Impact of Glucose-Lowering Medications on Health-Related Quality of Life in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

Diabetes is associated with reduced health-related quality of life (HRQoL). Information on the relationship between HRQoL and glucose-lowering medications in recently diagnosed type 2 diabetes (T2D) is limited. We assessed changes in HRQoL in participants with T2D receiving metformin plus one of four glucose-lowering medications in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).

RESEARCH DESIGN AND METHODS

A total of 5,047 participants, baseline mean age 57 years, with <10 years T2D duration and glycated hemoglobin level 6.8-8.5% and taking metformin monotherapy, were randomly assigned to glargine, glimepiride, liraglutide, or sitagliptin. HRQoL was evaluated at baseline for 4,885 participants, and at years 1, 2, and 3, with use of the self-administered version of the Quality of Well-being Scale (QWB-SA) and SF-36 physical (PCS) and mental (MCS) component summary scales. Linear models were used to analyze changes in HRQoL over time in intention-to-treat analyses.

RESULTS

None of the medications worsened HRQoL. There were no differences in QWB-SA or MCS by treatment group at any time point. PCS scores improved with liraglutide versus other groups at year 1 only. Greater weight loss during year 1 explained half the improvement in PCS scores with liraglutide versus glargine and glimepiride. Liraglutide participants in the upper tertile of baseline BMI showed the greatest improvement in PCS scores at year 1.

CONCLUSIONS

Adding liraglutide to metformin in participants within 10 years of T2D diagnosis showed improvement in the SF-36 PCS in comparisons with the other medications at 1 year, which was no longer significant at years 2 and 3. Improvement was related to weight loss and baseline BMI.

Emotional distress and cardiovascular disease risk among participants enrolled in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study

AIMS

People with type 2 diabetes (T2DM) have an increased risk of cardiovascular disease (CVD). We examined depressive symptoms (DS) and diabetes distress (DD) in relation to the estimated 10-year risk of CVD in adults with T2DM enrolled in the GRADE Emotional Distress Substudy.

METHODS

Linear regression models examined the associations of baseline DS and DD with estimated 10-year risk of CVD using the Atherosclerotic Cardiovascular Disease (ASCVD) risk score, adjusting for age, sex, race/ethnicity, education, income, diabetes duration, diabetes-related complications, and HbA1c.

RESULTS

A total of 1,605 GRADE participants were included: 54% Non-Latino (NL) White, 18% Latino, 19% NL-Black, 66% male, mean age 57.5 (SD = 10.25) years, diabetes duration 4.2 (SD = 2.8) years, and HbA1c 7.5% (SD = 0.5%). After incorporating covariates, only DS, especially cognitive-affective symptoms, were associated with ASCVD risk (estimate = 0.15 [95% CI: 0.04, 0.025], p = 0.006). Higher DS remained significantly associated with higher ASCVD risk when adding DD to covariates (estimate = 0.19 [95% CI: 0.07, 0.30], p = 0.002). DD was not associated with ASCVD risk when accounting for covariates.

CONCLUSIONS

Depressive symptoms, particularly cognitive-affective symptoms, are associated with increased 10-year predicted ASCVD risk among adults with early T2DM. Diabetes distress is not significantly associated with the predicted ASCVD risk when accounting for covariates.

The NIDDK Diabetic Foot Consortium

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diabetic Foot Consortium (DFC) was established in September 2018 by the NIDDK to build an organization to facilitate the highest quality of clinical research on diabetic foot ulcers (DFUs) that will answer clinically significant questions to improve DFU healing and prevent amputations. The initial focus of the DFC is to develop and validate biomarkers for DFUs that can be used in clinical care and research. The DFC consists of a data coordinating center (DCC) for operational oversight and statistical analysis, clinical sites for participant recruitment and evaluation, and biomarker analysis units (BAUs). The DFC is currently studying biomarkers to predict wound healing and recurrence and is collecting biosamples for future studies through a biorepository. The DFC plans to address the challenges of recruitment and eligibility criteria for DFU clinical trials by taking an approach of "No DFU Patient Goes Unstudied." In this platform approach, clinical history, DFU outcome, wound imaging, and biologic measurements from a large number of patients will be captured and the in-depth longitudinal data set will be analyzed to develop a computational-based DFU risk factor profile to facilitate scientifically sound clinical trial design. The DFC will expand its platform to include studies of the role of social determinants of health, such as food insecurity, housing instability, limited health literacy, and poor social support. The DFC is starting partnerships with the broad group of stakeholders in the wound care community.

On diabetic foot ulcer knowledge gaps, innovation, evaluation, prediction markers, and clinical needs

Diabetic foot ulcers (DFUs) remain a very prevalent and challenging complication of diabetes worldwide due to high morbidity, high risks of lower extremity amputation and associated mortality. Despite major advances in diabetes treatment in general, there is a paucity of FDA approved technologies and therapies to promote successful healing. Furthermore, accurate biomarkers to identify patients at risk of non-healing and monitor response-to-therapy are significantly lacking. To date, research has been slowed by a lack of coordinated efforts among basic scientists and clinical researchers and confounded by non-standardized heterogenous collection of biospecimen and patient associated data. Novel technologies, especially those in the single and 'multiomics' arena, are being used to advance the study of diabetic foot ulcers but require pragmatic study design to ensure broad adoption following validation. These high throughput analyses offer promise to investigate potential biomarkers across wound trajectories and may support information on wound healing and pathophysiology not previously well understood. Additionally, these biomarkers may be used at the point-of-care. In combination with national scalable research efforts, which seek to address the limitations and better inform clinical practice, coordinated and integrative insights may lead to improved limb salvage rates.

[Plasma homocysteine levels in patients with ischemic heart disease]

In the latest years it became clear that beside traditional cardiovascular risk factors the high plasma homocysteine level increases the risk of atherosclerotic diseases too. Metaanalysis of 27 papers found that 10% of population's coronary risk is attributable to homocysteine and a 5 mumol/l increase in its plasma level elevates the coronary risk by as much as 0.5 mumol/l cholesterol increase. Recent studies have shown an inverse relation between the levels of plasma homocysteine and that of folic acid, vitamin B6, vitamin B12. The latters are cofactors and substrates of the homocysteine and methionin metabolism. The plasma total cholesterol, HDL-cholesterol, triglyceride, lipoprotein(a), Apo A1, Apo B and homocysteine concentrations were examined in 39 patients suffering from coronary artery disease treated in the Cardiac Rehabilitation Department of our hospital. Twenty of them were treated by folic acid and vitamin B6 for a three week period. The mean (+/- SD) plasma homocysteine concentration was 15.60 +/- 6.14 mumol/l. In the treated subgroup the mean (+/- SD) plasma homocysteine concentration was 17.3 +/- 7.00 mumol/l, the mean (+/- SD) plasma folic acid level was 8.58 +/- 4.6 mumol/l. After the three week treatment period (folic acid and vitamin B6) the plasma homocysteine level decreased by 26.5% (p = 0.012), that of folic acid increased by 68.7% (p = 0.002). From the plasma lipids the level of total- and LDL-cholesterol decreased significantly (6.7% and 10.4%, P < 0.05), caused by the strict diet during hospital treatment. As for the genetic polymorphism of the V677 gen of the metylenetetrahydrofolate-reductase (MTHFR) enzyme there was a significant correlation with homocysteine level (r = 0.436, p = 0.010), and a negative, but not significant correlation with the folic acid level (r = -0.354).

[Significance of contractile reserve in the assessment of cardiac diseases]

One of the most important question in the revascularization of patients with impaired left ventricular function caused by coronary heart disease is the proper differentiation of necrotic myocardium and the region with the possibility of functional recovery. An improving in myocardial performance causes better survival in patients undergone revascularization. Preoperative assessment of segmental or global contractile reserve as a marker of myocardial viability by various methods in suitable to predict the improvement expected after procedure. It is useful in selection of the patients in whom the restoration of coronary blood flow takes a beneficial effect in their survival and quality of life. Authors based on relevant data summarize the methods in the evaluation of contractile reserve and its usefulness in clinical decision making of various heart diseases.

[The effects of statins on stroke and cardiovascular incidence in randomized, placebo-controlled trials with clinical endpoints]

In the mortality statistics behind the coronary heart disease and cancer the stroke is the third leading cause of death. The risk factors of stroke and coronary heart disease are similar, but in a recent meta-analysis (Prospective Studies Collaboration) on 450,000 patients from 45 studies didn't find close correlation between the occurrence of stroke and the cholesterol level. In the Multiple Risk Factor Intervention Trial the incidence of haemorrhagic and non-haemorrhagic stroke was analysed separately and a significant correlation has been found between the high cholesterol level and occurrence of the non-haemorrhagic stroke. The great statin trials in a large scale of patients' groups (different cholesterol and risk levels at the inclusion) beside the decline of coronary events proved a decrease in stroke incidence too. The mechanism of action of the statins on stroke is not known: beside the cholesterol lowering effect the so called pleiotropic effects (plaque stabilisation, improvement of endothelial dysfunction and antithrombotic properties) and a direct effect on vascular tone could get importance. The fact that statins could improve the incidence of coronary events with 24-34%, that of stroke with 10-31%, suggests, that this drugs has to be used more frequently in the clinical practice.

[Effect of enalapril on restrictive type diastolic filling disorder in severe congestive heart failure]

Authors investigated the effect of enalapril (10-20 mg daily) on twenty-nine patients with chronic heart failure in NYHA III-IV stadium who's ejection fraction value was under 40% and had restrictive type of diastolic filling abnormality. Parameters of left ventricular function were measured by echocardiography and the basal data were compared to data detected at the time of 3 and 6 months control. A beneficial effect of enalapril was found on functional cardiac status (reduction in NYHA score), on systolic function (augmentation in ejection fraction and mean mitral anulus motion amplitude). Parallel with the previous parameters in the severity of restrictive diastolic filling alterations (reducing the value of pathologically high E/A ratio and an increasing in deceleration time of early diastolic filling wave) a countable decrease was observed. Authors emphasize the favourable effect of angiotensin converting enzyme inhibitors on chronic heart failure caused by different reasons independently of its severity. The source of drug action is reduction of the preload and afterload as well as keeping under control the harmful ventricular remodelling based on impediment of myocardial angiotensin system.

[Motion of the mitral anulus and suitability of the motion amplitude for determination of left ventricular function in Q-type myocardial infarct]

Cardiac apex hardly changes its location during the time of cardiac cycle, but the mitral anulus--representing cardiac base--has a systolic descent toward the apex and in diastole moves to the left atrium. The whole amplitude of mitral anulus motion is so useful indicator of left ventricular systolic function as ejection fraction derived from enddiastolic and endsystolic parameters. Mitral anulus motion amplitude easy to measure noninvasively by echocardiography. Authors examined 110 patients with their first, Q-type acute myocardial infarction 7-10 days after the onset of symptoms. In the same time ejection fraction value was assessed by radionuclide ventriculography. Data of ejection fraction and mitral anulus motion amplitude were compared. Their conclusions: 1. mitral anulus motion amplitude well correlated with left ventricular ejection fraction 2. patients had a decreased mitral anulus motion amplitude at the site of infarction 3. investigation of mitral anulus motion amplitude is an useful and easy to make method to assess of systolic function of left ventricle in acute myocardial infarction.

[Acute myocardial infarction mortality in a hospital department during the last decades]

Authors surveyed the data of 2677 patients with acute myocardial infarction treated in cardiological department between 1970 and 1993. Activity of Coronary Care Unit (has been working from 1974) reduced the earlier hospital mortality in general internal medicine possibilities with 50%. Main cause of this reduction was the temporal electrotherapy of cardiac arrhythmias. Since the middle of last decade the goal of has been generally introduced combined therapy (beta-blockers, intravenous nitrates, acetyl-salicic acid, thrombolytics) is to reduce the mass of damaged myocardium and hereby increasing the ratio of survival. They reduced the hospital mortality around 10% with consistent application of this therapy. According to the authors application of thrombolytic therapy has basic importance in management of myocardial infarction, but they could not treat a lot of patients with streptokinase in consequence of too long prehospital time period and not properly controlled hypertension. The proportion of systemic thrombolytic therapy on their patients is almost a quarter of them. It would be very important to increase this beneficial ratio with reducing the time of patients decision to turn to health care and applying systemic thrombolytic therapy more than six hours after the onset of symptoms of myocardial infarction.

[Lipid status in extreme obesity]

50 extremely obese women < 35 years of age (their height 164 cm, weight 107 kg, BMI 40) were analyzed in this paper. Following lipidic and lipoprotein parameters were determined: total triglycerides, total HDL-, LDL-cholesterol, electrophoresis of serum's lipoproteins, and in the third of patients the level of apoproteins. AI, AII and B. In all patients the level of glycemia on an empty stomach was determined. Gathered results were compared with those of the control group which consisted of 32 metabolically healthy women of corresponding age. On the basis of gathered results it can be concluded that in extremely obese women the level of numerous atherogenic lipidic fractions such as total triglycerides, total cholesterol, LDL-cholesterol and apoprotein B was statistically significantly increased, while the level of protective HDL-cholesterol was statistically significantly decreased. Results of this investigation point to the common connection between obesity and disorder of metabolism considering lipids and lipoproteins which result in increased incidence of cardiovascular diseases in obese persons.

Tumor cell implantation with the use of Gelaspon gelatin sponge disc

Myelomonocytic leukemia (My) mesoblastic nephroma (Ne) and hepatocellular carcinoma (He) cells were implanted under the renal capsule of F344, Long-Evans (LE) and BDIX rats. Gelaspon sponge discs were used in the implantation procedure, which were resorbed within a few days. The tumor cells, which were located on the surface of these discs could then attach themselves to the renal capsule and thus grow. There was a correlation between the number of tumor cells and the difference between the two kidney masses. The correlation was linear between 10(4) and 10(6) cells, thus the method proved to be a simple, fast and quantitative model in experimental cancer prevention and therapy.