The association of smoking status with glycemic control, metabolic profile and diabetic complications- Results of the Australian National Diabetes Audit (ANDA)

Influence of quitting smoking on diabetes-related complications: A scoping review with a systematic search strategy

INTRODUCTION

Smoking in people with diabetes markedly elevates their risk of developing complications and increases the likelihood of cardiovascular mortality. This review is the first to specifically provide evidence-based analysis about the influence of quitting smoking on diabetes-related complications in people with type 2 diabetes.

METHOD

The present review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All human clinical studies assessing the effects of stopping smoking cessation on diabetes-related complications were included. PubMed and Embase were screened until January 2024. References of primary studies and principal peer-reviewed scientific journals in the field were manually screened.

RESULTS

We identified a total of 1023 studies. Only 26 met the criteria for eligibility. In general quitting smoking is associated with decreased risks of myocardial infarction and ischemic stroke. Regarding microvascular complications, the strongest evidence for the beneficial effects of smoking cessation is observed in diabetic nephropathy. However, the relationship between smoking cessation and retinopathy, neuropathy, diabetic foot complications and diabetic-related erectile dysfunction, is poorly investigated.

CONCLUSION

Quitting smoking offers significant advantages in managing diabetes-related complications, significantly lowering the risks of myocardial infarction, ischemic stroke, and diabetic nephropathy. This underscores the importance of cessation. Providing evidence-based information on the benefits of stopping smoking for people with type 2 diabetes who smoke, can bolster smoking cessation efforts in the context of diabetes management.

Investigation of smoking on the antiplatelet response to clopidogrel: Unravelling the smoker's paradox

The intricate relationship between smoking and the effects of the antiplatelet drug clopidogrel has been termed the "smoker's paradox". This paradox details the enhanced efficacy of clopidogrel in smokers compared to non-smokers. This review begins with an exploration of the proposed mechanisms of the smoker's paradox, particularly drawing attention to the induction of cytochrome P450 (CYP) isoenzymes via tobacco smoke, specifically the enzymes CYP1A2 and CYP2C19. Moreover, an investigation of the effects of genetic variability on the smoker's paradox was undertaken from both clinical and molecular perspectives, delving into the effects of ethnicity and genetic polymorphisms. The intriguing role of CYP1A2 genotypes and the response to clopidogrel in smoking and non-smoking populations was examined conferring insight into the individuality rather than universality of the smoker's paradox. CYP1A2 induction is hypothesised to elucidate the potency of smoking in exerting a counteracting effect in those taking clopidogrel who possess CYP2C19 loss of function polymorphisms. Furthermore, we assess the comparative efficacies of clopidogrel and other antiplatelet agents, namely prasugrel and ticagrelor. Studies indicated that prasugrel and ticagrelor provided a more consistent effect and further reduced platelet reactivity compared to clopidogrel within both smoking and non-smoking populations. Personalised dosing was another focus of the review considering patient comorbidities, genetic makeup, and smoking status with the objective of improving the antiplatelet response of those taking clopidogrel. In summation, this review provides insight into multiple areas of research concerning clopidogrel and the smoker's paradox taking into account proposed mechanisms, genetics, other antiplatelet agents, and personalised dosing.

Diabetic Sensorimotor Polyneuropathy: An Overview on Epidemiology, Risk Factors, Classification, Diagnosis, and Treatment

Diabetic distal symmetric sensorimotor polyneuropathy (DSPN) is a common complication of diabetes with devastating consequences. Hyperglycaemia is the major aetiological factor, while emerging data demonstrate that cardiometabolic risk factors also contribute to its development. Diagnosis of DSPN involves interview of medical and neurological history, foot inspection, and sensory and motor function examination with specific tests such as temperature and pinprick perception for small nerve fibers, and vibration and light touch assessments for large nerve fibers. Management includes optimised glycaemic control, treatment of cardiovascular risk factors, and symptomatic treatment aiming at improving life quality. This article provides an overview on epidemiology, risk factors, classification, diagnosis and current treatment of DSPN.

Evaluating the Role of Glycemic Control in Modulating Pulmonary Function Among Smokers With Diabetes Mellitus: A Systematic Review

BACKGROUND

Diabetes mellitus (DM) impacts multiple body systems, including lung function, and this impact can be further complicated by smoking. The connection between blood sugar control and lung health in individuals with diabetes who smoke has been extensively studied, but findings have been varied. This systematic review sought to compile and assess the research on how blood sugar control influences lung function in smokers with diabetes.

METHODS

We searched several databases, including PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, CINAHL, PsycINFO, and Google Scholar, in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included studies that looked at lung function tests in smokers with diabetes and examined the relationship with blood sugar control, as indicated by hemoglobin A1c (HbA1c) levels. We conducted thorough quality assessments, data extraction, and analysis.

RESULTS

We identified five relevant studies. The data from these studies indicated a clear trend: smokers with diabetes who had higher HbA1c levels typically showed worse lung function than those with better blood sugar control. Decreases in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were the most frequently observed issues. Some studies also pointed to a complex relationship between HbA1c levels and lung function, particularly when HbA1c was below 7.0%.

CONCLUSION

Our review indicates that smokers with DM who have poor blood sugar control tend to have worse lung function. These findings highlight the importance of managing blood sugar to help maintain lung health in these individuals. Further long-term research is needed to clarify the exact relationship and whether improving blood sugar control can reverse lung problems.

Acute-phase response following one-stage full-mouth versus quadrant non-surgical periodontal treatment in subjects with comorbid type 2 diabetes: A randomized clinical trial

AIM

To compare the level of inflammatory markers and endothelial function 24 h (Day 1) and 90 days (Day 90) after conventional quadrant-wise scaling and root planing (Q-SRP) versus one-stage full-mouth SRP (FM-SRP) in patients affected by type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

Patients affected by periodontitis and T2DM were randomly allocated to receive FM-SRP or Q-SRP and followed up at Day 1 and Day 90. Serum samples, vital signs, and flow-mediated dilation (FMD) parameters were collected at baseline, Day 1, and Day 90. Periodontal variables were collected at baseline and Day 90. The primary outcome was the C-reactive protein (CRP) concentration at Day 1 after periodontal treatment. Student's t-test for independent samples was used for between-group comparisons (Mann-Whitney U test for non-normal data), while analysis of variance with post hoc Tukey tests (Kruskal-Wallis and Dunn tests for non-normal data) were used for intra-group comparisons.

RESULTS

Forty subjects were included in the study. FM-SRP produced a significant increase in CRP and a significant reduction in FMD at Day 1 compared to Q-SRP (p < .05). The absolute change in HbA1c (mmol/mol) from baseline to Day 90 was significantly improved in the Q-SRP (ΔHbA1c = -1.59 [SD = 1.20]) compared to the FM-SRP group (ΔHbA1c = -0.8 [SD = 0.95]) (p = .04).

CONCLUSIONS

FM-SRP triggers a robust acute-phase response at 24 h after treatment compared to Q-SRP. Such systemic acute perturbations may offset the beneficial systemic effects of periodontal treatment in terms of HbA1c reduction and improvement in endothelial function in T2DM subjects.

Meta-analysis of the effects of smoking and smoking cessation on triglyceride levels

Smoking increases lipid levels, including triglycerides, leading to increased cardiovascular disease risk. We performed a meta-analysis to quantify the effects of smoking and smoking cessation on triglyceride levels. The PubMed and Scopus databases were searched to identify studies reporting either triglyceride levels in smokers and non-smokers or the effects of smoking cessation on triglyceride levels. Fixed- and random-effects models were used to perform the analyses when three or more studies/comparisons were available. We identified 169 and 21 studies evaluating the effects of smoking and smoking cessation, respectively, on triglyceride levels. Triglyceride levels were 0.50 mmol/L (95% confidence interval: 0.49-0.50 mmol/L) higher in smokers than non-smokers, but the effect differed widely across studies. No statistically significant effect was observed on triglyceride levels between baseline and 6 weeks (mean difference [MD] = 0.02 [-0.09, 0.12] mmol/L), 2 months (MD = 0.03 [-0.21, 0.27] mmol/L), 3 months (MD = 0.08 [-0.03, 0.21] mmol/L), or 1 year (MD = 0.04 [-0.06, 0.14] mmol/L) after quitting. However, a slightly significant decrease in triglyceride levels was observed at 1 month after cessation (MD = -0.15 [-0.15, -0.01] mmol/L). The results of this meta-analysis provide a basis for understanding the effects of smoking and smoking cessation on triglyceride levels, which could have important implications for public health.

Risk Factors of Microvascular Complications Among Type 2 Diabetic Patients Using Cox Proportional Hazards Models: A Cohort Study in Tabuk Saudi Arabia

Purpose

The burden of type 2 diabetes (T2D) is high in Saudi Arabia, but data related to its complications are limited. This study aimed to determine the incidence of microvascular complications caused by T2D and evaluate the impact of the associated risk factors.

Patients and Methods

This retrospective cohort study was conducted at two military hospitals in Tabuk, Saudi Arabia. Data on the socio-demographics, glycaemic profile, blood lipid indices, duration of T2D, and associated microvascular complications were collected from electronic health records and medical files. Descriptive statistics and Cox proportional hazards models were used for data analysis.

Results

This study included 1563 T2D patients. The incidence of microvascular complications was 34.3% (95% confidence interval [CI], 32.0-36.6). Retinopathy was the most common complication (incidence=20.0%; 95% CI, 18.0-22.0%), while nephropathy was the least common complication (incidence=12.2%; 95% CI, 10.6-13.8%). Advanced age (≥65 years) showed the highest risk of retinopathy (Hazard ratios [HR], 2.86; 95% CI, 2.56-3.21), neuropathy (HR, 2.70; 95% CI, 2.40-3.05), and nephropathy (HR, 2.37; 95% CI, 2.12-2.64) compared with their counterparts. After adjusting for potential confounders, the study found that the significant risk factors for microvascular complications were longer duration (≥10 years) of T2D (HR, 5.3; 95% CI, 5.1-5.6), uncontrolled hypertension (HR, 3.9; 95% CI, 3.3-4.2), poor glycaemic control (HR, 4.6; 95% CI, 4.3-5.1), obesity (HR, 2.3; 95% CI, 2.2-2.6), and dyslipidaemia (HR, 1.6; 95% CI, 1.2-2.0).

Conclusion

Given the high burden of microvascular complications in military healthcare facilities in Tabuk, Saudi Arabia, a context-specific accessible public health program focusing on the promotion of a healthy lifestyle, physical activity, and consumption of a healthy diet, as well as the early diagnosis and management of diabetes, needs to be developed and implemented.

Previously unrecognized risk factors for severe hypoglycaemia requiring emergency medical care in insulin-treated type 2 diabetes: Results from a real-world nested case-control study

AIM

Several risk factors for severe hypoglycaemia (SH) are associated with insulin-treated diabetes. This study explored potential risk factors in adults with insulin-treated type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

In this case-control study, adults with T2DM initiating insulin were identified in the IQVIA PharMetrics® Plus database. The index date was the date of the first SH event (cases). Using incidence-density sampling, controls were selected from those who had been exposed 'at risk' of SH for the same amount of time as each case. After exact-matching on the well-established factors, previously unreported risk factors were evaluated through conditional logistic regression.

RESULTS

In 3153 case-control pairs, pregnancy [odds ratios (OR) = 3.20, p = .0003], alcohol abuse (OR = 2.43, p < .0001), short-/rapid-acting insulin (OR = 2.22/1.47, p < .0001), cancer (OR = 1.87, p < .0001), dementia/Alzheimer's disease (OR = 1.73, p = .0175), peripheral vascular disease (OR = 1.59, p < .0001), antipsychotics (OR = 1.59; p = .0059), anxiolytics (OR = 1.51, p = .0012), paralysis/hemiplegia/paraplegia (OR = 1.51, p = .0416), hepatitis (OR = 1.50, p = .0303), congestive heart failure (OR = 1.47, p = .0002), adrenergic-corticosteroid combinations (OR = 1.45, p = .0165), β-adrenoceptor agonists (OR = 1.40, p = .0225), opioids (OR = 1.38, p < .0001), corticosteroids (OR = 1.35, p = .0159), cardiac arrhythmia (OR = 1.29. p = .0065), smoking (OR = 1.28, p = .005), Charlson Comorbidity Index score 2 (OR = 1.28, p = .0026), 3 (OR = 1.41, p = .0016) or ≥4 (OR = 1.57, p = .0002), liver/gallbladder/pancreatic disease (OR = 1.26, p = .0182) and hypertension (OR = 1.19, p = .0164) were independently associated with SH.

CONCLUSIONS

Although all people with insulin-treated diabetes are at risk of SH, these results have identified some previously unrecognized risk factors and sub-groups of insulin-treated adults with T2DM at greater risk. Scrutiny of current therapies and comorbidities are advised as well as additional glucose monitoring and education, when identifying and managing SH in vulnerable populations.

Health-risk behaviours among Indigenous Australians with diabetes: A study in the integrated Diabetes Education and Eye Screening (iDEES) project

AIM

To assess the prevalence of modifiable health-risk behaviours among Indigenous Australian adults with diabetes attending a regional Victorian Indigenous primary-care clinic.

DESIGN

A cross-sectional observational single-site study.

METHODS

As part of a multi-study project we administered the Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional wellbeing (SNAPE) survey tool during the study baseline visit to methodically capture health-related behavioural data in the nurse-led integrated Diabetes Education and Eye Screening (iDEES) project in a regional Indigenous primary healthcare setting between January 2018 and March 2020. This descriptive SNAPE study helps address the lack of health behaviour data for Indigenous people with diabetes.

RESULTS

Of 172 eligible adults, 135 (79%) were recruited to the iDEES study, 50 (37%) male. All participated in at least one survey. Median (range) age was 56 (46-67) years; 130 (96%) had Type 2 diabetes of median [IQR] duration 6 (2-12) years. All 135 provided smoking data; 88 (65%) completed all surveys. Forty-nine (36%) and 29 (22%) were current or former smokers, respectively; 5 (6%) met vegetable intake guidelines, 22 (25%) met fruit intake guidelines; 38 [43%] drank alcohol in the past year. On average, participants walked for ≥10 min at a time 4 days/week and sat for an average of 8 h on weekdays; 35 (40%) had minimal-mild, and 30 (34%) had moderate-severe depressive symptoms.

CONCLUSION

Suboptimal modifiable health-risk behaviours and depressive symptoms are common in Indigenous Australian adults with diabetes.

IMPACT

Orderly assessment and reporting of health-risk behaviours using a single multi-component survey instrument (SNAPE tool) during a nurse-led diabetes education clinical visit is feasible and efficient. Such data may facilitate personalised interventions and improve diabetes management at both individual and health service levels.

Association Between Serum Albumin Levels and Diabetic Peripheral Neuropathy Among Patients with Type 2 Diabetes: Effect Modification of Body Mass Index

BACKGROUND

The role of serum albumin in the risk of diabetic peripheral neuropathy (DPN) remains unclear. This study aimed to explore the relationship between serum albumin level and DPN, and to examine any possible effect modifiers among patients with type 2 diabetes mellitus.

METHODS

This cross-sectional study was conducted in Jiangxi, China, from May 2012 to December 2014. Serum albumin levels were determined in 523 subjects, and the association between serum albumin level and DPN was evaluated using linear regression models (odds ratio [OR] and corresponding 95% confidence interval [CI]).

RESULTS

There was a significant inverse association between serum albumin level (per 1 g/L increment, OR 0.95 [95% CI 0.92-0.98]) and the risk of DPN. Accordingly, when serum albumin was assessed as quartiles, a significantly lower risk of DPN was found in participants in quartile 4 (OR 0.49 [95% CI 0.25-0.95]), compared with those in quartile 1. Consistently, higher albumin levels (≥35 g/L) were associated with decreased odds for DPN (OR 0.36 [95% CI 0.17-0.74]) compared with lower levels. Furthermore, the albumin-DPN association was significantly stronger in patients with a relatively high body mass index (BMI; ≥24 kg/m²; OR 0.91 [95% CI 0.85-0.98]) than in those with a low BMI (<24 kg/m²; OR 0.99 [95% CI 0.94-1.04]; P for interaction = 0.042).

CONCLUSION

These data suggest that serum albumin level could be a novel risk factor for DPN among patients with type 2 diabetes and relatively high BMI (>24 kg/m²).

The Global Burden of Type 2 Diabetes Attributable to Tobacco: A Secondary Analysis From the Global Burden of Disease Study 2019

OBJECTIVES

Growing epidemiological studies have reported the relationship between tobacco and health loss among patients with type 2 diabetes (T2D). This study aimed to explore the secular trend and spatial distribution of the T2D burden attributable to tobacco on a global scale to better understand regional disparities and judge the gap between current conditions and expectations.

METHODS

As a secondary analysis, we extracted data of tobacco-attributable T2D burden from the 2019 Global Burden of Disease Study (GBD). Joinpoint regression was adopted to determine the secular trend of age-standardized rates (ASR), with average annual percentage change (AAPC). Gaussian process regression (GPR) was used to explore the average expected relationship between ASRs and the socio-demographic index (SDI). Spatial autocorrelation was used to indicate if there is clustering of age-standardized DALY rate (ASDR) with Moran's I value. Multi-scale geographically weighted regression (MGWR) was to investigate the spatial distribution and scales of influencing factors in ASDR attributable to tobacco, with the regression coefficients for each influencing factor among 204 countries.

RESULTS

Tobacco posed a challenge to global T2D health, particularly for the elderly and men from lower SDI regions. For women, mortality attributable to secondhand smoke was higher than smoking. A downward trend in age-standardized mortality rate (ASMR) of T2D attributable to tobacco was observed (AAPCs= -0.24; 95% CI -0.30 to -0.18), while the ASDR increased globally since 1990 (AAPCs= 0.19; 0.11 to 0.27). Oceania, Southern Sub-Saharan Africa, and Southeast Asia had the highest ASMRs and ASDRs, exceeding expectations based on the SDI. Also, "high-high" clusters were mainly observed in South Africa and Southeast Asian countries, which means a high-ASDR country is surrounded by high-ASDR neighborhoods in the above areas. According to MGWR model, smoking prevalence was the most sensitive influencing factor, with regression coefficients from 0.15 to 1.80.

CONCLUSION

The tobacco-attributable burden of T2D should be considered as an important health issue, especially in low-middle and middle-SDI regions. Meanwhile, secondhand smoke posed a greater risk to women. Regional disparities existed, with hot spots mainly concentrated in South Africa and Southeast Asian countries.

Mesoporous NiO@ZnO nanofiber membranes via single-nozzle electrospinning for urine metabolism analysis of smokers

A simple and efficient single-nozzle electrospinning strategy using polystyrene (PS) spheres and polyvinyl pyrrolidone (PVP) to construct a mesoporous NiO@ZnO nanofiber membrane was developed, which was used for the urine metabolism analysis of smokers.

Cigarette Smoke Stimulates SARS-CoV-2 Internalization by Activating AhR and Increasing ACE2 Expression in Human Gingival Epithelial Cells

A large body of evidence shows the harmful effects of cigarette smoke to oral and systemic health. More recently, a link between smoking and susceptibility to coronavirus disease 2019 (COVID-19) was proposed. COVID-19 is due to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which uses the receptor ACE2 and the protease TMPRSS2 for entry into host cells, thereby infecting cells of the respiratory tract and the oral cavity. Here, we examined the effects of cigarette smoke on the expression of SARS-CoV-2 receptors and infection in human gingival epithelial cells (GECs). We found that cigarette smoke condensates (CSC) upregulated ACE2 and TMPRSS2 expression in GECs, and that CSC activated aryl hydrocarbon receptor (AhR) signaling in the oral cells. ACE2 was known to mediate SARS-CoV-2 internalization, and we demonstrate that CSC treatment potentiated the internalization of SARS-CoV-2 pseudovirus in GECs in an AhR-dependent manner. AhR depletion using small interference RNA decreased SARS-CoV-2 pseudovirus internalization in CSC-treated GECs compared with control GECs. Our study reveals that cigarette smoke upregulates SARS-CoV-2 receptor expression and infection in oral cells. Understanding the mechanisms involved in SARS-CoV-2 infection in cells of the oral cavity may suggest therapeutic interventions for preventing viral infection and transmission.

Fasting biochemical hypoglycemia and related-factors in non-diabetic population: Kanagawa Investigation of Total Check-up Data from National Database-8

BACKGROUND

In healthy people, the lowest daily blood glucose concentration is usually observed in the early morning, after overnight fasting. However, the clinical relevance and the prevalence of fasting biochemical hypoglycemia (FBH) are poorly understood in people who do not have diabetes, although the clinical implications of such hypoglycemia have been extensively studied in patients with diabetes. FBH can be influenced by many factors, including age, sex, body mass, smoking, alcohol drinking, exercise levels, medications, and eating behaviors, such as breakfast skipping and late-night eating.

AIM

To determine the prevalence of FBH and investigated its association with potential risk factors in a population without diabetes.

METHODS

Clinical parameters and lifestyle-related factors were assessed in a cross-sectional study of 695613 people aged 40-74 years who had undergone a health check-up (390282 men and 305331 women). FBH was defined as fasting plasma glucose < 70 mg/dL (3.9 mmol/L) after overnight fasting, regardless of any symptoms. The absence of diabetes was defined as HbA1c < 6.5%, fasting plasma glucose < 126 mg/dL (7.0 mmol/L), and no pharmacotherapy for diabetes. Multivariate logistic regression analysis, with adjustment for confounding factors, was used to identify associations.

RESULTS

FBH was present in 1842 participants (0.26%). There were significantly more women in the FBH group (59.1%) than in the non-FBH group (43.9%). Values of most of the clinical parameters, but not age, were significantly lower in the FBH group than in the non-FBH group. Logistic regression analysis showed that a body mass index of ≤ 20.9 kg/m² (reference: 21-22.9 kg/m²) and current smoking were significantly associated with FBH, and this was not altered by adjustment for age, sex, and pharmacotherapy for hypertension or dyslipidemia. Female sex was associated with FBH. When the data were analyzed according to sex, men in their 60s or 70s appeared more likely to experience FBH compared with their 40s, whereas men in their 50s and women aged ≥ 50 years appeared less likely to experience FBH. The relationships of FBH with other factors including alcohol drinking and pharmacotherapies for hypertension and dyslipidemia also differed between men and women.

CONCLUSION

FBH occurs even in non-diabetic people, albeit at a very low frequency. FBH is robustly associated with low body mass and smoking, and its relationship with lifestyle factors varies according to sex.

What Gets Measured Gets Improved-Setting Standards and Accreditation for Quality Improvement for Diabetes Services in Australia

The purpose of this article is to illustrate that setting standards of care is the cornerstone for excellence in diabetes management. This is underpinned by 3 activities: a standards and accreditation process, an audit and benchmarking program and a linked quality improvement plan. While there are many examples of local auditing and quality improvement programs, there are very few that are at a national level. The National Association of Diabetes Centres (NADC) was formed by the Australian Diabetes Society and the Australian Diabetes Educators Association to set standards of diabetes care in Australia. A rigorous accreditation process was put in place to recognize primary, secondary, and tertiary level diabetes centers that meet these standards. The NADC accreditation process is underpinned by a quality improvement plan, which must be submitted for accreditation to be granted and is informed by the Australian National Diabetes Audit (ANDA). ANDA is conducted annually to gather information about treatments, complications, self-care practices and quality of life outcomes and provides a national as well as an individual report to the participating center that is used to benchmark against other like centers. The ANDA reports are important to inform national policy and advocacy for diabetes care and to also provide information for quality improvement purposes for the individual participating center. We believe that the NADC Standards and Accreditation can be an exemplar for other countries to adapt and adopt to standardize diabetes care at the highest level.

Effects of electronic cigarette aerosol exposure on oral and systemic health

Conventional cigarette smoke harms nearly every organ of the body and is the leading cause of death in the United States and in the world. Decades of research have associated conventional cigarette smoke with several diseases and death. Heavily marketed, electronic nicotine delivery systems such as electronic cigarettes (e-cigarettes) are available in a variety of flavors and high nicotine concentrations. In 2019, a severe lung disease outbreak linked to e-cigarette use led to several deaths, which was called electronic-cigarette or vaping product use-associated lung injury (EVALI). Even though the trend of e-cigarette use among teens continues to increase, information on the effects of e-cigarette smoke on oral and overall health are still scarce. This review discusses the possible health effects due to unregulated e-cigarette use, as well as the health effects of second-hand smoke and third-hand smoke on non-smokers.

Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes

Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.

The Relationship Between Blood Hypoxia-Inducible Factor-1α, Fetuin-A, Fibrinogen, Homocysteine, and Amputation Level

Reduced life expectancy has resulted from an increased incidence of chronic complications in patients with diabetes. The diabetic foot is one of these complications and generally presents together with diabetic neuropathy and vascular insufficiency. Hypoxia-inducible factor-1α (HIF-1α) is important in developing the adaptation response to hypoxia and facilitates healing through regulation of keratinocyte migration and epithelium restoration in wounds. Fetuin-A is a transporter protein that is synthesized in the liver and inhibits vascular and ectopic calcifications. It has been observed that altered fetuin-A is associated with peripheral artery disease through vascular calcification and is associated with inflammation and metabolic syndrome occurrence in diabetic patients. Fibrinogen is an acute-phase reactant and has a major role in homeostasis, tissue repair, and wound healing. Increased fibrinogen blood level is one of the factors that facilitates the hypercoagulability in diabetics. Homocysteine has atherogenic features and causes vascular toxicity by enhancing low-density lipoprotein oxidation. We evaluated the association of serum HIF-1α, fetuin-A, fibrinogen, and homocysteine levels with amputation in 31 patients diagnosed with diabetes mellitus. According to our evaluation, a negative correlation was determined between fetuin-A and amputation level (P = .012, r = -0.450), which was statistically significant. Unfortunately, there was no significant correlation between HIF-1α, fibrinogen, homocysteine, and amputation level (P > .05). As a result, it was suggested that vascular calcification due to fetuin-A deficiency may be important in the diabetic foot pathogenesis and that fetuin-A levels may be a predictor for amputation level.

Chronic complications in patients with newly diagnosed type 2 diabetes: prevalence and related metabolic and clinical features: the Verona Newly Diagnosed Type 2 Diabetes Study (VNDS) 9

INTRODUCTION

We explored the presence of chronic complications in subjects with newly diagnosed type 2 diabetes referred to the Verona Diabetes Clinic. Metabolic (insulin secretion and sensitivity) and clinical features associated with complications were also investigated.

RESEARCH DESIGN AND METHODS

The comprehensive assessment of microvascular and macrovascular complications included detailed medical history, resting ECG, ultrasonography of carotid and lower limb arteries, quantitative neurological evaluation, cardiovascular autonomic tests, ophthalmoscopy, kidney function tests. Insulin sensitivity and beta-cell function were assessed by state-of-the-art techniques (insulin clamp and mathematical modeling of glucose/C-peptide curves during oral glucose tolerance test).

RESULTS

We examined 806 patients (median age years, two-thirds males), of whom prior clinical cardiovascular disease (CVD) was revealed in 11.2% and preclinical CVD in 7.7%. Somatic neuropathy was found in 21.2% and cardiovascular autonomic neuropathy in 18.6%. Retinopathy was observed in 4.9% (background 4.2%, proliferative 0.7%). Chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m²) was found in 8.8% and excessive albuminuria in 13.2% (microalbuminuria 11.9%, macroalbuminuria 1.3%).Isolated microvascular disease occurred in 30.8%, isolated macrovascular disease in 9.3%, a combination of both in 9.1%, any complication in 49.2% and no complications in 50.8%.Gender, age, body mass index, smoking, hemoglobin A1c and/or hypertension were independently associated with one or more complications. Insulin resistance and beta-cell dysfunction were associated with macrovascular but not microvascular disease.

CONCLUSIONS

Despite a generally earlier diagnosis for an increased awareness of the disease, as many as ~50% of patients with newly diagnosed type 2 diabetes had clinical or preclinical manifestations of microvascular and/or macrovascular disease. Insulin resistance might play an independent role in macrovascular disease.

TRIAL REGISTRATION NUMBER

NCT01526720.