Impact of glucose level on morbidity and mortality in elderly with diabetes and pre-diabetes

Treatment of type 2 diabetes and stress using neuro-emotional technique: case report

This case report presents a novel, non-pharmacological treatment of Type 2 Diabetes in a 46-year-old male, demonstrating improvements in blood chemistry and psychometric markers after 8 treatments using a Mind-Body Intervention (MBI) called Neuro-Emotional Technique (NET). The patient presented with a diagnosis of Type 2 Diabetes (T2D), pain, psychosocial indicators of stress and anxiety, and a score of 4 on the ACE-Q (Adverse Childhood Experiences Questionnaire) that is consistent with a predisposition to chronic disease and autoimmune disorders. Glucose levels for this patient were above normal levels (typically between 10-15mmol/L where optimal range is between 4-10mmol/L) for at least two months prior to the 4-week NET intervention period, despite the standard use of conventional antidiabetic medications (insulin injections). The patient exhibited numerous indictors of chronic stress that were hypothesised to be underlying his medical diagnosis and a series of 8 NET treatments over a period of 4 weeks was recommended. Psychometric tests and glucose measurements were recorded at baseline (prior to treatment), 4 weeks (at the conclusion of treatment) and at 8 weeks (4 weeks following the conclusion of treatment). Results show that glucose levels were reduced, and self-reported measures of depression, anxiety, stress, distress and pain all decreased from high and extreme levels to within normal ranges after 4 weeks, with ongoing improvement at 8 weeks. McEwen described the concept of allostatic load and the disruptive effects that cumulative stress can have on both mental and physical health. It is hypothesized that NET reduces allostatic load thereby fortifying homeostasis and the salutogenic stress response mechanisms involved in recovery from chronic illness, possibly via the Psycho-Immune-Neuroendocrine (PINE) network. Further studies with larger sample sizes are required to establish whether these results could be extrapolated to a wider population, however the results of this case suggest that it may be beneficial to consider co-management of T2D with an MBI such as NET.

The evolving continuum of dysglycaemia: Non-diabetic hyperglycaemia in older adults

Identifying non-diabetic hyperglycaemia (NDH) and intervening to halt the progression to type 2 diabetes has become an essential component of cardiovascular and cerebrovascular risk reduction. Diabetes prevention programs have been instigated to address the increasing prevalence of NDH and type 2 diabetes by targeting lifestyle modifications. Evidence suggests that the risk of progression from NDH to type 2 diabetes declines with age, and that a diagnosis of type 2 diabetes in older adults is not associated with the same risk of adverse consequences as it is in younger age groups. The current definition of NDH is not adjusted based on a person's age. Therefore, there is debate about the emphasis that should be placed upon a diagnosis of NDH in older adults. This article will explore the evidence and current clinical practice surrounding dysglycaemia through the spectrum of different age ranges, and the potential implications this has for older adults.

A novel murine model of combined insulin-dependent diabetes and chronic kidney disease has greater skeletal detriments than either disease individually

Diabetes and chronic kidney disease (CKD) consistently rank among the top ten conditions in prevalence and mortality in the United States. Insulin-dependent diabetes (IDD) and CKD each increase the risk of skeletal fractures and fracture-related mortality. However, it remains unknown whether these conditions have interactive end-organ effects on the skeleton. We hypothesized that combining IDD and CKD in mice would cause structural and mechanical bone alterations that are more deleterious compared to the single disease states. Female C57BL6/J mice were divided into four groups: 1) N = 12 Control (CTRL), 2) N = 10 Streptozotocin-induced IDD (STZ), 3) N = 10 Adenine diet-induced CKD (AD), and 4) N = 9 Combination (STZ+AD). STZ administration resulted in significantly higher blood glucose, HbA1c (p < 0.0001), and glucose intolerance (p < 0.0001). AD resulted in higher blood urea nitrogen (p = 0.0002) while AD, but not STZ+AD mice, had high serum parathyroid hormone (p < 0.0001) and phosphorus (p = 0.0005). STZ lowered bone turnover (p = 0.001). Trabecular bone volume was lowered by STZ (p < 0.0001) and increased by AD (p = 0.003). Tissue mineral density was lowered by STZ (p < 0.0001) and AD (p = 0.02) in trabecular bone but only lowered by STZ in cortical bone (p = 0.002). Cortical porosity of the proximal tibia was increased by AD, moment of inertia was lower in both disease groups, and most cortical properties were lower in all groups vs CTRL. Ultimate force, stiffness, toughness, and total displacement/strain were lowered by STZ and AD. Fracture toughness was lower by AD (p = 0.003). Importantly, Cohen's D indicated that STZ+AD most strongly lowered bone turnover and mechanical properties. Taken together, structural and material-level bone properties are altered by STZ and AD while their combination resulted in greater detriments, indicating that improving bone health in the combined disease state may require novel interventions.

Incidence and Predictors of Mortality among Community-Dwelling Older Adults in Malaysia: A 5 Years Longitudinal Study

With older adults accounting for 10.7% of the Malaysian population, determining the predictors of mortality has now become crucial. Thus, this community-based longitudinal study aimed to investigate the predictors for mortality among community-dwelling older adults using a wide range of factors, including clinical or subclinical. A total of 2322 older adults were interviewed and assessed by trained fieldworkers using validated structured questionnaires. The questionnaire consisted of information on socio-demographic characteristics, health status, neuropsychological and psychosocial functions, lifestyle, dietary intake and biophysical measures. The incidence rate of mortality was 2.9 per 100 person-years. Cox regression analysis indicated that advancing age (Adjusted Hazard Ratio, Adj HR = 1.044, 95% CI: 1.024–1.064), male (Adj HR = 1.937, 95% CI: 1.402–2.675), non-married status (Adj HR = 1.410, 95% CI: 1.078–1.843), smoking (Adj HR = 1.314, 95% CI: 1.004–1.721), a higher fasting blood sugar (Adj HR = 1.075, 95% CI: 1.029–1.166), a lower serum albumin (Adj HR = 0.947, 95% CI: 0.905–0.990), a longer time to complete the TUG test (Adj HR = 1.059, 95% CI: 1.022–1.098), and a lower intake of total dietary fibre (Adj HR = 0.911, 95% CI: 0.873–0.980) were the predictors of mortality in this study. These findings provide an estimated rate of multiethnic mortality in middle-income countries and diet is one of the predictors. These predictors of mortality could be a reference in identifying new public health strategies to ensure longer healthier life spans with lower disability rate among community-dwelling older adults in Malaysia.

All-cause mortality, cardiovascular mortality, major cardiovascular events and hypoglycaemia of patients with diabetes onset at an older age: results from the 10-year nationwide cohort study

BACKGROUND

Longitudinal adverse outcomes are unclear among adults with diabetes according to the age of onset.

OBJECTIVE

To investigate the longitudinal diabetes-related outcomes in adults with new-onset diabetes stratified by age.

DESIGN

Retrospective cohort study.

SETTING

Taiwan National Health Insurance Research Database claims data from 2000 to 2015.

SUBJECTS

In total, 115,751 participants aged ≥40 years with new-onset diabetes in 2003 were recruited and stratified by the ages 40-64 (64.3%), 65-74 (21.2%), 75-84 (11.8%) and ≥85 years (2.7%) at the time of diagnosis.

METHODS

Time-varying multivariate Cox proportional hazards model adjusted for covariates was used to examine the associations between the ages of the patients at diabetes onset and the outcomes of interest [all-cause mortality, cardiovascular (CV) mortality, major cardiovascular events (MACE) and hypoglycaemia] during a 10-year follow-up period.

RESULTS

The results showed that compared with those patients aged 40-64 at diagnosis, patients with older-onset diabetes had significantly higher comorbidities (P < 0.01) and a higher diabetes severity (P < 0.01). Patients with older-onset diabetes had a higher risk of all-cause mortality [adjusted hazard ratio (aHR) 2.28, 4.48 and 10.07 in 65-74, 75-84 and ≥85 years old, respectively], CV mortality (aHR = 2.82, 6.06 and 15.91), MACE (aHR = 2.19, 3.01 and 4.15) and hypoglycaemia (aHR = 2.41, 3.59 and 4.62) than patients aged 40-64 during a 10-year follow-up period.

CONCLUSIONS

Patients with diabetes onset at an older age was associated with increased risks of all-cause mortality, CV mortality, MACE and hypoglycaemia after adjusting for the severity of diabetes and anti-diabetic treatment.

Pre-diabetes in the elderly and the see-saw model of paternalism

Pre-diabetes is a risk factor for the development of diabetes, not a disease in its own right. The prevalence increases with age and reaches nearly 50% of those aged over 75 years in the USA. While lifestyle modification and treatment are likely to benefit those with many years of life ahead of them, they are unlikely to benefit patients with a limited life expectancy. Despite this, some very elderly patients in the UK and elsewhere are being labelled as pre-diabetic. While ideal practice would be to carefully consider the impact of any potentially abnormal blood test before it is taken, this is not always possible in routine practice. In this paper, we discuss a pragmatic, ethical approach for clinicians managing pre-diabetic blood tests in very elderly patients. We argue that a 'see-saw' model of paternalism should be used in deciding which patients to inform that they can be labelled as pre-diabetic. Those patients that may benefit from the label should be informed, and those that will not, should not. Where the benefits/drawbacks are unclear, the result and its potential significance should be discussed in depth with the individual patient. We do not advocate withholding information from any patient. Instead we suggest clinicians use individual patient circumstances to contextualise the relevance of pre-diabetes to the patient and consider the benefits and drawbacks before informing them. This approach has the potential to be used for other pre-conditions and risk factors in addition to pre-diabetes.

Statins are associated with new onset type 2 diabetes mellitus (T2DM) in Medicare patients ≥65 years

BACKGROUND

To evaluate the association of statins and co-morbidities with new onset type 2 diabetes mellitus (T2DM) in patients 65 years and older.

METHODS

This retrospective study used de-identified administrative healthcare claims and enrolment data from a Medicare Advantage Prescription Drug (MAPD) health plan offered by a large multistate healthcare company. The plan covered >2.4 million individuals, of whom >1.7 million individuals were ≥65 years. Of these, 265 554 individuals had continuous MAPD enrolment January 2008 to December 2015. The unadjusted model assessed demographic, pharmacy and T2DM co-morbidities as covariates. Significant variables (P < .05) in the unadjusted model were then included in the adjusted model. The adjusted model used Cox proportional hazards to evaluate covariate effects. Matched propensity score analysis was used to analyse the association of statins and T2DM onset.

RESULTS

The cumulative rate of diagnosed T2DM onset in the study cohort was 4.82% (4314/89 390). Annualised incidence of T2DM diagnosis was 0.82%, 0.88%, 1.04% and 2.09% in 2012, 2013, 2014 and 2015, respectively. T2DM onset was associated with male sex, non-white (African American or Hispanic ethnicity), statin use, hypertension, hyperlipidaemia, heart failure, lower limb ulceration, atherosclerosis, other retinopathy, angina pectoris, poor vision and blindness and absence ischaemic heart disease (IHD). Matched propensity score analysis showed that statin use was significantly associated with T2DM onset (Odds Ratio = 1.26, 95% Confidence Interval: 1.12-1.41, P < .0001) in the adjusted model.

CONCLUSIONS

Analyses indicated that statin usage was associated with new onset T2DM after adjusting for covariates.

Understanding the diagnosis of pre-diabetes in patients aged over 85 in English primary care: a qualitative study

Background

The benefit of a “diagnosis” of pre-diabetes in very elderly patients is debated. How clinicians manage pre-diabetic blood results in these patients is unknown. This study aims to understand how clinicians are “diagnosing” older patients with pre-diabetic blood parameters.

Methods

Semi-structured interviews and focus groups with health care staff (24 total participants) were conducted in the north of England. Interviews and focus groups were recorded, transcribed and analysed thematically. A grounded theory approach was taken with the theory of candidacy being used as a sensitising concept through which questions were framed and results interpreted.

Results

There is a complex system of competing pressures that influence a clinician in deciding whether, and in what way, to inform a very elderly patient that they have pre-diabetes. The majority of clinicians adjust their management of pre-diabetes to the age and perceived risk/benefit for the patient. Whilst some clinicians choose not to inform certain patients of their blood results, many clinicians maintain, what could be seen as a somewhat paradoxical approach of labeling all older patients with pre-diabetes but downplaying the significance to the patient. The policy, organisational context, workload and professional constraints under which clinicians work, play a significant role in shaping how they deal with pre-diabetic blood results in the very elderly.

Conclusion

There has been recent acknowledgement of how policy and organisational context frames decision-making, but there is a lack of evidence on how this influences uncertainty and dilemmas in decision-making in practice. These findings add further weight for the argument that treatment burden should be included in clinical guidelines.

Type 2 Diabetes: How Much of an Autoimmune Disease?

Type 2 diabetes (T2D) is characterized by a progressive status of chronic, low-grade inflammation (LGI) that accompanies the whole trajectory of the disease, from its inception to complication development. Accumulating evidence is disclosing a long list of possible "triggers" of inflammatory responses, many of which are promoted by unhealthy lifestyle choices and advanced age. Diabetic patients show an altered number and function of immune cells, of both innate and acquired immunity. Reactive autoantibodies against islet antigens can be detected in a subpopulation of patients, while emerging data are also suggesting an altered function of specific T lymphocyte populations, including T regulatory (Treg) cells. These observations led to the hypothesis that part of the inflammatory response mounting in T2D is attributable to an autoimmune phenomenon. Here, we review recent data supporting this framework, with a specific focus on both tissue resident and circulating Treg populations. We also propose that selective interception (or expansion) of T cell subsets could be an alternative avenue to dampen inappropriate inflammatory responses without compromising immune responses.

Development of type 2 diabetes mellitus in people with intermediate hyperglycaemia

BACKGROUND

Intermediate hyperglycaemia (IH) is characterised by one or more measurements of elevated blood glucose concentrations, such as impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and elevated glycosylated haemoglobin A1c (HbA1c). These levels are higher than normal but below the diagnostic threshold for type 2 diabetes mellitus (T2DM). The reduced threshold of 5.6 mmol/L (100 mg/dL) fasting plasma glucose (FPG) for defining IFG, introduced by the American Diabetes Association (ADA) in 2003, substantially increased the prevalence of IFG. Likewise, the lowering of the HbA1c threshold from 6.0% to 5.7% by the ADA in 2010 could potentially have significant medical, public health and socioeconomic impacts.

OBJECTIVES

To assess the overall prognosis of people with IH for developing T2DM, regression from IH to normoglycaemia and the difference in T2DM incidence in people with IH versus people with normoglycaemia.

SEARCH METHODS

We searched MEDLINE, Embase, ClincialTrials.gov and the International Clinical Trials Registry Platform (ICTRP) Search Portal up to December 2016 and updated the MEDLINE search in February 2018. We used several complementary search methods in addition to a Boolean search based on analytical text mining.

SELECTION CRITERIA

We included prospective cohort studies investigating the development of T2DM in people with IH. We used standard definitions of IH as described by the ADA or World Health Organization (WHO). We excluded intervention trials and studies on cohorts with additional comorbidities at baseline, studies with missing data on the transition from IH to T2DM, and studies where T2DM incidence was evaluated by documents or self-report only.

DATA COLLECTION AND ANALYSIS

One review author extracted study characteristics, and a second author checked the extracted data. We used a tailored version of the Quality In Prognosis Studies (QUIPS) tool for assessing risk of bias. We pooled incidence and incidence rate ratios (IRR) using a random-effects model to account for between-study heterogeneity. To meta-analyse incidence data, we used a method for pooling proportions. For hazard ratios (HR) and odds ratios (OR) of IH versus normoglycaemia, reported with 95% confidence intervals (CI), we obtained standard errors from these CIs and performed random-effects meta-analyses using the generic inverse-variance method. We used multivariable HRs and the model with the greatest number of covariates. We evaluated the certainty of the evidence with an adapted version of the GRADE framework.

MAIN RESULTS

We included 103 prospective cohort studies. The studies mainly defined IH by IFG5.6 (FPG mmol/L 5.6 to 6.9 mmol/L or 100 mg/dL to 125 mg/dL), IFG6.1 (FPG 6.1 mmol/L to 6.9 mmol/L or 110 mg/dL to 125 mg/dL), IGT (plasma glucose 7.8 mmol/L to 11.1 mmol/L or 140 mg/dL to 199 mg/dL two hours after a 75 g glucose load on the oral glucose tolerance test, combined IFG and IGT (IFG/IGT), and elevated HbA1c (HbA1c5.7: HbA1c 5.7% to 6.4% or 39 mmol/mol to 46 mmol/mol; HbA1c6.0: HbA1c 6.0% to 6.4% or 42 mmol/mol to 46 mmol/mol). The follow-up period ranged from 1 to 24 years. Ninety-three studies evaluated the overall prognosis of people with IH measured by cumulative T2DM incidence, and 52 studies evaluated glycaemic status as a prognostic factor for T2DM by comparing a cohort with IH to a cohort with normoglycaemia. Participants were of Australian, European or North American origin in 41 studies; Latin American in 7; Asian or Middle Eastern in 50; and Islanders or American Indians in 5. Six studies included children and/or adolescents.Cumulative incidence of T2DM associated with IFG5.6, IFG6.1, IGT and the combination of IFG/IGT increased with length of follow-up. Cumulative incidence was highest with IFG/IGT, followed by IGT, IFG6.1 and IFG5.6. Limited data showed a higher T2DM incidence associated with HbA1c6.0 compared to HbA1c5.7. We rated the evidence for overall prognosis as of moderate certainty because of imprecision (wide CIs in most studies). In the 47 studies reporting restitution of normoglycaemia, regression ranged from 33% to 59% within one to five years follow-up, and from 17% to 42% for 6 to 11 years of follow-up (moderate-certainty evidence).Studies evaluating the prognostic effect of IH versus normoglycaemia reported different effect measures (HRs, IRRs and ORs). Overall, the effect measures all indicated an elevated risk of T2DM at 1 to 24 years of follow-up. Taking into account the long-term follow-up of cohort studies, estimation of HRs for time-dependent events like T2DM incidence appeared most reliable. The pooled HR and the number of studies and participants for different IH definitions as compared to normoglycaemia were: IFG5.6: HR 4.32 (95% CI 2.61 to 7.12), 8 studies, 9017 participants; IFG6.1: HR 5.47 (95% CI 3.50 to 8.54), 9 studies, 2818 participants; IGT: HR 3.61 (95% CI 2.31 to 5.64), 5 studies, 4010 participants; IFG and IGT: HR 6.90 (95% CI 4.15 to 11.45), 5 studies, 1038 participants; HbA1c5.7: HR 5.55 (95% CI 2.77 to 11.12), 4 studies, 5223 participants; HbA1c6.0: HR 10.10 (95% CI 3.59 to 28.43), 6 studies, 4532 participants. In subgroup analyses, there was no clear pattern of differences between geographic regions. We downgraded the evidence for the prognostic effect of IH versus normoglycaemia to low-certainty evidence due to study limitations because many studies did not adequately adjust for confounders. Imprecision and inconsistency required further downgrading due to wide 95% CIs and wide 95% prediction intervals (sometimes ranging from negative to positive prognostic factor to outcome associations), respectively.This evidence is up to date as of 26 February 2018.

AUTHORS' CONCLUSIONS

Overall prognosis of people with IH worsened over time. T2DM cumulative incidence generally increased over the course of follow-up but varied with IH definition. Regression from IH to normoglycaemia decreased over time but was observed even after 11 years of follow-up. The risk of developing T2DM when comparing IH with normoglycaemia at baseline varied by IH definition. Taking into consideration the uncertainty of the available evidence, as well as the fluctuating stages of normoglycaemia, IH and T2DM, which may transition from one stage to another in both directions even after years of follow-up, practitioners should be careful about the potential implications of any active intervention for people 'diagnosed' with IH.

Differentiation of Diabetes by Pathophysiology, Natural History, and Prognosis

The American Diabetes Association, JDRF, the European Association for the Study of Diabetes, and the American Association of Clinical Endocrinologists convened a research symposium, "The Differentiation of Diabetes by Pathophysiology, Natural History and Prognosis" on 10-12 October 2015. International experts in genetics, immunology, metabolism, endocrinology, and systems biology discussed genetic and environmental determinants of type 1 and type 2 diabetes risk and progression, as well as complications. The participants debated how to determine appropriate therapeutic approaches based on disease pathophysiology and stage and defined remaining research gaps hindering a personalized medical approach for diabetes to drive the field to address these gaps. The authors recommend a structure for data stratification to define the phenotypes and genotypes of subtypes of diabetes that will facilitate individualized treatment.

Multiprofessional Treatment of High Blood Pressure in Very Elderly Patients

BACKGROUND

As the world population ages, patients older than 80 years, known as very elderly, are more frequently found. There are no studies in this age group aimed at analyzing the multidisciplinary intervention in the treatment of systemic arterial hypertension (SAH) and some comorbidities.

OBJECTIVES

To assess the effect of a multidisciplinary approach in very elderly hypertensives cared for at a specialized service.

METHODS

Longitudinal retrospective cohort study in a multidisciplinary service specialized in the SAH treatment in the Brazilian West-Central region. Patients aged 80 years and older by June 2015 were included. Data from the first (V1) and last visit (Vf) were assessed. Anthropometric variables, blood pressure (BP), renal function, pharmacological treatment, lifestyle, comorbidities and cardiovascular events were studied, comparing data from V1 and Vf. Controlled BP was defined as systolic blood pressure (SBP) lower than 140 mm Hg and diastolic blood pressure (DBP) lower than 90 mm Hg. Statistical analyses were performed with SPSSR software, version 21.0. Values of p<0,05 were considered significant.

RESULTS

Data of 71 patients were assessed with a mean follow-up time of 15,22 years. Their mean age at V1 was 69.2 years, and, at Vf, 84.53 years, and 26.8% of them were males. There was a significant reduction in mean SBP (157.3 x 142.1 mm Hg; p<0.001) and DBP (95.1 x 77.8 mm Hg; p<0.001), with an increase in BP control rates from V1 to Vf (36.6 x 83.1%; p<0.001). The number of antihypertensive drugs used increased (1.49 x 2.85; p<0.001), with an increase in the use of angiotensin-converting enzyme inhibitors (22.5 x 46.5%; p=0.004), angiotensin II receptor blockers (4.2 x 35.2%; p<0.001) and calcium-channel blockers (18.3 x 67.6%; p<0.001). There was a reduction in total cholesterol (217.9 x 191 mg/dL; p<0.001) and LDL-cholesterol (139.6 x 119.0 mg/dL; p<0.001), but worsening of the glomerular filtration rate (62.5 x 45.4 mL/min; p<0.001).

CONCLUSION

The multidisciplinary intervention in very elderly hypertensives increased BP control rate, with optimization of the pharmacological treatment.

Determinants of mortality in patients with type 2 diabetes: a review

We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria.

RESULTS

The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.

Explaining the increased mortality in type 1 diabetes

Despite large improvements in the management of glucose levels and in the treatment of cardiovascular risk factors, the mortality rate in individuals with type 1 diabetes (T1D) is still high. Recently, Lind et al found that T1D individuals with glycated hemoglobin levels of 6.9% or lower had a risk of death from any cause or from cardiovascular causes that is twice as high as the risk for matched controls. T1D is a chronic disease with an early onset (e.g., pediatric age) and thus in order to establish a clear correlation between death rate and the glycometabolic control, the whole history of glycemic control should be considered; particularly in the early years of diabetes. The switch from a normo- to hyperglycemic milieu in an individual with T1D in the pediatric age, represents a stressful event that may impact outcomes and death rate many years later. In this paper we will discuss the aforementioned issues, and offer our view on these findings, paying a particular attention to the several alterations occurring in the earliest phases of T1D and to the many factors that may be associated with the chronic history of T1D. This may help us to better understand the recently published death rate data and to develop future innovative and effective preventive strategies.

Circulating cell-free mitochondrial DNA as the probable inducer of early endothelial dysfunction in the prediabetic patient

Recent evidence has shown that 346million people in the world have diabetes mellitus (DM); this number will increase to 439million by 2030. In addition, current data indicate an increase in DM cases in the population between 40 and 59years of age. Diabetes is associated with the development of micro- and macro-vascular complications, derived from chronic hyperglycemia on the endothelium. Some reports demonstrate that people in a prediabetic state have a major risk of developing early endothelial dysfunction (ED). Today, it is accepted that individuals considered as prediabetic patients are in a pro-inflammatory state associated with endothelial and mitochondrial dysfunction. It is important to mention that impaired mitochondrial functionality has been linked to endothelial apoptosis and release of mitochondrial DNA (mtDNA) in patients with sepsis, cardiac disease, or atherosclerosis. This free mtDNA could promote ED, as well as other side effects on the vascular system through the activation of the toll-like receptor 9 (TLR9). TLR9 is expressed in different cell types (e.g., T or B lymphocytes, mastocytes, and epithelial and endothelial cells). It is localized intracellularly and recognizes non-methylated dinucleotides of viral, bacterial, and mitochondrial DNA. Recently, it has been reported that TLR9 is associated with the pathogenesis of lupus erythematosus, rheumatoid arthritis, and autoimmune diabetes. In this work, it is hypothesized that the increase in the levels of circulating mtDNA is the trigger of early ED in the prediabetic patient, and later on in the older patient with diabetes, through activation of the TLR9 present in the endothelium.