 to 0.92 with a median C-statistic of 0.71 (for stroke as the outcome) and 0.70 (for stroke as part of a composite CVD outcome). Seventeen models were externally validated in diabetes populations with a pooled C-statistic of 0.68.

CONCLUSIONS

Overall, the performance of these diabetes-specific stroke prediction models was not satisfactory. Research is needed to identify and incorporate new risk factors into the model to improve models' predictive ability and further external validation of the existing models in diverse population to improve generalisability.

Type 2 diabetes in midlife and risk of cerebrovascular disease in late life: a prospective nested case-control study in a nationwide Swedish twin cohort

AIMS/HYPOTHESIS

We aimed to examine the association between midlife type 2 diabetes mellitus and cerebrovascular disease (CBD) in late life, and further to explore whether genetic and early-life familial environmental factors (such as shared childhood socioeconomic status and adolescent environment) play a role in this association.

METHODS

In this prospective nested case-control study based on the Swedish Twin Registry, 33,086 twin individuals who were born in 1958 or earlier and were CBD-free before the age of 60 were included. Midlife (40-59 years) type 2 diabetes was ascertained from self-report, the National Patient Registry (NPR) and glucose-lowering medication use. CBD diagnosis (cerebral infarction, occlusion of cerebral arteries, subarachnoid haemorrhage, intracerebral haemorrhage and unspecified CBD) and onset age were identified from the NPR. Late-life CBD was defined as CBD onset age ≥60 years. Generalised estimating equation (GEE) models were used to analyse unmatched case-control data (adjusted for the clustering of twins within a pair). Conditional logistic regression was used in co-twin matched case-control analyses in CBD-discordant twin pairs.

RESULTS

Of all the participants, 1248 (3.8%) had midlife type 2 diabetes and 3121 (9.4%) had CBD in late life. In GEE models adjusted for age, sex, education, BMI, smoking, alcohol consumption, marital status, hypertension and heart disease, the ORs (95% CIs) of type 2 diabetes were 1.29 (1.03, 1.61) for cerebral infarction, 2.03 (1.20, 3.44) for occlusion of cerebral arteries, 0.52 (0.12, 2.21) for subarachnoid haemorrhage and 0.78 (0.45, 1.36) for intracerebral haemorrhage. In multi-adjusted conditional logistic regression, the OR of the type 2 diabetes-cerebral infarction association was 0.96 (0.51, 1.80). The differences in ORs from the GEE and co-twin control analyses were not statistically significant (p = 0.780).

CONCLUSIONS/INTERPRETATION

Midlife type 2 diabetes is significantly associated with increased risk of cerebral infarction and occlusion of cerebral arteries, but not intracerebral haemorrhage or subarachnoid haemorrhage in late life. Genetic and early-life familial environmental factors do not appear to account for the type 2 diabetes-cerebral infarction association, but further clarification is needed.

Medical Comorbidity in Alzheimer's Disease: A Nested Case-Control Study

BACKGROUND

Little is known about the distribution of medical comorbidities in Alzheimer's disease (AD).

OBJECTIVE

We aimed to describe the comorbidity pattern of AD in a nested case-control study.

METHODS

Incident AD cases were identified by International Classification of Diseases codes in a random sample of 2 million individuals in Taiwan National Health Insurance program during 2001-2011. We further restricted cases to those treated with AD drugs of approved reimbursement. We sampled a set of age- and sex-matched control subjects (2:1 ratio) and employed conditional logistic regression to estimate the associations between pre-specified 14 comorbidities and AD. The clusters of multiple chronic diseases were then identified by exploratory factor analysis.

RESULTS

A total of 2,618 AD cases were identified during 2001-2011 with a mean age of 76.1 years and female preponderance (59%). The most common 5 comorbidities in AD were hypertension (55.1%), osteoarthritis (38.2%), depression (32.3%), diabetes mellitus (DM) (25.7%), and cerebrovascular disease (CVD) (22.7%). After adjusting for age and sex, DM, osteoporosis, depression, and CVD were significantly associated with AD. The number of comorbidity was 3-fold greater in the AD group. The cluster of hypertension, DM, and hyperlipidemia was the most common combination in old age, whereas the cluster osteoarthritis and osteoporosis was the only multimorbidity pattern significantly associated with AD.

CONCLUSION

Multimorbidity is common in AD. Depression, CVD, osteoporosis, and DM are associated with incident AD, supporting that their co-existence is a typical feature of AD at old age. Comorbidity care should be integrated into current management for patients with AD.

Bilirubin and Ischemic Stroke: Rendering the Current Paradigm to Better Understand the Protective Effects of Bilirubin

Novel and innovative methods are critical in fostering new treatments and improving clinical outcomes in patients who suffer from ischemic stroke. Bilirubin has long been considered metabolic waste that can be harmful to the body; however, it is now becoming recognized as one of the body's most potent antioxidant, anti-inflammatory, and neuroprotective molecules. These properties facilitate bilirubin's anti-atherogenic effects to impede and prevent the formation of thrombi in ischemic stroke. These functions allow for protection from neuronal injury during an ischemic state and suggest that elevated bilirubin levels may be linked to a lower rate of morbidity and mortality. Therefore, here we discuss the pathophysiology of stroke and the molecular properties of bilirubin to better understand their beneficial relationship. We outline clinical studies looking at the relationship between serum bilirubin levels and ischemic stroke prevalence. At this time, few studies have rigorously looked at the relationship between bilirubin and ischemic stroke, whether it is positive or negative. Thus, rigorous research is needed to provide evidence supporting the current studies, expand on these studies, and facilitate their translation to bedside therapy for patients who suffer from ischemic stroke.

Risk factors for developing dementia in type 2 diabetes mellitus patients with mild cognitive impairment

BACKGROUND

Dementia and cognitive dysfunction have many causes. There is strong evidence that diabetes mellitus (DM) increases the risk of cognitive impairment and dementia. Optimal glycemic control, identification of diabetic risk factors, and prophylactic approach are essential in the prevention of cognitive complications.

AIMS

The main purpose of this study was to establish the cognitive impairment in DM patients, cared for in the Diabetes Center from Timisoara. Also, we investigated the prevalence of dementia in our group as well as the risk factors involved in the progression of mild cognitive impairment (MCI) to dementia.

PATIENTS AND METHODS

We considered a sample of 207 type 2 DM (T2DM) patients, aged between 33 and 81 years, mean 57.49 (±11.37) years. We established the diagnosis of dementia based on the Mini-Mental State Examination (MMSE) test, as well as on the psychological testing, psychiatric and neurological investigations, and imaging tests (computerized tomography and MRI).

RESULTS

A percentage of 42.03% of patients presented MCI, mean age 63 (57.00-71.00) years, being older than patients without MCI, mean age 52.00 (45.00-61.00) years, P<0.001. We observed that diabetes duration was a significant risk factor for developing dementia. Also, patients with MCI presented higher values of body fat than patients without MCI. Moreover, we found that glucose levels, low-density lipoprotein cholesterol levels, the presence of stroke events, and the presence of cardiovascular disease were significant risk factors for MCI conversion to dementia.

CONCLUSION

Patients with T2DM at early to severe stages of MCI are more likely to develop dementia and should be regularly evaluated for their cognitive status. Regular administrations of the MMSE test can be done to detect early stages of MCI development. Also, to reduce the progression of cognitive impairment to dementia, it is worthwhile to give greater importance to glycemic control and overall DM management.

Assessing Baseline and Temporal Changes in Cardiometabolic Risk Using Metabolic Syndrome Severity and Common Risk Scores

Background Type 2 diabetes mellitus (T2 DM ) is considered a cardiovascular disease ( CVD ) risk equivalent, thereby linking assessment of cardiometabolic risk with that of CVD risk over time. Our goal was to determine how commonly used CVD risk scores and metabolic syndrome (MetS) severity performed in predicting T2 DM with and without ultimate CVD . Methods and Results We assessed data from 8273 participants of the ARIC (Atherosclerosis Risk in Communities) Study, using the pooled cohort atherosclerotic CVD risk score, the Framingham Risk Score, and a MetS severity Z score to assess their association with future risk for CVD alone, T2 DM alone, or both over 20 years of follow-up. Baseline levels of all scores were significantly associated with isolated incident T2 DM (odds ratios [ OR s] for each 1- SD increase: atherosclerotic CVD =1.7, Framingham risk score=1.7, MetS Z score=5.1). All 3 baseline scores were also significantly associated with isolated incident CVD (atherosclerotic CVD OR =2.4, Framingham risk score OR =2.3, MetS Z-score OR =1.8), with the 2 CVD scores remaining significant independent of MetS severity. MetS severity was strongly associated with future T2 DM leading to CVD (MetS Z-score OR =7.0, atherosclerotic CVD OR =3.9, Framingham risk score OR =3.5). Furthermore, changes in MetS severity were independently associated with future T2 DM - CVD progression. Conclusions CVD risk scores are associated with risk for future isolated T2 DM in addition to isolated CVD . However, MetS severity (both baseline and changes over time) was more strongly associated with T2 DM , including T2 DM ultimately leading to CVD . Following MetS severity within patients over time may identify those at greatest risk of combined cardiometabolic disease.

The Cut-off Values of Surrogate Measures for Insulin Sensitivity in a Healthy Population in Korea according to the Korean National Health and Nutrition Examination Survey (KNHANES) 2007-2010

BACKGROUND

This study aimed to identify the gender-specific characteristics of the surrogate measures of insulin resistance and to establish valid cut-off values for metabolic abnormalities in a representative sample in Korea.

METHODS

Data were collected from the datasets of the Korean National Health and Nutrition Examination Survey between 2007 and 2010. The total number of eligible participants was 10,997. We used three measures of insulin resistance: the homeostasis model assessment-insulin resistance (HOMA-IR), McAuley index, and triglyceride and glucose (TyG) index. The estimated cut-off values were determined using the highest score of the Youden index.

RESULTS

The area under the curve (AUC) of the HOMA-IR, McAuley index, and TyG index were 0.737 (95% confidence interval [CI], 0.725-0.750), 0.861 (95% CI, 0.853-0.870), and 0.877 (95% CI, 0.868-0.885), respectively. The cut-off values of the HOMA-IR were 2.20 in men, 2.55 in premenopausal women, and 2.03 in postmenopausal women, and those of the McAuley index were 6.4 in men and 6.6 in premenopausal and postmenopausal women. For the TyG index, the cut-off values were 4.76 in men and 4.71 in premenopausal and postmenopausal women.

CONCLUSION

In conclusion, the present study provides the valid cut-off values of the indirect surrogate measures of insulin sensitivity. These values may be used as reference for insulin sensitivity in a clinical setting and may provide a simple and supplementary method for identifying populations at risk of insulin resistance.

Interaction of diabetes and smoking on stroke: a population-based cross-sectional survey in China

OBJECTIVES

Diabetes and smoking are known independent risk factors for stroke; however, their interaction concerning stroke is less clear. We aimed to explore such interaction and its influence on stroke in Chinese adults.

DESIGN

Cross-sectional study.

SETTING

Community-based investigation in Xuzhou, China.

PARTICIPANTS

A total of 39 887 Chinese adults who fulfilled the inclusion criteria were included.

METHODS

Participants were selected using a multistage stratified cluster method, and completed self-reported questionnaires on stroke and smoking. Type 2 diabetes mellitus (DM2) was assessed by fasting blood glucose or use of antidiabetic medication. Interaction, relative excess risk owing to interaction (RERI), attributable proportion (AP) and synergy index (S) were evaluated using a logistic regression model.

RESULTS

After adjustment for age, sex, marital status, educational level, occupation, physical activity, body mass index, hypertension, family history of stroke, alcohol use and blood lipids, the relationships between DM2 and stroke, and between smoking and stroke, were still significant: ORs were 2.75 (95% CI 2.03 to 3.73) and 1.70 (95% CI 1.38 to 2.10), respectively. In subjects with DM2 who smoked, the RERI, AP and S values (and 95% CIs) were 1.80 (1.24 to 3.83), 0.52 (0.37 to 0.73) and 1.50 (1.18 to 1.84), respectively.

CONCLUSIONS

The results suggest there are additive interactions between DM2 and smoking and that these affect stroke in Chinese adults.

Insulin resistance and cardiovascular outcomes in the ORIGIN trial

AIMS

In the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial (Clinicaltrials.gov: NCT000069784), titrated doses of basal insulin glargine targeting fasting normoglycaemia had a neutral effect on cardiovascular outcomes. The dose of insulin required to achieve normoglycaemia provides a unique measurement of each individual's resistance to insulin's action, and was therefore used to examine the link between insulin resistance and cardiovascular outcomes.

MATERIALS AND METHODS

Self-titration of insulin doses targeting a fasting plasma glucose ≤5.3 mmoL/L (95 mg/dL) was promoted at every visit and cardiovascular and other serious health outcomes were ascertained. All analyses were restricted to participants allocated to insulin glargine, who added it to lifestyle or 1 glucose-lowering oral agent at randomization. Normoglycaemia was defined as a fasting plasma glucose <5.6 mmol/L and HbA1c <6% at the 2-year visit. The median of the natural logarithm of insulin doses (expressed per kg of fat-free mass), recorded at every visit from randomization until either the penultimate visit or the first occurrence of a cardiovascular outcome, was analysed.

RESULTS

Higher median insulin doses did not reflect incident cardiovascular events overall or in the subset that achieved normoglycaemia. When the dose taken before a cardiovascular event or the penultimate visit was analysed, the adjusted hazard of the composite of cardiovascular death, myocardial infarction or stroke was 0.94 (95% CI 0.88, 1.00) per unit higher dose overall, and 0.91 (95% CI 0.81, 1.01) in the normoglycaemic subset.

CONCLUSIONS

Insulin resistance may not promote cardiovascular outcomes in individuals with dysglycaemia.

Limb Remote Ischemic Conditioning: Mechanisms, Anesthetics, and the Potential for Expanding Therapeutic Options

Novel and innovative approaches are essential in developing new treatments and improving clinical outcomes in patients with ischemic stroke. Remote ischemic conditioning (RIC) is a series of mechanical interruptions in blood flow of a distal organ, following end organ reperfusion, shown to significantly reduce infarct size through inhibition of oxidation and inflammation. Ischemia/reperfusion (I/R) is what ultimately leads to the irreversible brain damage and clinical picture seen in stroke patients. There have been several reports and reviews about the potential of RIC in acute ischemic stroke; however, the focus here is a comprehensive look at the differences in the three types of RIC (remote pre-, per-, and postconditioning). There are some limited uses of preconditioning in acute ischemic stroke due to the unpredictability of the ischemic event; however, it does provide the identification of biomarkers for clinical studies. Remote limb per- and postconditioning offer a more promising treatment during patient care as they can be harnessed during or after the initial ischemic insult. Though further research is needed, it is imperative to discuss the importance of preclinical data in understanding the methods and mechanisms involved in RIC. This understanding will facilitate translation to a clinically feasible paradigm for use in the hospital setting.

Impact of obesity on mortality in patients with diabetes: Meta-analysis of 20 studies including 250,016 patients

AIMS/INTRODUCTION

The impact of body mass index on mortality among patients with diabetes remains controversial. Therefore, we carried out a meta-analysis of pertinent studies.

MATERIALS AND METHODS

We searched OVID/MEDLINE, EMBASE and Cochrane databases for all reported studies, which investigated the relationship between body mass index and mortality in patients with diabetes. Summary estimates of hazard ratios (HRs) were obtained with a random effects model. Univariate meta-regressions were carried out.

RESULTS

A total of 20 studies including 250,016 patients with diabetes were identified. The results of the present study showed a significantly reduced risk of all-cause mortality in overweight patients (HR 0.82, 95% CI: 0.74-0.91, P < 0.0001, and I2 = 91.6%) as compared with normal weight patients. The survival benefits of obesity were only observed in the elderly patients (HR 0.69, 95% CI: 0.63-0.75, P < 0.0001, and I2 = 50.4%), but not in the younger patients (HR 1.01, 95% CI: 0.84-1.20, P = 0.96, I2 = 80.1%). Furthermore, the beneficial prognostic impacts on overweight (coefficient = 0.030, P = 0.041) and obesity (coefficient = 0.032, P = 0.010) were attenuated with clinical follow-up duration.

CONCLUSIONS

The present meta-analysis showed a significantly lower risk of all-cause mortality in overweight patients with diabetes compared with normal weight patients. However, the survival benefits of obesity were only observed among the elderly patients.

Potential Therapeutics for Vascular Cognitive Impairment and Dementia

BACKGROUND

As the human lifespan increases, the number of people affected by agerelated dementia is growing at an epidemic pace. Vascular pathology dramatically affects cognitive profiles, resulting in dementia and cognitive impairment. While vascular dementia itself constitutes a medical challenge, hypo-perfusion/vascular risk factors enhance amyloid toxicity and other memory- damaging factors and hasten Alzheimer's disease (AD) and other memory disorders' progression, as well as negatively affect treatment outcome.

METHODS

Research and online content related to vascular cognitive impairment and dementia is reviewed, specifically focusing on the potential treatment of the disorder.

RESULTS

Few therapeutic options are currently available to improve the prognosis of patients with vascular dementia and cognitive impairment, mixed AD dementia with vascular pathology, or other memory disorders. Emerging evidence, however, indicates that, like AD and other memory disorders, synaptic impairment underlies much of the memory impairment in the cognitive decline of vascular cognitive impairment and vascular dementia.

CONCLUSION

Effective rescues of the memory functions might be achieved through synaptic and memory therapeutics, targeting distinct molecular signaling pathways that support the formation of new synapses and maintaining their connections. Potential therapeutic agents include: 1) memory therapeutic agents that rescue synaptic and memory functions after the brain insults; 2) antipathologic therapeutics and an effective management of vascular risk factors; and 3) preventative therapeutic agents that achieve memory therapy through functional enhancement. These therapeutic agents are also likely to benefit patients with AD and/or other types of memory disorders.

Brain function and structure and risk for incident diabetes: The Atherosclerosis Risk in Communities Study

INTRODUCTION

Diabetes is prospectively associated with cognitive decline. Whether lower cognitive function and worse brain structure are prospectively associated with incident diabetes is unclear.

METHODS

We analyzed data for 10,133 individuals with cognitive function testing (1990-1992) and 1212 individuals with brain magnetic resonance imaging (1993-1994) from the Atherosclerosis Risk in Communities cohort. We estimated hazard ratios for incident diabetes through 2014 after adjustment for traditional diabetes risk factors and cohort attrition.

RESULTS

Higher level of baseline cognitive function was associated with lower risk for diabetes (per 1 standard deviation, hazard ratio = 0.94; 95% confidence interval = 0.90, 0.98). This association did not persist after accounting for baseline glucose level, case ascertainment methods, and cohort attrition. No association was observed between any brain magnetic resonance imaging measure and incident diabetes.

DISCUSSION

This is one of the first studies to prospectively evaluate the association between both cognitive function and brain structure and the incidence of diabetes.

Diabetes mellitus and stroke: A clinical update

Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus (DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.

Critical Carotid Artery Stenosis in Coronary and Non-Coronary Patients - Frequency of Risk Factors

INTRODUCTION

Stroke is one of the largest socio medical problems of modern times. In addition to the third leading cause of death, it is the first cause of non-trauma disability. Numerous studies show a correlation of risk factors and arteriosclerotic lesions in the coronary arteries and carotid arteries.

PATIENTS AND METHODS

Study was conducted at the Clinical Center University of Sarajevo, Clinic for Cardiology surgery, methodologically cross-sectional study and partly manipulative and clinical prevention study, conducted on a representative sample of 100 patients. The subject was divided into 2 groups, coronary and non-coronary patients. Both groups of patients underwent color Doppler of carotid arteries, medical history and laboratory analysis.

RESULTS

The results confirm the hypothesis that the critical carotid artery stenosis is more present in patients with coronary disease, while the association of risk factors has been demonstrated for diabetes, hypertension and dyslipidemia.

CONCLUSION

Screening of carotid arteries in patients scheduled for coronary revascularization is essential. With the presence of critical stenosis of the carotid artery, surgery of carotid artery should be done before coronary revascularization. The implementation of aggressive education and prevention of risk factors for cardiovascular disease is needed.

Cerebrovascular complications of diabetes: focus on cognitive dysfunction

The incidence of diabetes has more than doubled in the United States in the last 30 years and the global disease rate is projected to double by 2030. Cognitive impairment has been associated with diabetes, worsening quality of life in patients. The structural and functional interaction of neurons with the surrounding vasculature is critical for proper function of the central nervous system including domains involved in learning and memory. Thus, in this review we explore cognitive impairment in patients and experimental models, focusing on links to vascular dysfunction and structural changes. Lastly, we propose a role for the innate immunity-mediated inflammation in neurovascular changes in diabetes.

Diabetes mellitus and cognitive impairments

There is strong evidence that diabetes mellitus increases the risk of cognitive impairment and dementia. Insulin signaling dysregulation and small vessel disease in the base of diabetes may be important contributing factors in Alzheimer’s disease and vascular dementia pathogenesis, respectively. Optimal glycemic control in type 1 diabetes and identification of diabetic risk factors and prophylactic approach in type 2 diabetes are very important in the prevention of cognitive complications. In addition, hypoglycemic attacks in children and elderly should be avoided. Anti-diabetic medications especially Insulin may have a role in the management of cognitive dysfunction and dementia but further investigation is needed to validate these findings.

Relationship between glycated hemoglobin A1c and cognitive function in nondemented elderly patients with type 2 diabetes

Elderly patients with type 2 diabetes are at a greater risk for cognitive decline. The purpose of this study was to assess the relationship between the degree of hyperglycemia and cognitive status in nondemented, elderly diabetics. Between Jan 2013 and Dec 2014, 1174 geriatric patients with type 2 diabetes were enrolled in the study (579 males; age ≥ 60 years; from Fuzhou, Fujian, China). Cognitive function was measured with the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). A statistically significant, age-adjusted association was observed between the A1C levels and the scores on two cognitive tests (MMSE and MoCA). Specifically, a 1% higher A1C value was associated with a 0.21-point lower MMSE score (95% CI; compare -0.11 to -0.28; P < 0.0001), as well as a 0.11-point lower MoCA score (95% CI; compare -0.10 to -0.38; P < 0.0001). Higher A1C levels were not significantly associated with lower MMSE and MoCA test scores after adjusting for all variables. No significant correlation was found between the two variables in patients older than 80 years of age (n = 215; OR = 1.019; 95% CI = 0.968 - 1.099; p = 0.251). Evidence strongly suggests that chronic hyperglycemia is associated with a decline in cognitive function in nondemented elderly patients with type 2 diabetes. When cognitive assessments are made, comprehensive factors such as advanced age, education level, duration of diabetes, hypertension and other vascular risks should be taken into account. For older geriatric patients (age ≥ 80 years), there is no significant correlation between A1c levels and cognitive function.

Diabetes is associated with cerebrovascular but not Alzheimer's disease neuropathology

INTRODUCTION

The relationship of diabetes to specific neuropathologic causes of dementia is incompletely understood.

METHODS

We used logistic regression to evaluate the association between diabetes and infarcts, Braak neurofibrillary tangle stage, and neuritic plaque score in 2365 autopsied persons. In a subset of >1300 persons with available cognitive data, we examined the association between diabetes and cognition using Poisson regression.

RESULTS

Diabetes increased odds of brain infarcts (odds ratio [OR] = 1.57, P < .0001), specifically lacunes (OR = 1.71, P < .0001), but not Alzheimer's disease neuropathology. Diabetes plus infarcts was associated with lower cognitive scores at end of life than infarcts or diabetes alone, and diabetes plus high level of Alzheimer's neuropathologic changes was associated with lower mini-mental state examination scores than the pathology alone.

DISCUSSION

This study supports the conclusions that diabetes increases the risk of cerebrovascular but not Alzheimer's disease pathology, and at least some of diabetes' relationship to cognitive impairment may be modified by neuropathology.

Ischemic Stroke and Its Risk Factors in a Registry-Based Large Cross-Sectional Diabetic Cohort in a Country Facing a Diabetes Epidemic

The main aim of this study is to determine the prevalence and risk factors of ischemic stroke among diabetic patients registered in the Saudi National Diabetes Registry (SNDR) database. A cross-sectional sample of 62,681 diabetic patients aged ≥25 years was used to calculate ischemic stroke prevalence and its risk factors. Univariate and multivariate logistic regression analyses were used to assess the roles of different risk factors. The prevalence of ischemic stroke was 4.42% and was higher in the older age group with longer diabetes duration. Poor glycemic control and the presence of chronic diabetes complications were associated with a high risk of ischemic stroke. History of smoking and type 2 diabetes were more frequent among stroke patients. Obesity significantly decreased the risk for ischemic stroke. Regression analysis for ischemic stroke risk factors proved that age ≥45 years, male gender, hypertension, coronary artery disease (CAD), diabetes duration ≥10 years, insulin use, and hyperlipidemia were significant independent risk factors for ischemic stroke. We conclude that ischemic stroke is prevalent among diabetic individuals, particularly among those with type 2 diabetes. Good glycemic, hypertension, and hyperlipidemia control, in addition to smoking cessation, are the cornerstones to achieve a significant reduction in ischemic stroke risk.