Adherence to liraglutide among individuals with overweight and obesity: Patient characteristics and clinical measures

AIM

To identify the sociodemographic, clinical and laboratory determinants relating to patient adherence to liraglutide treatment among individuals with overweight or obesity.

METHODS

We retrospectively analysed patients with overweight or obesity who were treated with liraglutide between 2019 and 2022. Over a 6-month follow-up period, measurements of body mass index, sociodemographic characteristics, clinical and laboratory data, and prescription records for liraglutide were collected. Treatment adherence was assessed using the proportion of days covered (PDC) measure, with a PDC ≥80% indicating high adherence.

RESULTS

The study population included 1890 participants (78.1% female, mean age 46 ± 12 years). At the end of the follow-up period, 84.9% of the participants exhibited low adherence to liraglutide treatment. Adherence to treatment improved with age (p = 0.04, odds ratio [OR] 1.013, confidence interval [CI] 1.001-1.025). Significant weight loss during treatment increased the likelihood of high adherence (p < 0.001, OR 1.251, CI 1.167-1.341). Individuals with a higher socioeconomic status displayed greater adherence (p = 0.023, OR 1.906, CI 1.091-3.328). Greater adherence was also seen in non-smokers (p = 0.047, OR 0.725, CI 0.528-0.996).

CONCLUSIONS

Only 15.1% of study participants exhibited high adherence to treatment (PDC ≥80%) after 6 months of follow-up. Further research is needed to explore approaches to enhance adherence to liraglutide, including strategies to educate and support patients in their efforts to achieve and maintain weight loss with the use of this drug.

Circulating miRNAs Detect High vs Low Visceral Adipose Tissue Inflammation in Patients Living With Obesity

CONTEXT

The severity of visceral adipose tissue (VAT) inflammation in individuals with obesity is thought to signify obesity subphenotype(s) associated with higher cardiometabolic risk. Yet, this tissue is not accessible for direct sampling in the nonsurgical patient.

OBJECTIVE

We hypothesized that circulating miRNAs (circ-miRs) could serve as biomarkers to distinguish human obesity subgroups with high or low extent of VAT inflammation.

METHODS

Discovery and validation cohorts of patients living with obesity undergoing bariatric surgery (n = 35 and 51, respectively) were included. VAT inflammation was classified into low/high based on an expression score derived from the messenger RNA levels of TNFA, IL6, and CCL2 (determined by reverse transcription polymerase chain reaction). Differentially expressed circ-miRs were identified, and their discriminative power to detect low/high VAT inflammation was assessed by receiver operating characteristic-area under the curve (ROC-AUC) analysis.

RESULTS

Fifty three out of 263 circ-miRs (20%) were associated with high-VAT inflammation according to Mann-Whitney analysis in the discovery cohort. Of those, 12 (12/53 = 23%) were differentially expressed according to Deseq2, and 6 significantly discriminated between high- and low-VAT inflammation with ROC-AUC greater than 0.8. Of the resulting 5 circ-miRs that were differentially abundant in all 3 statistical approaches, 3 were unaffected by hemolysis and validated in an independent cohort. Circ-miRs 181b-5p, 1306-3p, and 3138 combined with homeostatic model assessment of insulin resistance (HOMA-IR) exhibited ROC-AUC of 0.951 (95% CI, 0.865-1) and 0.808 (95% CI, 0.654-0.963) in the discovery and validation cohorts, respectively, providing strong discriminative power between participants with low- vs high-VAT inflammation. Predicted target genes of these miRNAs are enriched in pathways of insulin and inflammatory signaling, circadian entrainment, and cellular senescence.

CONCLUSION

Circ-miRs that identify patients with low- vs high-VAT inflammation constitute a putative tool to improve personalized care of patients with obesity.

Circulating isomiRs May Be Superior Biomarkers Compared to Their Corresponding miRNAs: A Pilot Biomarker Study of Using isomiR-Ome to Detect Coronary Calcium-Based Cardiovascular Risk in Patients with NAFLD

Circulating miRNAs are increasingly being considered as biomarkers in various medical contexts, but the value of analyzing isomiRs (isoforms of canonical miRNA sequences) has not frequently been assessed. Here we hypothesize that an in-depth analysis of the full circulating miRNA landscape could identify specific isomiRs that are stronger biomarkers, compared to their corresponding miRNA, for identifying increased CV risk in patients with non-alcoholic fatty liver disease (NAFLD)-a clinical unmet need. Plasma miRNAs were sequenced with next-generation sequencing (NGS). Liver fat content was measured with magnetic-resonance spectrometry (MRS); CV risk was determined, beyond using traditional biomarkers, by a CT-based measurement of coronary artery calcium (CAC) score and the calculation of a CAC score-based CV-risk percentile (CAC-CV%). This pilot study included n = 13 patients, age > 45 years, with an MRS-measured liver fat content of ≥5% (wt/wt), and free of overt CVD. NGS identified 1103 miRNAs and 404,022 different isomiRs, of which 280 (25%) and 1418 (0.35%), respectively, passed an abundance threshold. Eighteen (sixteen/two) circulating miRNAs correlated positively/negatively, respectively, with CAC-CV%, nine of which also significantly discriminated between high/low CV risk through ROC-AUC analysis. IsomiR-ome analyses uncovered 67 isomiRs highly correlated (R ≥ 0.55) with CAC-CV%. Specific isomiRs of miRNAs 101-3p, 144-3p, 421, and 484 exhibited stronger associations with CAC-CV% compared to their corresponding miRNA. Additionally, while miRNAs 140-3p, 223-3p, 30e-5p, and 342-3p did not correlate with CAC-CV%, specific isomiRs with altered seed sequences exhibited a strong correlation with coronary atherosclerosis burden. Their predicted isomiRs-specific targets were uniquely enriched (compared to their canonical miRNA sequence) in CV Disease (CVD)-related pathways. Two of the isomiRs exhibited discriminative ROC-AUC, and another two showed a correlation with reverse cholesterol transport from cholesterol-loaded macrophages to ApoB-depleted plasma. In summary, we propose a pipeline for exploring circulating isomiR-ome as an approach to uncover novel and strong CVD biomarkers.

Visceral adipocyte size links obesity with dysmetabolism more than fibrosis, and both can be estimated by circulating miRNAs

OBJECTIVE

In obesity, adipocyte hypertrophy is detrimental to health, but its' interrelation with fibrosis in the visceral adipose tissue (VAT) depot remains unclear. Because VAT is less accessible via biopsy, biomarkers for VAT quality are needed. The authors hypothesized that VAT adipocyte size and fibrosis are interrelated and can be estimated by circulating microRNAs (circ-miRNAs), contributing to subphenotyping obesity.

METHODS

Adipocyte size and AT fibrosis were estimated in n = 43 participants (BMI ≥ 30 kg/m2 ). Circ-miRNAs were sequenced (Next Generation Sequencing).

RESULTS

Participants with above- versus below-median VAT adipocyte area exhibited metabolic dysfunction but lower total and pericellular fibrosis. VAT adipocyte size remained associated with metabolic dysfunction even when controlling for BMI or VAT fibrosis in the entire cohort, as in matched-pairs subanalyses. Next Generation Sequencing uncovered 22 and 6 circ-miRNAs associated with VAT adipocyte size and fibrosis, respectively, with miRNA-130b-3p common to both analyses. The combination of miRNA-130b-3p + miR-150-5p + high-density lipoprotein cholesterol discriminated among those with large versus small VAT adipocytes (receiver operating characteristic-area under the curve: 0.872 [95% CI: 0.747-0.996]), whereas miRNA-130b-3p + miRNA-15a-5p + high-density lipoprotein cholesterol discriminated among those with low and high fibrosis (receiver operating characteristic-area under the curve: 0.823 [95% CI: 0.676-0.97]).

CONCLUSIONS

These findings suggest that VAT adipocyte size and fibrosis are inversely correlated in obesity and can be estimated by distinct circ-miRNAs, providing a potential tool to subphenotype obesity via a liquid biopsy-like approach to assess VAT health in nonsurgical patients.

Ethnicity Affects A1C Levels in Patients With Diagnosed Type 2 Diabetes in Southern Israel

Purpose

To assess whether ethnicity affects the association between A1C and fasting glucose in people with type 2 diabetes.

Methods

This investigation was an epidemiological, cross-sectional study based on computerized medical records of the Southern District of Clalit Health Services. The study population comprised patients ≥40 years of age with type 2 diabetes who underwent blood tests between 8 August 2015 and 20 July 2020. A normal-error multiple linear regression model was used to assess differences in associations among ethnic groups (i.e., Arabs, Ethiopian Jews, and non-Ethiopian Jews) and A1C.

Results

A total of 59,432 patients with type 2 diabetes were included in the study. Of these, 1,804 were Jews of Ethiopian origin, 49,296 were non-Ethiopian Jews, and 8,332 were Arabs. Compared with non-Ethiopian Jews, A1C levels were increased by 0.1% (1 mmol/mol) among Ethiopian Jews and by 0.3% (3 mmol/mol) among Arabs. Ethnicity was a strong predictor of A1C, explaining 0.6% of its variance. An A1C level of 7% (53 mmol/mol) correlated with fasting glucose levels of 141, 136, and 126 mg/dL in non-Ethiopian Jews, Ethiopian Jews, and Arabs, respectively.

Conclusion

Ethnic differences in A1C should be considered by clinicians, researchers, and policymakers.

Simplifying carb counting: A randomized controlled study - Feasibility and efficacy of an individualized, simple, patient-centred carb counting tool

INTRODUCTION

The purpose of this study was to introduce and test a simple, individualized carbohydrate counting tool designed for persons with Type 1 Diabetes Mellitus (T1DM) in order to determine whether the tool improved A1C levels for participants with age, education or language barriers.

METHODS

In a randomized controlled trial, 85 participants were offered six diabetes instructional sessions free of charge over a six-month period. Forty-one received guidance using the regular carbohydrate counting (RCC) method. Forty-four received guidance using an individualized 'Simple Carb Counting' (SCC), involving two customized tables prepared for participants.

RESULTS

The simple, individualized SCC tool for carbohydrate counting was non-inferior to the standard method of RCC. The SCC tool was more effective among participants aged 40 and older, while no differences were found when comparing participants by education level. Irrespective of intervention group, all participants improved their A1C level (9.9% = 13.2 mmol/L vs 8.6% = 11.1 mmol/L, p = .001). A greater improvement in A1C level was seen in newly diagnosed participants (-6.1 vs -0.7, p = .005, -3.4 vs 0.9, p = .032) in both the RCC and SCC groups. All participants expressed improved emotional level per their PAID5 questionnaires (Problem Areas in Diabetes Scale-PAID), (10.6 (±5.7) vs 9.5 (±5.7), p = .023), with women reporting greater improvement than men.

CONCLUSIONS

SCC is a simple, individualized, feasible, low-tech tool for carbohydrate counting, which promotes and enables accurate insulin dosing in people with T1DM. It was found more effective among participants aged 40 and older. Additional studies are needed to corroborate these findings.

Glycemic control and macular edema in patients undergoing cataract surgery

AIMS

Cataract, the most common cause of blindness, has higher prevalence among patients with diabetes mellitus. About 20% of cataract surgeries are performed on patients with diabetes. One of the complications of cataract surgery is pseudophakic cystoid macular edema (CME). This study examined whether patients' glycemic control (as indicated by HbA1c level before cataract surgery) is associated with CME incidence within one year post-surgery.

METHODS

We conducted a retrospective cohort study of 1285 diabetes patients over age 18 who underwent cataract surgery between January 2015 and January 2020. Data were obtained from medical records reporting glycated hemoglobin (HbA1c) level prior to surgery and post-operative CME with intraocular anti-vascular endothelial growth factor injections.

RESULTS

The patients with CME complications were younger, with longer duration diabetes, and higher percentages of type 1 diabetes and diabetic retinopathy. The main variables influencing risk of post-operative CME were found to be diabetic retinopathy and HbA1c level. Multivariate analysis revealed that HbA1c is an independent risk for post-operative CME with a relative risk of 2.01 when HBa1c is above 7 c (95% CI, 1.10-3.67).

CONCLUSION

The study demonstrates that pre-cataract surgery diabetes control, measured by HbA1c level, is an independent risk factor for developing post-surgery CME.

Comparison of Insulin Dose Adjustments Made by Artificial Intelligence-Based Decision Support Systems and by Physicians in People with Type 1 Diabetes Using Multiple Daily Injections Therapy

Objective: Artificial intelligence-based decision support systems (DSS) need to provide decisions that are not inferior to those given by experts in the field. Recommended insulin dose adjustments on the same individual data set were compared among multinational physicians, and with recommendations made by automated Endo.Digital DSS (ED-DSS). Research Design and Methods: This was a noninterventional study surveying 20 physicians from multinational academic centers. The survey included 17 data cases of individuals with type 1 diabetes who are treated with multiple daily insulin injections. Participating physicians were asked to recommend insulin dose adjustments based on glucose and insulin data. Insulin dose adjustments recommendations were compared among physicians and with the automated ED-DSS. The primary endpoints were the percentage of comparison points for which there was agreement on the trend of insulin dose adjustments. Results: The proportion of agreement and disagreement in the direction of insulin dose adjustment among physicians was statistically noninferior to the proportion of agreement and disagreement observed between ED-DSS and physicians for basal rate, carbohydrate-to insulin ratio, and correction factor (P < 0.001 and P ≤ 0.004 for all three parameters for agreement and disagreement, respectively). The ED-DSS magnitude of insulin dose change was consistently lower than that proposed by the physicians. Conclusions: Recommendations for insulin dose adjustments made by automatization did not differ significantly from recommendations given by expert physicians regarding the direction of change. These results highlight the potential utilization of ED-DSS as a useful clinical tool to manage insulin titration and dose adjustments.

The roles of personal interview and cognitive abilities at admission to medical school in predicting performance of medical students in their internal medicine sub-internship

BACKGROUND

The medical school admission process is complicated, perhaps reflecting unresolved debates concerning the most important skills necessary to become an ideal physician. The Goldman Medical School at Ben-Gurion University in Israel is known for placing great emphasis on the personal attributes of candidates in addition to their academic excellence. To this end, 1-h consecutive interviews are embedded in the admission process. This study aims to determine whether there is an association between candidates' personal interview ratings and the ratings assigned to these students at the conclusion of their 6^th year internal medicine sub-internship.

METHODS

Our study sample included 136 students who were admitted to the medical school in 2015, and who completed their 6^th year internal medicine sub-internship in 2019-2020. Our data were derived from the admissions information for each candidate and from structured interviews concerning medical competence and personal traits, which were completed by medical personnel who were in contact with these students during their clinical rounds.

RESULTS

Higher interview ratings of candidates during the admission process were associated with a higher probability that students would be evaluated as top-rated internists 6 years later (Odds Ratio (OR) = 9.4, p-value = 0.049), independent of gender (OR for male vs female = 0.2, p-value = 0.025) and age (OR = 1.3 per each year, p-value = 0.115). Although significant, the numeric difference in interview rating was relatively small (median 9.5 and 9.4 for top-rated and not top-rated internists, respectively).

CONCLUSIONS

Our study shows that high personal interview ratings assigned to candidates as part of the medical school admission process are predictive of high performance ratings of students after they complete their 6^th year internal medicine sub-internships. These findings demonstrate the value and importance of using semi-structured personal interviews in the medical school admission process.

Heterogenicity of diabetes as a risk factor for all-cause mortality after acute myocardial infarction: Age and sex impact

AIM

Type 2 diabetes mellitus (T2DM) is a risk factor for mortality after acute myocardial infarction (AMI). We studied the impact of T2DM related to sex and age on post-AMI long-term mortality.

METHODS

A retrospective study included post-AMI patients. Data were obtained from electronic medical records. We defined the study groups by T2DM, stratified by age-sex.

OUTCOME

up-to-10 years post-discharge all-cause mortality.

RESULTS

16,168 patients were analyzed, 40.3% had T2DM. Ten-year mortality rates were 50.3% with T2DM vs. 33.1% without T2DM, adjHR = 1.622 (p < 0.001). Females (adjHR = 1.085, p = 0.052) and increased age (adjHR = 1.056 for one-year increase, p < 0.001) were associated with a higher risk of mortality (borderline statistical significance for sex). The relationship between T2DM and mortality was stronger in females than in males at < 50 and 60-69 years (p-for-interaction 0.025 and 0.009 respectively), but not for other age groups.

CONCLUSIONS

The study implies heterogeneity in the impact of T2DM on mortality of post-AMI patients, being greater among young patients, particularly females, and no significant impact in octogenarians. That implies that young women with T2DM should have advanced measures for early detection of coronary artery disease and tight control of cardiovascular risk factors to lower the propensity to develop AMI.

Human adipose tissue is a putative direct target of daytime orexin with favorable metabolic effects: A cross-sectional study

OBJECTIVE

Orexin/hypocretin (Ox) and its receptors (OxR), a neuroendocrine system centrally regulating sleep/wakefulness, were implicated in the regulation of peripheral metabolism. It was hypothesized that human adipose tissue constitutes a direct target of the OxA/OxR system that associates with distinct metabolic profile(s).

METHODS

Serum Ox levels and abdominal subcutaneous and visceral adipose tissue expression of Ox/HCRT, OxR1/HCRTR1, and OxR2/HCRTR2 were measured in n = 81 patients.

RESULTS

Higher morning circulating Ox levels were associated with improved lipid profile and insulin sensitivity, independently of BMI (β = -0.363, p = 0.018 for BMI-adjusted homeostatic model of insulin resistance). Adipose HCRT mRNA was detectable in <20% of patients. Visceral HCRT expressers were mostly (80%) males and, compared with nonexpressers, had lower total and LDL cholesterol. HCRTR1 was readily detectable, and HCRTR2 was undetectable. HCRTR1 mRNA and OxR1 protein expression were higher in subcutaneous than visceral adipose tissue, and among nonobese patients, patients with obesity, and patients with obesity and T2DM were 3.4 (1.0), 0.7 (0.1), 0.6 (0.1) (AU) (p < 0.001) and 1.0 (0.2), 0.5 (0.1), 0.4 (0.1) (AU) (p = NS), respectively. Higher visceral HCRTR1 expression was associated with lower fasting insulin and homeostatic model of insulin resistance, also after adjusting for BMI. In human adipocytes, HCRTR1 expression did not exhibit significant oscillation.

CONCLUSIONS

Human adipose tissue is a putative direct target of the OxA-OxR1 system, with higher morning input being associated with improved metabolic profile.

A TRAIL-TL1A Paracrine Network Involving Adipocytes, Macrophages, and Lymphocytes Induces Adipose Tissue Dysfunction Downstream of E2F1 in Human Obesity

Elevated expression of E2F1 in adipocyte fraction of human visceral adipose tissue (hVAT) associates with a poor cardiometabolic profile. We hypothesized that beyond directly activating autophagy and MAP3K5 (ASK)-MAP kinase signaling, E2F1 governs a distinct transcriptome that contributes to adipose tissue and metabolic dysfunction in obesity. We performed RNA sequencing of hVAT samples from age-, sex-, and BMI-matched patients, all obese, whose visceral E2F1 protein expression was either high (E2F1^high) or low (E2F1^low). Tumor necrosis factor superfamily (TNFSF) members, including TRAIL (TNFSF10), TL1A (TNFSF15), and their receptors, were enriched in E2F1^high While TRAIL was equally expressed in adipocytes and stromal vascular fraction (SVF), TL1A was mainly expressed in SVF, and TRAIL-induced TL1A was attributed to CD4⁺ and CD8⁺ subclasses of hVAT T cells. In human adipocytes, TL1A enhanced basal and impaired insulin-inhibitable lipolysis and altered adipokine secretion, and in human macrophages it induced foam cell biogenesis and M1 polarization. Two independent human cohorts confirmed associations between TL1A and TRAIL expression in hVAT and higher leptin and IL6 serum concentrations, diabetes status, and hVAT-macrophage lipid content. Jointly, we propose an intra-adipose tissue E2F1-associated TNFSF paracrine loop engaging lymphocytes, macrophages, and adipocytes, ultimately contributing to adipose tissue dysfunction in obesity.

Higher Mast Cell Accumulation in Human Adipose Tissues Defines Clinically Favorable Obesity Sub-Phenotypes

The identification of human obesity sub-types may improve the clinical management of patients with obesity and uncover previously unrecognized obesity mechanisms. Here, we hypothesized that adipose tissue (AT) mast cells (MC) estimation could be a mark for human obesity sub-phenotyping beyond current clinical-based stratifications, both cross-sectionally and prospectively. We estimated MC accumulation using immunohistochemistry and gene expression in abdominal visceral AT (VAT) and subcutaneous (SAT) in a human cohort of 65 persons with obesity who underwent elective abdominal (mainly bariatric) surgery, and we validated key results in two clinically similar, independent cohorts (n = 33, n = 56). AT-MC were readily detectable by immunostaining for either c-kit or tryptase and by assessing the gene expression of KIT (KIT Proto-Oncogene, Receptor Tyrosine Kinase), TPSB2 (tryptase beta 2), and CMA1 (chymase 1). Participants were characterized as VAT-MC^low if the expression of both CMA1 and TPSB2 was below the median. Higher expressers of MC genes (MC^high) were metabolically healthier (lower fasting glucose and glycated hemoglobin, with higher pancreatic beta cell reserve (HOMA-β), and lower triglycerides and alkaline-phosphatase) than people with low expression (MC^low). Prospectively, higher MC accumulation in VAT or SAT obtained during surgery predicted greater postoperative weight-loss response to bariatric surgery. Jointly, high AT-MC accumulation may be used to clinically define obesity sub-phenotypes, which are associated with a “healthier” cardiometabolic risk profile and a better weight-loss response to bariatric surgery.

Improvement of Blood Samples Preanalytic Management Alters the Clinical Results of Glucose Values: Population Study

BACKGROUND

Prolonged time elapsing between the blood drawing and separation of the cell mass may result in decreased sample glucose levels due to continuous glycolysis. This can lead to underdiagnoses of hyperglycemic states and overdiagnosis of hypoglycemia. We aimed to evaluate the clinical impact of shortened transit time and earlier centrifugation of laboratory specimens on reported glucose results and diagnosis of clinically significant hypoglycemia (<50 mg/dL) or elevated glucose levels (>100 mg/dL).

METHODS

We assessed all fasting-serum glucose tests from the adult population (190 767 subjects) without known diabetes residing in Southern Israel. Before and after intervention periods were compared: 268 359 blood tests were performed during 2009-2010, and 317 336 during 2012-2013.

RESULTS

While glucose levels were 94.17 mg/dL ± 14.12 in 2012-2013 versus 83.53 mg/dL ± 14.50 in 2009-2010 (12.75% ± 0.88 increase, P < .001), the difference in glycated hemoglobin levels was statistically significant but clinically negligible: 5.84% ± 0.56 in 2012-2013 versus 5.88% ± 0.56 in 2009-2010 (0.53% ± 0.78 decrease, P < .01). There was an increased likelihood of a glucose result to be above 100 mg/dL following intervention: 9.80% versus 25.90%, P < .001. For clinics distanced over 40 km from the laboratory, age-adjusted odds ratio value was 1.26 (95% CI 1.13, 1.41). The proportion of samples with hypoglycemia values decreased from 0.33% to 0.03% (P < .001).

CONCLUSIONS

We demonstrated an important change in glucose values over a two-year period following an improvement of the preanalytic processes. The intervention was related to an increase in the frequency of hyperglycemia results and a decrease in the number of hypoglycemia results. Future administrative projects should consider clinical consequences with involvement of all relevant stakeholders.

Effect of wine on carotid atherosclerosis in type 2 diabetes: a 2-year randomized controlled trial

BACKGROUND/OBJECTIVES

The progression of carotid-plaque volume in patients with type 2 diabetes is common. Previous observational studies showed an association between moderate alcohol and reduced risk of coronary disease. We examined whether consuming moderate wine affects the progression of carotid atherosclerosis.

SUBJECTS/METHODS

In the CASCADE (CArdiovaSCulAr Diabetes and Ethanol), a 2-year randomized controlled trial, we randomized abstainers with type 2 diabetes were to drink 150 ml of either red wine, white wine, or water, provided for 2 years. In addition, groups were guided to maintain a Mediterranean diet. We followed 2-year changes in carotid total plaque volume (carotid-TPV) and carotid vessel wall volume (carotid-VWV), using three-dimensional ultrasound.

RESULTS

Carotid images were available from 174 of the 224 CASCADE participants (67% men; age = 59 yr; HbA1C = 6.8%). Forty-five percent had detectable plaque at baseline. After 2 years, no significant progression in carotid-TPV was observed (water, -1.4 (17.0) mm³, CI (-2.7, 5.5), white-wine, -1.2 (16.9) mm³, CI (-3.8, 6.2), red wine, -1.3 (17.6) mm³, CI (-3.4, 6.0; p = 0.9 between groups)). In post hoc analysis, we divided the 78 participants with detectable baseline carotid plaque into tertiles. Those with the higher baseline plaque burden, whom were assigned to drink wine, reduced their plaque volume significantly after 2 years, as compared to baseline. Two-year reductions in Apo(B)/Apo(A) ratio(s) were independently associated with regression in carotid-TPV (β = 0.4; p < 0.001). Two-year decreases in systolic blood pressure were independently associated with regression in carotid-VWV (β = 0.2; p = 0.005).

CONCLUSIONS

No progression in carotid-TPV was observed. In subgroup analyses, those with the greatest plaque burden assigned to drink wine may have had a small regression of plaque burden.

The Association Between Air Pollution Exposure and Glucose and Lipids Levels

CONTEXT

Evidence from recent decades supports a causal association between air pollution (particulate matter <10 μm in diameter [PM10] and PM <2.5 μm in diameter [PM2.5]) and oxidative stress, possibly involving impaired metabolism of glucose and lipids.

OBJECTIVE

Using a satellite based model to assess PM exposure at 1-km spatial resolution, we examined the associations between PM and glucose, hemoglobin A1c (HbA1c), and lipids.

DESIGN

Population-based retrospective cohort study of a 10-year period.

SETTING

Members of the largest health care provider in Southern Israel.

PARTICIPANTS

We included all serum glucose, HbA1c, and lipids tests of subjects with known cardiovascular diseases and risk factors. Subjects' glycemic status was defined as normal or diabetes.

MAIN OUTCOME

Log-transformed glucose, HbA1c, and lipid values were explored by mixed models, with adjustment for personal and seasonal confounders.

RESULTS

We assessed 73 117 subjects with over 600 000 samples. Three-month average concentration of PM10, but not 1- to 7-d exposure, was associated with increases of serum glucose, HbA1c, low-density lipoprotein and triglycerides, and decrease of high-density lipoprotein. The strongest associations were observed among subjects with diabetes (percent increase [95% confidence interval], for interquartile range increase of PM10 and PM2.5): 3.58% (1.03%; 6.20%) and 2.93% (0.35%; 5.59%) increase in HbA1c and 2.37% (2.11%; 2.63%) and 1.54% (1.26%; 1.83%) increase in low-density lipoprotein. Antidiabetic medications (other than insulin) attenuated the air pollution effect on serum glucose.

CONCLUSIONS

Intermediate-term, but not short term, exposure to PM is associated with alterations in glucose, HbA1c, and lipids, especially among people with diabetes.

[THE EFFECT OF 5 DAYS IMMERSION IN DEAD SEA WATER ON BLOOD GLUCOSE LEVELS IN TYPE 2 DIABETES MELLITUS PATIENTS]

BACKGROUND

Body immersion in plain water or mineral water induces significant and unique physiological changes in most body systems. In a previous pilot study, a significant reduction in blood glucose levels among diabetes mellitus (DM) patients was found following a single immersion in Dead Sea water but not after immersion in plain water.

OBJECTIVE

To study the immediate and long term effects of immersion in mineral water for five consecutive days on blood glucose in patients with type 2 DM.

METHODS

A total of 34 patients with type 2 DM were divided into 2 groups: The first immersed in a plain water pool and the second immersed in a Dead Sea water pool; both pools were warmed to a temperature of 35°C. Immersions for 20 minutes occurred twice daily: two hours after breakfast and before dinner. Seven samples of capillary blood glucose levels were taken: fasting, before and after every immersion, prior to lunch and before bedtime. Hemoglobin A1C (HbA1c) was taken prior to the study and a re-check was conducted during the 12 weeks following the study.

RESULTS

Blood glucose levels significantly decreased immediately after immersion both in Dead Sea water and plain water compared to their values prior to immersion (p<0.001). No significant difference was noted between both types of water. A decrease in fasting glucose levels was observed only in the group immersed in Dead Sea water when compared to plain water (6.83±5.68 mg/dl versus 4.37±1.79 respectively and the difference was close to statistical significance (p=0.071. There were no changes in HbA1c levels.

CONCLUSION

Immersion for 20 minutes in water (Dead Sea or plain water) at a temperature of 35°C induced an immediate reduction in glucose levels in patients with type 2 DM.

Effects of Initiating Moderate Alcohol Intake on Cardiometabolic Risk in Adults With Type 2 Diabetes: A 2-Year Randomized, Controlled Trial

BACKGROUND

Recommendations for moderate alcohol consumption remain controversial, particularly in type 2 diabetes mellitus (T2DM). Long-term randomized, controlled trials (RCTs) are lacking.

OBJECTIVE

To assess cardiometabolic effects of initiating moderate alcohol intake in persons with T2DM and whether the type of wine matters.

DESIGN

2-year RCT (CASCADE [CArdiovaSCulAr Diabetes & Ethanol] trial). (ClinicalTrials.gov: NCT00784433).

SETTING

Ben-Gurion University of the Negev-Soroka Medical Center and Nuclear Research Center Negev, Israel.

PATIENTS

Alcohol-abstaining adults with well-controlled T2DM.

INTERVENTION

Patients were randomly assigned to 150 mL of mineral water, white wine, or red wine with dinner for 2 years. Wines and mineral water were provided. All groups followed a Mediterranean diet without caloric restriction.

MEASUREMENTS

Primary outcomes were lipid and glycemic control profiles. Genetic measurements were done, and patients were followed for blood pressure, liver biomarkers, medication use, symptoms, and quality of life.

RESULTS

Of the 224 patients who were randomly assigned, 94% had follow-up data at 1 year and 87% at 2 years. In addition to the changes in the water group (Mediterranean diet only), red wine significantly increased high-density lipoprotein cholesterol (HDL-C) level by 0.05 mmol/L (2.0 mg/dL) (95% CI, 0.04 to 0.06 mmol/L [1.6 to 2.2 mg/dL]; P < 0.001) and apolipoprotein(a)1 level by 0.03 g/L (CI, 0.01 to 0.06 g/L; P = 0.05) and decreased the total cholesterol-HDL-C ratio by 0.27 (CI, -0.52 to -0.01; P = 0.039). Only slow ethanol metabolizers (alcohol dehydrogenase alleles [ADH1B*1] carriers) significantly benefited from the effect of both wines on glycemic control (fasting plasma glucose, homeostatic model assessment of insulin resistance, and hemoglobin A1c) compared with fast ethanol metabolizers (persons homozygous for ADH1B*2). Across the 3 groups, no material differences were identified in blood pressure, adiposity, liver function, drug therapy, symptoms, or quality of life, except that sleep quality improved in both wine groups compared with the water group (P = 0.040). Overall, compared with the changes in the water group, red wine further reduced the number of components of the metabolic syndrome by 0.34 (CI, -0.68 to -0.001; P = 0.049).

LIMITATION

Participants were not blinded to treatment allocation.

CONCLUSION

This long-term RCT suggests that initiating moderate wine intake, especially red wine, among well-controlled diabetics as part of a healthy diet is apparently safe and modestly decreases cardiometabolic risk. The genetic interactions suggest that ethanol plays an important role in glucose metabolism, and red wine's effects also involve nonalcoholic constituents.

PRIMARY FUNDING SOURCE

European Foundation for the Study of Diabetes.

Air Pollution and Serum Glucose Levels: A Population-Based Study

Recent studies demonstrated an adverse effect of chronic exposure to air pollution (AP) on metabolic syndrome and its components. In a population-based study, we investigated the association between exposure to ambient AP and serum glucose (SG), among subjects with normal glucose, impaired fasting glucose (IFG), and diabetes mellitus (DM).We included 1,063,887 SG tests performed in 131,882 subjects (years 2001-2012). Exposure data included daily levels of SO2, NO2 and other pollutants of industrial, traffic, and nonanthropogenic sources. Demographical, clinical, and medications purchase data were assessed. Log-transformed SG levels were analyzed by linear mixed models adjusted for seasonal variables and personal characteristics.SG increases (%increase [95% CI]), among subjects with normal glucose, IFG, and DM, respectively, were associated with 6.36 ppb increase of NO2 measured 24 to 72 hours before the test (0.40% [0.31%; 0.50%], 0.56% [0.40%; 0.71%], and 1.08% [0.86%; 1.29%]); and with 1.17 ppb increase of SO2 measured 24 hours before the test (0.29% [0.22%; 0.36%], 0.20% [0.10%; 0.31%], and 0.33% [0.14%; 0.52%]). Among DM population, weakest association was observed among patients treated with Metformin (0.56% increase in SG [0.18%; 0.95%]).In conclusion, NO2 and SO2 exposure is associated with small but significantly increased levels of SG. Although DM patients were found to be more susceptible to the AP induced SG variations, Metformin treatment seem to have a protective effect. Given the chronic lifetime exposure to AP and the broad coverage of the population, even small associations such as those found in our study can be associated with detrimental health effects and may have profound public health implications.

Prognostic Value of Glycated Hemoglobin for One Year Mortality Following Hospitalization in the Internal Medicine Ward

BACKGROUND

The impact of admission glycated hemoglobin (HbA1c) on hospital outcome is controversial.

OBJECTIVES

To evaluate the association between admission glucose and HbA1c levels and mortality 1 year after hospitalization in the internal medicine ward.

METHODS

HbA1c level of consecutive patients was measured during the first 24 hours of admission to the internal medicine ward and divided at the cutoff point of 6.5%. Three groups of patients were prospectively identified: patients with preexisting diabetes mellitus (DM), patients with glucose > 140 mg/dl (hyperglycemia) on admission and no known diabetes (H), and patients without diabetes or hyperglycemia (NDM). The primary end-point was 1 year all-cause mortality.

RESULTS

A total of 1024 patients were enrolled, 592 (57.8%) belonged to the DM group, 119 (11.6/6) to the H group and 313 (30.6%) to the NDM group. At 1 year, death occurred in 70 (11.9%) in the DM group, 12 (10.0%) in the H group and 15 (4.8%) in the NDM group (P = 0.002). Elevated admission glucose levels did not influence outcome in any of the groups. HbA1c levels were similar for survivors and non-survivors (P = 0.60). Within-group multivariate analysis adjusted for comorbidities and age showed that in the H group HbA1C levels of 6.5% or above were associated with increased mortality risk [hazard ratio (HR) 8.25, 95% confidence interval (CI) 1.93-35.21]. In the DM group, HbA1c levels below 6.5% were associated with increased mortality risk (HR = 2.05, 95% CI 1.25-3.36).

CONCLUSIONS

Glucose levels upon admission did not affect mortality. However, HbA1c levels below 6.5% had opposite effects on 1 year mortality in diabetes patients and patients with hyperglycemia.

Clinical characteristics and survival of patients with diabetes mellitus following non-traumatic lower extremity amputation

BACKGROUND

Diabetes mellitus-related lower extremity amputation is a major complication severely affecting patient survival and quality of life.

OBJECTIVES

To analyze epidemiological and clinical trends in the incidence and survival of lower extremity amputations among diabetes patients.

METHODS

We conducted a retrospective observational cohort study of 565 consecutive diabetes patients who underwent their first non-traumatic lower extremity amputation between January 2002 and December 2009.

RESULTS

Major amputations were performed in 316 (55.9%) patients: 142 above the knee (25.1%) and 174 below (30.8%); 249 (44.1%) had a minor amputation. The incidence rates of amputations decreased from 2.9 to 2.1 per 1000 diabetes patients. Kaplan-Meier survival analysis showed that first year mortality rates were lower among patients with minor amputations (31.7% vs. 39.6%, P = 0.569). First year mortality rates following below-knee amputation were somewhat lower than above-knee amputation (33.1 vs. 45.1%, respectively). Cox regression model of survival at 1 year after the procedure found that age (HR 1.06 per year, 95% CI 1.04-1.07, P < 0.001), above-knee amputation (HR 1.36, 95% CI 1.01-1.83, P = 0.045) and ischemic heart disease (HR 1.68, 95% CI 1.26-2.24, P < 0.001) significantly increased one year mortality risk.

CONCLUSIONS

In this population-based study the incidence rate of non-traumatic amputations in diabetes patients between January 2002 and December 2009 decreased slightly. However, one year mortality rates after the surgery did not decline and remained high, stressing the need for a multidisciplinary effort to prevent amputations in diabetes patients.

Abdominal superficial subcutaneous fat: a putative distinct protective fat subdepot in type 2 diabetes

OBJECTIVE

Unlike visceral adipose tissue (VAT), the association between subcutaneous adipose tissue (SAT) and obesity-related morbidity is controversial. In patients with type 2 diabetes, we assessed whether this variability can be explained by a putative favorable, distinct association between abdominal superficial SAT (SSAT) (absolute amount or its proportion) and cardiometabolic parameters.

RESEARCH DESIGN AND METHODS

We performed abdominal magnetic resonance imaging (MRI) in 73 patients with diabetes (mean age 58 years, 83% were men) and cross-sectionally analyzed fat distribution at S1-L5, L5-L4, and L3-L2 levels. Patients completed food frequency questionnaires, and subgroups had 24-h ambulatory blood pressure monitoring and 24-h ambulatory electrocardiography.

RESULTS

Women had higher %SSAT (37 vs. 23% in men; P < 0.001) despite a similar mean waist circumference. Fasting plasma glucose (P = 0.046) and HbA(1c) (P = 0.006) were both lower with increased tertile of absolute SSAT. In regression models adjusted for age, waist circumference, and classes of medical treatments used in this patient population, increased %SSAT was significantly associated with decreased HbA(1c) (β = -0.317; P = 0.013), decreased daytime ambulatory blood pressure (β = -0.426; P = 0.008), and increased HDL cholesterol (β = 0.257; P = 0.042). In contrast, increased percent of deep SAT (DSAT) was associated with increased HbA(1c) (β = 0.266; P = 0.040) and poorer heart rate variability parameters (P = 0.030). Although total fat and energy intake were not correlated with fat tissue distribution, increased intake of trans fat tended to be associated with total SAT (r = 0.228; P = 0.05) and DSAT (r = 0.20; P = 0.093), but not with SSAT.

CONCLUSIONS

Abdominal SAT is composed of two subdepots that associate differently with cardiometabolic parameters. Higher absolute and relative distribution of fat in abdominal SSAT may signify beneficial cardiometabolic effects in patients with type 2 diabetes.

Mitogen-activated protein kinases, inhibitory-kappaB kinase, and insulin signaling in human omental versus subcutaneous adipose tissue in obesity

MAPKs and inhibitory-kappaB kinase (IKK) were suggested to link various conditions thought to develop in adipose tissue in obesity (oxidative, endoplasmic reticulum stress, inflammation) with insulin resistance. Yet whether in obesity these kinases are affected in a fat-depot-differential manner is unknown. We assessed the expression and phosphorylation of these kinases in paired omental and abdominal-sc fat biopsies from 48 severely obese women (body mass index > 32 kg/m(2)). Protein and mRNAs of p38MAPK, ERK, c-Jun kinase-1, and IKKbeta were increased 1.5-2.5-fold in omental vs. sc fat. The phosphorylated (activated) forms of these kinases were also increased to similar magnitudes as the total expression. However, phosphorylation of insulin receptor substrate-1 on Ser312 (equivalent of murine Ser307) was not increased in omental, compared with sc, fat. Consistently, fat tissue fragments stimulated with insulin demonstrated that tyrosine phosphorylation and signal transduction to Akt/protein kinase B in omental fat was not inferior to that observable in sc fat. Comparison with lean women (body mass index 23.2 +/- 2.9 kg/m(2)) revealed similar ERK2 and IKKbeta expression and phosphorylation in both fat depots. However, as compared with lean controls, obese women exhibited 480 and 270% higher amount of the phosphorylated forms of p38MAPK and c-Jun kinase, respectively, in omental, but not sc, fat, and this expression level correlated with clinical parameters of glycemia and insulin sensitivity. Increased expression of stress-activated kinases and IKK and their phosphorylated forms in omental fat occurs in obesity, potentially contributing to differential roles of omental and sc fat in the pathophysiology of obesity.

Exogenously imposed postprandial-like rises in systemic glucose and GLP-1 do not produce an incretin effect, suggesting an indirect mechanism of GLP-1 action

The insulinotropic intestinal hormone GLP-1 is thought to exert one of its effects by direct action on the pancreatic beta-cell receptors. GLP-1 is rapidly degraded in plasma, such that only a small amount of the active form reaches the pancreas, making it questionable whether this amount is sufficient to produce a direct incretin effect. The aim of our study was to assess, in a dog model, the putative incretin action of GLP-1 acting directly on the beta-cell in the context of postprandial rises in GLP-1 and glucose. Conscious dogs were fed a high-fat, high-carbohydrate meal, and insulin response was measured. We also infused systemic glucose plus GLP-1, or glucose alone, to simulate the meal test values of these variables and measured insulin response. The results were as follows: during the meal, we measured a robust insulin response (52 +/- 9 to 136 +/- 14 pmol/l, P < 0.05 vs. basal) with increases in portal glucose and GLP-1 but only limited increases in systemic glucose (5.3 +/- 0.1 to 5.7 +/- 0.1 mmol/l, P = 0.1 vs. basal) and GLP-1 (6 +/- 0 to 9 +/- 1 pmol/l, P = 0.5 vs. basal). Exogenous infusion of systemic glucose and GLP-1 produced a moderate increase in insulin (43 +/- 5 to 84 +/- 15 pmol/l, 43% of the meal insulin). However, infusion of glucose alone, without GLP-1, produced a similar insulin response (37 +/- 6 to 82 +/- 14 pmol, 53% of the meal insulin, P = 0.7 vs. glucose and GLP-1 infusion). In conclusion, in dogs with postprandial rises in systemic glucose and GLP-1, the hormone might not have a direct insulinotropic effect and could regulate glycemia via indirect, portohepatic-initiated neural mechanisms.

Synergistic effect of portal glucose and glucagon-like peptide-1 to lower systemic glucose and stimulate counter-regulatory hormones

AIMS

Glucagon-like peptide-1 (GLP-1) is an insulinotropic hormone released from the gut in response to nutrients. Besides its well-established direct effect on pancreatic beta cells, GLP-1 may also act by activating sensors in the hepatoportal area. We therefore studied the impact of putative GLP-1 sensors in the splanchnic circulation.

METHODS

We infused GLP-1 into the portal vein of conscious dogs, while also infusing glucose intraportally or systemically. In the first experiment, we infused glucose intraportally, simulating portal glucose values obtained during a previous mixed-meal test, with or without co-infusion of intraportal GLP-1. In the second experiment, by infusing glucose systemically, with or without intraportal GLP-1, we investigated whether the effects of systemic glucose with or without portal GLP-1 infusion are similar to those observed in the first experiment.

RESULTS

Intraportal infusion of GLP-1 and glucose significantly raised peripheral GLP-1 levels, but did not produce an insulin response different from intraportal glucose alone. However, the resulting peripheral glycaemia was significantly lower compared to glucose infusion alone, and there were elevations in glucagon, cortisol and lactate. In contrast to the portal glucose infusions, there were no significant differences in glucose, insulin, glucagon, cortisol or lactate levels between systemic glucose infusion with or without GLP-1.

CONCLUSIONS/INTERPRETATION

Portal GLP-1 and portal glucose, but not systemic glucose, can produce decreased peripheral glucose levels independently of hyperinsulinaemia. This suggests that portal GLP-1 and glucose receptors mediate insulin-independent changes in peripheral glycaemia and determine a strong counter-regulatory response, as reflected by changes in glucagon and cortisol.

A simple bedside test of 1-minute heart rate variability during deep breathing as a prognostic index after myocardial infarction

BACKGROUND

We evaluate a simple, bedside test that measures 1-minute heart rate variability in deep breathing as a predictor of death after myocardial infarction.

METHODS

Bedside heart rate variability was assessed in 185 consecutive patients 5.1 +/- 2.5 days after a first myocardial infarction. Patients were instructed to take 6 deep respirations in 1 minute while changes in heart rate were measured and calculated by an electrocardiographic recorder. An abnormal test result was defined as a difference of less than 10 beats/min between the shortest and longest heart rate interval.

RESULTS

Heart rate variability <10 beats/min was found in 65 patients (35%) and was significantly lower (P <.05) in women, patients >60 years of age, patients with diabetes, patients with congestive heart failure, and patients taking angiotensin-converting enzyme inhibitors. Mean follow-up period was 16 months. Ten patients died during follow-up: 9 of cardiac causes and 1 of stroke. Nine of these 10 patients had heart rate variability <10 beats/min (P =.004). The sensitivity and specificity of this test for cardiovascular mortality is 90.0% and 68.0%, respectively. The negative predictive value is 99.2% and the relative risk is 16.6. Heart rate variability <10 beats/min remained a significant predictor of death after adjusting for clinical, demographic, and left ventricular function with an odds ratio of 1.38 (95% confidence interval, 1.13-1.63).

CONCLUSIONS

This simple, brief bedside deep breathing test of heart rate variability in patients after myocardial infarction appears to be a good predictor for all-cause mortality and sudden death. It may be used as a clinical test for risk stratification after myocardial infarction.