Approaches to prevention of cardiovascular complications and events in diabetes mellitus

Potentiation of aspirin-induced cerebroprotection by minocycline: a therapeutic approach to attenuate exacerbation of transient focal cerebral ischaemia

Cerebrovascular disease is a major cause of mortality and disability in adults. Diabetes mellitus increases the risk of cerebral ischaemia and is associated with worse clinical outcome following an event. Upregulation of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) in diabetes appears to play a role in vascular complications of diabetes. We hypothesised that inhibition of MMP-2 and MMP-9 by minocycline can be potentiated by aspirin through inhibition of cyclooxygenase-2 and tissue plasminogen activator, resulting in amelioration of clinical cerebral ischaemia in diabetes. In the present study, cerebral ischaemia/reperfusion injury was induced in streptozotocin diabetic rats by 1 h middle cerebral artery occlusion and 24 h reperfusion. Infarct volume, cerebral oedema, neurological severity score and blood-brain barrier disruption were significantly increased in diabetic animals compared with the normoglycemic control group. The combination of aspirin and minocycline treatment significantly improved these parameters in diabetic animals. Moreover, this therapy was associated with significantly lower mortality and reduction in MMP-2 and MMP-9 levels. Our data indicate that combination of aspirin and minocycline therapy protects from the consequences of cerebral ischaemia in animal models of diabetes and is associated with inhibition of MMP-2 and MMP-9. Therefore, this combination therapy may represent a novel strategy to reduce the neurological complications of cerebral ischaemia in diabetes.

Calyculin A reveals serine/threonine phosphatase protein phosphatase 1 as a regulatory nodal point in canonical signal transducer and activator of transcription 3 signaling of human microvascular endothelial cells

Vascular inflammation is initiated by stimuli acting on endothelial cells. A clinical feature of vascular inflammation is increased circulating interleukin 6 (IL-6) type cytokines such as leukemia inhibitory factor (LIF), but their role in vascular inflammation is not fully defined. IL-6 type cytokines activate transcription factor signal transducer and activator of transcription 3 (STAT3), which has a key role in inflammation and the innate immune response. Canonical STAT3 gene induction is due to phosphorylation of (1) Y705, leading to STAT3 dimerization and DNA binding and (2) S727, enhancing homodimerization and DNA binding by recruiting p300/CBP. We asked whether enhancing S727 STAT3 phosphorylation using the protein phosphatase 1 (PP1) inhibitor, calyculin A, would enhance LIF-induced gene expression in human microvascular endothelial cells (HMEC-1). Cotreatment with calyculin A and LIF markedly increased STAT3 S727 phosphorylation, without affecting the increase in the nuclear fraction of STAT3 phosphorylated on Y705. PP2A inhibitors, okadaic acid and fostriecin, did not enhance STAT3 S727 phosphorylation. Surprisingly, calyculin A eliminated LIF-induced gene expression: (1) calyculin A reduced binding of nuclear extracts to a STAT3 consensus site, thereby reducing the overall level of binding observed with LIF; and (2) calyculin A caused p300/CBP phosphorylation, thus resulting in reduced acetylation activity and degradation. Together, these findings reveal a pivotal role of a protein serine/threonine phosphatases that is likely PP1 in HMEC in controlling STAT3 transcriptional activity.

Lycopene attenuates endothelial dysfunction in streptozotocin-induced diabetic rats by reducing oxidative stress

CONTEXT

Diabetes mellitus is characterized by oxidative stress, which in turn induces endothelial dysfunction. As a potent antioxidant compound, lycopene might rescue diabetic endothelial dysfunction by reducing oxidative stress.

OBJECTIVE

The present study investigated whether lycopene could lower oxidative stress and attenuate endothelial dysfunction in diabetic rats.

METHODS

Different doses of lycopene (10, 30, and 60 mg/kg/day, p.o.) were administered for 30 days to streptozotocin (STZ) (60 mg/kg)-induced diabetic rats. Biochemical parameters and aortic malondialdehyde (MDA) content, superoxidase dismutase (SOD) activity, nitric oxide (NO) levels, constitutive NOS (cNOS) activity, and inducible NOS (iNOS) activity were determined. Endothelium-dependent and endothelium-independent vasorelaxation were measured in aortas for estimating endothelial function.

RESULTS

Compared with normal controls, endothelial function was significantly reduced in diabetic rats and the blunted endothelial function was dependently ameliorated with lycopene treatment. Compared with normal controls, the serum oxidized low-density lipoprotein (ox-LDL) levels, the aortic MDA levels, and iNOS activity in diabetic rats were increased by 113, 197, and 100%, respectively, whereas aortic SOD activity, NO levels, and cNOS activity were decreased by 73, 53, and 65%, respectively. Exogenous administration of lycopene to diabetic rats caused a dose-dependent decrease of serum glucose and ox-LDL levels, an increase of aortic SOD activity, NO levels, and cNOS activity, and a decrease of aortic MDA levels and iNOS activity.

CONCLUSION

Chronic lycopene treatment could attenuate endothelial dysfunction by reducing oxidative stress in STZ-induced diabetic rats. These results indicate that chronic lycopene treatment might be useful in preventing diabetic vascular complications associated with endothelial dysfunction.

Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Exercise and type 2 diabetes

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes mellitus (T2DM), many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay T2DM, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower T2DM risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes, and safe and effective practices for PA with diabetes-related complications.

High glucose induced rat aorta vascular smooth muscle cell oxidative injury: involvement of protein tyrosine nitration

The alteration and further damage of vascular smooth muscle function have been implicated in the development of vascular complications and diabetes. Little is known about protein tyrosine nitration in vascular smooth muscle cell injury induced by high glucose. In this article, vascular smooth muscle cell was exposed to 30 and 40 mM high glucose for 72 h, and then the cell injury in vascular smooth muscle cell induced by high glucose was studied. It was found that high glucose stimulated vascular smooth muscle cell injury in a dose-dependent manner, including decreasing intracellular and extracellular glutathione contents, increasing malondialdehyde and intracellular reactive oxygen species content, increasing the production of nitric oxide (increased nitrite content in cell and medium), as well as increasing protein tyrosine nitration. By comparing protein tyrosine nitration induced by high glucose conditions and extrinsic factors (hemin-nitrite-glucose oxidase system and 3-morpholinosydnonimine), it may be speculated that protein is nitrated selectively, and specific protein tyrosine nitration is involved in diabetic vascular complications.

Hyperglycemic Ins2AkitaLdlr⁻/⁻ mice show severely elevated lipid levels and increased atherosclerosis: a model of type 1 diabetic macrovascular disease

Accelerated atherosclerosis is the leading cause of death in type 1 diabetes, but the mechanism of type 1 diabetes-accelerated atherosclerosis is not well understood, in part due to the lack of a good animal model for the long-term studies required. In an attempt to create a model for studying diabetic macrovascular disease, we have generated type 1 diabetic Akita mice lacking the low density lipoprotein receptor (Ins2(Akita)Ldlr⁻/⁻). Ins2(Akita)Ldlr⁻/⁻ mice were severely hyperglycemic with impaired glucose tolerance. Compared with Ldlr⁻/⁻ mice, 20-week-old Ins2(Akita)Ldlr⁻/⁻ mice fed a 0.02% cholesterol AIN76a diet showed increased plasma triglyceride and cholesterol levels, and increased aortic root cross-sectional atherosclerotic lesion area [224% (P < 0.001) in males and 30% (P < 0.05) in females]. Microarray and quantitative PCR analyses of livers from Ins2(Akita)Ldlr⁻/⁻ mice revealed altered expression of lipid homeostatic genes, including sterol-regulatory element binding protein (Srebp)1, liver X receptor (Lxr)α, Abca1, Cyp7b1, Cyp27a1, and Lpl, along with increased expression of pro-inflammatory cytokine genes, including interleukin (Il)1α, Il1β, Il2, tumor necrosis factor (Tnf)α, and Mcp1. Immunofluorescence staining showed that the expression levels of Mcp1, Tnfα, and Il1β were also increased in the atherosclerotic lesions and artery walls of Ins2(Akita)Ldlr⁻/⁻ mice. Thus, the Ins2(Akita)Ldlr⁻/⁻ mouse appears to be a promising model for mechanistic studies of type 1 diabetes-accelerated atherosclerosis.

Prescribing exercise for individuals with type 2 diabetes: recommendations and precautions

An increasing prevalence of obesity and sedentary behavior has strongly contributed to the epidemic of type 2 diabetes mellitus. Although regular exercise improves glycemic control and is associated with reduced morbidity and mortality, many physicians fail to prescribe it. This article highlights the recommended types and quantities of physical activities that can (and should) be undertaken by individuals with type 2 diabetes, along with precautions required to maximize the safety of exercise in those using various medications and in the presence of diabetes-related complications. This article assesses the need for pre-exercise stress testing, reviews the latest exercise prescription recommendations for individuals with type 2 diabetes, and recommends strategies to assist individuals in adopting and maintaining an active lifestyle.

Self-monitoring technologies for type 2 diabetes and the prevention of cardiovascular complications: perspectives from end users

BACKGROUND

The objective of this study was to explore facilitators and barriers to the adoption of self-monitoring devices in individuals with type 2 diabetes mellitus (T2DM).

METHODS

Individuals with T2DM who were currently using one or more devices to monitor their disease participated in focus groups. Transcripts of focus group meetings were coded into themes by two reviewers using NVivo qualitative software.

RESULTS

Twenty-eight adults with T2DM reported using a blood glucose meter, and almost half reported monitoring their blood pressure. Few individuals consistently monitored other aspects of their cardiovascular health. Four major themes impacting device use/disuse were identified: knowledge gaps, relationships with health care providers, environment, and personal experience. Knowledge barriers included lack of information regarding diabetes and the associated risk of complications. Perceptions of inconvenience, pain, and financial restrictions were important factors influencing the adoption, use, and abandonment of self-monitoring devices. Community-run programs, as well as dieticians and pharmacists, were identified as important resources for accessing information related to T2DM.

CONCLUSIONS

We identified the need for development of accessible and relevant education material; improved communication of disease-specific information between patients and providers, as well as providers and community resources; and strategies to improve the convenience and cost of monitoring devices.

Lifestyle strategies for the prevention of vision loss

As the baby boom generation ages, it is anticipated that half a million cases per year will be added to the 19 to 21 million Americans not living in institutions or serving in the military who have low vision or blindness. The 4 major causes of vision loss and blindness in the United States are cataract, diabetic retinopathy, glaucoma, and age-related macular degeneration. All 4 diseases involve change in the microcirculation in eye structures. Holistic approaches to health incorporate attention to individuals' lifestyle choices. Relevant research literature was reviewed to identify strategies for lifestyle modification that nurses can use to prevent or slow progression of these diseases. Prevention strategies in general are those that promote avoidance of cardiovascular disease and diabetes. Because vision loss has been shown to be associated with diminished quality of life and increased mortality, lifestyle changes that prevent or moderate the impact of these diseases are an important focus of nursing care.

Treatment of dyslipidemia in patients with type 2 diabetes

Type 2 diabetes is associated with significant cardiovascular morbidity and mortality. Although low-density lipoprotein cholesterol levels may be normal in patients with type 2 diabetes, insulin resistance drives a number of changes in lipid metabolism and lipoprotein composition that render low-density lipoprotein cholesterol and other lipoproteins more pathogenic than species found in patients without type 2 diabetes. Dyslipidemia, which affects almost 50% of patients with type 2 diabetes, is a cardiovascular risk factor characterized by elevated triglyceride levels, low high-density lipoprotein cholesterol levels, and a preponderance of small, dense, low-density lipoprotein particles. Early, aggressive pharmacological management is advocated to reduce low-density lipoprotein cholesterol levels, regardless of baseline levels. A number of lipid-lowering agents, including statins, fibrates, niacin, and bile acid sequestrants, are available to target normalization of the entire lipid profile. Despite use of combination and high-dose lipid-lowering agents, many patients with type 2 diabetes do not achieve lipid targets. This review outlines the characteristics and prevalence of dyslipidemia in patients with type 2 diabetes and discusses strategies that may reduce the risk of cardiovascular disease in this population.

Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes, many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type 2 diabetes, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.

Distinguishing the economic costs associated with type 1 and type 2 diabetes

The objective was to estimate the economic costs of diagnosed type 1 (T1DM) and type 2 (T2DM) diabetes mellitus in the United States in 2007. Medical claims were analyzed to estimate the proportion of diagnosed diabetes cases and excess medical costs by diabetes type. Indirect costs associated with T1DM and T2DM were estimated by using findings from the literature on diagnosed diabetes, as well as differences in health per case of T1DM and T2DM. This study builds on the Cost of Diabetes Model developed for the American Diabetes Association to estimate the economic burden of diagnosed diabetes. T1DM accounts for an estimated 5.7% (1.0 million) of the 17.5 million people with diagnosed diabetes. Approximately $14.9 billion (8.6%) of the economic burden of diagnosed diabetes is associated with T1DM, including medical costs of $10.5 billion and indirect costs of $4.4 billion. Costs associated with T2DM are $159.5 billion, including medical costs of $105.7 billion and indirect costs of $53.8 billion. The economic burden per case of diabetes is greater for T1DM than for T2DM, and the difference increases with age. The prevalence of T2DM is significantly greater than the prevalence of T1DM, so T2DM is responsible for most of the economic burden of diabetes. Estimates for T1DM are sensitive to the criteria used to identify people with diabetes using claims data; estimates for T2DM are relatively stable. Improved coding of diabetes type in medical claims and identification of diabetes type in survey data could lead to more precise estimates of the economic burden by diabetes type.

Physical inactivity and cardiovascular risk: baseline observations from men and premenopausal women

INTRODUCTION

Physical activity or exercise is a proven deterrent of cardiovascular (CV) diseases.

PURPOSE

In this study, we examined the relationships between baseline values of parameters related to physical activity and known markers of CV disease, including markers of oxidative stress.

METHODS

A total of 455 healthy men and women between the ages of 18 and 50 were recruited to participate in the study. Levels of lipids/lipoproteins and markers of oxidative stress and inflammation were measured along with the VO(2) and duration time spent on treadmill.

RESULTS

Women, in general, had a significantly (P<0.0001) higher plasma high density lipoprotein (1.51+/-0.30 mmol/l), decreased (P<0.0001) low density lipoprotein (LDL) (2.75+/-0.66 mmol/l), and decreased (P<0.0001) triglycerides levels (2.09+/-0.85 mmol/l), compared with males (1.21+/-0.23 mmol/l, 2.92+/-0.81 mmol/l, and 3.02+/-1.34 mmol/l, respectively). There was a direct correlation between the levels of plasma LDL and the levels oxidized LDL levels (P<0.0001) in both men and women. Despite a better antiatherogenic lipid profile, the levels of C-reactive protein in women were significantly (P<0.0001) elevated (3.78+/-3.66 ng/ml) as compared with those in men (1.82+/-2.37 ng/ml).

CONCLUSION

These results suggest intrinsic sex differences between men and women in relation to atherogenic risk.

Aspirin for primary prevention of cardiovascular events in patients with diabetes: A meta-analysis

BACKGROUND

To systematically review trials concerning the benefit and risk of aspirin therapy for primary prevention of cardiovascular events in patients with diabetes mellitus.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Eligible studies were prospective, randomized controlled trials of aspirin therapy for primary cardiovascular prevention in patients with diabetes with follow-up duration at least 12 months.

RESULTS

7 trials included 11,618 individuals with diabetes. Aspirin therapy was not associated with a statistically significant reduction in major cardiovascular events (relative risk [RR] 0.92, 95% confidence interval [CI] 0.83-1.02, p=0.11). Aspirin use also did not significantly reduce all-cause mortality (0.95, 95% CI 0.85-1.06; p=0.33), cardiovascular mortality (0.95, 95% CI 0.71-1.27; p=0.71), stroke (0.83, 95% CI 0.63-1.10; p=0.20), or myocardial infarction (MI) (0.85, 95% CI 0.65-1.11; p=0.24). There was no significant increased risk of major bleeding in aspirin group (2.46, 95% CI 0.70-8.61; p=0.16). Meta-regression suggested that aspirin agent could reduce the risk of stroke in women and MI in men.

CONCLUSIONS

In patients with diabetes, aspirin therapy did not significantly reduce the risk of cardiovascular events without an increased risk of major bleeding, and showed sex-specific effects on MI and stroke.

Diabetes, vascular complications and antiplatelet therapy: open problems

Diabetes mellitus is commonly associated with both microvascular and macrovascular complications (coronary artery disease, cerebrovascular events, severe peripheral vascular disease, nephropathy and retinopathy). There is wide evidence demonstrating that platelet degranulation and synthesis of TxA2 are increased in diabetic patients. For this reason, many studies on anti-platelet therapy have been made to reduce thrombotic complication of diabetes mellitus. Some diabetic patients, although treated with ASA, have a high prevalence of recurrent thrombotic events, which may presumably be due to an "ASA resistance". Nevertheless, this drug remains the one with the greatest benefit. To optimize its function, we should try to understand the causes of "aspirin resistance", try to find the most suitable dosage, recommending patients to comply constantly with the prescription given and to avoid interactions with other drugs. "Clopidogrel resistance" is a term not clearly defined. The clinical implications of "clopidogrel resistance" are unknown. An important consideration affecting the use of aspirin in diabetic patients is its interaction with ACE-inhibitors. Another question is antiplatelet therapy in nephropathic diabetic patients. Although these patients are at high thrombotic and haemorrhagic risk, they should nevertheless be considered eligible to undergo antithrombotic therapy, taking into account the individual's haemorrhagic risk.

Rotenone partially reverses decreased BK Ca currents in cerebral artery smooth muscle cells from streptozotocin-induced diabetic mice

1. Reactive oxygen species (ROS) cause vascular complications and impair vasodilation in diabetes mellitus. Large-conductance Ca(2+)-activated potassium channels (BK(Ca)) modulate vascular tone and play an important negative feedback role in vasoconstriction. In the present study, we tested the hypothesis that ROS regulate the function of BK(Ca) in diabetic cerebral artery smooth muscle cells. 2. Diabetes was induced in male BALB/c mice by injection of streptozotocin (STZ; 180 mg/kg, i.p., dissolved in sterile saline). Control and diabetic mice were treated with 12.7 micromol/L rotenone, an inhibitor of the mitochondrial electron transport chain complex I, or placebo every other day for 5 weeks. The whole-cell patch clamp-technique and functional vasomotor methods were used to record BK(Ca) currents and myogenic tone of cerebral artery smooth muscle cells. 3. In the diabetic group, there was a significant decrease in spontaneous transient outward currents in cerebral artery smooth muscle cells compared with control. Although the currents were only moderately increased in rotenone-treated diabetic mice, they remained significantly lower than in the control group. Furthermore, the macroscopic BK(Ca) currents that were decreased in diabetic mice were partially recovered in rotenone-treated diabetic mice (P < 0.05 vs untreated diabetic group). 4. The posterior cerebral artery from diabetic mice had a significantly higher myogenic tone than the control group, but this impaired contraction was partially reversed in the rotenone-treated diabetic group (P < 0.05 vs untreated diabetic group). 5. The H(2)O(2) concentration was significantly increased in cerebral arteries from diabetic mice compared with control. This increase in H(2)O(2) was significantly blunted by rotenone treatment. 6. In conclusion, rotenone partially reverses the decreased macroscopic BK(Ca) currents in STZ-induced Type 1 diabetic mice and this reversal of BK(Ca) currents may be related to the inhibitory effects of rotenone on H(2)O(2) production. Reactive oxygen species, particularly H(2)O(2), are important regulators of BK(Ca) channels and myogenic tone in diabetic cerebral artery.

Effect of pharmaceutical interventions targeting thromboxane receptors and thromboxane synthase in cardiovascular and renal diseases

The present review focuses on the roles of thromboxane A2 (TxA2) in arterial thrombosis, atherogenesis, vascular stent-related ischemic events and renal proteinuria. Particular emphasis is laid on therapeutic interventions targeting the TxA2 (TP) receptors and TxA2 synthase (TS), including dual TP-receptor antagonists and TS inhibitors. Their significant inhibitory efficacies on arterial thrombogenesis, atherogenesis, restenosis after stent placement, vasoconstriction and proteinuria indicate novel and improved treatments for cardiovascular and selected renal diseases. New therapeutic interventions of the TxA2 pathway may also be beneficial for patients with poor biological antiplatelet drug response, for example, to aspirin and/or clopidogrel. These new TP/TS agents offer novel improved treatments to efficiently and simultaneously interfere with thrombogenesis and atherogenesis, and to enlarge the existing panel of platelet inhibitors for efficient prophylaxis and treatment of arterial thrombosis and renal proteinuria.

Effect of salvianolic acid A on vascular reactivity of streptozotocin-induced diabetic rats

AIMS

The present study aims to evaluate the beneficial effect of salvianolic acid A (SAA) on the alterations in vascular reactivity of streptozotocin (STZ)-induced diabetic rats.

MAIN METHODS

Diabetes was induced by a single intraperitoneal injection of STZ (60 mg/kg). Following 16 weeks of SAA treatment (1 mg/kg/day), thoracic aortic rings of rats were mounted in organ baths. Contractile responses to noradrenaline (NA) and KCl and relaxant responses to acetylcholine (ACh) and sodium nitroprusside (SNP) were assessed.

KEY FINDINGS

Loss of weight, hyperglycemia, elevated content of malondialdehyde (MDA) and decline of total antioxidant capacity (TAC) were observed in diabetic rats. SAA could reverse these metabolic and biochemical abnormalities. Compared to the control, the maximum contraction (E(max)) to NA, but not sensitivity (pD(2)), increased significantly in diabetic aortas, which was prevented by SAA treatment. However, the response of rat aortas to KCl (E(max) and pD(2)) was not altered either in diabetic group or SAA treatment compared with that of normal control group. We also observed the significant decrease in relaxation to ACh rather than SNP in diabetic group compared with controls, and SAA treatment could revert the ACh response.

SIGNIFICANCE

It is concluded that oral administration of SAA can significantly improve glucose metabolism and inhibit oxidative injury as well as protect against impaired vascular responsiveness in STZ-induced diabetic rats.

Mulberry leaf extract restores arterial pressure in streptozotocin-induced chronic diabetic rats

Free radical-induced vascular dysfunction plays a key role in the pathogenesis of vascular disease found in chronic diabetic patients. Morus alba (MA) leaf extract is promoted for good health especially in diabetic patients. Interestingly, antidiabetic and antioxidant activities of MA have been reported in experimental animals. Thus, the hypothesis of this study was that the long-term treatment with MA could improve vascular reactivity of chronic diabetic rats. To test this hypothesis, we examined the effect of long-term treatment with MA on the vascular responses to vasoactive agents in streptozotocin-induced chronic diabetic rats. The diabetic rats were either orally administered with distilled water, MA (0.25, 0.5 and 1 g/kg per day) or subcutaneously injected with insulin (4 U/kg per day) for 8 weeks. After each treatment, the fasting blood glucose, blood pressure, vascular responses to vasoactive agents and tissue malondialdehyde were examined. Morus alba at the doses of 0.5 and 1 g/kg, which significantly reduced blood glucose level, also significantly decreased the high blood pressure in diabetic rats. Vascular responses of the chronic diabetic rats to vasodilators, acetylcholine (3-30 nmol/kg) and sodium nitroprusside (1-10 nmol/kg) were significantly suppressed by 26% to 44% and 45% to 77% respectively, whereas those to vasoconstrictor, phenylephrine (0.01-0.1 micromol/kg) were significantly increased by 23% to 38% as compared to normal rats. Interestingly, the administration of 0.5 and 1 g/kg MA or 4 U/kg insulin significantly restored the vascular reactivities of diabetic rats. Moreover, 8 weeks of diabetes resulted in the elevation of malondialdehyde content in tissues (liver, kidney, heart, and aorta), and MA treatment significantly lessened this increase. These results provide the first evidence for the efficacy of MA in restoring the vascular reactivity of diabetic rats, the mechanism of which may associate with the alleviation of oxidative stress.

Stem cell sources to treat diabetes

We review progress towards the goal of utilizing stem cells as a source of engineered pancreatic beta-cells for therapy of diabetes. Protocols for the in vitro differentiation of embryonic stem (ES) cells based on normal developmental cues have generated beta-like cells that produce high levels of insulin, albeit at low efficiency and without full responsiveness to extracellular levels of glucose. Induced pluripotent stem (iPS) cells also can yield insulin-producing cells following similar approaches. An important recent report shows that when transplanted into mice, human ES-derived cells with a phenotype corresponding to pancreatic endoderm matured to yield cells capable of maintaining near-normal regulation of blood sugar [Kroon et al., 2008]. Major hurdles that must be overcome to enable the broad clinical translation of these advances include teratoma formation by ES and iPS cells, and the need for immunosuppressive drugs. Classes of stem cells that can be expanded extensively in culture but do not form teratomas, such as amniotic fluid-derived stem cells and hepatic stem cells, offer possible alternatives for the production of beta-like cells, but further evidence is required to document this potential. Generation of autologous iPS cells should prevent transplant rejection, but may prove prohibitively expensive. Banking strategies to identify small numbers of stem cell lines homozygous for major histocompatibility loci have been proposed to enable beneficial genetic matching that would decrease the need for immunosuppression.

HMG-CoA reductase inhibitors (statin) prevents retinal neovascularization in a model of oxygen-induced retinopathy

PURPOSE

Retinal neovascularization (RNV) is a primary cause of blindness and involves the dysfunction of retinal capillaries. Recent studies have emphasized the beneficial effects of inhibitors of HMG-CoA reductase (statins) in preventing vascular dysfunction. In the present study, the authors characterized the therapeutic effects of statins on RNV.

METHODS

Statin treatment (10 mg/kg/d fluvastatin) was tested in a mouse model of oxygen-induced retinopathy. Morphometric analysis was conducted to determine the extent of capillary growth. Pimonidazole hydrochloride was used to assess retinal ischemia. Western blot and immunohistochemical analyses were used to assess protein expression levels and immunolocalization. Lipid peroxidation and superoxide radical formation were determined to assess oxidative changes.

RESULTS

Fluvastatin treatment significantly reduced the area of the capillary-free zone (P < 0.01), decreased the formation of neovascular tufts (P < 0.01), and ameliorated retinal ischemia. These morphologic and functional changes were associated with statin effects in preventing the upregulation of VEGF, HIF-1 alpha, phosphorylated STAT3, and vascular expression of the inflammatory mediator ICAM-1 (P < 0.01). Superoxide production and lipid peroxidation in the ischemic retina were also reduced by statin treatment (P < 0.01).

CONCLUSIONS

These data suggest the beneficial effects of statin treatment in preventing retinal neovascularization. These beneficial effects appear to result from the anti-oxidant and anti-inflammatory properties of statins.

Contribution of natural inhibitors to the understanding of the PI3K/PDK1/PKB pathway in the insulin-mediated intracellular signaling cascade

The critical initial steps in insulin action include phosphorylation of adapter proteins and activation of phosphatidylinositol 3-kinase (PI3K). One of important components in this process is a protein called Akt/protein kinase B (PKB). The work of numerous different researchers indicates a role of PKB in regulating insulin-stimulated glucose uptake. The crucial role of lipid second messengers in PKB activation has been dissected through the use of the PI3K-specific inhibitors wortmannin and LY294002. Receptor-activated PI3K synthesizes the lipid second messenger PtdIns[3,4,5]-trisphosphate, leading to the recruitment of PKB to the membrane. Membrane attachment of PKB is mediated by its pleckstrin homology domain binding to PtdIns[3,4,5]-trisphosphate or PtdIns[3,4]-bisphosphate with high affinity. Activation of PKB alpha is then achieved at the plasma membrane by phosphorylation of Thr308 in the activation-loop of the kinase domain and Ser473 in the carboxy-terminal regulatory region, respectively. 3-Phosphoinositide-dependent protein kinase-1 (PDK1) is responsible for T308 phosphorylation. The usage of specific inhibitors and natural compound has significantly contributed to investigate the molecular mechanism of PI3K/PDK1/PKB signaling pathway, leading to the putative therapeutics benefits of patients. This review focuses on the contribution of natural inhibitor or compound in our understanding of the mechanism by which insulin induces, especially in PI3K/PDK1/PKB signaling.

Diabetes mellitus complicating systemic lupus erythematosus – analysis of the UCL lupus cohort and review of the literature

Systemic lupus erythematosus (SLE) often coexists with other diseases. Diabetes mellitus (DM) is an example and patients with overlap SLE-DM can present with clinical features common to both disorders. In this review, we describe the patients with overlap SLE-DM, focussing on the clinical features common to both diseases that these patients can present, and on the challenges of managing such complications. A detailed review of the patients’ notes ( n = 485) was performed. At every outpatient appointment the patients’ urine was tested for glucose, protein and blood. Patients with persistent glycosuria were investigated with fasting blood glucose and a glucose tolerance test to help make the diagnosis of DM. Particular note was made of those patients whose symptoms could be due to SLE, DM or both. Nine patients with DM were identified. Three had type 1 DM, four had type 2 DM and two were considered to have steroid-induced DM. Among these patients, three had renal involvement (two with WHO class IV lupus nephritis); two had peripheral neuropathy (one had a mixed sensory and motor neuropathy, one had a sensory peripheral neuropathy); two patients had retinopathy and cataracts and one had angina. The combination of SLE and DM is uncommon but the predisposition to renal, peripheral neuropathy and retinal disease means that great care must be taken when deciding which clinical feature is due to which disease, because active SLE requires additional immunosuppression whereas DM requires optimization of the metabolic control. Interestingly, although in theory patients with SLE and DM are in double-jeopardy of developing atherosclerosis, to date, only one of our overlap patients has developed angina.

Antiplatelet drugs in cardiological practice: established strategies and new developments

A common pathophysiological course in vascular diseases is an overwhelming activation and aggregation of blood platelets, which results in atherothrombosis. By causing the last decisive step of cerebral, coronary, or peripheral arterial ischemia thrombotic complications of atherosclerotic disease represent a major player in death cause statistics of most western countries. The development of novel therapies against platelet-dependent thrombosis and the concurrent improvement of existing therapeutic strategies thus is a paramount focus of pharmaceutical research. Currently, efficiency, dosing and indications of established antiplatelet substances are being re-evaluated, whilst new, so far unrecognized molecular targets for inhibition of platelet activity come up front. This not only allows for interesting new therapeutical options, but also widens our insight into the role platelets play in atherosclerosis in general. This article summarizes the relevant pathophysiology of platelet activation, presents current concepts in antiplatelet drug therapy, and highlights the role of platelets in vascular diseases apart from atherothrombosis.

Short term effects of atorvastatin on endothelial functions and oxidized LDL levels in patients with type 2 diabetes

OBJECTIVE

This study was designed in order to investigate the short term effects of atorvastatin on endothelial function and oxidized LDL (oxLDL) levels and to evaluate the association of endothelial dysfunction to oxLDL levels and inflammatory markers in type 2 diabetic patients.

MATERIAL AND METHODS

Thirty type 2 diabetic and 11 healthy subjects with LDL levels between 100-160 mg/dl. without a history of cardiovascular event were included in the study. Both groups were matched with respect to age, gender, body mass indices and lipid levels. Flow- mediated dilatation (endothelium dependent, FMD) and nitroglycerine-induced dilatation (endothelium independent, NID) were measured in the brachial artery using high-resolution ultrasound in all participants and carotid artery intima media thickness (IMT) were also evaluated. OxLDL levels, lipid parameters, blood glucose, C-peptide, HbA1c and inflammatory markers including C-reactive protein (CRP), fibrinogen, erythrocyte sedimentation rate (ESR) were studied. Type 2 diabetic patients received 10 mg. Atorvastatin for 6 weeks and FMD and NID were reevaluated and oxLDL levels and inflammatory markers remeasured.

RESULTS

Basal FMD, NID, IMT and oxLDL levels besides inflammatory markers were not significantly different between patients and controls. No correlation was found between inflammatory markers and FMD and NID. Only IMT correlated with fibrinogen levels obtained before treatment. In non-diabetics, IMT also correlated with oxLDL levels (p: 0.013). FMD and NID significantly improved after atorvastatin therapy ((7.62 +/- 7.6 vs. 12.65 +/- 7.8, p<0.001 and 18.22 +/- 9.57 vs. 21.43 +/- 9.6, p: 0.007, respectively). Atorvastatin significantly reduced oxLDL levels (57.85 +/- 10.33 vs. 44.36 +/- 6.34, p<0.001).

CONCLUSION

Atorvastatin improves endothelial functions and reduces oxLDL levels in type 2 diabetics with average lipid levels in the short term and may have beneficial effects in the prevention of early atherosclerotic changes.

Endothelial dysfunction in impaired fasting glycemia, impaired glucose tolerance, and type 2 diabetes mellitus

The aim of this study was to evaluate whether abnormal endothelial function is present in early stages of diabetes, such as impaired glucose tolerance (IGT) and impaired fasting glucose (IFG). Endothelial function was assessed by measuring flow-mediated dilatation and nitrate-induced dilatation of the brachial artery using high-resolution ultrasound. Fasting serum lipid levels were determined, and glucose and insulin values in response to a 75-g oral glucose load were also measured. The results showed the following new findings: (1) compared with subjects with normal glucose tolerance, those with IFG and IGT had impaired flow-mediated dilatation, more remarkable in subjects with type 2 diabetes mellitus than those with IFG and IGT, and (2) flow-mediated dilatation was inversely and strongly related to the extent of hyperglycemia. In conclusion, endothelial dysfunction is present in subjects with IGT and IFG, indicating endothelial damage in these stages.

The role of aspirin in cardiovascular prevention: implications of aspirin resistance

Aspirin is well recognized as an effective antiplatelet drug for secondary prevention in subjects at high risk of cardiovascular events. However, most patients receiving long-term aspirin therapy still remain at substantial risk of thrombotic events due to insufficient inhibition of platelets, specifically via the thromboxane A2 pathway. Although the exact prevalence is unknown, estimates suggest that between 5.5% and 60% of patients using this drug may exhibit a degree of "aspirin resistance," depending upon the definition used and parameters measured. To date, only a limited number of clinical studies have convincingly investigated the importance of aspirin resistance. Of these, few are of a sufficient scale, well designed, and prospective, with aspirin used at standard doses. Also, most studies do not sufficiently address the issue of noncompliance to aspirin as a frequent, yet easily preventable cause of resistance to this antiplatelet drug. This review article provides a comprehensive overview of aspirin resistance, discussing its definition, prevalence, diagnosis, and therapeutic approaches. Moreover, the clinical implications of aspirin resistance are explored in various cardiovascular disease states, including diabetes mellitus, hypertension, heart failure, and other similar disorders where platelet reactivity is enhanced.

Targeting cardiovascular risk in patients with diabetes: management of dyslipidemia

PURPOSE OF REVIEW

The management of dyslipidemia in patients with diabetes is a key component of cardiovascular risk reduction. In particular, the atherogenic dyslipidemia of diabetes often requires combination therapy to target aspects of the lipid profile beyond low-density lipoprotein cholesterol. This article will review the characteristics of dyslipidemia in diabetes, and discuss guidelines and strategies for treatment to reduce cardiovascular disease risk.

RECENT FINDINGS

A number of clinical outcomes trials supports the use of statins to reduce cardiovascular events in patients with type 2 diabetes mellitus. The disappointing results of clinical trials involving torcetrapib to increase high-density lipoprotein levels may lead to renewed interest and utilization of niacin for the management of atherogenic dyslipidemia. Long-term use of fibrate therapy in patients with atherogenic dyslipidemia has recently been associated with reduction in all-cause, cancer, and cardiovascular mortality rates. Ongoing trials are investigating whether addition of niacin or fibrate to statin therapy is superior to statin therapy alone in preventing cardiovascular events.

SUMMARY

Aggressive low-density lipoprotein control continues to be the primary goal of therapy in dyslipidemia management. Given the growing body of evidence showing the cardiovascular benefits of treating other lipid components, however, it is easy to anticipate that full normalization of the lipid profile may become the standard of care for diabetic dyslipidemia.

Economic costs of diabetes in the U.S. In 2007

OBJECTIVE

The prevalence of diabetes continues to grow, with the number of people in the U.S. with diagnosed diabetes now reaching 17.5 million. The objectives of this study are to quantify the economic burden of diabetes caused by increased health resource use and lost productivity, and to provide a detailed breakdown of the costs attributed to diabetes.

RESEARCH DESIGN AND METHODS

This study uses a prevalence-based approach that combines the demographics of the population in 2007 with diabetes prevalence rates and other epidemiological data, health care costs, and economic data into a Cost of Diabetes Model. Health resource use and associated medical costs are analyzed by age, sex, type of medical condition, and health resource category. Data sources include national surveys and claims databases, as well as a proprietary database that contains annual medical claims for 16.3 million people in 2006.

RESULTS

The total estimated cost of diabetes in 2007 is $174 billion, including $116 billion in excess medical expenditures and $58 billion in reduced national productivity. Medical costs attributed to diabetes include $27 billion for care to directly treat diabetes, $58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes, and $31 billon in excess general medical costs. The largest components of medical expenditures attributed to diabetes are hospital inpatient care (50% of total cost), diabetes medication and supplies (12%), retail prescriptions to treat complications of diabetes (11%), and physician office visits (9%). People with diagnosed diabetes incur average expenditures of $11,744 per year, of which $6,649 is attributed to diabetes. People with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than what expenditures would be in the absence of diabetes. For the cost categories analyzed, approximately $1 in $5 health care dollars in the U.S. is spent caring for someone with diagnosed diabetes, while approximately $1 in $10 health care dollars is attributed to diabetes. Indirect costs include increased absenteeism ($2.6 billion) and reduced productivity while at work ($20.0 billion) for the employed population, reduced productivity for those not in the labor force ($0.8 billion), unemployment from disease-related disability ($7.9 billion), and lost productive capacity due to early mortality ($26.9 billion).

CONCLUSIONS

The actual national burden of diabetes is likely to exceed the $174 billion estimate because it omits the social cost of intangibles such as pain and suffering, care provided by nonpaid caregivers, excess medical costs associated with undiagnosed diabetes, and diabetes-attributed costs for health care expenditures categories omitted from this study. Omitted from this analysis are expenditure categories such as health care system administrative costs, over-the-counter medications, clinician training programs, and research and infrastructure development. The burden of diabetes is imposed on all sectors of society-higher insurance premiums paid by employees and employers, reduced earnings through productivity loss, and reduced overall quality of life for people with diabetes and their families and friends.