Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Identification of Biological Pathways to Alzheimer's Disease Using Polygenic Scores

Introduction

Single nucleotide polymorphisms (SNPs) contribute small increases in risk for late-onset Alzheimer's disease (LOAD). LOAD SNPs cluster around genes with similar biological functions (pathways). Polygenic risk scores (PRS) aggregate the effect of SNPs genome-wide. However, this approach has not been widely used for SNPs within specific pathways.

Objectives

We investigated whether pathway-specific PRS were significant predictors of LOAD case/control status.

Methods

We mapped SNPs to genes within 8 pathways implicated in LOAD. For our polygenic analysis, the discovery sample comprised 13,831 LOAD cases and 29,877 controls. LOAD risk alleles for SNPs in our 8 pathways were identified at a P-value threshold of 0.5. Pathway-specific PRS were calculated in a target sample of 3332 cases and 9832 controls. The genetic data were pruned with R2 > 0.2 while retaining the SNPs most significantly associated with AD. We tested whether pathway-specific PRS were associated with LOAD using logistic regression, adjusting for age, sex, country, and principal components. We report the proportion of variance in liability explained by each pathway.

Results

The most strongly associated pathways were the immune response (NSNPs = 9304, = 5.63 × 10−19, R2 = 0.04) and hemostasis (NSNPs = 7832, P = 5.47 × 10−7, R2 = 0.015). Regulation of endocytosis, hematopoietic cell lineage, cholesterol transport, clathrin and protein folding were also significantly associated but accounted for less than 1% of the variance. With APOE excluded, all pathways remained significant except proteasome-ubiquitin activity and protein folding.

Conclusions

Genetic risk for LOAD can be split into contributions from different biological pathways. These offer a means to explore disease mechanisms and to stratify patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The challenges of meeting nutritional requirements in children and adults with epidermolysis bullosa: proceedings of a multidisciplinary team study day

This is a report of a study day held in London on 3 March 2010 to discuss measures with which to meet the nutritional requirements of patients with epidermolysis bullosa (EB). Members of national and international multidisciplinary teams (MDTs) caring for patients with EB attended this event. The study day focused on four challenging aspects of management intimately associated with nutritional status in EB, necessitating close cooperation between MDT members: iron-deficiency anaemia, gastrostomy placement and feeding, muscle mass and mobility, and dental health. The study day provided a unique forum for dietitians, doctors, nurses, physiotherapists, psychologists, psychotherapists, dentists, dental hygienists and occupational therapists to share knowledge and debate problems common to all who strive to promote best practice in this rare and complex group of conditions.

Nutrient and sediment concentrations and corresponding loads during the historic June 2008 flooding in eastern Iowa

A combination of above-normal precipitation during the winter and spring of 2007-2008 and extensive rainfall during June 2008 led to severe flooding in many parts of the midwestern United States. This resulted in transport of substantial amounts of nutrients and sediment from Iowa basins into the Mississippi River. Water samples were collected from 31 sites on six large Iowa tributaries to the Mississippi River to characterize water quality and to quantify nutrient and sediment loads during this extreme discharge event. Each sample was analyzed for total nitrogen, dissolved nitrate plus nitrite nitrogen, dissolved ammonia as nitrogen, total phosphorus, orthophosphate, and suspended sediment. Concentrations measured near peak flow in June 2008 were compared with the corresponding mean concentrations from June 1979 to 2007 using a paired t test. While there was no consistent pattern in concentrations between historical samples and those from the 2008 flood, increased flow during the flood resulted in near-peak June 2008 flood daily loads that were statistically greater (p < 0.05) than the median June 1979 to 2007 daily loads for all constituents. Estimates of loads for the 16-d period during the flood were calculated for four major tributaries and totaled 4.95 x 10(7) kg of nitrogen (N) and 2.9 x 10(6) kg of phosphorus (P) leaving Iowa, which accounted for about 22 and 46% of the total average annual nutrient yield, respectively. This study demonstrates the importance of large flood events to the total annual nutrient load in both small streams and large rivers.

Transfer of 137Cs from Chernobyl debris and nuclear weapons fallout to different Swedish population groups

Data from measurements on the body burden of (134)Cs, (137)Cs and (40)K in various Swedish populations between 1959 and 2001 has been compiled into a national database. The compilation is a co-operation between the Departments of Radiation Physics in Malmö and Göteborg, the National Radiation Protection Authority (SSI) and the Swedish Defense Research Agency (FOI). In a previous study the effective ecological half time and the associated effective dose to various Swedish populations due to internal contamination of (134)Cs and (137)Cs have been assessed using the database. In this study values of human body burden have been combined with data on the local and regional ground deposition of fallout from nuclear weapons tests (only (137)Cs) and Chernobyl debris (both (134)Cs and (137)Cs), which have enabled estimates of the radioecological transfer in the studied populations. The assessment of the database shows that the transfer of radiocesium from Chernobyl fallout to humans varies considerably between various populations in Sweden. In terms of committed effective dose over a 70 y period from internal contamination per unit activity deposition, the general (predominantly urban) Swedish population obtains 20-30 microSv/kBq m(-2). Four categories of populations exhibit higher radioecological transfer than the general population; i.) reindeer herders ( approximately 700 microSv/kBq m(-2)), ii.) hunters in the counties dominated by forest vegetation ( approximately 100 microSv/kBq m(-2)), iii.) rural non-farming populations living in sub-arctic areas (40-150 microSv/kBq m(-2)), and iv.) farmers ( approximately 50 microSv/kBq m(-2)). Two important factors determine the aggregate transfer from ground deposition to man; i.) dietary habits (intakes of foodstuff originating from natural and semi-natural ecosystems), and ii.) inclination to follow the recommended food restriction by the authorities. The transfer to the general population is considerably lower ( approximately a factor of 3) for the Chernobyl fallout than during the 1960s and 70s, which is partly explained by a higher awareness of the pathways of radiocaesium to man both by the public and by the regulating authorities, and by the time-pattern of the nuclear weapons fallout during the growth season in Sweden.

Ecological half-time and effective dose from chernobyl debris and from nuclear weapons fallout of 137Cs as measured in different Swedish populations

The fallout in Sweden of radiocesium from nuclear weapons tests during the 1960's (137Cs) and from the Chernobyl accident in 1986 (134Cs and 137Cs) has transferred to humans through different ecological pathways. Data from whole-body burden measurements of 134Cs, 137Cs, and 40K in various Swedish populations between 1964 and 2002 have been compiled. This database enables an evaluation of the temporal and geographical dependence of the transfer of radiocesium from ground deposition to humans and the associated absorbed dose. The body burdens of 137Cs gradually decrease after the peak values reached in 1965 from nuclear weapons fallout and in 1987 from the Chernobyl fallout, but at a varying rate depending on the population. Assuming a dual exponential decrease, a short-term component of typically 1-2 y and a long-term component of 5-10 y are found in urban populations in Sweden. Among reindeer herders and hunters the effective ecological half-time is mono-exponential with a half-time of 5-7 y. The estimated time-integrated effective dose to an individual during a period of 50 y from the Chernobyl fallout is, on average, approximately 10 mSv for reindeer herders, which is 10-100 times higher than the estimated dose received by urban populations in the three major Swedish urban areas (Malmö, Göteborg, and Stockholm).

Retinal microvascular abnormalities and their relationship with hypertension, cardiovascular disease, and mortality

Retinal microvascular abnormalities, such as generalized and focal arteriolar narrowing, arteriovenous nicking and retinopathy, reflect cumulative vascular damage from hypertension, aging, and other processes. Epidemiological studies indicate that these abnormalities can be observed in 2-15% of the nondiabetic general population and are strongly and consistently associated with elevated blood pressure. Generalized arteriolar narrowing and arteriovenous nicking also appear to be irreversible long-term markers of hypertension, related not only to current but past blood pressure levels as well. There are data supporting an association between retinal microvascular abnormalities and stroke, but there is no convincing evidence of an independent or direct association with atherosclerosis, ischemic heart disease, or cardiovascular mortality. New computer-related imaging methods are currently being developed to detect the presence and severity of retinal arteriolar narrowing and other microvascular characteristics. When reliably quantified, retinal microvascular abnormalities may be useful as risk indicators for cerebrovascular diseases.

Photographic measures of cytomegalovirus retinitis as surrogates for visual outcomes in treated patients

OBJECTIVE

To evaluate photographic measures of cytomegalovirus (CMV) retinitis as surrogate outcomes for changes in vision in patients with CMV retinitis related to the acquired immunodeficiency syndrome.

METHODS

Data from 3 clinical trials of CMV retinitis treatments were analyzed. Two photographic assessments of retinitis in eyes involved at baseline were evaluated: progression (lesion border movement > or = 750 microm or occurrence of a new lesion) and change in area of retina involved with retinitis. Vision measures were decline in best-corrected visual acuity and change in visual field. Photographic measures were evaluated as surrogate outcomes based on 4 criteria: (1) association with vision measure; (2) ability to account for treatment-related differences in vision measure; (3) data completeness; and (4) sample size requirements.

RESULTS

Data from 1001 involved eyes (666 patients) were analyzed. Progression and change in area involved were predictive of declines in vision measures, accounted for 50% and 66% of the treatment effect on visual field, and were available from 93% and 64% of involved eyes, respectively. Sample size estimates for a clinical trial were smallest with progression as the design outcome.

CONCLUSION

Progression and change in area involved met the first and second criteria for surrogate outcomes for visual field loss; a complete evaluation for visual acuity decline was not possible because treatment-related differences were not observed. Progression met the logistical and sample size criteria better than change in area of retina involved with retinitis.

Use of the stable isotope (106)Cd for studying dietary cadmium absorption in humans

Hydroponically grown wheat was intrinsically labelled with the stable isotope 106cadmium (106Cd) and the flour made into a porridge. The abundance of the isotope in the porridge was approximately 30 times the natural abundance, but the total level of Cd in the porridge was 0.03 mg/kg fresh weight, which was the same as expected in a normal diet. Cadmium measurements were made using inductively coupled plasma-mass spectrometry (ICP-MS). The porridge was eaten at breakfast by adult and infant volunteers. Bulked faecal collections were analysed for unabsorbed Cd. Initial results suggest that the apparent absorption of Cd may be higher than 5% as commonly quoted, but longer faecal collection times may be necessary to confirm this.

Cytomegalovirus retinitis and viral resistance: 3. Culture results. CMV Retinitis and Viral Resistance Study Group

PURPOSE

To evaluate the relationship between blood and urine cultures for cytomegalovirus and clinical outcomes in patients with cytomegalovirus retinitis.

METHODS

Prospective epidemiologic study of 108 patients with newly diagnosed cytomegalovirus retinitis. Blood and urine were cultured for cytomegalovirus at diagnosis of retinitis, at 1 month and 3 months after diagnosis, and every 3 months thereafter.

RESULTS

Of the patients, 80.6% were found to have either a positive blood culture or urine culture for cytomegalovirus at the time of diagnosis of retinitis, and a positive blood culture at diagnosis was associated with an increased mortality (odds ratio = 1.91, P = .012). Follow-up cultures were positive in approximately 20% of patients, and the rate was constant over time. The development of a positive blood or urine culture during follow-up correlated with the occurrence of cytomegalovirus retinitis in the contralateral eye in those patients with unilateral disease at diagnosis (odds ratio = 5.74, P = .001).

CONCLUSIONS

Patients with cytomegalovirus retinitis and positive blood cultures for cytomegalovirus have a poorer prognosis.

Evaluation of the safety and efficacy of ketorolac versus morphine by patient-controlled analgesia for postoperative pain

STUDY OBJECTIVE

To compare ketorolac tromethamine with morphine for pain management after major abdominal surgery.

DESIGN

Double-blind, randomized study.

SETTING

Hospital recovery room and postoperative surgical unit.

PATIENTS

One hundred ninety-one patients with at least moderate pain after major abdominal surgery.

INTERVENTIONS

Patients received ketorolac by patient-controlled analgesia (PCA) bolus alone (Ket B), ketorolac by bolus plus infusion (Ket I), or morphine by PCA bolus (morphine), with injectable morphine available for supplementation.

MEASUREMENTS AND MAIN RESULTS

Levels of sedation, pain intensity, pain relief, and adverse events were recorded at baseline, at 2, 4, and 6 hours, and at termination. Supplemental morphine was required by 71% of Ket B patients, 67% of Ket I patients, and 38% of morphine patients (p < or = 0.001 for Ket B vs morphine). Although patients receiving ketorolac required more supplemental morphine than the morphine group (6.0 mg Ket I, 6.2 mg Ket B, 4.0 mg morphine), there was a large morphine-sparing effect in both ketorolac groups (total morphine 6.0 mg Ket I, 6.2 mg Ket B, 33.3 mg morphine). Overall pain relief scores were similar for morphine and Ket I groups, and were lower for Ket B than for morphine (p = 0.002). There were no differences among groups in numbers of patients with adverse events.

CONCLUSION

Ketorolac may be effective when administered by PCA device, and has a clear morphine-sparing effect.

The evolution of apical dominance in maize

The domestication of crop plants has often involved an increase in apical dominance (the concentration of resources in the main stem of the plant and a corresponding suppression of axillary branches). A striking example of this phenomenon is seen in maize (Zea mays spp. mays), which exhibits a profound increase in apical dominance compared with its probable wild ancestor, teosinte (Zea mays ssp. parviglumis). Previous research has identified the teosinte branched1 (tb1) gene as a major contributor to this evolutionary change in maize. We have cloned tb1 by transposon tagging and show here that it encodes a protein with homology to the cycloidea gene of snapdragon. The pattern of tb1 expression and the morphology of tb1 mutant plants suggest that tb1 acts both to repress the growth of axillary organs and to enable the formation of female inflorescences. The maize allele of tb1 is expressed at twice the level of the teosinte allele, suggesting that gene regulatory changes underlie the evolutionary divergence of maize from teosinte.

The risk of infection associated with epidural analgesia

Four infections were identified among 4,832 patients receiving epidural analgesia (an attack rate of 0.08%). The infections involved cesarean-section patients and occurred within a 9-month period. Findings suggest that the risk of infection is decreased by maintaining a closed system for the duration of the analgesia course.

Oral ganciclovir as maintenance treatment for cytomegalovirus retinitis in patients with AIDS. Syntex Cooperative Oral Ganciclovir Study Group

BACKGROUND

Cytomegalovirus retinitis, a sight-threatening infection associated with the acquired immunodeficiency syndrome (AIDS), currently requires lifelong intravenous treatment. An effective oral treatment would be an important advance.

METHODS

We compared oral with intravenous ganciclovir in an open-label, randomized study in patients with AIDS and newly diagnosed, stable cytomegalovirus retinitis (the disease was stabilized by three weeks of treatment with intravenous ganciclovir). Sixty subjects were randomly assigned to maintenance therapy with intravenous ganciclovir at a dose of 5 mg per kilogram of body weight daily, and 63 to maintenance therapy with oral ganciclovir at a dose of 3000 mg daily. The subjects were followed for up to 20 weeks, with photography of the fundi conducted every other week. The photographs were evaluated at the completion of the study by an experienced grader who was unaware of the subjects' treatment assignments.

RESULTS

Efficacy could be evaluated in 117 subjects; photographs were ungradable for 2 of the 117. On the basis of the masked assessment of photographs from 115 subjects, the mean time to the progression of retinitis was 62 days in those given intravenous ganciclovir and 57 days in those given oral ganciclovir (P = 0.63; relative risk [oral vs. intravenous], 1.08; 95 percent confidence interval for the difference in means, -22 to +12 days). On the basis of funduscopy by ophthalmologists who were aware of the subjects' treatment assignments, the mean time to progression was 96 days in subjects given intravenous ganciclovir and 68 days in subjects given oral ganciclovir (P = 0.03; relative risk [oral vs. intravenous], 1.68; 95 percent confidence interval for the difference in means, -45 to -11 days). Survival, changes in visual acuity, the incidence of viral shedding, and the incidence of adverse gastrointestinal events were similar in the two groups. Neutropenia, anemia, intravenous-catheter-related adverse events, and sepsis were more common in the group given intravenous ganciclovir.

CONCLUSIONS

Oral ganciclovir is safe and effective as maintenance therapy for cytomegalovirus retinitis and is more convenient for patients to take than intravenous ganciclovir.

Vegetative and Seed-Specific Forms of Tonoplast Intrinsic Protein in the Vacuolar Membrane of Arabidopsis thaliana

Reports from a number of laboratories describe the presence of a family of proteins (the major intrinsic protein family) in a variety of organisms. These proteins are postulated to form channels that function in metabolite transport. In plants, this family is represented by the product of NOD26, a nodulation gene in soybean that encodes a protein of the peribacteroid membrane, and tonoplast intrinsic protein (TIP), an abundant protein in the tonoplast of protein storage vacuoles of bean seeds (KD Johnson, H Höfte, MJ Chrispeels [1990] Plant Cell 2: 525-532). Other homologs that are induced by water stress in pea and in Arabidopsis thaliana and that are expressed in the roots of tobacco have been reported, but the location of the proteins they encode is not known. We now report the presence and derived amino acid sequences of two different TIP proteins in A. thaliana. alpha-TIP is a seed-specific protein that has 68% amino acid sequence identity with bean seed TIP; gamma-TIP is expressed in the entire vegetative body of A. thaliana and has 58% amino acid identity with bean seed TIP. Both proteins are associated with the tonoplast. Comparisons of the derived amino acid sequences of the seven known plant proteins in the major intrinsic protein family show that genes with similar expression patterns (e.g. water stress-induced or seed specific) are more closely related to each other than the three A. thaliana homologs are related. We propose that the nonoverlapping gene expression patterns reported here, and the evolutionary relationships indicated by the phylogenetic tree, suggest a functional specialization of these proteins.

Development of an acute pain service monitoring and evaluation system

In 1990, Schumpert Medical Center, Shreveport, Louisiana--a 625-bed acute care hospital--established an acute pain service (APS) department and implemented the ten-step monitoring and evaluation process as recommended by the Joint Commission to facilitate the quality assurance program for pain management therapy. The program, which entails the cooperative effort of anesthesiologists and registered nurses, is intended to provide individualized pain management therapy to qualified APS patients on a 24-hour, seven-day-a-week basis. Through continuous, systematic monitoring and evaluation of six aspects of care and their indicators and thresholds, the quality of APS patient care can be determined and improved.

The Wisconsin age-related maculopathy grading system

A new system for grading age-related maculopathy is described and measures of reliability are reported. A number of characteristics of age-related maculopathy are graded in a semiquantitative fashion from stereoscopic 30 degrees color fundus photographs, using a grid to define subfields, standard circles printed on plastic to assess size and area, and a specially designed lightbox to allow better discrimination of subtle drusen. The degree of exact agreement achieved between two trained graders across a variety of lesions ranged from 67.1% for drusen size to 99.6% for geographic atrophy. Kappa scores ranged from 0.55 (for drusen confluence) to 0.95 for geographic atrophy. This system will be useful in epidemiologic studies and clinical trials.

Cloning, nucleotide sequence, and expression of the nitroreductase gene from Enterobacter cloacae

The "classical" nitroreductases of enteric bacteria are flavoproteins which catalyze the reduction of a variety of nitroaromatic compounds to metabolites which are highly toxic, mutagenic, or carcinogenic. The gene for the nitroreductase Enterobacter cloacae has now been cloned using an antibody specific to this protein. The nucleotide sequence of the structural gene and flanking regions are reported. Sequence analysis indicates that this gene belongs to a gene family of flavoproteins which have not been previously described. Analysis of the 5'-untranslated region reveals the presence of putative regulatory elements which may be involved in the modulation of the expression of this enzyme. The cloned gene was placed under the control of a T7 promoter for overexpression of the protein in Escherichia coli. The expressed recombinant protein was purified to homogeneity and exhibited physical, spectral, and catalytic properties identical to the protein isolated from E. cloacae.

Detection of diabetic macular edema. Ophthalmoscopy versus photography--Early Treatment Diabetic Retinopathy Study Report Number 5. The ETDRS Research Group

Clinical and photographic methods were used to assess retinopathy during the examinations of diabetic patients enrolled in the Early Treatment Diabetic Retinopathy Study (ETDRS). In analyzing available data from eyes randomly selected for deferral of treatment, the authors compare the clinical detection (including contact lens biomicroscopy) with photographic detection (30 degrees stereoscopic color fundus photographs) of diabetic macular edema. Based on clinical detection, 53% (1778 patients) had hard exudates within 1 disc diameter (DD) of the center of macula, 56% (1868 patients) had retinal thickening within this region, and 31% (1027 patients) had thickening at the center of macula. These analyses show agreements of 83, 78, and 83% between retinal specialists and photographic graders when assessing these three characteristics, respectively. Agreement was 81% in the detection of macular edema for which treatment is indicated (clinically significant macular edema). Each method has its advantages but in general there was close agreement between these methods, particularly for clinically significant macular edema, which supports the reliability of each method.

Urinary and hematologic indexes of hypohydration

As part of a large-scale field feeding system test we were able to collect and study hundreds of aliquots of overnight urine samples obtained immediately prior to a fasting blood sample on days 1, 20, and 44 of the field test. The large number of experimental samples (greater than 650) and concomitant collection of blood and urine aliquots along with data on body weights gave us the opportunity to assess and quantitate the sensitivity of commonly used criteria of hypohydration. Urine aliquots for all test days were initially categorized by specific gravity (SG) greater than or equal to 1.03 (n = 124) or less than 1.03 (n = 540). Creatinine levels were elevated (P less than 0.001) in the concentrated urine samples, but a decreased trend in sodium-to-potassium ratios in these samples failed to achieve statistical significance (P greater than 0.05). However, when individuals with high SG urine were subclassified by a criterion of weight loss greater than 3% from original body weight, then creatinine concentrations were elevated (P = 0.05), whereas sodium-to-potassium ratios were decreased (P = 0.05) when subjects also with high SG but weight loss less than 3% were compared. Because of the moderate altitude (2,000 m) of the field site and the time of sojourn (44 days), there occurred a slight, but significant (P less than 0.001), erythropoietic response. Hematocrit and serum osmolality were not significantly different when examined by the criteria of high or low SG urine and weight loss greater than or less than 3% original body weight.(ABSTRACT TRUNCATED AT 250 WORDS)