Diabetes Mellitus-Related All-Cause and Cardiovascular Mortality in a National Cohort of Adults

Associations of cardiovascular and diabetes-related risk factors with myocardial perfusion reserve assessed by 201Tl/99mTc-tetrofosmin single-photon emission computed tomography in patients with diabetes mellitus and stable coronary artery disease

We aimed to examine the associations of cardiovascular risk factors with myocardial perfusion reserve (MPR) in patients with type 2 diabetes and stable coronary artery disease. The study patients were retrospectively identified from a database of patients with diabetes and stable coronary artery disease at Asan Medical Center (Seoul, Republic of Korea), covering the period from 2017 to 2019. The primary outcome variable was MPR assessed by dynamic stress 201Tl/rest 99mTc-tetrofosmin SPECT. Univariable and stepwise multivariable analyses were performed to assess the associations of cardiovascular risk factors with MPR. A total of 276 patients (236 men and 40 women) were included. The median global MPR was 2.4 (interquartile range 1.9-3.0). Seventy-five (27.2%) patients had an MPR < 2.0. Multivariable linear regression showed that smoking (ß = - 0.44, 95% confidence interval - 0.68 to - 0.21, P < 0.001), hypertension (ß = - 0.24, 95% confidence interval - 0.47 to - 0.02, P = 0.033), and summed difference score (ß = - 0.05, 95% confidence interval - 0.07 to - 0.03, P < 0.001) were independently associated with MPR. Abnormal MPR (< 2.0) was associated with a higher incidence of cardiac death or myocardial infarction (P = 0.034). MPR assessed by dynamic stress 201Tl/rest 99mTc-tetrofosmin SPECT was impaired in a large cohort of patients with diabetes. After adjusting for risk variables, including standard myocardial perfusion imaging characteristics, smoking, and hypertension were associated with MPR. Our results may aid in identifying patients with impaired MPR and stratifying patients with type 2 diabetes.

Relationship Among Diabetes, Obesity, and Cardiovascular Disease Phenotypes: A UK Biobank Cohort Study

OBJECTIVE

Obesity and diabetes frequently coexist, yet their individual contributions to cardiovascular risk remain debated. We explored cardiovascular disease biomarkers, events, and mortality in the UK Biobank stratified by BMI and diabetes.

RESEARCH DESIGN AND METHODS

A total of 451,355 participants were stratified by ethnicity-specific BMI categories (normal, overweight, obese) and diabetes status. We examined cardiovascular biomarkers including carotid intima-media thickness (CIMT), arterial stiffness, left ventricular ejection fraction (LVEF), and cardiac contractility index (CCI). Poisson regression models estimated adjusted incidence rate ratios (IRRs) for myocardial infarction, ischemic stroke, and cardiovascular death, with normal-weight nondiabetes as comparator.

RESULTS

Five percent of participants had diabetes (10% normal weight, 34% overweight, and 55% obese vs. 34%, 43%, and 23%, respectively, without diabetes). In the nondiabetes group, overweight/obesity was associated with higher CIMT, arterial stiffness, and CCI and lower LVEF (P < 0.005); these relationships were diminished in the diabetes group. Within BMI classes, diabetes was associated with adverse cardiovascular biomarker phenotype (P < 0.005), particularly in the normal-weight group. After 5,323,190 person-years follow-up, incident myocardial infarction, ischemic stroke, and cardiovascular mortality rose across increasing BMI categories without diabetes (P < 0.005); this was comparable in the diabetes groups (P-interaction > 0.05). Normal-weight diabetes had comparable adjusted cardiovascular mortality to obese nondiabetes (IRR 1.22 [95% CI 0.96-1.56]; P = 0.1).

CONCLUSIONS

Obesity and diabetes are additively associated with adverse cardiovascular biomarkers and mortality risk. While adiposity metrics are more strongly correlated with cardiovascular biomarkers than diabetes-oriented metrics, both correlate weakly, suggesting that other factors underpin the high cardiovascular risk of normal-weight diabetes.

Effects of GLP-1 Agonists on mortality and arrhythmias in patients with Type II diabetes

Background

Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RA) are frequently used for the management of diabetes. The impact of GLP-1 RA on cardiovascular outcomes is unclear. We aim to assess the effect of GLP-1 RA on mortality, atrial and ventricular arrhythmias, and sudden cardiac death in patients with type II diabetes.

Methods

We searched databases including Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar and CINAHL, from inception to May 2022, for randomized controlled trials reporting the relationship between GLP-1 RA (including albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, and semaglutide) and mortality, atrial arrhythmias, and the combined incidence of ventricular arrhythmias and sudden cardiac death. The search was not restricted to time or publication status.

Results

A total of 464 studies resulted from literature search, of which 44 studies, including 78,702 patients (41,800 GLP-1 agonists vs 36,902 control), were included. Follow up ranged from 52 to 208 weeks. GLP-1 RA were associated with lower risk of all-cause mortality (odds ratio 0.891, 95% confidence interval 0.837-0.949; P < 0.01) and reduced cardiovascular mortality (odds ratio 0.88, 95% confidence interval 0.881-0.954; P < 0.01). GLP-1 RA were not associated with increased risk of atrial (odds ratio 0.963, 95% confidence interval 0.869-1.066; P 0.46) or ventricular arrhythmias and sudden cardiac death (odds ratio 0.895, 95% confidence interval 0.706-1.135; P 0.36).

Conclusion

GLP-1 RA are associated with decreased all-cause and cardiovascular mortality, and no increased risk of atrial and ventricular arrhythmias and sudden cardiac death.

Atherosclerotic Cardiovascular Disease in Type 2 Diabetes: A Retrospective, Observational Study of Economic and Clinical Burden in Sweden

INTRODUCTION

Individuals with type 2 diabetes (T2D) are at high risk of experiencing atherosclerotic cardiovascular disease (ASCVD), which is associated with morbidity, mortality and healthcare resource utilisation. Clinical guidelines recommend the use of glucose-lowering medications with cardiovascular benefits in individuals with T2D and cardiovascular disease, but there is evidence that this is not reflected in clinical practice. We used linked national registry data from Sweden to compare outcomes in people with T2D and ASCVD against matched controls with T2D without ASCVD, over 5 years. Direct costs (inpatient, outpatient and selected drug costs), indirect costs resulting from work absence, early retirement, cardiovascular events and mortality were examined.

METHODS

Individuals with T2D who were at least 16 years old and were alive and resident in Sweden on 1 January 2012 were identified in an existing database. In four separate analyses, individuals with a record indicating ASCVD according to a broad definition, peripheral artery disease (PAD), stroke or myocardial infarction (MI) before 1 January 2012 were identified using diagnosis and/or procedure codes and propensity score matched 1:1 to controls with T2D and without ASCVD, using covariates for birth, sex and level of education in 2012. Follow-up continued until death, migration from Sweden or the end of the study period in 2016.

RESULTS

In total, 80,305 individuals with ASCVD, 15,397 individuals with PAD, 17,539 individuals with previous stroke and 25,729 individuals with previous MI were included. Total mean annual costs per person were €14,785 for PAD (2.7 × costs for controls), €11,397 for previous stroke (2.2 × controls), €10,730 for ASCVD (1.9 × controls) and €10,342 for previous MI (1.7 × controls). Indirect costs and costs of inpatient care were the major cost drivers. ASCVD, PAD, stroke and MI were all associated with an increased likelihood of early retirement, cardiovascular events and mortality.

CONCLUSIONS

ASCVD is associated with considerable costs, morbidity and mortality in individuals with T2D. These results support structured assessment of ASCVD risk and broader implementation of guideline-recommended treatments in T2D healthcare.

A study of factors influencing long-term glycemic variability in patients with type 2 diabetes: a structural equation modeling approach

Aim

The present study aims to utilize structural equation modeling (SEM) to investigate the factors impacting long-term glycemic variability among patients afflicted with type 2 diabetes.

Method

The present investigation is a retrospective cohort study that involved the collection of data on patients with type 2 diabetes mellitus who received care at a hospital located in Chengdu, Sichuan Province, over a period spanning from January 1, 2013, to October 30, 2022. Inclusion criteria required patients to have had at least three laboratory test results available. Pertinent patient-related information encompassing general demographic characteristics and biochemical indicators was gathered. Variability in the dataset was defined by standard deviation (SD) and coefficient of variation (CV), with glycosylated hemoglobin variation also considering variability score (HVS). Linear regression analysis was employed to establish the structural equation models for statistically significant influences on long-term glycemic variability. Structural equation modeling was employed to analyze effects and pathways.

Results

Diabetes outpatient special disease management, uric acid variability, mean triglyceride levels, mean total cholesterol levels, total cholesterol variability, LDL variability, baseline glycated hemoglobin, and recent glycated hemoglobin were identified as significant factors influencing long-term glycemic variability. The overall fit of the structural equation model was found to be satisfactory and it was able to capture the relationship between outpatient special disease management, biochemical indicators, and glycated hemoglobin variability. According to the total effect statistics, baseline glycated hemoglobin and total cholesterol levels exhibited the strongest impact on glycated hemoglobin variability.

Conclusion

The factors that have a significant impact on the variation of glycosylated hemoglobin include glycosylated hemoglobin itself, lipids, uric acid, and outpatient special disease management for diabetes. The identification and management of these associated factors can potentially mitigate long-term glycemic variability, thereby delaying the onset of complications and enhancing patients' quality of life.

Dose- and Time-Dependent Effect of Dietary Blueberries on Diabetic Vasculature Is Correlated with Gut Microbial Signature

Evidence from our lab and others indicates the vascular effects of dietary blueberries. In the present study, we determined dietary blueberries' dose- and time-dependent effects on diabetic vasculature and their association with gut microbes. Seven-week-old db/db diabetic male mice were fed a diet supplemented with ± freeze-dried wild blueberry powder (FD-BB) for 4, 8, or 12 weeks (three cohorts). Diets contained 0%, 1.23%, 2.46%, and 3.7% of FD-BB, equivalent to 0, ½, 1, and 1.5 human servings of wild blueberries, respectively. The non-diabetic db/+ mice fed a standard diet served as controls. Metabolic parameters, vascular inflammation, and gut microbiome were assessed. Dietary supplementation of 3.7% FD-BB improved vascular inflammation in diabetic mice without improving systemic milieu in all three cohorts. Blueberries improved diabetes-induced gut dysbiosis depending on blueberry dosage and treatment duration. Spearman's correlation indicated that the opportunistic microbes and commensal microbes were positively and negatively associated with indices of vascular inflammation, respectively. Dietary blueberries reduced the opportunistic microbe that was positively associated with vascular inflammation (Desulfovibrio), and increased the commensal microbe that was negatively associated with vascular inflammation (Akkermansia). Dietary blueberries could be a potential adjunct strategy to beneficially modulate gut microbes and improve vascular complications in diabetes.

The Presence of Diabetes Mellitus or Pre-diabetes Mellitus Increases Mortality from Heart Disease in a Taiwanese Population: A 10-year Follow-Up Study

BACKGROUND

We evaluated hyperglycemia-associated mortality in the Taiwanese population by conducting a 10-year retrospective cohort study.

METHODS

From 2007 to 2017, all participants, regardless of their age or underlying diseases, were identified at a Health Screening Center in Taiwan. Overall, 114,534 participants were included in the analysis. They were classified into three subgroups according to glycemia and smoking status by combining survival for data analysis.

RESULTS

The mean follow-up time, age, and body mass index (BMI) were 8.14 ± 2.22 years, 40.95 ± 12.14 years, and 23.24 ± 3.65 kg/m², respectively. The cumulative death rate increased from 0.9% in the normal fasting blood glucose(FBG) subgroup to approximately 6% in the diabetes FBG subgroup. After adjusting for age, gender, BMI, high-density lipoprotein, triglycerides, waist circumference(WC), and smoking status, the hazard ratio (HR) for all-cause, cancer, and heart disease mortality in the diabetes mellitus(DM) subgroup was 1.560, 1.381, and 1.828, respectively.HR was 0.989 in all-cause, 0.940 in cancer, and 1.326 in heart disease in the pre-DM subgroup.

CONCLUSION

Being tested for pre-DM is related to a higher risk of death from heart disease in the Taiwanese population at baseline. Therefore, cardiovascular risk must be actively measured among diabetes patients every visit.

Different exercise training intensities prevent type 2 diabetes mellitus-induced myocardial injury in male mice

Type 2 diabetes mellitus (T2DM) usually develop myocardial injury and that exercise may have a positive effect on cardiac function. However, the effect of exercise intensity on cardiac function has not yet been fully examined. This study aimed to explore different exercise intensities on T2DM-induced myocardial injury. 18-week-old male mice were randomly divided into four groups: a control group, the T2DM, T2DM + medium-intensity continuous training (T2DM + MICT), and T2DM + high-intensity interval training (T2DM + HIIT) groups. In the experimental group, mice were given high-fat foods and streptozotocin for six weeks and then divided into two exercise training groups, in which mice were subjected to exercise five days per week for 24 consecutive weeks. Finally, metabolic characteristics, cardiac function, myocardial remodeling, myocardial fibrosis, oxidative stress, and apoptosis were analyzed. HIIT treatment improved cardiac function and improved myocardial injury. In conclusion, HIIT may be an effective means to guard against T2DM-induced myocardial injury.

Elevated plasma factor XI predicts cardiovascular events in patients with type 2 diabetes: a long-term observational study

BACKGROUND

Type 2 diabetes mellitus (T2DM) patients are at high risk of cardiovascular (CV) events. Factor XI (FXI) is associated with arterial thromboembolism, including myocardial infarction (MI), stroke, and CV mortality. The role of FXI in T2DM is unknown. We investigated whether plasma FXI is associated with CV events in T2DM patients in long-term observation.

METHODS

In 133 T2DM patients (aged 66 ± 8 years, 40.6% women, median T2DM duration 5 [2-10] years) we assessed plasma FXI levels, along with fibrin clot properties, thrombin generation, and fibrinolysis proteins. A composite endpoint of MI, stroke, or CV death, as well as CV mortality alone were assessed during a median follow-up of 72 months.

RESULTS

Plasma FXI above the 120% upper normal limit was detected in 25 (18.8%) patients and showed positive association with LDL cholesterol and thrombin activatable fibrinolysis inhibitor, but not glycated hemoglobin, inflammatory markers or thrombin generation. The composite endpoint (n = 21, 15.8%) and CV death alone (n = 16, 12%) were more common in patients with elevated FXI (hazard ratio [HR] 10.94, 95% confidence interval [CI] 4.46-26.87, p < 0.001 and HR 7.11, 95% CI 2.61-19.31, p < 0.001, respectively). On multivariable analysis, FXI remained an independent predictor of the composite endpoint and CV death, regardless of concomitant coronary artery disease.

CONCLUSIONS

To our knowledge, this study is the first to show that in T2DM patients, elevated FXI could predict major CV events, including mortality, which suggest that anti-FXI agents might be a potential novel antithrombotic option in this disease.

SGLT1: A Potential Drug Target for Cardiovascular Disease

SGLT1 and SGLT2 are the two main members of the sodium-glucose cotransporters (SGLTs), which are mainly responsible for glucose reabsorption in the body. In recent years, many large clinical trials have shown that SGLT2 inhibitors have cardiovascular protection for diabetic and non-diabetic patients independent of lowering blood glucose. However, SGLT2 was barely detected in the hearts of humans and animals, while SGLT1 was highly expressed in myocardium. As SGLT2 inhibitors also have a moderate inhibitory effect on SGLT1, the cardiovascular protection of SGLT2 inhibitors may be due to SGLT1 inhibition. SGLT1 expression is associated with pathological processes such as cardiac oxidative stress, inflammation, fibrosis, and cell apoptosis, as well as mitochondrial dysfunction. The purpose of this review is to summarize the protective effects of SGLT1 inhibition on hearts in various cell types, including cardiomyocytes, endothelial cells, and fibroblasts in preclinical studies, and to highlight the underlying molecular mechanisms of protection against cardiovascular diseases. Selective SGLT1 inhibitors could be considered a class of drugs for cardiac-specific therapy in the future.

An overview of complications associated with type 1 and type 2 diabetes

Elevated blood glucose levels (hyperglycaemia) and insulin resistance over time are determinants of the onset and progression of a range of complications associated with diabetes mellitus, including cardiovascular disease, neuropathy (nerve damage), diabetic kidney disease and eye conditions. Maintaining optimal glycaemic control may reduce the risk of developing such complications and has been shown to reduce the severity of some renal and eye conditions. However, achieving optimal glycaemic control can be challenging because of various physical and psychological factors that can cause fluctuations in blood glucose levels. This article provides an overview of some of the complications associated with type 1 and type 2 diabetes.

Guardians For Health: A Practical Approach to Improving Quality of Life and Longevity in People with Type 2 Diabetes

Type 2 diabetes is one of the fastest-growing health emergencies of the twenty-first century, in part due to its association with cardiovascular and renal disease. Successful implementation of evidence-based guidelines for the management of patients with diabetes and pre-diabetes has been shown to improve patient outcomes by controlling risk factors for cardiovascular and renal disease. Recommendations include the early introduction of lifestyle adjustments, supported by pharmacological tools. Despite the availability of regularly updated, evidence-based guidelines, guideline implementation in clinical practice is low. As a result, people living with type 2 diabetes are not consistently receiving ideal clinical care. Improving guideline adherence has the potential to improve quality of life and longevity in patients with type 2 diabetes. This article introduces Guardians For Health, a global initiative that aims to improve guideline adherence by simplifying patient management and encouraging patient participation in the implementation of guidelines for type 2 diabetes. Guardians For Health is supported by a global community of implementers, with tools to support decision-making and quality assurance. Through achieving better guideline adherence, Guardians For Health hopes to achieve its vision to "stop early mortality by reducing cardiovascular and kidney complications in people with type 2 diabetes".

Evaluation of the Prevalence and Risk Factors of Drug-Related Problems in Hypertension and Type 2 Diabetes Mellitus Patients at a Tertiary Care Hospital: A Cross-Sectional Study

Background Drug-related problems (DRPs) potentially interfere with the desired treatment goals which may lead to increased healthcare costs, morbidity, and mortality. Despite the negative consequences of DRPs, there is a lack of comprehensive research on their prevalence and risk factors, particularly in chronic diseases such as hypertension and type 2 diabetes mellitus (DM). This study aims to evaluate the prevalence and contributing factors of DRPs among hypertension, type 2 DM, and hypertension with type 2 DM in the outpatient general medicine department. Methodology A hospital-based, prospective, observational study was conducted over three months. DRPs were classified using the Helper-Strand classification. The potential risk factors contributing to DRPs were assessed using binary and multinomial logistic regression methods. A p-value <0.05 was considered statistically significant. Results Among the 236 study participants, DRPs were more prevalent in males, and the mean age of the participants was 51.73 ± 9.47 years. DRPs were found in 76% of the study participants, and the mean number of DRPs per patient was 1.16 ± 0.45. Among the identified DRPs, suboptimal therapeutic goals (33%) were the most frequently observed, followed by ineffective drugs (32%), medication non-adherence (23%), and drug-drug interaction (5%). Therapeutic duplication and overdose were less commonly encountered as DRPs. The presence of comorbidity (adjusted odds ratio (AOR) = 5.77), and smoking (AOR = 21.07) were found to be significant risk factors (p < 0.05) contributing to DRPs. Conclusions DRPs are more prevalent in hypertension, type 2 DM, and hypertension with type 2 DM. Age range (40-60 years), comorbidity, and smoking were found to be associated with a higher incidence of DRPs. The implementation of a multidisciplinary team approach involving clinical pharmacists and physicians can effectively identify the prevalence and determine the associated risk factors of DRPs and subsequently may help employ targeted interventions to mitigate the development of DRPs.

Pharmacologic Activation of Angiotensin-Converting Enzyme II Alleviates Diabetic Cardiomyopathy in db/db Mice by Reducing Reactive Oxidative Stress

BACKGRUOUND

Diabetes mellitus is one of the most common chronic diseases worldwide, and cardiovascular disease is the leading cause of morbidity and mortality in diabetic patients. Diabetic cardiomyopathy (DCM) is a phenomenon characterized by a deterioration in cardiac function and structure, independent of vascular complications. Among many possible causes, the renin-angiotensin-aldosterone system and angiotensin II have been proposed as major drivers of DCM development. In the current study, we aimed to investigate the effects of pharmacological activation of angiotensin-converting enzyme 2 (ACE2) on DCM.

METHODS

The ACE2 activator diminazene aceturate (DIZE) was administered intraperitoneally to male db/db mice (8 weeks old) for 8 weeks. Transthoracic echocardiography was used to assess cardiac mass and function in mice. Cardiac structure and fibrotic changes were examined using histology and immunohistochemistry. Gene and protein expression levels were examined using quantitative reverse transcription polymerase chain reaction and Western blotting, respectively. Additionally, RNA sequencing was performed to investigate the underlying mechanisms of the effects of DIZE and identify novel potential therapeutic targets for DCM.

RESULTS

Echocardiography revealed that in DCM, the administration of DIZE significantly improved cardiac function as well as reduced cardiac hypertrophy and fibrosis. Transcriptome analysis revealed that DIZE treatment suppresses oxidative stress and several pathways related to cardiac hypertrophy.

CONCLUSION

DIZE prevented the diabetes mellitus-mediated structural and functional deterioration of mouse hearts. Our findings suggest that the pharmacological activation of ACE2 could be a novel treatment strategy for DCM.

Expected Health Benefits of SGLT-2 Inhibitors and GLP-1 Receptor Agonists in Older Adults

Background. Older and sicker adults with type 2 diabetes (T2D) were underrepresented in randomized trials of glucagon-like peptide 1 receptor-agonist (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2I), and thus, health benefits are uncertain in this population. Objective. To assess the impact of age, health status, and life expectancy in older adults with T2D on health benefits of GLP1RA and SGLT2I. Design. We used the United Kingdom Prospective Diabetes Study (UKPDS) model to simulate lifetime health outcomes. We calibrated the UKPDS model to improve mortality prediction in older adults using a common geriatric prognostic index. Participants. National Health and Nutrition Examination Survey 2013-2018 participants 65 y and older with T2D, eligible for GLP1RA or SGLT2I according to American Diabetes Association guidelines. Interventions. GLP1RA or SGLT2I use versus no additional medication. Main Measures. Lifetime complications and weighted life-years (LYs) and quality-adjusted life-years (QALYs) across overall treatment arms and life expectancies. Key Results. The overall older adult population was predicted to experience significant health benefits from GLP1RA (+0.29 LY [95% confidence interval: 0.27, 0.31], +0.15 QALYs [0.14, 0.16]) and SGLT2I (+0.26 LY [0.24, 0.28], +0.13 QALYs [0.12, 0.14]) as compared with no added medication. However, expected benefits declined in subgroups with shorter life expectancies. Participants with <4 y of life expectancy had minimal gains of <0.05 LY and <0.03 QALYs from added medication. Accounting for injection-related disutility, GLP1RA use reduced QALYs (-0.03 QALYs [-0.04, -0.02]). Conclusions. While GLP1RA and SGLT2I have substantial health benefits for many older adults with type 2 diabetes, benefits are not clinically significant in patients with <4 y of life expectancy. Life expectancy and patient preferences are important considerations when prescribing newer diabetes medications.

Highlights

On average, older adults benefit significantly from SGLT2I and GLP1RA use. However, the benefits of these drugs are not clinically significant among older patients with life expectancy less than 4 y.There is potential harm in injectable GLP1RA use in the oldest categories of adults with type 2 diabetes.Heterogeneity in life expectancy and patient preferences for injectable versus oral medications are important to consider when prescribing newer diabetes medications.

Machine learning for spatial stratification of progressive cardiovascular dysfunction in a murine model of type 2 diabetes mellitus

Speckle tracking echocardiography (STE) has been utilized to evaluate independent spatial alterations in the diabetic heart, but the progressive manifestation of regional and segmental cardiac dysfunction in the type 2 diabetic (T2DM) heart remains understudied. Therefore, the objective of this study was to elucidate if machine learning could be utilized to reliably describe patterns of the progressive regional and segmental dysfunction that are associated with the development of cardiac contractile dysfunction in the T2DM heart. Non-invasive conventional echocardiography and STE datasets were utilized to segregate mice into two pre-determined groups, wild-type and Db/Db, at 5, 12, 20, and 25 weeks. A support vector machine model, which classifies data using a single line, or hyperplane, that best separates each class, and a ReliefF algorithm, which ranks features by how well each feature lends to the classification of data, were used to identify and rank cardiac regions, segments, and features by their ability to identify cardiac dysfunction. STE features more accurately segregated animals as diabetic or non-diabetic when compared with conventional echocardiography, and the ReliefF algorithm efficiently ranked STE features by their ability to identify cardiac dysfunction. The Septal region, and the AntSeptum segment, best identified cardiac dysfunction at 5, 20, and 25 weeks, with the AntSeptum also containing the greatest number of features which differed between diabetic and non-diabetic mice. Cardiac dysfunction manifests in a spatial and temporal fashion, and is defined by patterns of regional and segmental dysfunction in the T2DM heart which are identifiable using machine learning methodologies. Further, machine learning identified the Septal region and AntSeptum segment as locales of interest for therapeutic interventions aimed at ameliorating cardiac dysfunction in T2DM, suggesting that machine learning may provide a more thorough approach to managing contractile data with the intention of identifying experimental and therapeutic targets.

Fat Mass is Associated with Subclinical Left Ventricular Systolic Dysfunction in Patients with Type 2 Diabetes Mellitus Without Established Cardiovascular Diseases

INTRODUCTION

Left ventricular global longitudinal strain (GLS) is considered to be the first marker of diabetes mellitus-related subclinical cardiac dysfunction, but whether it is attributable to fat mass and distribution remains uncertain. In this study, we explored whether fat mass, especially fat mass in the android area, is associated with subclinical systolic dysfunction before the onset of cardiac disease.

METHODS

We conducted a single-center prospective cross-sectional study between November 2021 and August 2022 on inpatients of the Department of Endocrinology, Nanjing Drum Tower Hospital. We included 150 patients aged 18-70 years with no signs, symptoms, or history of clinical cardiac disease. Patients were evaluated with speckle tracking echocardiography and dual energy X-ray absorptiometry. The cutoff values for subclinical systolic dysfunction were set at a global longitudinal strain (GLS) < 18%.

RESULTS

After adjusting for sex and age, patients with GLS < 18% had a higher mean (± standard deviation) fat mass index (8.06 ± 2.39 vs. 7.10 ± 2.09 kg/m², p = 0.02), higher mean trunk fat mass (14.9 ± 4.9 vs. 12.8 ± 4.3 kg, p = 0.01), and higher android fat mass (2.57 ± 1.02 vs. 2.18 ± 0.86 kg, p = 0.02) than those in the GLS ≥ 18%. Partial correlation analysis showed that the fat mass index, truck fat mass, and android fat mass were negatively correlated with GLS after adjusting for sex and age (all p < 0.05). Adjusted for traditional cardiovascular metabolic factors, fat mass index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.05-1.55, p = 0.02), trunk fat mass (OR 1.13, 95% CI 1.03-1.24, p = 0.01), and android fat mass (OR 1.77, 95% CI 1.16-2.82, p = 0.01) were independent risk factors for GLS < 18%.

CONCLUSION

Among patients with type 2 diabetes mellitus without established clinical cardiac disease, fat mass, especially android fat mass, was associated with subclinical systolic dysfunction independently of age and sex.

Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common comorbidity associated with obesity, particularly in patients with body mass index (BMI) ≥ 50 kg/m². We aim to study real-world T2DM long-term remission in patients with BMI ≥ 50 kg/m² following Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

METHODS

This was a retrospective study of the electronic medical records of all patients with BMI ≥ 50 kg/m², T2DM, and have undergone RYGB or SG at three tertiary referral centers in the United States. We assessed the change in T2DM outcomes after bariatric surgery using a matched paired t-test for continuous variables and Bowker and Pearson test for categorical variables. We performed a multivariate logistic regression to determine predictors of remission.

RESULTS

A total of 279 patients with T2DM (65% females, mean age 51.0 ± 11.7 years, 89% white, BMI 56.6 ± 5.9 kg/m²) were analyzed. Long-term T2DM remission (≥ 5 years) was demonstrated in 47% of patients. The duration of T2DM (p < 0.0001), number of T2DM medications (p = 0.003) and weight loss (p = 0.048) were the only independent factors for long-term T2DM remission.

CONCLUSIONS

In this cohort of patients with BMI ≥ 50 kg/m², RYGB and SG demonstrated significant and similar long-term T2DM remission rates and weight loss outcomes.

Adherence therapy for adults with type 2 diabetes: a feasibility study of a randomized controlled trial

BACKGROUND

Adherence Therapy is a candidate intervention to promote consistent medication taking in people with type 2 diabetes. The aim of this study was to establish the feasibility of conducting a randomized controlled trial of adherence therapy in people with type 2 diabetes who were non-adherent with medication.

METHODS

The design is an open-label, single-center, randomized controlled feasibility trial. Participants were randomly allocated to receive either eight sessions of telephone-delivered adherence therapy or treatment as usual. Recruitment occurred during the COVID-19 pandemic. Outcome measures-adherence, beliefs about medication, and average blood glucose (sugar) levels (HbA1c)-were administered at baseline and after 8 weeks (TAU group) or at the completion of the treatment (AT group). Feasibility outcomes included the number of people approached to participate in the trial and the numbers that consented, completed study measures, finished treatment with adherence therapy, and dropped out of the trial. Fieldwork for this trial was conducted in the National Guard Hospital, a tertiary care provider, in the Kingdom of Saudi Arabia.

RESULTS

Seventy-eight people were screened, of which 47 met eligibility criteria and were invited to take part in the trial. Thirty-four people were excluded for various reasons. The remaining thirteen who consented to participate were enrolled in the trial and were randomized (AT, n = 7) (TAU, n = 6). Five (71%) of the seven participants in the adherence therapy arm completed treatment. Baseline measures were completed by all participants. Week 8 (post-treatment) measures were completed by eight (62%) participants. Dropout may have been linked to a poor understanding of what was involved in taking part in the trial.

CONCLUSIONS

It may be feasible to conduct a full RCT of adherence therapy, but careful consideration should be given to developing effective recruitment strategies, consent procedures, rigorous field testing, and clear support materials.

TRIAL REGISTRATION

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12619000827134, on the 7th of June 2019.

Identifying Reasons for Statin Nonuse in Patients With Diabetes Using Deep Learning of Electronic Health Records

Background Statins are guideline-recommended medications that reduce cardiovascular events in patients with diabetes. Yet, statin use is concerningly low in this high-risk population. Identifying reasons for statin nonuse, which are typically described in unstructured electronic health record data, can inform targeted system interventions to improve statin use. We aimed to leverage a deep learning approach to identify reasons for statin nonuse in patients with diabetes. Methods and Results Adults with diabetes and no statin prescriptions were identified from a multiethnic, multisite Northern California electronic health record cohort from 2014 to 2020. We used a benchmark deep learning natural language processing approach (Clinical Bidirectional Encoder Representations from Transformers) to identify statin nonuse and reasons for statin nonuse from unstructured electronic health record data. Performance was evaluated against expert clinician review from manual annotation of clinical notes and compared with other natural language processing approaches. Of 33 461 patients with diabetes (mean age 59±15 years, 49% women, 36% White patients, 24% Asian patients, and 15% Hispanic patients), 47% (15 580) had no statin prescriptions. From unstructured data, Clinical Bidirectional Encoder Representations from Transformers accurately identified statin nonuse (area under receiver operating characteristic curve [AUC] 0.99 [0.98-1.0]) and key patient (eg, side effects/contraindications), clinician (eg, guideline-discordant practice), and system reasons (eg, clinical inertia) for statin nonuse (AUC 0.90 [0.86-0.93]) and outperformed other natural language processing approaches. Reasons for nonuse varied by clinical and demographic characteristics, including race and ethnicity. Conclusions A deep learning algorithm identified statin nonuse and actionable reasons for statin nonuse in patients with diabetes. Findings may enable targeted interventions to improve guideline-directed statin use and be scaled to other evidence-based therapies.

In-Hospital Mortality and Its Predictors among Hospitalized Diabetes Patients: A Prospective Observational Study

Background. Diabetes mellitus (DM) is one of the leading health emergencies of the 21st century and among the top ten causes of death among adults globally in 2017. Although Ethiopia has been victimized by the growing prevalence of DM, data regarding in-hospital mortality among admitted diabetic patients in Ethiopia, specifically in Jimma Medical Center (JMC), are lacking. Objective. The aim of the study is to assess in-hospital mortality and its predictors among DM patients admitted to Jimma Medical Center. Methods. A hospital-based prospective observational study was employed involving 120 diabetes patients admitted to JMC from October 01, 2020, to June 30, 2021. Data were collected on variables related to the patient, disease, medication, and clinical outcomes. Data were entered into Epidata version 4.6.0.4 for cleaning and exported to SPSS version 23.0 for analysis. Kaplan–Mayer and cox-regression analyses were used to compare the survival experience and to determine the predictors of clinical outcomes, respectively. Hazard ratio with its two-sided $p$ value <0.05 was considered to declare the statistical significance. Result. Of 120 DM patients, 81 (67.5%) of them were males. The in-hospital mortality was 13.34% (16/120). Rural residence (AHR: 3.46; 95% CI (1.12, 9.81)), age (AHR: 1.03; 95% CI: (1.001, 1.059)), admission with diabetic ketoacidosis (AHR: 5.01; 95% CI (1.12, 21.88)), and multiple comorbidities: five comorbidities (AHR: 9.65; 95% CI (1.07, 19.59)) and six comorbidities (AHR: 14.02; 95% CI (1.74, 21.05)) were independently associated with in-hospital mortality. On the other hand, exposure to nonantidiabetic medications decreased the hazard of mortality by 86.5% (AHR: 0.135; 95% CI (0.04, 0.457)). Conclusion. This study showed the rate of in-hospital mortality was noticeably high. The study showed that rural residence, age, DKA, and having comorbidities (five and six) were the statistically significant predictors of in-hospital mortality. In contrast, the use of nonantidiabetic medications such as statins, ASA, and other antihypertensive agents before admission remained protective. Thus, proper strategies have to be devised to improve in-hospital mortality among admitted DM patients.

Effect of Exenatide on Nonalcoholic Steatohepatitis and Inflammation-Related Indices in Diabetic Patients with Non-Alcoholic Fatty Liver Disease

Purpose: Diabetes mellitus is a chronic disease often associated with nonalcoholic steatohepatitis (NASH) and obesity. Both obesity and NASH are closely related to inflammation. In this study, we examined how exenatide, a glucagon-like peptide 1 analog, affects inflammatory and NASH-related markers in patients with diabetes. Methods: This retrospective study was conducted on 100 patients who visited our hospital with a diagnosis of type 2 diabetes mellitus. NASH-related indices and inflammatory indices were calculated from data obtained at baseline and at the third month of exenatide treatment. All data were analyzed first in all patients, and then the patients were grouped according to glycosylated hemoglobin A1c (HbA1c) levels of <8% or ≥8% and body mass index (BMI) of <40 or ≥40 kg/m² and their data were reanalyzed. Results: A highly significant improvement was found in the conventional lipid profile. Among NASH-related indices, the nonalcoholic fatty liver disease (NAFLD) fibrosis score and aspartate aminotransferase-platelet ratio index (APRI) showed statistically significant decreases (P < 0.001 and P = 0.016, respectively). In particular, these significant decreases were independent of BMI and glycemic parameters. No statistically significant change was found in inflammatory indices. The decreases in NAFLD fibrosis score and APRI were statistically more significant in the group with HbA1c ≥8% (P = 0.021 and P = 0.002, respectively) and the group with BMI ≥40 kg/m² (P = 0.002 and P = 0.029, respectively). Conclusions: Besides its established effects, such as lowering fasting plasma glucose levels and weight loss, exenatide exerts positive effects on the conventional lipid profile and NASH-associated indexes.

The state of diabetes care and obstacles to better care in Aceh, Indonesia: a mixed-methods study

BACKGROUND

Cardio-metabolic diseases are a major cause of death worldwide, including in Indonesia, where diabetes is one of the most critical diseases for the health system to manage.

METHODS

We describe the characteristics, levels of control, health behavior, and diabetes-related complications of diabetes patients in Aceh, Indonesia. We use baseline data and blood testing from a randomized-controlled trial. We conducted semi-structured interviews with eight health providers from Posbindu and Prolanis programs that target diabetes and other non-communicable diseases (NCDs). We also conducted three focus group discussions with 24 diabetes patients about their experiences of living with diabetes and the existing support programs.

RESULTS

The blood tests revealed average HbA1c levels indicative of poor glycemic control in 75.8 percent of patients and only 20.3 percent were free from any symptoms. Our qualitative findings suggest that patients are diagnosed after diabetes-related symptoms manifest, and that they find it hard to comply with treatment recommendations and lifestyle advice. The existing programs related to NCDs are not tailored to their needs.

CONCLUSION

We identify the need to improve diabetes screening to enable earlier treatment and achieve better control of the disease. Among diagnosed patients, there are widespread beliefs about diabetes medication and alternative forms of treatment that need to be addressed in a respectful dialogue between healthcare professionals and patients. Current diabetes screening, treatment and management programs should be revised to meet the needs of the affected population and to better respond to the increasing burden of this disease.

The Effect of Vitamin D on Inflammation and Dyslipidemia in Type 2 Diabetes Mellitus: Protocol for a Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Type 2 diabetes mellitus is a chronic disease that contributes to an increasing global burden on the health system. It has a high chance of leading to macrovascular complications and cardiovascular disease. As an inflammatory condition, it would be essential to target inflammatory pathways when developing therapeutic drugs for type 2 diabetes mellitus.

OBJECTIVE

We aimed to evaluate the effect of vitamin D on markers of inflammation and lipid profile among adult patients with diabetes.

METHODS

A systematic review will seek studies published on Embase, Google Scholar, PubMed, Web of Science, and Science Direct. This planned systematic review and meta-analysis will be limited to randomized controlled trials; moreover, the search will include published studies regarding the effects of vitamin D on pro-inflammatory cytokines and lipid profiles. The review will include studies published from inception until December 30, 2022. The study identification and selection will be based on the eligibility criteria by 2 independent reviewers. Additionally, a meta-analysis will only be performed if more than 2 studies are available and explore the same outcomes, and this will be analyzed using RevMan (version 5.4.1). The quality and risk of bias will be assessed following the Cochrane risk of bias tool and Jadad checklist.

RESULTS

The process for searching literature review has already started, and this is conducted independently by 2 reviewers using a predefined eligibility and "participants, intervention, comparator, and outcome" criteria. This systematic review and meta-analysis will not require any direct involvement of patients and the public; thus, no ethical approval was required.

CONCLUSIONS

The findings obtained from the proposed study will be presented in scientific seminars, journal clubs, and conferences and published in peer-reviewed journals.

TRIAL REGISTRATION

International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202260022; https://inplasy.com/?s=INPLASY202260022.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/42193.

Adapted Diabetes Complications Severity Index and Charlson Comorbidity Index in predicting all-cause and cause-specific mortality among patients with type 2 diabetes

INTRODUCTION

Adapted Diabetes Complications Severity Index (aDCSI) is a commonly used severity measure based on the number and severity of diabetes complications using diagnosis codes. The validity of aDCSI in predicting cause-specific mortality has yet to be verified. Additionally, the performance of aDCSI in predicting patient outcomes compared with Charlson Comorbidity Index (CCI) remains unknown.

RESEARCH DESIGN AND METHODS

Patients aged 20 years or older with type 2 diabetes prior to January 1, 2008 were identified from the Taiwan National Health Insurance claims data and were followed up until December 15, 2018. Complications for aDCSI including cardiovascular, cerebrovascular and peripheral vascular disease, metabolic disease, nephropathy, retinopathy and neuropathy, along with comorbidities for CCI, were collected. HRs of death were estimated using Cox regression. Model performance was evaluated by concordance index and Akaike information criterion.

RESULTS

1,002,589 patients with type 2 diabetes were enrolled, with a median follow-up of 11.0 years. After adjusting for age and sex, aDCSI (HR 1.21, 95% CI 1.20 to 1.21) and CCI (HR 1.18, 1.17 to 1.18) were associated with all-cause mortality. The HRs of aDCSI for cancer, cardiovascular disease (CVD) and diabetes mortality were 1.04 (1.04 to 1.05), 1.27 (1.27 to 1.28) and 1.28 (1.28 to 1.29), respectively, and the HRs of CCI were 1.10 (1.09 to 1.10), 1.16 (1.16 to 1.17) and 1.17 (1.16 to 1.17), respectively. The model with aDCSI had a better fit for all-cause, CVD and diabetes mortality with C-index of 0.760, 0.794 and 0.781, respectively. Models incorporating both scores had even better performance, but the HR of aDCSI for cancer (0.98, 0.97 to 0.98) and the HRs of CCI for CVD (1.03, 1.02 to 1.03) and diabetes mortality (1.02, 1.02 to 1.03) became neutral. When aDCSI and CCI were considered time-varying scores, the association with mortality was stronger. aDCSI had a strong correlation with mortality even after 8 years (HR 1.18, 1.17 to 1.18).

CONCLUSIONS

The aDCSI predicts all-cause, CVD and diabetes deaths but not cancer deaths better than the CCI. aDCSI is also a good predictor for long-term mortality.

A review of disparities in peripheral artery disease and diabetes-related amputations during the COVID-19 pandemic

The COVID-19 pandemic has profoundly affected health care delivery. In addition to the significant morbidity and mortality associated with acute illness from COVID-19, the indirect impact has been far-reaching, including substantial disruptions in chronic disease care. As a result of pandemic disruptions in health care, vulnerable and minority populations have faced health inequalities. The aim of this review was to investigate how the COVID-19 pandemic has impacted vulnerable populations with limb-threatening peripheral artery disease and diabetic foot infections.

Analysis of the Incidence of Type 2 Diabetes, Requirement of Insulin Treatment, and Diabetes-Related Complications among Patients with Cancer

This retrospective nationwide population-based cohort study used a dataset collected from the Korean National Health Insurance Service. We evaluated incident type 2 diabetes, insulin requirements, and diabetes-associated complications during a 10-year follow-up period using the log-rank test and Cox proportional hazards regression models. In total, 8114 and 16,228 individuals with and without cancer, respectively, were enrolled. We found a higher incidence rate and an increased adjusted hazard ratio (HR) for new cases of type 2 diabetes in patients with cancer, compared with those without cancer. Additionally, patients with cancer had a higher risk of insulin requirement than patients without cancer (adjusted HR 1.43, 95% confidence interval [CI], 1.14-1.78). Although there was no significant association between diabetes-associated complications and overall cancer diagnosis, specific cancer types (pancreas, bladder, and prostate) showed an increased risk of subsequent diabetic nephropathy. Therefore, clinicians should closely monitor patients with cancer for the early detection of type 2 diabetes and related morbidities.

Urinary Proteome Differences in Patients with Type 2 Diabetes Pre and Post Liraglutide Treatment

Diabetes mellitus is a chronic multisystem disease with a high global prevalence. The glucagon-like peptide-1 (GLP-1) receptor agonist liraglutide is known to lower glucose levels and reduce weight. However, the mechanisms underlying the benefits of liraglutide treatment in patients with type 2 diabetes mellitus (T2DM) remain unclear. Twelve male patients with T2DM (pre and post liraglutide treatment) and HbA1c between 8% and 11% were recruited. In the present study, a two-dimensional difference gel electrophoresis (2D-DIGE) matrix-assisted laser desorption/ionization-time of flight (MALDI TOF) mass spectrometric approach combined with bioinformatics and network pathway analysis was used to explore the urine proteomic profile. The mean age of the patients was 52.4 ± 7.5 years. After treatment with liraglutide, a statistically significant change (p < 0.006) was observed in HbA1c with no significant changes in body weight or markers of dyslipidemia. Two-dimensional difference gel electrophoresis identified significant changes (≥1.5-fold change, ANOVA, p ≤ 0.05) in 32 proteins (4 down- and 28 upregulated) in liraglutide post treatment compared to the pre-treatment state. Albumin, serotransferrin, metallothionein-2 (MT-2), and keratins K1 and K10 were found to be upregulated after liraglutide treatment. The patients showed significant improvement in glycemic control after the 12-week treatment with liraglutide. The renoprotective effect of liraglutide may be linked to the increased urinary abundance of MT-2 and the decreased abundance of zinc alpha 2-glycoprotein (ZAG) and Alpha-1 antitrypsin (α1-AT). More studies are needed to elucidate the molecular mechanisms behind the renoprotective effects of liraglutide.

Association of Modifiable Health Conditions and Social Determinants of Health With Late Mortality in Survivors of Childhood Cancer

IMPORTANCE

Associations between modifiable chronic health conditions (CHCs), social determinants of health, and late mortality (defined as death occurring ≥5 years after diagnosis) in childhood cancer survivors are unknown.

OBJECTIVE

To explore associations between modifiable CHCs and late mortality within the context of social determinants of health.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used data from 9440 individuals who were eligible to participate in the St Jude Lifetime Cohort (SJLIFE), a retrospective cohort study with prospective clinical follow-up that was initiated in 2007 to characterize outcomes among childhood cancer survivors. Eligible individuals had survived 5 or more years after childhood cancer diagnosis, were diagnosed between 1962 and 2012, and received treatment at St Jude Children's Research Hospital were included in mortality estimates. A total of 3407 adult SJLIFE participants (aged ≥18 years) who completed an on-campus assessment were included in risk factor analyses. Vital status, date of death, and cause of death were obtained by linkage with the National Death Index (coverage from inception to December 31, 2016). Deaths occurring before inception of the National Death Index were obtained from the St Jude Children's Research Hospital Cancer Registry. Data were analyzed from June to December 2022.

EXPOSURES

Data on treatment exposures and causes of death were abstracted for individuals who were eligible to participate in the SJLIFE study. Information on modifiable CHCs (dyslipidemia, hypertension, diabetes, underweight or obesity, bone mineral deficiency, hypogonadism, hypothyroidism, and adrenal insufficiency, all graded by the modified Common Terminology Criteria for Adverse Events), healthy lifestyle index (smoking status, alcohol consumption, body mass index [calculated as weight in kilograms divided by height in meters squared], and physical activity), area deprivation index (ADI; which measures neighborhood-level socioeconomic disadvantage), and frailty (low lean muscle mass, exhaustion, low energy expenditure, slowness, and weakness) was obtained for participants.

MAIN OUTCOMES AND MEASURES

National Death Index causes of death were used to estimate late mortality using standardized mortality ratios (SMRs) and 95% CIs, which were calculated based on US mortality rates. For the risk factor analyses (among participants who completed on-campus assessment), multivariable piecewise exponential regression analysis was used to estimate rate ratios (RRs) and 95% CIs for all-cause and cause-specific late mortality.

RESULTS

Among 9440 childhood cancer survivors who were eligible to participate in the SJLIFE study, the median (range) age at assessment was 27.5 (5.3-71.9) years, and the median (range) duration of follow-up was 18.8 (5.0-58.0) years; 55.2% were male and 75.3% were non-Hispanic White. Survivors experienced increases in all-cause mortality (SMR, 7.6; 95% CI, 7.2-8.1) and health-related late mortality (SMR, 7.6; 95% CI, 7.0-8.2). Among 3407 adult SJLIFE participants who completed an on-campus assessment, the median (range) age at assessment was 35.4 (17.9-69.8) years, and the median (range) duration of follow-up was 27.3 (7.3-54.7) years; 52.5% were male and 81.7% were non-Hispanic White. Models adjusted for attained age, sex, race and ethnicity, age at diagnosis, treatment exposures, household income, employment status, and insurance status revealed that having 1 modifiable CHC of grade 2 or higher (RR, 2.2; 95% CI, 1.2-4.0; P = .01), 2 modifiable CHCs of grade 2 or higher (RR, 2.6; 95% CI, 1.4-4.9; P = .003), or 3 modifiable CHCs of grade 2 or higher (RR, 3.6; 95% CI, 1.8-7.1, P < .001); living in a US Census block with an ADI in the 51st to 80th percentile (RR, 5.5; 95% CI, 1.3-23.5; P = .02), an ADI in the 81st to 100th percentile (RR, 8.7; 95% CI, 2.0-37.6; P = .004), or an unassigned ADI (RR, 15.7; 95% CI, 3.5-70.3; P < .001); and having frailty (RR, 2.3; 95% CI, 1.3-3.9; P = .004) were associated with significant increases in the risk of late all-cause death. Similar associations were observed for the risk of late health-related death (1 modifiable CHC of grade ≥2: RR, 2.2 [95% CI, 1.1-4.4; P = .02]; 2 modifiable CHCs of grade ≥2: RR, 2.5 [95% CI, 1.2-5.2; P = .01]; 3 modifiable CHCs of grade ≥2: RR, 4.0 [95% CI, 1.9-8.4; P < .001]; ADI in 51st-80th percentile: RR, 9.2 [95% CI, 1.2-69.7; P = .03]; ADI in 81st-100th percentile: RR, 16.2 [95% CI, 2.1-123.7; P = .007], unassigned ADI: RR, 27.3 [95% CI, 3.5-213.6; P = .002]; and frailty: RR, 2.3 [95% CI, 1.2-4.1; P = .009]).

CONCLUSIONS AND RELEVANCE

In this cohort study of childhood cancer survivors, living in a Census block with a high ADI and having modifiable CHCs were independently associated with an increased risk of late death among survivors of childhood cancer. Future investigations seeking to mitigate these factors will be important to improving health outcomes and developing risk-stratification strategies to optimize care delivery to childhood cancer survivors.

Antidiabetic Drug Prescription Pattern in Hospitalized Older Patients with Diabetes

OBJECTIVE

To describe the prescription pattern of antidiabetic and cardiovascular drugs in a cohort of hospitalized older patients with diabetes.

METHODS

Patients with diabetes aged 65 years or older hospitalized in internal medicine and/or geriatric wards throughout Italy and enrolled in the REPOSI (REgistro POliterapuie SIMI-Società Italiana di Medicina Interna) registry from 2010 to 2019 and discharged alive were included.

RESULTS

Among 1703 patients with diabetes, 1433 (84.2%) were on treatment with at least one antidiabetic drug at hospital admission, mainly prescribed as monotherapy with insulin (28.3%) or metformin (19.2%). The proportion of treated patients decreased at discharge (N = 1309, 76.9%), with a significant reduction over time. Among those prescribed, the proportion of those with insulin alone increased over time (p = 0.0066), while the proportion of those prescribed sulfonylureas decreased (p < 0.0001). Among patients receiving antidiabetic therapy at discharge, 1063 (81.2%) were also prescribed cardiovascular drugs, mainly with an antihypertensive drug alone or in combination (N = 777, 73.1%).

CONCLUSION

The management of older patients with diabetes in a hospital setting is often sub-optimal, as shown by the increasing trend in insulin at discharge, even if an overall improvement has been highlighted by the prevalent decrease in sulfonylureas prescription.

Associations Between Mean HbA1c, HbA1c Variability, and Both Mortality and Macrovascular Complications in Patients with Diabetes Mellitus: A Registry-Based Cohort Study

Background

We investigate the association between mean HbA1c, HbA1c variability, and all-cause mortality and diabetes-related macrovascular complications in patients with diabetes.

Methods

We performed a retrospective cohort study using patients present in the Singapore Health Services diabetes registry (SDR) during 2013 to 2014. We assessed mean HbA1c using three models: a baseline mean HbA1c for 2013-14, the mean across the whole follow-up period, and a time-varying yearly updated mean. We assessed HbA1c variability at baseline using the patient's HbA1c variability score (HVS) for 2013-14. The association between mean HbA1c, HVS, and 6 outcomes were assessed using Cox proportional hazard models.

Results

We included 43,837-53,934 individuals in the analysis; 99.3% had type 2 diabetes mellitus. The data showed a J-shaped distribution in adjusted hazard ratios (HRs) for all-cause mortality, ischemic heart disease, acute myocardial infarction, peripheral arterial disease, and ischemic stroke, with an increased risk of developing these outcomes at HbA1c <6% (42 mmol/mol) and ≥8% (64 mmol/mol). With the addition of HVS, the J-shaped distribution was maintained for the above outcomes, but HRs were greater at HbA1c <6.0% (42 mmol/mol) and reduced at HbA1c ≥8.0% (64 mmol/mol) when compared to models without HVS. The risk for all outcomes increased substantially with increasing glycaemic variability.

Conclusion

Both low (<6.0% [42 mmol/mol]) and high (≥8.0% [64 mmol/mol]) levels of glycaemic control are associated with increased all-cause mortality and diabetes-related macrovascular complications. Glycaemic variability is independently associated with increased risk for these outcomes. Therefore, patients with stable glycaemic level of 6-8% (42-64mmol/mol) are at lowest risk of all-cause mortality and diabetes-related macrovascular complications.

Streptozotocin-Induced Type 1 and 2 Diabetes Mellitus Mouse Models Show Different Functional, Cellular and Molecular Patterns of Diabetic Cardiomyopathy

The main cause of morbidity and mortality in diabetes mellitus (DM) is cardiovascular complications. Diabetic cardiomyopathy (DCM) remains incompletely understood. Animal models have been crucial in exploring DCM pathophysiology while identifying potential therapeutic targets. Streptozotocin (STZ) has been widely used to produce experimental models of both type 1 and type 2 DM (T1DM and T2DM). Here, we compared these two models for their effects on cardiac structure, function and transcriptome. Different doses of STZ and diet chows were used to generate T1DM and T2DM in C57BL/6J mice. Normal euglycemic and nonobese sex- and age-matched mice served as controls (CTRL). Immunohistochemistry, RT-PCR and RNA-seq were employed to compare hearts from the three animal groups. STZ-induced T1DM and T2DM affected left ventricular function and myocardial performance differently. T1DM displayed exaggerated apoptotic cardiomyocyte (CM) death and reactive hypertrophy and fibrosis, along with increased cardiac oxidative stress, CM DNA damage and senescence, when compared to T2DM in mice. T1DM and T2DM affected the whole cardiac transcriptome differently. In conclusion, the STZ-induced T1DM and T2DM mouse models showed significant differences in cardiac remodeling, function and the whole transcriptome. These differences could be of key relevance when choosing an animal model to study specific features of DCM.

Magnitude, Distribution and Contextual Risk Enhancing Predictors of High 10-Year Cardiovascular Risk Among Diabetic Patients in Tanzania

Introduction

Atherosclerotic Cardiovascular Disease (ASCVD) is the leading cause of death worldwide. In Diabetics, ASCVD is associated with poor prognosis and a higher case fatality rate compared with the general population. Sub-Saharan Africa is facing an epidemiological transition with ASCVD being prevalent among young adults. To date, over 20 million people have been living with DM in Africa, Tanzania being one of the five countries in the continent reported to have a higher prevalence. This study aimed to identify an individual's 10-year ASCVD absolute risk among a diabetic cohort in Tanzania and define contextual risk enhancing factors.

Methods

A prospective observational study was conducted at the Aga Khan hospital, Mwanza, for a period of 8 months. The hospital is a 42-bed district-level hospital in Tanzania. Individuals 10-year risk was calculated based on the ASCVD 2013 risk calculator by ACC/AHA. Pearson's chi-square or Fischer's exact test was used to compare categorical and continuous variables. Multivariable analysis was applied to determine contextual factors for those who had a high 10-year risk of developing ASCVD.

Results

The overall cohort included 573 patients. Majority of the individuals were found to be hypertensive (n = 371, 64.7%) and obese (n = 331, 58%) having a high 10-year absolute risk (n = 343, 60%) of suffering ASCVD. The study identified duration of Diabetes Mellitus (>10 years) (OR 8.15, 95% CI 5.25-14.42), concomitant hypertension (OR 1.82 95% CI 1.06-3.06), Diabetic Dyslipidemia (OR 1.44, 95% CI 1.08-1.92) and deranged serum creatinine (OR 1.03, 95% CI 1.02-1.03) to be the risk enhancing factors amongst our population.

Conclusion

The study confirms the majority of diabetic individuals in the lake region of Tanzania to have a high 10-year ASCVD risk. The high prevalence of obesity, hypertension and dyslipidemia augments ASCVD risk but provides interventional targets for health-care workers to decrease these alarming projections.

Efficacy and safety of intensive versus conventional glucose targets in people with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

The aim of study is to re-evaluate the risk-benefits of intensive glycemic control in the context of multi-factorial intervention in adults with T2D.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane, and CINHAL for randomized control trials comparing standard glucose targets to intensive glucose targets with pre-specified HbA_1clevels. Subgroup analysis was also performed to account for the inclusion of glucose only versus multi-factorial intervention trials. Results are reported as risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Fifty-seven publications including 19 trials were included. Compared to conventional glycemic control, intensive glycemic control decreased the risk of non-fatal myocardial infarction (0.8, 0.7-0.91), macroalbuminuria (0.72, 0.5--0.87), microalbuminuria (0.67, 0.52-0.85), major amputation (0.6, 0.38-0.96), retinopathy (0.75 ,0.63-0.9), and nephropathy (0.78, 0.63-0.97). The risk of hypoglycemia increased with intensive glycemic control than conventional treatment (2.04, 1.34-3.1). No reduction in all-cause or cardiovascular mortality was observed. However, in the context of multifactorial intervention, intensive glucose control was associated with a significant reduction in all-cause mortality (0.74, 0.57-0.95).

CONCLUSION

Targeting HbA_1c levels should be individualized based on the clinical status, balancing risks and benefits and potential risk for developing these complications among people with T2D.

Novel Approaches to the Management of Diabetes Mellitus in Patients with Coronary Artery Disease

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in individuals with diabetes mellitus (DM). Although benefit has been attributed to the strict control of hyperglycemia with traditional antidiabetic treatments, novel antidiabetic medications have demonstrated cardiovascular (CV) safety and benefits by reducing major adverse cardiac events, improving heart failure (HF), and decreasing CVD-related mortality. Emerging data underline the interrelation between diabetes, as a metabolic disorder, and inflammation, endothelial dysfunction, and oxidative stress in the pathogenesis of microvascular and macrovascular complications. Conventional glucose-lowering medications demonstrate controversial CV effects. Dipeptidyl peptidase- 4 inhibitors have not only failed to prove to be beneficial in patients with coronary artery disease, but also their safety is questionable for the treatment of patients with CVD. However, metformin, as the first-line option for type 2 DM (T2DM), shows CVD protective properties for DM-induced atherosclerotic and macrovascular complications. Thiazolidinedione and sulfonylureas have questionable effects, as evidence from large studies shows a reduction in the risk of CV events and deaths, but with an increased rate of hospitalization for HF. Moreover, several studies have revealed that insulin monotherapy for T2DM treatment increases the risk of major CV events and deaths from HF, when compared to metformin, although it may reduce the risk of myocardial infarction. Finally, this review aimed to summarize the mechanisms of action of novel antidiabetic drugs acting as glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors that show favorable effects on blood pressure, lipid levels, and inflammation, leading to reduced CVD risk in T2DM patients.

Pregnancy Loss and Risk of All-Cause Mortality in Chinese Women: Findings From the China Kadoorie Biobank

Objectives: Pregnancy loss is a common obstetric complication that may be associated with maternal mortality. However, evidence is sparse and inconsistent. This study aims to investigate the association between pregnancy loss with the risk of all-cause mortality among Chinese women. Methods: Data on 299,582 women aged 30-79 years old from the China Kadoorie Biobank were used. Cox proportional hazard regression was conducted to investigate the association between the occurrence of pregnancy loss and all-cause mortality. Results: Two or more pregnancy losses was associated with long-term all-cause mortality (adjusted hazard ratio (aHR) of 1.10, 95% CI: 1.03-1.18). Specifically, more than one spontaneous abortion or stillbirth was associated with long-term all-cause mortality (aHR 1.10, 95% CI: 1.01-1.21 and 1.14, 95% CI: 1.04-1.25, respectively). When stratified by the presence of cardiovascular disease or diabetes, as well as age at baseline, two or more pregnancy losses in women aged ≥50 diagnosed with cardiovascular disease (aHR 1.32, 95% CI: 1.18-1.48) or diabetes (aHR 1.30, 95% CI: 1.06-1.60) was associated with all-cause mortality. Conclusion: Recurrent pregnancy loss, in particular two or more spontaneous abortions and stillbirths were associated with increased risk of all-cause mortality. The associations between recurrent pregnancy losses and all-cause mortality were more pronounced in women aged ≥50 with cardiovascular disease or diabetes at baseline.

Mechanisms of Vascular CaV1.2 Channel Regulation During Diabetic Hyperglycemia

Diabetes is a leading cause of disability and mortality worldwide. A major underlying factor in diabetes is the excessive glucose levels in the bloodstream (e.g., hyperglycemia). Vascular complications directly result from this metabolic abnormality, leading to disabling and life-threatening conditions. Dysfunction of vascular smooth muscle cells is a well-recognized factor mediating vascular complications during diabetic hyperglycemia. The function of vascular smooth muscle cells is exquisitely controlled by different ion channels. Among the ion channels, the L-type CaV1.2 channel plays a key role as it is the main Ca2+ entry pathway regulating vascular smooth muscle contractile state. The activity of CaV1.2 channels in vascular smooth muscle is altered by diabetic hyperglycemia, which may contribute to vascular complications. In this chapter, we summarize the current understanding of the regulation of CaV1.2 channels in vascular smooth muscle by different signaling pathways. We place special attention on the regulation of CaV1.2 channel activity in vascular smooth muscle by a newly uncovered AKAP5/P2Y11/AC5/PKA/CaV1.2 axis that is engaged during diabetic hyperglycemia. We further describe the pathophysiological implications of activation of this axis as it relates to myogenic tone and vascular reactivity and propose that this complex may be targeted for developing therapies to treat diabetic vascular complications.

Budget impact of introducing oral semaglutide to the public healthcare benefit package in Saudi Arabia

BACKGROUND

The Kingdom of Saudi Arabia (KSA) has embarked on a Health Sector Transformation Program as part of the Kingdom's Vision 2030 initiatives with the facilitation of access to healthcare services for the millions in KSA with diabetes an essential part of the Program. Decision-making tools, such as budget impact models, are required to consider the addition of new medications like oral semaglutide that have multifaceted health benefits and address barriers related to therapeutic inertia to reduce diabetes-related complications.

OBJECTIVE

To determine the financial impact of the introduction of oral semaglutide as a treatment option for people with type 2 diabetes mellitus (T2DM) in KSA.

METHODS

From the public payer's perspective, the budget impact model estimates the costs before and after the introduction of oral semaglutide over a 5-year time horizon. The budget impact of introducing oral semaglutide (primary comparator) compared with three different classes of diabetes medicines: glucagon-like peptide-1 receptor agonists (GLP-1), sodium-glucose transport protein 2 inhibitors (SGLT 2i) and dipeptidyl peptidase 4 inhibitors (DDP-4i) have been calculated based on the projected market shares. The model includes the cost of care through the incorporation of health outcomes that have an impact on the national payer's budget in Saudi Riyals (SAR).

RESULTS

The budget impact over the five-year time horizon indicates a medication cost increase (17,424,788 SAR), and cost offsets which include a difference in diabetes management costs (-3,625,287 SAR), CV complications costs (-810,733 SAR) and weight loss savings of 453,936 SAR. The cumulative total cost difference is 12,427,858 SAR (0.66%).

CONCLUSION

The introduction of oral semaglutide 14 mg as a second-line treatment option after metformin is indicated as budget-neutral to slightly budget-inflating for the public pharmaceutical formulary of KSA. The price difference is offset by positive health outcomes and costs. This conclusion was confirmed through a probabilistic sensitivity analysis.

Effects of High-Intensity Interval Training and Continuous Training on Exercise Capacity, Heart Rate Variability and Isolated Hearts in Diabetic Rats

BACKGROUND

High-intensity interval training (HIIT) has been suggested as an alternative for continuous training (CT) in people with diabetes mellitus (DM) due to its short duration and potential to improve adherence to exercise. However, data on its impact on heart rate variability (HRV) are scarce.

OBJECTIVES

To assess and compare the effects of HIIT and CT on exercise capacity, HRV and isolated hearts in diabetic rats.

METHODS

DM (intravenous streptozotocin, 45 mg.kg -1 ) and control (C) animals performed 20 sessions (5 days/week, 50 min, for 4 weeks) of CT on a treadmill (70% of maximal exercise capacity) or HIIT (cycles of 1:1min at 50% and 90% of maximal exercise capacity). HRV was assessed by continuous electrocardiogram, and cardiac function assessed in isolated perfused hearts. For data analysis, we used the framework of the multivariate covariance generalized linear model or one-way ANOVA followed by Tukey's test, considering p<0.05 as significant.

RESULTS

Higher exercise capacity (m/min) was achieved in HIIT (DM-HIIT: 36.5 [IQR 30.0-41.3]; C-HIIT: 41.5 [37.8-44.5], both n=10) compared to CT (DM-CT: 29.0 [23.8-33.0]; C-CT: 32.0 [29.5-37.0], both n=10) (p<0.001). Heart rate (bpm) was lower in DM compared to controls (p<0.001) both in vivo (DM-HIIT:348±51, C-HIIT:441±66, DM-CT:361±70, C-CT:437±38) and in isolated hearts. There were no differences in HRV between the groups. Maximum and minimal dP/dt were reduced in DM, except +dP/dt in DM-HIIT vs. C-HIIT (mean difference: 595.5±250.3, p=0.190).

CONCLUSION

Short-term HIIT promotes greater improvement in exercise performance compared to CT, including in DM, without causing significant changes in HRV.

The Importance of SGLT-2 Inhibitors as Both the Prevention and the Treatment of Diabetic Cardiomyopathy

According to the 2021 report of the International Diabetes Federation (IDF), there have been approximately 573 million cases of type 2 diabetes mellitus (T2DM) among adults, which sets the disease as a major concern in healthcare worldwide. The development of T2DM is strongly promoted by unhealthy lifestyle factors associated with urbanization and western civilization. The disease is associated with a broad list of systemic complications that can result in premature death, disability and significantly reduced quality of life. The most dramatic in their consequences are cardiovascular complications of T2DM. Our work focuses on one such complication that is specific for diabetes, named diabetic cardiomyopathy (DC). In this condition cardiac dysfunction occurs despite the absence of underlying hypertension, coronary artery disease and valvular disease, which suggest a leading role for metabolic disturbances as a cause. We aimed to establish the role of relatively new hypoglycaemic drugs that have taken the medical world by storm with their broad pleiotropic effects-SGLT-2 inhibitors-in the prevention and treatment of DC at any stage.

Diabetes mellitus: what the neurologists need to know

Diabetes mellitus is a common condition associated with numerous complications and comorbidities. The diabetes spectrum includes type 1, type 2 and other forms of diabetes, which may be associated with medical therapies and genetic factors. Type 2 diabetes is managed with lifestyle, oral therapies, non-insulin-based injectables and subsequently insulin. Type 1 diabetes requires insulin from the time of diagnosis. In recent years, there have been considerable developments in the therapies available to treat type 2 diabetes and some of these also afford cardiorenal protection. This review summarises the nature, complications and therapeutic advances in the field of diabetes and provides a concise review for neurologists. Managing diabetes optimally prevents complications and all medical specialties need a basic understanding of the principles involved in diabetes care.

Event dependent overall survival in the population-based LIFE-Adult-Study

BACKROUND

Information about the direct comparability of big data of epidemiological cohort studies and the general population still is lacking, especially regarding all-cause mortality rates. The aim of this study was to investigate the overall survival and the influence of several diagnoses in the medical history on survival time, adjusted to common risk factors in a populations-based cohort.

METHODS

From 10,000 subjects of the population-based cohort LIFE-Adult-Study (Leipzig Research Centre for Civilization Diseases), the medical history and typical risk factors such as age, smoking status and body-mass-index (BMI) were assessed. The survival status was identified from the saxonian population register. Univariate and multivariate analyses were used to determine the influence of the medical history and risk factors on overall survival. To develope an optimal model, the method by Collet [1] was used.

RESULTS

The mortality rate of the participants is approximately half the mortality rate expected for the german population. The selection bias in epidemiological studies needs to be considered whenever interpreting results of epidemiological cohort studies. Nevertheless we have shown that several diagnoses proved to have a negative influence on overall survival time even in this relatively healthy cohort. This study showed the significantly increased mortality risk if the following diseases are reported in medical history of the participants in a large population-based cohort study including adults aged 18 and over: diabetes mellitus (HR 1.533, p = 0.002), hypertension (HR 1.447, p = 0.005), liver cirrhosis (HR 4.251, p < 0.001), osteoporosis (HR 2.165, p = 0.011), chronic bronchitis (HR 2.179, p < 0.001), peptic ulcer disease (HR 1.531, p = 0.024) and cancer (HR 1.797, p < 0.001). Surprisingly, asthma has the opposite effect on survival time (HR 0.574, p = 0.024), but we believe this may be due to an overrepresentation of mild to moderate asthma and its management, which includes educating patients about a healthy lifestyle.

CONCLUSION

In the LIFE-Adult-Study, common risk factors and several diseases had relevant effect on overall survival. However, selection bias in epidemiological studies needs to be considered whenever interpreting results of epidemiological cohort studies. Nevertheless it was shown that the general cause-and-effect principles also apply in this relatively healthy cohort.

Reconsidering the role of glycaemic control in cardiovascular disease risk in type 2 diabetes: A 21st century assessment

It is well known that the multiple factors contributing to the pathogenesis of type 2 diabetes (T2D) confer an increased risk of developing cardiovascular disease (CVD). Although the relationship between hyperglycaemia and increased microvascular risk is well established, the relative contribution of hyperglycaemia to macrovascular events has been strongly debated, particularly owing to the failure of attempts to reduce CVD risk through normalizing glycaemia with traditional therapies in high-risk populations. The debate has been further fuelled by the relatively recent discovery of the cardioprotective properties of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors. Further, as guidelines now recommend individualizing glycaemic targets, highlighting the importance of achieving glycated haemoglobin (HbA1c) goals safely, the previously observed negative influences of intensive therapy on CVD risk might not present if trials were repeated using current-day treatments and individualized HbA1c goals. Emerging longitudinal data illuminate the overall effect of excess glucose, the impacts of magnitude and duration of hyperglycaemia on disease progression and risk of CVD complications, and the importance of glycaemic control at or early after diagnosis of T2D for prevention of complications. Herein, we review the role of glucose as a modifiable cardiovascular (CV) risk factor, the role of microvascular disease in predicting macrovascular risk, and the deleterious impact of therapeutic inertia on CVD risk. We reconcile new and old data to offer a current perspective, highlighting the importance of effective, early treatment in reducing latent CV risk, and the timely use of appropriate therapy individualized to each patient's needs.

Low Serum Bicarbonate Levels Increase the Risk of All-Cause, Cardiovascular Disease, and Cancer Mortality in Type 2 Diabetes

CONTEXT

The evidence regarding bicarbonate status and mortality among diabetes is scarce.

OBJECTIVE

The purpose of this study was to investigate the associations of bicarbonate concentrations with risk of all-cause, cardiovascular disease (CVD), and cancer mortality among patients with type 2 diabetes (T2D).

METHODS

This study included 8163 adult diabetic patients from the National Health and Nutrition Examination Survey (NHANES), 1999 to 2018. Death outcomes were ascertained by linkage to National Death Index records through 31 December 2019. The Cox proportional-risk model was used to estimate hazard ratios (HR) and 95% CIs for mortality from all causes, CVD, and cancer. The mediating effects of 11 metabolic, cardiovascular, and renal biomarkers were evaluated using a logistic regression model within a counterfactual framework.

RESULTS

During 8163 person-years of follow-up, 2310 deaths were documented, including 659 CVD deaths and 399 cancer deaths. After multivariate adjustment, lower serum bicarbonate levels were significantly linearly correlated with higher all-cause, CVD, and cancer mortality: The risk of all-cause death increased by 40%, the risk of CVD death increased by 48%, and the risk of cancer death increased by 84% compared with the normal group (all P < .05). Altered levels of estimated glomerular filtration rate explained 12.10% and 16.94% of the relation between serum bicarbonate with all-cause and CVD mortality, respectively. Total cholesterol mediated 4.70% and 10.51% of the associations of all-cause and CVD mortality, respectively.

CONCLUSION

Lower serum bicarbonate concentrations were significantly associated with higher all-cause, CVD, and cancer mortality. These findings suggest that maintaining adequate bicarbonate status may lower mortality risk in individuals with T2D.

TSH levels within the normal range and risk of cardiovascular and all-cause mortality among individuals with diabetes

BACKGROUND

Evidence regarding thyroid-stimulating hormone (TSH) levels within the normal range and mortality in adults with diabetes is scarce. This study aimed to identify the association between TSH levels and cardiovascular disease (CVD) and all-cause mortality among euthyroid patients with diabetes.

METHODS

This prospective cohort study included 1830 adults with diabetes from the Third National Health and Nutrition Examination Survey III. Mortality outcomes were ascertained by linkage to National Death Index records through December 31, 2019. Participants were categorized by tertiles of TSH levels (low-normal, 0.39-1.30 mIU/L; medium-normal, 1.30-2.09 mIU/L; high-normal, 2.09-4.60 mIU/L). Multivariable Cox proportional hazards models were used to explore the association between TSH levels within the normal range and overall and CVD mortality. Furthermore, restricted cubic spline analyses were used to determine the nonlinear relationship between TSH levels and mortality.

RESULTS

During a median follow-up of 17.1 years, 1324 all-cause deaths occurred, including 525 deaths from CVD. After multivariate adjustment, a U-shaped relationship was observed between TSH levels in euthyroid status and all-cause or CVD mortality among patients with diabetes (both P < 0.05 for nonlinearity). Compared with participants with medium-normal TSH levels, those with high-normal TSH levels had a significantly higher risk of all-cause (hazard ratio, 1.31; 95% confidence interval, 1.07-1.61) and CVD (1.52; 1.08-2.12) mortality. Similarly, low-normal TSH levels also increased all-cause (1.39; 1.12-1.73) and CVD (1.69; 1.17-2.44) mortality risk. In stratum-specific analyses, we found that high-normal TSH levels were associated with higher mortality risk in younger (< 60 years) patients with diabetes but not in older (≥ 60 years) participants.

CONCLUSION

Low- and high-normal serum TSH levels were associated with increased all-cause and CVD mortality in euthyroid adults with diabetes. Further studies are needed to confirm the present observation in a wider population.

Cardiovascular events and mortality in chronic kidney disease in primary care patients with previous type 2 diabetes and/or hypertension. A population-based epidemiological study (KIDNEES)

BACKGROUND

Chronic Kidney Disease (CKD), Type 2 Diabetes (T2D) and Hypertension (HTN) are frequently associated with adverse outcomes. We aimed to estimate the impact of a prior diagnosis of T2D and/or HTN on clinical characteristics, cardiovascular events (CVE) and all-cause mortality (ACM) of patients with CKD.

METHODS

We conducted a retrospective cohort study based on primary care electronic health records of people without atherosclerotic cardiovascular disease, aged 18-90 years with incident CKD between January 1, 2007, and December 31, 2017. The association between CKD groups classified according to prior diagnosis of T2D and/or HTN and risk of ACM and CVE at follow-up was evaluated with Cox and Fine-Gray regression models, respectively.

RESULTS

398,477 patients were included. Median age was 74 years and 55.2% were women. Individuals were classified as CKD with HTN (51.9%), CKD with T2D (3.87%), CKD with HTN/T2D (31.4%) and CKD without HTN/T2D (12.9%). In the multivariate analysis, with the CKD without HTN/T2D group as reference, the ACM Hazard Ratio (HR) was 0.74 (95%CI 0.72-0.75) for the CKD with HTN group, 0.81 (95%CI 0.79-0.83) for CKD with HTN/T2D and 1.14 (95%CI 1.10-1.19) for the CKD with T2D group. The sub distribution HRs for CVE were 1.40 (95%CI 1.34-1.47), 1.70 (95%CI 1.61-1.80) and 1.37 (95%CI 1.26-1.48), respectively.

CONCLUSION

In patients with CKD, the risk of ACM and CVE differed in patients with previous HTN and/or T2D. These comorbidities can help identify individuals at higher risk of adverse outcomes and improve the management of patients with CKD in primary care.

The pattern of dyslipidemia among Somali type 2 diabetic patients: a cross-sectional study

BACKGROUND

Diabetes mellitus (DM) is a major public health concern. This study aims to determine frequency, pattern, and potential determinants of dyslipidemia among adults with type 2 DM (T2DM) at Somalia's only diabetes outpatient clinic.

METHODS

Five hundred twenty-nine consecutive patients with T2DM who applied to our outpatient clinic between January 2020 and June 2020 were included in this cross-sectional hospital-based study. Demographic characteristics of participants, including lipid panel, were extracted from the registry system. Correlation analysis was performed between lipid profile and related parameters. Multivariate binary logistic regression models were used to identify independent determinants of dyslipidemia for further analysis.

RESULTS

The overall population's mean age was 51.9 ± 12.2 years, with 177 (33.5%) males. Total and atherogenic dyslipidemias were found in 92.8% and 24.8%, respectively. The most common isolated pattern of dyslipidemia was high non-high-density lipoprotein cholesterol (non-HDL-C) (82.8%), followed by high low-density lipoprotein cholesterol (LDL-C) (72.6%), high total cholesterol (TC) (54.3%), and low HDL-C (48.3%). Females were found to have a higher prevalence of high TC (63.4% vs. 54.2%, p = 0.043) and lower HDL-C (57.4% vs. 46.3%, p = 0.016). High LDL-C with low HDL-C was the most common pattern among combined type dyslipidemias (18.1%), followed by high LDL-C with high triglyceride (TG) (17.8%), as well as low TG with low HDL-C (3.6%). Females had a higher proportion of high LDL-C with low HDL-C than males (20.3% vs. 13.6%, p = 0.036). Age, gender, body mass index, central obesity, spot urinary proteinuria, fasting blood glucose, poor glycemic control, creatinine, and Hs-CRP were all associated with different dyslipidemia patterns in multivariate logistic regression analyses.

CONCLUSIONS

We found that the prevalence of dyslipidemia, especially atherogenic patterns, was extremely high among Somali T2DM patients. An enhanced health policy should, therefore, be established to detect, treat and prevent dyslipidemia.

Heart rate-corrected QT interval prolongation is associated with decreased heart rate variability in patients with type 2 diabetes

We investigated the association between the heart rate-corrected QT interval (QTc interval) measured by standard electrocardiography and heart rate variability (HRV) in patients with type 2 diabetes mellitus (T2DM). From March 1, 2009, to December 12, 2009, 411 patients with T2DM who underwent resting 12-lead electrocardiography and cardiovascular autonomic function testing concurrently without the exclusion criteria were consecutively recruited in this cross-sectional study. Time- and frequency-domain HRV variables were assessed for 5 minutes by beat-to-beat HRV recording. The QT interval was corrected for the heart rate using Bazett's formula. QTc interval measurements of >440 ms were considered abnormally prolonged. The mean age and diabetes duration were 56.3 ± 10.6 years and 9.6 ± 7.3 years, respectively. A total of 90 patients had QTc interval prolongation (21.9%). The participants with a prolonged QTc interval were older (59.4 ± 10.1 years vs 55.5 ± 10.6 years, P = .002), were more likely to be a woman (72.2% vs 51.7%, P = .001), had a higher prevalence of hypertension (46.7% vs 33.4%, P = .022), had a higher hemoglobin A1c level (8.8% ± 2.2% vs 8.2% ± 1.8%, P = .045), and had decreased values for the variables measuring HRV, except for the low frequency (LF)/high frequency (HF) ratio (total power [TP], 147.7 [74.1-335.9] ms vs 328.7 [185.7-721.7] ms, P = .002). After adjusting for multiple confounders, QTc interval prolongation was associated with the lowest quartile of the HRV parameters of TP (odds ratio [OR] = 3.99; 95% confidence interval [CI]: 2.29-6.96), HF (OR = 3.20; 95% CI: 1.84-5.58), LF (OR = 3.68; 95% CI: 2.10-6.43), standard deviation of the normal-to-normal interval (OR = 3.31; 95% CI: 1.89-5.77), and root-mean-square of the successive differences (OR = 1.98; 95% CI: 1.13-3.47) in patients with T2DM. Decreased values for the variables measuring HRV, except for the LF/HF ratio, might be associated with QTc interval prolongation in patients with T2DM.