Non-traditional cardiovascular risk factors contribute to peripheral arterial disease in patients with type 2 diabetes

Interim Spacer Exchange for Treatment of Periprosthetic Joint Infection: Almost Half the Patients Subsequently Fail

BACKGROUND

Interim spacer exchange may be performed in patients undergoing 2-stage exchange for periprosthetic joint infection. Several studies have demonstrated that interim spacer exchange is associated with poor outcomes. This study investigated the survivorship and risk factors for failure in patients with an interim spacer exchange.

METHODS

Two institutional databases identified 182 patients who underwent spacer exchange from 2000 to 2017. Primary outcomes included progression to reimplantation, treatment success, and mortality. Bivariate analysis was performed to evaluate risk factors associated with failure. Kaplan-Meier curves using host and local grades were generated to evaluate for primary outcomes and differences in survivorship.

RESULTS

The overall failure rate was 49% in patients with a spacer exchange. Most patients (60%) failed before 2 years. Higher comorbidity scores, elevated erythrocyte sedimentation rate, and non-White race were more prevalent in patients who failed. Negative cultures at the time of exchange were more prevalent in patients who did not fail. Failure rate was higher in immunocompromised conditions, and those who had revision prior to exchange. After considering clinically relevant variables, advanced host grade C was the single factor associated with treatment failure. Although survivorship curves were not significantly different between extremity local grades, higher host grades were associated with treatment failure.

CONCLUSION

Almost 1 out of 2 patients with spacer exchange were found to fail the intended 2-stage revision arthroplasty. Benefits of delivering additional antibiotic load with a new spacer should be balanced against poor outcomes in patients with the aforementioned risk factors.

Serum Uric Acid and Diabetes: From Pathophysiology to Cardiovascular Disease

Hyperuricemia, has been traditionally related to nephrolithiasis and gout. However, it has also been associated with the development of type 2 diabetes mellitus (T2DM) and cardiometabolic and cardiovascular diseases. Pathophysiologically, elevated serum uric acid (SUA) levels may be associated with abnormal lipid and glucose metabolism. In this narrative review, we consider the associations between hyperuricemia, hyperglycemia, atherosclerosis and thrombosis. Furthermore, we comment on the available evidence linking elevated SUA levels with the incidence and outcomes of coronary heart disease, stroke, peripheral artery disease and non-alcoholic fatty liver in subjects with T2DM. The effects of antidiabetic drugs (e.g. metformin, pioglitazone, sulfonylureas, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors and insulin) on SUA concentrations are also reviewed.

Prevalence of peripheral arterial disease and associated factors in people with type 2 diabetes

Abstract Introduction: The high rate of diabetes mellitus index (DM), along with the increase in cardiovascular compromise that DM favors, and the scarcity of epidemiological data regarding the prevalence of peripheral arterial disease (PAD) in this population, make it important to study risk factors associated with the development of PAD in the population with type 2 diabetes mellitus (DM2). Objective: To estimate the prevalence of PAD together with the associated factors in a sample of patients with DM2, treated in the Family Health Strategies (FHS) program, in the municipality of Pindamonhangaba, SP. Methods: Quantitative research in a cross-sectional study of 38 individuals who were diagnosed with DM2, between 40 and 77 years old, selected by convenience sampling and treated in the family health program in two different districts of the municipality. The method consisted of the evaluation of personal and anthropometric data, anamnesis and physical examination including the ankle-brachial index (ABI). Results: PAD was present in 21.1% (95%CI: 16.9 to 25.8) of the investigated population. Risk factors observed were age range of 51 to 69 years (75%), overweight (50%), systemic arterial hypertension (SAH) (100%), smoking (62.5%) and physical inactivity (87.5%). Conclusion: The prevalence of PAD was more than a fifth of those diagnosed with DM2, and the most prevalent associated risk factors were SAH, physical inactivity, smoking and overweight with and without PAD.

Correlation between lower extremity arterial disease and skeletal muscle mass in patients with type 2 diabetes mellitus

Objectives

To evaluate skeletal muscle mass in patients with both type 2 diabetes mellitus (T2DM) and concomitant lower extremity arterial disease (LEAD) and determine the contribution of skeletal muscle mass to macrovascular diseases.

Methods

In total, 112 patients with T2DM were divided into the T2DM and T2DM + LEAD groups. Hepatic function, renal function, uric acid, blood glucose, and glycated hemoglobin (HbA1C) were measured. Dual-energy X-ray absorptiometry was used to measure visceral fat area and skeletal muscle mass index (SMI).

Results

Waist-to-hip ratio, uric acid, and body fat percentage were significantly higher in the T2DM+LEAD group than in the T2DM group; SMI was significantly lower in the T2DM+LEAD group than in the T2DM group. There were no significant differences in albumin, creatinine, fasting blood glucose, HbA1C, or blood lipids. Uric acid, SMI, and body fat percentage were significantly positively correlated with T2DM and concomitant LEAD. Logistic regression analyses suggested that SMI is an independent risk factor for LEAD in T2DM (odds ratio = 1.517; 95% confidence interval: 1.082–2.126).

Conclusions

Skeletal muscle mass is lower in patients with T2DM and concomitant LEAD than in patients with T2DM who do not exhibit LEAD. SMI is an important risk factor for LEAD.

Advances in our understanding of the influence of gender on patient outcomes with peripheral arterial disease co-occurring with diabetes

Peripheral arterial disease is an important predictor of cardiovascular morbidity and mortality. Patients with peripheral arterial disease are at a higher risk of myocardial infarction and stroke. The well-known coronary artery disease risk factors such as diabetes, hypertension, smoking and dyslipidemia are also risk factors for peripheral arterial disease. Hyperglycemia is an important mediator in the pathogenesis of this disease in diabetics, more so in women. The morbidity and poor outcomes associated with peripheral arterial disease in women are emerging. Women are more likely to present at an older age are often asymptomatic and have poorer outcomes with revascularization. Women experience specific sex-related challenges in the various diagnostic methods which could lead to a delay in diagnosis. This is a group which needs close attention and aggressive risk factor modification.

Effect of metabolic control on oxidative stress, subclinical atherosclerosis and peripheral artery disease in diabetic patients

Introduction

By rising diabetes mellitus prevalence, the prevalence of its most complication; cardiovascular disease (CVD) is also increasing. Moreover, oxidative stress has important role in pathogenesis of diabetes and its complications. We investigated relationship between total antioxidant status (TAS) and surrogate measures of subclinical atherosclerosis (SA) with glycemic status in diabetics.

Methods & materials

In a cross-sectional study, we recorded height, weight, waist circumference (WC) and blood pressure of 267 subjects. Blood samples were collected to measure fasting blood sugar (FBS), glycated hemoglobin (HbA1c), lipid profiles and TAS. The surrogate measures of SA were Carotid Intima Media Thickness (CIMT), and Ankle Brachial Index (ABI).

Results

We found significantly lower TAS leves and ABI values and higher CIMT in diabetic patients especially in poor glycemic group. There was a nonsignificant, weak correlation between TAS, ABI and CIMT with glycemic status (r = −0.10, −0.16, and +0.09, respectively). Multivariate regression analysis showed a significant influence of increasing age and diabetes duration on worsening CIMT in poor glycemic group.

Conclusions

Our study showed poor glycemic control leads to worse CIMT by increasing age and duration of diabetes. However we did not find a significan correlation between glycemic status and TAS levels. We suggest CIMT measurement along with other SA markers in poor glycemic diabetics, especially in older patients with longer duration of diabetes, to identify high risk CVD patients.

The Relationship Between High Pulse Pressure and Low Ankle-Brachial Index. Potential Utility in Screening for Peripheral Artery Disease in Population-Based Studies

INTRODUCTION

The ankle-brachial index (ABI) is a reliable screening procedure for peripheral artery disease detection. However, ABI testing is time-consuming and requires trained personnel, which may preclude its routine use in population-based surveys. Preliminary data suggest a relationship between ABI values and pulse pressure (PP) levels.

AIM

To assess whether PP calculation might help to detect persons who need ABI screening in population-based studies.

METHODS

All Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo ABI testing. Non-consented persons and those with ABI ≥1.4 were excluded. Using generalized linear and logistic regression models adjusted for demographics and cardiovascular risk factors, as well as receiver operator characteristics curve analysis, we evaluated the association between PP values and ABI, as well as the reliability of PP to identify candidates for ABI testing.

RESULTS

Out of 239 participants (mean age 70 ± 8 years, 62 % women), 46 (19 %) had an ABI ≤0.9 and 136 (57 %) had PP >65 mmHg, with a negative relationship between them (R = -0.386, p < 0.0001). A PP >65 mmHg was associated with an ABI ≤ 0.9 in the logistic regression model (OR 3.46, 95 % CI 1.07-11.2, p = 0.038). Continuous PP levels also correlated negatively with ABI (β -0.0014, 95 % CI -0.0024 to -0.0004, p = 0.005). The sensitivity of a PP >65 mmHg to predict a low ABI was 85 %, and the specificity was 50 %. In contrast, the sensitivity of blood pressure ≥140/90 mmHg was 27 % and the specificity was 10 %. The area under the curve for the predictive value of a PP >65 mmHg was 0.673 (95 % CI 0.609-0.736), and that of a blood pressure ≥140/90 mmHg was 0.371 (95 % CI 0.30-0.443), with a significant difference between them (p < 0.0001).

CONCLUSIONS

PP calculation may be a simple tool to detect candidates for ABI testing in population-based studies.

Cyclophilin A is associated with peripheral artery disease and chronic kidney disease in geriatrics: The Tianliao Old People (TOP) study

Cyclophilin A (CyPA), secreted by vascular smooth muscle cells in response to oxidative stress, is important in the pathogenesis of progressive peripheral arterial occlusion disease (PAOD), which is common among chronic kidney disease. We explored the prevalence of PAOD in Taiwan’s elderly (≥ 65 years old) population and its association with CyPA and renal function. Residents of Tianliao District, a rural community in southern Taiwan, were surveyed. An ankle-brachial index (ABI) < 0.91 was defined as PAOD. Chronic kidney disease (CKD) was defined based on eGFR levels < 60 mL/min/1.73 m². Serum CyPA was measured. Of the 473 participants, 68 (14.4%) had PAOD. Multiple logistic regression analysis showed PAOD was significantly associated with lower eGFR, lower BMI, higher glycated hemoglobin and higher pulse pressure. Serum CyPA levels in participants with PAOD were significantly higher than those with normal ABI values (47.3 ± 0.4 vs. 25.5 ± 0.2 ng/mL, p < 0.001). Moreover, eGFR inversely correlated with serum CyPA level (p < 0.05) in participants with CKD, but not in participants with normal renal function. In conclusion, with a prevalence of PAOD as high as 14.4% in an elderly community, CyPA might be the link between PAOD and advanced impaired renal function.

[Prevalence and factors associated with peripheral artery disease in patients with type 2 diabetes mellitus in Primary Care]

INTRODUCTION

Peripheral artery disease in the lower limbs (PAD) is a prevalent condition that entails high morbidity in diabetic patients; this study assesses PAD in these patients and its socio-demographic and clinic associated variables.

MATERIAL AND METHODS

Descriptive study in a systematic sample of diabetic patients (DM2) aged 50-80 years, in Primary Care settings. The dependent variable was the presence of PAD diagnosed by ankle-brachial index (ABI) ≤ 0.9; independent variables: socio-demographic, clinical and laboratory.

STATISTICS

bivariate and multiple logistic regression analyses were performed to determine the variables associated with low ABI.

RESULTS

A sample of 251 patients, 52.6% women; mean age: 68.5 ±8.5. A low ABI was detected in 18.3% (95% Confidence Interval (95% CI):13.3-23.3%), with 6 subjets (2.4%) previously diagnosed as suffering PAD. Age (OR=1.07; 95% CI: 1.02-1.12) and retinopathy (OR=2.69; 95% CI: 1.06-6.81) were associated (multiple logistic regression analysis) with ABI.

CONCLUSIONS

The percentage of patients diagnosed with PAD is very low, although PAD prevalence is high among DM2 patients attending Primary Care clinics, especially in older patients and those with retinopathy. We emphasize the recommendation of performing the ABI test in this population at risk.

The cross-sectional association between uric acid and atherosclerosis and the role of low-grade inflammation: the CODAM study

OBJECTIVES

The aims of this study were to investigate (i) associations between uric acid and prevalent cardiovascular disease (CVD), ankle-arm blood pressure index (AAIx) and carotid intima-media thickness (CIMT) in the total population and in predefined subgroups according to glucose metabolism status and (ii) the extent to which these associations are explained by low-grade inflammation.

METHODS

Cross-sectional analyses were conducted among 530 individuals [60.6% men, mean age 58.9 years (s.d. 6.9), 52.6% normal glucose metabolism (NGM)] at increased risk of CVD from the Cohort of Diabetes and Atherosclerosis Maastricht study. A low-grade inflammation score was computed by averaging the z-scores of eight inflammation markers [CRP, TNF-α, IL-6, IL-8, serum amyloid A, intercellular adhesion molecule 1 (ICAM-1), ceruloplasmin and haptoglobin].

RESULTS

After adjustment for traditional CVD risk factors, plasma uric acid (per s.d. of 81 μmol/l) was associated with CVD in individuals with NGM [odds ratio (OR) = 1.66, 95% CI 1.06, 2.58] but not with disturbed glucose metabolism (DGM) (OR = 0.81, 95% CI 0.55, 1.19, P interaction = 0.165). Uric acid was associated with CIMT in the total population (β = 0.024, 95% CI 0.007, 0.042) and slightly more strongly in individuals with NGM (β = 0.030, 95% CI 0.006, 0.054) than DGM (β = 0.018, 95% CI -0.009, 0.044, P interaction = 0.443). There was no association between uric acid and AAIx in any group (P interaction = 0.058). Uric acid was associated with low-grade inflammation in the total population (β = 0.074, 95% CI 0.013, 0.134, P interaction = 0.737). Adding low-grade inflammation to the models did not attenuate any of the associations.

CONCLUSION

The associations for uric acid with CIMT, and with CVD in NGM only, were not explained by low-grade inflammation. A difference in the strength of the associations between individuals with NGM and DGM was suggested.

Toe brachial index in middle aged patients with diabetes mellitus type 2: not just a peripheral issue

AIM

To explore risk factors for peripheral arterial disease (PAD) as well as the association between toe blood pressure and subclinical and clinical central vascular disease in patients with type 2 diabetes.

METHOD

Toe brachial index (TBI) was cross-sectionally analyzed in 742 middle-aged (54-66 years) patients with type 2 diabetes as well as non-diabetic controls and related to other vascular measures (e.g. carotid intima media thickness (IMT), presence of carotid plaque, central arterial stiffness and left ventricular mass index) and previous cardiovascular events.

RESULTS

A TBI ≤ 0.7 was seen in 22% of the patients but only one patient had severe TBI reduction (TBI ≤ 0.3). The corresponding figures in the controls were 13% and 0%, respectively. Mean TBI was significantly lower in patients with type 2 diabetes than in controls (0.81 ± 0.14 vs. 0.87 ± 0.15, p<0.001). In patients with diabetes, a lower TBI was associated with increased central arterial stiffness (p<0.001), IMT (p<0.001) and carotid plaque (p<0.001) as well as with decreasing glomerular filtration rate (p<0.001). Lower TBI was found in patients with previous macrovascular ischemic events. Furthermore, TBI was negatively correlated with age (p<0.001), diabetes duration (p<0.001) and HbA1c (p=0.01).

CONCLUSION

PAD, assessed with TBI, is common in a Swedish middle-aged diabetes type 2 cohort, affecting about one-fifth. As ankle pressure may be confounded by falsely high values in patients with diabetes due to media calcification we conclude that information about TBI may improve the risk evaluation regarding arteriosclerotic disease in both small and large vessels in type 2 diabetes.

Dyslipidemia associated with poor glycemic control in type 2 diabetes mellitus and the protective effect of metformin supplementation

The nature of the dyslipidemia associated with diabetes mellitus is complex and is the major risk factor for atherosclerosis and coronary artery disease. Aim of this study was to assess the effect of glycemic control, achieved by metformin, glibenclamide and insulin, on lipid profile in type 2 diabetic patients. One hundred and sixty-five type 2 diabetes mellitus patients were classified into good glycemic control (Group I) and poor glycemic control (Group II) on the basis of their blood HbA1c values. The Group II was characterized with high serum triglyceride (190.46 ± 15.20 mg/dl), total cholesterol (175.3 ± 6.31 mg/dl) as well as high LDL-cholesterol (109.0 ± 5.88 mg/dl). Significant correlations were evident between HbA1c and dyslipidemia, particularly serum TG (r = 0.28, P < 0.05), and between HbA1c and total cholesterol (r = 0.310, P < 0.05). Better glycemic control and improved dyslipidemia were observed in patients on combination therapy of metformin plus glibenclamide.

Prevalence of low ankle brachial index and its association with pulse pressure in an elderly Chinese population: a cross-sectional study

Background

We investigated the prevalence of low ankle brachial index (ABI) and the association of low ABI with pulse pressure among elderly community residents in China.

Methods

This population-based cross-sectional study was conducted in Beijing and recruited 2982 participants who were aged 60 years or older in 2007. Low ABI was defined as an ABI value less than 0.9 in either leg. Participants with or without stroke or coronary heart disease (CHD) were analyzed separately. The association between pulse pressure and low ABI was examined by using multiple logistic regression models.

Results

The prevalence of low ABI was 5.65% (4.24% among men and 6.52% among women; P = 0.0221) among participants without stroke or CHD and 10.91% (13.07% among men and 9.49% among women; P = 0.1328) among those with stroke or CHD. After adjusting for confounders, the odds ratio (95% CI) for each 5-mm Hg increase in pulse pressure was 1.19 (1.07, 1.33) and 1.10 (1.02, 1.20) for men and women, respectively, among participants without stroke or CHD and 1.17 (1.03, 1.34) and 1.15 (1.02, 1.30) for men and women with stroke or CHD. When pulse pressure was classified into quartiles and the lowest quartile was used as reference, the association between pulse pressure and low ABI remained positive in men and women.

Conclusions

Low ABI was prevalent among elderly Chinese, and pulse pressure was positively associated with low ABI.

Monocyte chemoattractant protein 1 is correlated with glycemic control and peripheral arterial disease in type 2 diabetic patients with metabolic syndrome

We evaluated the serum levels of monocyte chemoattractant protein 1 (MCP-1) and their association with peripheral arterial disease (PAD) in 199 patients with type 2 diabetes mellitus (T2DM) and metabolic syndrome ([MetS], group A) in comparison with 109 healthy controls (group B). In group A, MCP-1 levels were significantly (P < .001) higher than group B and exhibited a positive correlation with HbA1c (P < .001) and a negative correlation with ankle-brachial index (P < .001). In the same group, patients with PAD had significantly higher MCP-1 levels compared with those without PAD (P < .001). In conclusion, T2DM patients with MetS exhibit higher serum MCP-1 levels. The latter is associated with worse glycemic control and PAD. These results suggest a potential contributory role for MCP-1 in the pathogenesis of PAD in the presence of hyperglycemia and MetS in T2DM.

TRC150094 attenuates progression of nontraditional cardiovascular risk factors associated with obesity and type 2 diabetes in obese ZSF1 rats

Chronic overnutrition and consequential visceral obesity is associated with a cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus. Moreover, individuals who have a triad of hypertension, dysglycemia, and elevated triglycerides along with reduced high-density lipoprotein cholesterol have a greater residual cardiovascular risk even after factoring for the traditional risk factors such as age, smoking, diabetes, and elevated low-density lipoprotein cholesterol. In our previous study we demonstrated that TRC150094, when administered to rats receiving a high-fat diet, stimulated mitochondrial fatty acid oxidation (FAO) and reduced visceral adiposity, opening an interesting perspective for a possible clinical application. In the present study, oral administration of TRC150094 to obese Zucker spontaneously hypertensive fatty rats (obese ZSF1) improved glucose tolerance and glycemic profile as well as attenuated a rise in blood pressure. Obese ZSF1 rats treated with TRC150094 also showed reduced hepatic steatosis, reduced progression of nephropathy, and improved skeletal muscle function. At the cellular level, TRC150094 induced a significant increase in mitochondrial respiration as well as an increased FAO in liver and skeletal muscle, ultimately resulting in reduced hepatic as well as total body fat accumulation, as evaluated by magnetic resonance spectroscopy and magnetic resonance imaging, respectively. If reproduced in humans, these results could confirm that TRC150094 may represent an attractive therapeutic agent to counteract multiple residual cardiovascular risk components.