Diabetes and hypertension physiopathology and therapeutics

Quality of Chronic Disease (Diabetes & Hypertension) Care in Health Care Facilities in High Disease Burden Areas in Sidama Region: Cross-Sectional Study

Background

Diabetes and hypertension are major synergistic risk factors for microvasculopathy, microangiopathy, and neuropathy problems among patients with chronic disorder. Control of hypertension and diabetes have significant value in delaying these complications. The key for delaying complications in diabetes and hypertension is the quality of care.

Objective

This study explored the quality of diabetes-hypertension care in health care facilities with high disease burden in Sidama region.

Methodology

An institution-based cross-sectional study was carried out. Patients with diabetes and hypertension were included in the study. In this study, we included 844 patients were included in the study. For data collection, the application software Kobo Collect was utilized. For data analysis, SPSS version 25 was used. Logistic regression was used to identify factors associated with quality of care. To measure quality, we employed patient outcome indicators focusing on long-term complications of the eye, heart, fasting blood pressure, and neuropathic complications. Ethical approval clearance was obtained from Hawassa University, College of Medicine and Health Sciences ethical review board.

Results

The mean age of patients was 47.99 ± 15.26 years, with a range of 18-90 years, while men make up 62% of the overall number of respondents. In terms of marital status, 700 (82.9%) were married. Concerning place of residence; 433 (51.3%) were from rural area. The primary diagnosis is diabetes for 419 (49.6%) patients, and nearly 23% of patients have both diabetes and hypertension. In terms of blood pressure, the average systolic pressure was 129.6 mmHg and the average diastolic pressure was 82.6 mmHg. Among the study participants, 391 (46.33%) patients received poor quality of chronic disease care. Patients living alone, patients who have professional work, fasting blood glucose in normal range, patients with higher education, and patients with serum creatinine receive relatively good chronic illness care.

Unveiling the effects of living standards on diabetes and hypertension with the mediating role of overweight and obesity: a cross-sectional study in Bangladesh

OBJECTIVE

The purpose of the study was to ascertain how the standard of living is associated with the likelihood of developing diabetes and hypertension directly as well as indirectly through overweight and obesity.

STUDY DESIGN

The study used 2017-2018 Bangladesh Demographic and Health Survey data. It examined the household living standard (LSD) as the main factor, and body mass index (BMI) as a mediator. Outcomes included diabetes status, hypertension status and their co-occurrence. Structural equation modelling with logistic regression and bootstrapping were used for mediation analysis and computing bias-corrected SEs.

SETTING

The research was carried out in Bangladesh and included both male and female adults.

PARTICIPANTS

The study encompassed a total of 11 961 adults (5124 males and 6837 females) aged 18 years or older.

RESULTS

Among the participants, 10.3% had diabetes, 28.6% had hypertension and 4.9% had both conditions. The prevalence of diabetes, hypertension or both conditions was 18.5%, 33.5% and 9.7%, respectively, among those with a high LSD. Regression analysis demonstrated that individuals with high LSD had significantly elevated risks of these conditions compared with those with low LSD: 133% higher odds for diabetes (OR 2.22; 95% CI 1.97 to 2.76), 25% higher odds for hypertension (OR 1.25; 95% CI 1.10 to 1.42) and 148% higher odds for both conditions (OR 2.48; 95% CI 1.96 to 3.14). Moreover, the indirect effects of high LSD through obesity surpassed its direct effects for developing diabetes, hypertension or both conditions.

CONCLUSION

This study emphasises that with the enhancement of LSD, individuals often experience weight gain, resulting in elevated BMI levels. This cascade effect significantly amplifies the risks of diabetes, hypertension or both conditions. To counteract this concerning trajectory, policy interventions and targeted awareness campaigns are imperative. These efforts must prioritise the promotion of heightened physical activity and the mitigation of the overweight/obesity surge associated with rising LSD.

Microneedles and Their Application in Transdermal Delivery of Antihypertensive Drugs-A Review

One of the most cutting-edge, effective, and least invasive pharmaceutical innovations is the utilization of microneedles (MNs) for drug delivery, patient monitoring, diagnostics, medicine or vaccine delivery, and other medical procedures (e.g., intradermal vaccination, allergy testing, dermatology, and blood sampling). The MN-based system offers many advantages, such as minimal cost, high medical effectiveness, comparatively good safety, and painless drug application. Drug delivery through MNs can possibly be viewed as a viable instrument for various macromolecules (e.g., proteins, peptides, and nucleic acids) that are not efficiently administered through traditional approaches. This review article provides an overview of MN-based research in the transdermal delivery of hypertensive drugs. The critical attributes of microneedles are discussed, including the mechanism of drug release, pharmacokinetics, fabrication techniques, therapeutic applications, and upcoming challenges. Furthermore, the therapeutic perspective and improved bioavailability of hypertensive drugs that are poorly aqueous-soluble are also discussed. This focused review provides an overview of reported studies and the recent progress of MN-based delivery of hypertensive drugs, paving the way for future pharmaceutical uses. As MN-based drug administration bypasses first-pass metabolism and the high variability in drug plasma levels, it has grown significantly more important for systemic therapy. In conclusion, MN-based drug delivery of hypertensive drugs for increasing bioavailability and patient compliance could support a new trend of hypertensive drug delivery and provide an alternative option, overcoming the restrictions of the current dosage forms.

Medicated-related burden and adherence in patients with co-morbid type 2 diabetes mellitus and hypertension

Background

Medication adherence is an integral component in the management of patients with co-morbid type 2 diabetes mellitus (T2DM) and hypertension. However due to their combined conditions, there is likelihood of polypharmacy and medication-related burden, which could negatively impact adherence to therapy. This study aimed to assess the perceived medication-related burden among patients with co-morbid T2DM and hypertension and to evaluate the association between the perceived burden and adherence to medication therapy.

Methods

A cross-sectional study was conducted among adult patients with co-morbid T2DM and hypertension attending a primary health facility. The living with medicines questionnaire and the medication adherence report scale were used to assess extent of medication-related burden and adherence respectively. Binary logistic regression model was used to estimate the adjusted odds and their corresponding 95% confidence interval for medication-related burden and adherence outcomes. All observed categorical variables were considered for the multivariable binary logistic regression model.

Results

The total number of participants was 329 with a median age of 57.5 ± 13.2 years. The median score for the overall burden was 99 (IQR: 93-113), and this significantly varied by sex (p = 0.012), monthly income (p = 0.025), monthly expenditure on medications (p = 0.012), frequency of daily dose of medications (p = 0.020) and family history of T2DM (p < 0.001). About 30.7% and 36.8% of participants reported moderate/high burden and medication adherence respectively. Uncontrolled diastolic blood pressure (AOR: 2.46, 95% CI: 1.20-5.05, p = 0.014), high glucose (AOR: 4.24, 95% CI: 2.13-8.46, p < 0.001) and no family history of T2DM (AOR: 2.14, 95% CI: 1.14-4.02, p = 0.026) were associated with moderate/high medication burden. Uncontrolled diastolic blood pressure (AOR: 0.48, 95% CI: 0.25-0.94, p = 0.031), at least 5 years since hypertension diagnosis (AOR: 0.55, 95% CI: 0.30-0.99, p = 0.045) and moderate/high medication-related burden (AOR: 0.33, 95% CI: 0.16-0.69, p = 0.003) were associated with lower odds of medication adherence.

Conclusion

These findings suggest that to improve the preventive and optimal care of patients with T2DM and hypertension, interventions that aim to reduce medication-related burden and morbidity are recommended. The study proposes that health stakeholders such as clinicians, pharmacists, and policy makers, develop multidisciplinary clinical and pharmaceutical care interventions to include provision of counselling to patients on adherence. In addition, developing policies and sensitization activities on deprescribing and fixed-dose drug combinations aimed at reducing medication-related burden, while promoting better adherence, blood pressure and blood glucose outcomes are recommended.

Analytical quality by design-based RP-HPLC method for quantification of pioglitazone and candesartan cilexetil in bilayer tablet and its forced degradation studies

Aim: The current project involves developing an RP-HPLC method for simultaneous quantification of Candesartan Cilexetil and Pioglitazone based on analytical quality by design (AQbD).

Materials and methods: When analysed in the Design Expert application, the critical method parameters were systematically refined using Central Composite Design and contours were derived for significant variables. A contour plot has been used to discover the technique operable design region that governs response variation, which is then empirically tested.

Results: Successful chromatographic separation of title analytes was achieved on kromasil C18 (150 × 4.6 mm, 5 µm) column at 30 °C with mobile phase comprising 60% 20 Mm Potassium dihydrogen orthophosphate and 40% acetonitrile (v/v), isocratic elution pattern, 0.9 mL/min flow rate, and UV detection at 220 nm. The linear model for Candesartan Cilexetil was from 4 to 24 µg/ mL and Pioglitazone at 7.5–45 µg/ mL, respectively.

Conclusion: The method met all the ICH Q2 (R1) validation criteria. The current approach aided for analysing simultaneous drugs can be expanded into quantifying drugs in biological matrix predominance with maximum recovery.

The rs705708 A allele of the ERBB3 gene is associated with lower prevalence of diabetic retinopathy and arterial hypertension and with improved renal function in type 1 diabetic patients

INTRODUCTION

The Erb-b2 receptor tyrosine kinase 3 (ERBB3) is involved in autoimmune processes related to type 1 diabetes mellitus (T1DM) pathogenesis. Accordingly, some studies have suggested that single nucleotide polymorphisms (SNPs) in the ERBB3 gene confer risk for T1DM. Proliferation-associated protein 2G4 (PA2G4) is another candidate gene for this disease because it regulates cell proliferation and adaptive immunity. Moreover, PA2G4 regulates ERBB3. To date, no study has evaluated the association of PA2G4 SNPs and T1DM.

AIM

To evaluate the association of ERBB3 rs705708 (G/A) and PA2G4 rs773120 (C/T) SNPs with T1DM and its clinical and laboratory characteristics.

METHODS

This case-control study included 976 white subjects from Southern Brazil, categorized into 501 cases with T1DM and 475 non-diabetic controls. The ERBB3 and PA2G4 SNPs were genotyped by allelic discrimination-real-time PCR.

RESULTS

ERBB3 rs705708 and PA2G4 rs773120 SNPs were not associated with T1DM considering different inheritance models and also when controlling for covariables. However, T1DM patients carrying the ERBB3 rs705708 A allele developed T1DM at an earlier age vs. G/G patients. Interestingly, in the T1DM group, the rs705708 A allele was associated with lower prevalence of diabetic retinopathy and arterial hypertension as well as with improved renal function (higher estimated glomerular filtration rate and lower urinary albumin excretion levels) compared to G/G patients.

CONCLUSIONS

Although no association was observed between the ERBB3 rs705708 and PA2G4 rs773120 SNPs and T1DM, the rs705708 A allele was associated, for the first time in literature, with lower prevalence of diabetic retinopathy and arterial hypertension. Additionally, this SNP was associated with improved renal function.

Prevalence of hypertension among individuals with diabetes and its determinants: Evidences from the National Family Health Survey 2015-16, India

BACKGROUND

The incidence of Diabetes mellitus (DM) has escalated in recent decades, and the risk of diabetes-related mortality has increased dramatically due to the co-existence of hypertension (HTN). DM and HTN, having similar aetiology and disease mechanism, are influenced by lifestyle factors and greatly contribute to critical health complications.

AIM

The present study attempted to explore the co-existence of DM-HTN and the potential determinants considering rapid upsurge of both the diseases.

SUBJECTS AND METHODS

National Family Health Survey data were used, which included 7092 adult diabetic individuals, to find out the prevalence rate of HTN in diabetic persons in India. Appropriate statistical analyses were performed to accomplish the study objectives.

RESULTS

Prevalence rate of HTN in diabetic individuals was approximately 37%. Higher BMI was associated with DM-HTN co-existence. In males, increased age, higher BMI, alcohol consumption, poorest wealth index, and non-smoking (tobacco) were the significant determinants of the co-existence of DM-HTN, while in females, they were increased age, higher BMI, and geographical region.

CONCLUSION

This study unveiled the significance of healthy lifestyle maintenance and equitable health care services to prevent HTN among the diabetics, along with promotion of the awareness and management of DM and HTN through appropriate pharmacological treatments.

Hypertension and its related factors among patients with type 2 diabetes mellitus – a multi-hospital study in Bangladesh

Background

Hypertension and type 2 diabetes are associated with each other, and their coexistence is linked to diabetes-related complications such as stroke, coronary artery disease, kidney disease, retinopathy and diabetic foot. This study aimed to determine the prevalence, awareness and control of hypertension and factors associated with hypertension among people with type 2 diabetes mellitus (T2DM) in Bangladesh.

Methods

A cross-sectional and retrospective study was conducted in 2017, and data from 1252 adults with T2DM were collected from six hospitals that specialise in diabetes care. These hospitals provide primary, secondary and tertiary healthcare and cover the rural and urban populations of Bangladesh. Cross-sectional data were collected from patients via face-to-face interviews, and retrospective data were collected from patients’ past medical records (medical passport), locally known as the patients’ guidebook or record book. The associations between hypertension and its related factors were examined using the bootstrapping method with multiple logistic regression to adjust for potential confounders.

Results

The mean age of participants was 55.14 (± 12.51) years. Hypertension was found to be present among 67.2% of participants, and 95.8% were aware that they had it. Of these, 79.5% attained the blood pressure control. The mean duration of diabetes was 10.86 (± 7.73) years. The variables that were found to be related to hypertension include an age of above 60 years, physical inactivity, being overweight or obese, a longer duration of diabetes and chronic kidney disease.

Conclusion

The prevalence of hypertension as well as its awareness and control were very high among people with known type 2 diabetes. As there is a strong relationship between hypertension and diabetes, patients with diabetes should have their blood pressure regularly monitored to prevent major diabetes-related complications.

Plantain based dough meal: nutritional property, antioxidant activity and dyslipidemia ameliorating potential in high-fat induced rats

Background

Dyslipidemia is an aberrant rise in blood lipids due to diet and lifestyle. It has implicated as the major risk factor for developing hypertension among other diseases. This study was designed to evaluate plantain based dough meal nutritional property, antioxidant activity and dyslipidemia ameliorating potential in high-fat induced rats.

Methods

The flour blends, i.e., PSC (Plantain 70%, Soycake 30%), PSR (Plantain 65%, Soycake 30%, Rice-bran 5%), PSO (Plantain 65%, Soycake 30%, Oat-bran 5%), PSRO (Plantain 60%, Soycake 30%, Rice-bran 5%, Oat-bran 5%) and controls (100% Plantain flour & Cerolina) were evaluated for chemical, antioxidants and antihyperlipidemia.

Results

Protein, fiber and energy composition varied from 2.2–4.97 g/100 g, 16.44–19.59 g/100 g and 369.7–385.5 kcal/100 g, respectively. Essential amino acid index and predicted-biological values of the foods ranged from 68.31–76.31% and 62.19–71.48%, respectively. Phenolic profiles (mg/g) were gallic acid (25.33–31.26), caffeic acid (2.75–4.61), ferulic acid (5.16–12.73), luteolin (16.31–23.60), kaempferol (21.51–30.64), quercetin (24.28–37.13), chlorogenic acid (42.25–59.78), myricetin (28.41–38.41), 3,5-dicaffeoylquinic acid (27.17–41.59) and 4, 5-dicaffeoylquinic acid (39.96–51.28). The antioxidant activity of PSRO on ABTS, DPPH, FRAP, Fe2+ chelation and OH free radicals was higher than other foods. Atherogenic index, coronary risk index and log (TG/HDL-conc.) of rats fed on experimental foods were lower than recommended values.

Conclusion

The study established that PSRO had higher antioxidant and anti-hyperlipidemia properties; hence, it may be suitable as a functional food.

Hypertension prevalence and associated factors among patients with diabetes: A retrospective cross-sectional study from Jordan

Background

Hypertension (HTN) is a common comorbidity among diabetic patients. Studies reported that HTN prevalence in patients with diabetes mellitus (DM) depends on many risk factors related to the disease (the type and duration of DM), patients (age, sex, race/ethnicity, BMI), and medical history (glycemic control, renal problems). Best to our knowledge, limited evidence is available in this regard among Jordanian population.

Objectives

This retrospective cross-sectional study aimed to determine the prevalence of HTN among patients with DM in Jordan and factors that might be associated with the concurrence of both diseases.

Materials and methods

A cross-sectional study was conducted to determine HTN prevalence and risk factors among diabetic outpatients in Jordan. Patients were asked about their sociodemographic information and medical history. A descriptive analysis was used to determine HTN prevalence and a fit bivariate logistic regression model was used to identify the significant risk factors of HTN in patients with type 2 DM (T2DM).

Results

HTN was found to be concurrently occurring in approximately 80% of T2DM patients. This was found to increase with age. In addition, dyslipidemia, gout disease, ischemic heart disease, renal impairment, or a family history of HTN were found to be associated with the concurrence of HTN among T2DM patients.

Conclusion

Findings from this study highlight the need for proper monitoring of DM patients to reduce the co-occurrence of HTN. Specific attention should be directed to control the patients' glycemic and lipid profiles as well as the cardiac and renal health using non-pharmacological and pharmacological measures. This is of particular importance in T2DM patients at old age and with family history of HTN, to reduce patients’ deterioration. Results from this study will also be informative for the development of public health strategies to increase the awareness of the general population regarding T2DM and HTN since both diseases are very common among Jordanian population.

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Hypertension is concurrently occurring in around 80 % of Jordanian diabetics.

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The risk of having hypertension in diabetics increases with patient age, family history of hypertension, and dyslipidemia.

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Gout disease, ischemic heart disease, and renal impairment increase the risk of hypertension in diabetics.

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Public health strategies are needed to increase the awareness of general population regarding diabetes and hypertension.

Lipospheres for Simultaneous Controlled Release and Improved Pharmacokinetic Profiles of Saxagliptin-Enalapril: Formulation, Optimization, and Comparative In Vitro-In Vivo Evaluation

The current study aims at formulating and optimizing lipospheres (LS) by the Box-Behnken design (BBD) from safe biodegradable carnauba wax (CW) to co-administer saxagliptin (SG) and enalapril (EP) for co-existing chronic hypertensive diabetes in order to overcome inadequacies of conventional modes of drug administration. Optimized liposphere formulation (OLF) was selected by a numerical optimization procedure and a comparative in vivo pharmacokinetic study of OLF and commercial brands was also performed. Discrete, free-flowing, spherical, smooth-surface LS having a size range of 5-10 μm and zeta potential of - 20 to - 30 mV were successfully formulated. Compatibility studies by FTIR and DSC proved the lack of interaction of components while XRD suggested the transformation of crystalline drugs to amorphous form. Outcomes of dependent optimizing variables like percentage yield (30-90%), EP-release (32-92%), and SG-release (28-95%) followed a polynomial quadratic model. Pharmacokinetics studies indicated a significantly lower C_max of EP (125.22 ± 6.32) and SG (75.63 ± 3.85) and higher mean T_max values (9.4 h for EP and 10.73 h for SG) from OLF in comparison with reference brands of EP (257.54 ± 8.23 ng/mL) and SG (393.66 ± 2.97 ng/mL). Additionally, a potential rise in half-life and MRT of SG and EP was achieved reaching approximately 2- to 3-fold higher than noted for reference brands. Importantly, the enhanced T_max and AUC_0-24 specified the achievement of enhanced bioavailability of both drugs from LS. Consequently, such an innovative approach could not only control drug release in both in vitro and in vivo analyses but also maintain plasma drug concentration for a longer time without maximizing C_max leading towards effective management of chronic illnesses.

Prevalence and Awareness of Stroke and Other Comorbidities Associated with Diabetes in Northwest India

Objectives  The main purpose of this study is to investigate the prevalence of comorbid conditions in diabetic, prediabetic, and nondiabetic individuals. Additionally, the current study examines the levels of awareness of those comorbidities among North Indian population.

Methods  As a part of a national study (Niyantrit Madhumeh Bharat [NMB] screening program), different comorbidity parameters were screened in the northern part of India between April and September 2017. There were 1,215 participants recruited in this study. Biochemical analyses of hemoglobin A1c (HbA1c) were conducted on the study subjects. Subsequently, the study subjects were divided into diabetic, prediabetic, and nondiabetic groups based on their HbA1c results.

Results  The study analysis reveals a higher prevalence of peripheral vascular disease (21.2%), ocular diseases (18%), and hypertension (13.4%) in diabetics with other comorbidities. Furthermore, the study found that a vast majority of the participants were unaware of the presence of hypertension (67.2%), dyslipidemia (84.5%), kidney disease (95.2%), peripheral vascular disease (34.5%), and stroke (95.1%).

Conclusion  The study concluded that in the northern India, the prevalence of multiple comorbid conditions, such as peripheral vascular disease and hypertension, is higher among diabetic population. Also, the level of awareness of diabetic comorbidities is surprisingly low, which has implications for policymakers, health practitioners, and educators of alternate medicine to increase awareness about diabetes, comorbid conditions, health risk, and possible solution at community and rural level, such as periodic screening programs in this population.

Abnormal Glucose Metabolism and Associated Risk Factors Among Adults in Mekelle City, Ethiopia

BACKGROUND

In the past decade, the prevalence of diabetes has grown more rapidly in low- and middle-income countries than in high-income countries. In 2019, Ethiopia is the fourth highest contributor to cases with diabetes in Africa with 1.7 million total cases. The present study was aimed to determine the prevalence of abnormal glucose metabolism and associated factors in Mekelle city, Northern Ethiopia.

METHODS AND MATERIALS

Community-based cross-sectional study was conducted among 321 randomly selected participants aged 20 years and above. Sociodemographic, lifestyle, clinical, and anthropometric data were collected in accordance with the STEPwise approach as recommended by the World Health Organization (WHO) for non-communicable disease (NCDs) surveillance. Blood glucose and lipid profiles were determined using a fasting venous blood sample. Bivariate and multivariable logistic regression analysis was used to identify factors associated with abnormal glucose metabolism. The level of statistical significance was set at p ≤0.05.

RESULTS

More than half (54.8%) of the participants were women with an overall mean (±SD) age of 39.0 (±14.2) years. The overall prevalence of pre-diabetes and diabetes was 12.5% and 9.3%, respectively, with a mean (±SD) fasting blood glucose of 97.42 (±38.03) mg/dL. More than two-thirds (70.0%) of adults with diabetes were not aware of being diabetes. Advanced age, hypercholesterolemia, medium and high rank of heart rate, and raised waist to height ratio were significantly associated with a higher risk of pre-diabetes, whereas having house servant, systolic hypertension, and hypercholesterolemia were significantly associated with diabetes.

CONCLUSION

We found a high prevalence of prediabetes and diabetes with more than two-thirds (70.0%) of newly diagnosed adults with diabetes, which showed a lack of awareness in the community. Awareness creation together with access to basic diagnostics in the primary health-care settings should therefore be a top priority to prevent its progression and complication.

Association between hypertensive disorders of pregnancy and the risk of postpartum hypertension: a cohort study in women with gestational diabetes

Previous studies in general people indicated that hypertensive disorders of pregnancy (HDP) increased the risk of subsequent hypertension after delivery. Some studies found that women with gestational diabetes mellitus (GDM) had an increased risk of HDP. However, very few studies have assessed the association between HDP and the risk of postpartum hypertension among GDM women. To evaluate the association between HDP and the risk of postpartum hypertension among GDM women, a retrospective cohort study was conducted in 1261 women with prior GDM at their postpartum 1–5 years using the baseline data from Tianjin Gestational Diabetes Mellitus Prevention Program. Cox regression models were applied to assess the single and joint associations of having a history of HDP, maternal pre-pregnancy Body mass index (BMI) (normal weight, overweight and obesity), and weight change from preconception to post-delivery with the risk of subsequent hypertension among the GDM women. We found that GDM women with a history of HDP, high pre-pregnancy BMI and weight gain more than 7 kg from preconception to post-delivery had an increased risk of postpartum hypertension. Joint effects analysis revealed that the positive association between a history of HDP in the index pregnancy and the risk of postpartum hypertension was consistent in GDM women with different levels of pre-pregnancy BMI or weight gain from preconception to post-delivery. In conclusion, a history of HDP, high pre-pregnancy BMI and weight gain more than 7 kg from preconception to post-delivery increase the risk of subsequent hypertension in postpartum 1–5 years among GDM women.

Double product break point estimates ventilatory threshold in individuals with type 2 diabetes

[Purpose] To verify the identification of the anaerobic threshold through the double product breakpoint (DPBP) method for individuals with type 2 diabetes. [Subjects and Methods] Nine individuals with T2D (7 females; age=63.2 ± 8.9 y) and 10 non-diabetic (ND) (7 females; age=58.3 ± 7.8 y) performed an incremental exercise test on a cycle ergometer. Heart rate (HR), blood pressure (BP) and expired gas were measured at the end of each stage. The ventilatory threshold (VT) and DPBP were considered as the exercise intensities above which an over proportional increases in VE and DP were observed in relation to increasing workload. [Results] No differences were observed between the workloads, HR and VO2 corresponding to the AT identified respectively by VT and DPBP. For the T2D, strong correlations between VT and DBPB workloads (r=0.853), HR (r=0.714), and VO2 (r=0.863) were found. These relationships were similar to those found for the control group (r=0.923; r=0.881; and r=0.863, respectively). [Conclusion] These results demonstrate that the DPBP enables for the prediction of AT and correlated well the VT in both the T2D and ND participants.

Comparison of carotid and cerebrovascular stenosis between diabetic and nondiabetic patients using digital subtraction angiography

BACKGROUND

The aim of our study was to evaluate the differences of prevalence and manifestation of extracranial and intracranial artery stenosis between patients with and without type 2 diabetes using digital subtraction angiography.

METHODS

A retrospective study was conducted by analyzing clinical and lifestyle data collected from 1137 patients enrolled in the Nanjing Stroke Registry Program between June 2004 and March 2011. Vascular risk factors were analyzed, and carotid and cerebrovascular artery stenoses were measured in 383 patients with type 2 diabetes mellitus and 754 nondiabetic patients by digital subtraction angiography.

RESULTS

In all, 1069 stenoses were found among 383 diabetic patients and 1990 among 754 nondiabetic patients. No statistical differences were observed for the distribution of stenosis in intracranial-extracranial vessels between diabetic and nondiabetic patients (P=.210). There was no difference in the distribution of stenosis in the anterior and posterior circulation vessels between these 2 groups (P=.628). Among diabetic patients with stenosis, a single stenosis was found in 116 (30.29%) and multiple stenoses were found in 267 (69.71%). In their nondiabetic counterparts, a single stenosis was found in 249 (33.02%) and multiple stenoses were found in 505 (66.98%). Compared with nondiabetic patients, the diabetic patients have a tendency of a higher incidence of multiple stenosis. Nonobstructive stenosis occurs more often in diabetic than in nondiabetic patients (P=.002).

CONCLUSIONS

This retrospective study suggests that diabetes be associated with higher incidence of nonobstructive stenosis and that there be no significant difference observed in the extent and distribution of the extra- and intracranial artery stenoses between diabetic and nondiabetic patients.

Blood pressure control among hypertensive patients with and without diabetes mellitus in six public primary care clinics in Malaysia

Hypertension is a common comorbidity among diabetic patients. This study aimed to determine blood pressure (BP) control among hypertensive patients with and without diabetes. This was a cross-sectional study in 6 public primary care clinics in Wilayah Persekutuan, Malaysia. Hypertensive patients aged ≥18 years and attending the clinics were selected via systematic random sampling. The BP control target was defined as <130/80 mm Hg for diabetic patients and <140/90 mm Hg for nondiabetic patients. A total of 1107 hypertensive patients participated in this study and 540 (48.7%) had diabetes. About one fourth (24.3%) of the hypertensive patients with diabetes achieved BP control target, compared with 60.1% patients without diabetes (P < .001). Being diabetic and on ≥2 antihypertensive treatments were associated with poor BP control. Attention needs to be given to these groups of patients when managing patients with hypertension.

Hypertension strengthens δ-ALA-D activity inhibition and increases it reactivation index in type 2 diabetic patients

AIMS

To assess the effect of hypertension on δ-aminolevulinate dehydratase (δ-ALA-D) activity of type 2 diabetic patients (T2DM).

METHODS

δ-ALA-D activity and reactivation index, as well as markers of oxidative stress, biochemical and anthropometrics parameters were determined in T2DM (n=23), type 2 diabetic patients with hypertension (T2DM/HT) (n=30) and controls (n=30).

RESULTS

T2DM/HT presented a greater inhibition of δ-ALA-D activity, a higher reactivation index (p<0.05) and a greater depletion of plasma protein thiol groups (P-SH) when compared to T2DM. Moreover, δ-ALA-D activity was positively associated with SH groups and negatively associated with serum protein carbonyl (PC) while its reactivation index was negatively associated with SH groups and positively associated with PC.

CONCLUSIONS

These results point out that there is a possible interference of hypertension on the mechanism of the δ-ALA-D activity suggesting that this condition aggravated the oxidative stress of diabetes mellitus.

Efficacy and safety of combination therapy with candesartan cilexetil and pioglitazone hydrochloride in patients with hypertension and type 2 diabetes mellitus

OBJECTIVE

To evaluate the efficacy and safety of combination therapy with candesartan cilexetil (CC) and pioglitazone hydrochloride (PIO) in patients with hypertension and type 2 diabetes mellitus.

METHODS

A 12-week, double-blind, randomized, parallel-group study in patients with mild-to-moderate essential hypertension and type 2 diabetes mellitus was followed by a 40-week, single-blind study. Patients (N = 377) were randomized to treatment with CC 8 mg/PIO 30 mg (n = 62), CC 8 mg/PIO 15 mg (n = 63), CC 4 mg/PIO 30 mg (n = 63), CC 4 mg/PIO 15 mg (n = 63), CC 8 mg/PIO 0 mg (n = 63), or CC 0 mg/PIO 30 mg (n = 63). Primary efficacy measures were changes in diastolic blood pressure (DBP) and HbA(1C) at Week 12.

RESULTS

CC/PIO combination therapy improved blood pressure (BP)/glycemic control for 52 weeks. At the end of 12-week treatment period, DBP decreased to a significantly greater extent in the 8/30 + 8/15 + 8/0 (combined CC 8 mg) group (-10.5 mmHg, p < 0.0001) and the 4/30 + 4/15 (combined CC 4 mg) group (-9.1 mmHg, p = 0.0022) than in the 0/30 (CC 0 mg) group (-5.3 mmHg). HbA(1C) significantly decreased in the 8/30 + 4/30 + 0/30 (combined PIO 30 mg) group (-0.35%, p < 0.0001) and the 8/15 + 4/15 (combined PIO 15 mg) group (-0.15%, p < 0.0001) compared with the 8/0 (PIO 0 mg) group (0.35%). Urinary albumin excretion reduction seen with the 0/30 and the 8/0 groups was significantly enhanced by CC/PIO combination. Clinical significance of this renoprotective effect of CC/PIO combination therapy needs to be studied further. Prolonged combined use of CC/PIO did not increase adverse events. Drug-related adverse events were similar to those during clinical use of CC and PIO.

CONCLUSION

CC/PIO combination therapy improved BP/glycemic control and was well tolerated for 52 weeks. Thus, CC/PIO combination therapy is useful in patients with hypertension and type 2 diabetes mellitus.

Validation of the Comprehensive ICF Core Sets for Diabetes Mellitus: A Malaysian Perspective

Introduction: Diabetes mellitus (DM) is a chronic disease that is prevalent in many countries. The prevalence of DM is on the rise, and its complications pose a heavy burden on the healthcare systems and on the patients’ quality of life worldwide. Materials and Methods: This is a multicentre, cross-sectional study involving 5 Health Clinics conducted by Family Medicine Specialists in Malaysia. Convenience sampling of 100 respondents with DM were selected. The International Classification of Functioning, Disability and Health (ICF) based measures were collected using the Comprehensive Core Set for DM. SF-36 and self-administered forms and comorbidity questionnaire (SCQ) were also used. Results: Ninety-seven percent had Type 2 DM and 3% had Type 1 DM. The mean period of having DM was 6 years. Body functions related to physical health including exercise tolerance (b455), general physical endurance (b4550), aerobic capacity (b4551) and fatiguability (b4552) were the most affected. For body structures, the structure of pancreas (s550) was the most affected. In the ICF component of activities and participation, limitation in sports (d9201) was the highest most affected followed by driving (d475), intimate relationships (d770), handling stress and other psychological demands (d240) and moving around (d455). Only 7% (e355 and e450) in the environmental category were documented as being a relevant factor by more than 90% of the patients. Conclusion: The content validity of the comprehensive ICF Core set DM for Malaysian population were identified and the results show that physical and mental functioning were impaired in contrast to what the respondents perceived as leading healthy lifestyles. Key words: Disability, Functioning, Health, Linear Models

O-GlcNAcylation: a novel pathway contributing to the effects of endothelin in the vasculature

Glycosylation with O-linked β-N-acetylglucosamine (O-GlcNAc) or O-GlcNAcylation on serine and threonine residues of nuclear and cytoplasmic proteins is a posttranslational modification that alters the function of numerous proteins important in vascular function, including kinases, phosphatases, transcription factors, and cytoskeletal proteins. O-GlcNAcylation is an innovative way to think about vascular signaling events both in physiological conditions and in disease states. This posttranslational modification interferes with vascular processes, mainly vascular reactivity, in conditions where endothelin-1 (ET-1) levels are augmented (e.g. salt-sensitive hypertension, ischemia/reperfusion, and stroke). ET-1 plays a crucial role in the vascular function of most organ systems, both in physiological and pathophysiological conditions. Recognition of ET-1 by the ET(A) and ET(B) receptors activates intracellular signaling pathways and cascades that result in rapid and long-term alterations in vascular activity and function. Components of these ET-1-activated signaling pathways (e.g., mitogen-activated protein kinases, protein kinase C, RhoA/Rho kinase) are also targets for O-GlcNAcylation. Recent experimental evidence suggests that ET-1 directly activates O-GlcNAcylation, and this posttranslational modification mediates important vascular effects of the peptide. This review focuses on ET-1-activated signaling pathways that can be modified by O-GlcNAcylation. A brief description of the O-GlcNAcylation biology is presented, and its role on vascular function is addressed. ET-1-induced O-GlcNAcylation and its implications for vascular function are then discussed. Finally, the interplay between O-GlcNAcylation and O-phosphorylation is addressed.

Hypotheses, rationale, design, and methods for prognostic evaluation in type 2 diabetic patients with angiographically normal coronary arteries. The MASS IV-DM Trial

Background

The MASS IV-DM Trial is a large project from a single institution, the Heart Institute (InCor), University of São Paulo Medical School, Brazil to study ventricular function and coronary arteries in patients with type 2 diabetes mellitus.

Methods/Design

The study will enroll 600 patients with type 2 diabetes who have angiographically normal ventricular function and coronary arteries. The goal of the MASS IV-DM Trial is to achieve a long-term evaluation of the development of coronary atherosclerosis by using angiograms and coronary-artery calcium scan by electron-beam computed tomography at baseline and after 5 years of follow-up. In addition, the incidence of major cardiovascular events, the dysfunction of various organs involved in this disease, particularly microalbuminuria and renal function, will be analyzed through clinical evaluation. In addition, an effort will be made to investigate in depth the presence of major cardiovascular risk factors, especially the biochemical profile, metabolic syndrome inflammatory activity, oxidative stress, endothelial function, prothrombotic factors, and profibrinolytic and platelet activity. An evaluation will be made of the polymorphism as a determinant of disease and its possible role in the genesis of micro- and macrovascular damage.

Discussion

The MASS IV-DM trial is designed to include diabetic patients with clinically suspected myocardial ischemia in whom conventional angiography shows angiographically normal coronary arteries. The result of extensive investigation including angiographic follow-up by several methods, vascular reactivity, pro-thrombotic mechanisms, genetic and biochemical studies may facilitate the understanding of so-called micro- and macrovascular disease of DM.

Vascular oxidative stress: the common link in hypertensive and diabetic vascular disease

Vascular disease in hypertension and diabetes is associated with increased oxidants. The oxidants arise from NADPH oxidase, xanthine oxidase, and mitochondria. Superoxide anion and hydrogen peroxide are produced by both leukocytes and vascular cells. Nitric oxide is produced in excess by inducible nitric oxide synthase, and the potent oxidant, peroxynitrite, is formed from superoxide and nitric oxide. The damage to proteins caused by oxidants is selective, affecting specific oxidant-sensitive amino acid residues. With some important vascular proteins, for example, endothelial nitric oxide synthase, prostacycline synthase, and superoxide dismutase, oxidation of a single susceptible amino acid inactivates the enzyme. The beneficial effects of antioxidants, at least in animal models of hypertension and diabetes, can in part be ascribed to protection of these and other proteins. Mutant proteins lacking their reactive constituent can recapitulate some disease phenotypes suggesting a pathogenic role of the oxidation. Thus, many of the shared functional abnormalities of hypertensive and diabetic blood vessels may be caused by oxidants. Although studies using antioxidants have failed in patients, the successful treatment of vascular disease with HMG-CoA reductase inhibitors, thromboxane A2 antagonists, and polyphenols may depend on their anti-inflammatory effects and ability to decrease production of damaging oxidants.

Endothelial dysfunction in diabetes mellitus

Diabetes mellitus is associated with an increased risk of cardiovascular disease, even in the presence of intensive glycemic control. Substantial clinical and experimental evidence suggest that both diabetes and insulin resistance cause a combination of endothelial dysfunctions, which may diminish the anti-atherogenic role of the vascular endothelium. Both insulin resistance and endothelial dysfunction appear to precede the development of overt hyperglycemia in patients with type 2 diabetes. Therefore, in patients with diabetes or insulin resistance, endothelial dysfunction may be a critical early target for preventing atherosclerosis and cardiovascular disease. Microalbuminuria is now considered to be an atherosclerotic risk factor and predicts future cardiovascular disease risk in diabetic patients, in elderly patients, as well as in the general population. It has been implicated as an independent risk factor for cardiovascular disease and premature cardiovascular mortality for patients with type 1 and type 2 diabetes mellitus, as well as for patients with essential hypertension. A complete biochemical understanding of the mechanisms by which hyperglycemia causes vascular functional and structural changes associated with the diabetic milieu still eludes us. In recent years, the numerous biochemical and metabolic pathways postulated to have a causal role in the pathogenesis of diabetic vascular disease have been distilled into several unifying hypotheses. The role of chronic hyperglycemia in the development of diabetic microvascular complications and in neuropathy has been clearly established. However, the biochemical or cellular links between elevated blood glucose levels, and the vascular lesions remain incompletely understood. A number of trials have demonstrated that statins therapy as well as angiotensin converting enzyme inhibitors is associated with improvements in endothelial function in diabetes. Although antioxidants provide short-term improvement of endothelial function in humans, all studies of the effectiveness of preventive antioxidant therapy have been disappointing. Control of hyperglycemia thus remains the best way to improve endothelial function and to prevent atherosclerosis and other cardiovascular complications of diabetes. In the present review we provide the up to date details on this subject.

Vascular inflammation in hypertension and diabetes: molecular mechanisms and therapeutic interventions

More than 80% of patients with type 2 diabetes mellitus develop hypertension, and approx. 20% of patients with hypertension develop diabetes. This combination of cardiovascular risk factors will account for a large proportion of cardiovascular morbidity and mortality. Lowering elevated blood pressure in diabetic hypertensive individuals decreases cardiovascular events. In patients with hypertension and diabetes, the pathophysiology of cardiovascular disease is multifactorial, but recent evidence points toward the presence of an important component dependent on a low-grade inflammatory process. Angiotensin II may be to a large degree responsible for triggering vascular inflammation by inducing oxidative stress, resulting in up-regulation of pro-inflammatory transcription factors such as NF-kappaB (nuclear factor kappaB). These, in turn, regulate the generation of inflammatory mediators that lead to endothelial dysfunction and vascular injury. Inflammatory markers (e.g. C-reactive protein, chemokines and adhesion molecules) are increased in patients with hypertension and metabolic disorders, and predict the development of cardiovascular disease. Lifestyle modification and pharmacological approaches (such as drugs that target the renin-angiotensin system) may reduce blood pressure and inflammation in patients with hypertension and metabolic disorders, which will reduce cardiovascular risk, development of diabetes and cardiovascular morbidity and mortality.

Role of AT1 receptors in permeability of the blood–brain barrier in diabetic hypertensive rats

The precise mechanisms of vascular diseases in patients with diabetic hypertensive are not clearly understood. There are evidences of alteration in permeability of blood-brain barrier (BBB) in diabetic hypertensive rats. This study sought to examine the effect of candesartan on the systolic blood pressure and the brain endothelial barrier function and antioxidant enzymes in rat brain. Five groups of eight male Sprague-Dawley rats include: control group (gpI), diabetic hypertensive group (gpII), diabetic hypertensive group treated with candesartan (gpIII), diabetic hypertensive rats with epinephrine (gpIV) and diabetic hypertensive rats with epinephrine treated with candesartan (gpV). Diabetes was induced by single injection of 55 mg kg(-1) streptozotocin (STZ) i.p. Blood glucose was measured, rats with blood glucose higher than 300 mg/dl were identified as diabetic. After induction of diabetes, rats received L-NAME (0.5 mg/ml in drinking water for 1 week) starting on the day 4 after STZ injection. Systolic blood pressure (SBP) was recorded two times, at day 0 (before starting L-NAME) and at day 7 (after L-NAME treatment). Also, body weight was measured two times, at initial time (before STZ injection) and terminal (at the last day in the experiment). On the day of acute experiment, rats were anesthetized with sodium pentobarbital (35 mg/kg, i.p.). The integrity of the BBB was investigated using Evans blue (EB) dye (4 ml/kg, 2%). Epinephrine was used (40 micro g/kg) to increase the permeability of the brain. After decapitation, first the brain was removed, next homogenized and then the content of EB dye in the brain was measured. Another five groups of rats manipulated with the same manner except EB dye injection. These second group to evaluate antioxidant enzymes, reduced glutathione (GSH), lipid peroxides and superoxide dismutase (SOD) in brain homogenate. This study indicates that, in diabetic hypertensive rats, epinephrine administration leads to increase in microvascular-EB-albumin efflux to brain. However, candesartan treatment significantly attenuates this permeability to brain tissue and significantly increased GSH and SOD activity, while level of lipid peroxides was decreased significantly. The finding supports that the use of candesartan may offer a good alternative in the treatment of diabetic hypertensive subjects because it has an action that might be mediated through an antioxidant effect and beneficial effects on vascular endothelial permeability as well.

Treating dyslipidaemia in the setting of diabetes mellitus and cardiovascular disease: a less commonly perceived therapeutic perspective in clinical practice

Diabetes mellitus and cardiovascular disease are being managed more belligerently in recent times, with multifactorial cardiovascular risk reduction being the focus of therapeutic interventions. We review some of the caveats to be exercised in the treatment of these patients that are pertinent to clinicians in daily clinical practice.

Risk factors for encephalitis and death from West Nile virus infection

We conducted a nested case-control study to determine potential risk factors for developing encephalitis from West Nile virus (WNV) infection. Retrospective medical chart reviews were completed for 172 confirmed WNV cases hospitalized in Houston between 2002 and 2004. Of these cases, 113 had encephalitis, including 17 deaths, 47 had meningitis, and 12 were fever cases; 67% were male. Homeless patients were more likely to be hospitalized from WNV compared to the general population. A multiple logistic regression model identified age [odds ratio (OR) 1.1, P<0.001], history of hypertension, including those cases taking hypertension-inducing drugs (OR 2.9, P=0.012), and history of cardiovascular disease (OR 3.5, P=0.061) as independent risk factors for developing encephalitis from WNV infection. After adjusting for age, race/ethnicity (being black) (OR 12.0, P<0.001), chronic renal disease (OR 10.6, P<0.001), hepatitis C virus (OR 23.1, P=0.0013), and immunosuppression (OR 3.9, P=0.033) were identified as risk factors for death from WNV infection.

West Nile virus: where are we now?

Since the publication of a comprehensive review on West Nile virus (WNV) in 2002, there has been substantial progress in understanding of transmission, epidemiology, and geographic distribution of the virus and manifestations of disease produced by the infection. There have also been advances in development of diagnostic and therapeutic agents and vaccines. Nevertheless, many questions about the epidemic remain unanswered, and several new issues have arisen--for example: whether the epidemic will increase as the virus spreads to the Pacific coast of North America; whether arthropods other than mosquitoes will act as vectors for the infection; whether WNV will spread to South America and cause an epidemic there; whether the distribution of WNV in Asia and Europe will increase; and whether adaptation of WNV to new ecosystems will produce viruses with altered genetic and phenotypic properties. This review aims to provide an update on knowledge of WNV biology that can be used to highlight the advances in the field during the past 2 years and help to define the questions that academic, industrial, and public-health communities must address in development of measures to control WNV disease.

Role of angiotensin II AT1 receptor blockers in the treatment of arterial hypertension

Hypertension is a very common condition and the most important risk factor for the occurrence of cardiovascular events. The hyperactivity of the renin-angiotensin-aldosterone system is considered a cardiovascular risk factor in subjects with essential hypertension. The intrinsic vascular abnormality in which the renin-angiotensin-aldosterone system is clearly the milieu for the development of the pathologic changes in blood vessel walls is one of the causes of the establishment of hypertension. Many drugs with different mechanisms of action have been used for the treatment of hypertension and its vascular complications. Nevertheless, the utilities of many drugs are limited by their adverse effects. Continuous research in the search for new pharmacological agents for the treatment of hypertension has led to the development of angiotensin II receptor type AT1 blockers. The most important functions mediated by AT1 receptors include: vasoconstriction, induction of the production and release of aldosterone, renal reabsorption of sodium, cardiac cellular growth, proliferation of vascular smooth muscle, increase of peripheral noradrenergic action and the central activity of the sympathetic nervous system, stimulation of vasopressin release, and inhibition of renin release from the kidney. The angiotensin II receptor type AT1 blockers inhibit the interaction of angiotensin II with its AT1 receptor. These agents lower blood pressure without producing cough as a side effect since, unlike the angiotensin-converting enzyme inhibitors they do not influence the levels of bradykinin or substance P. Hence, these drugs are suitable for the treatment of hypertensive patients who require therapy with a drug blocking the effect of angiotensin-converting enzyme but cannot use angiotensin-converting enzyme inhibitors due to cough as a side effect.

Effect of losartan on the blood–brain barrier permeability in diabetic hypertensive rats

Our previous publication has stressed the benefits of losartan, an angiotensin II receptor blocker, on the permeability of blood-brain barrier (BBB) and blood pressure during L-NAME-induced hypertension. This study reports the impacts of anti-hypertensive treatment by losartan on the brain endothelial barrier function and the arterial blood pressure, during acute hypertension episode, in experimentally diabetic hypertensive rats. Systolic blood pressure measurements were taken with tail cuff method before and during administration of L-NAME (0.5 mg/ml). We induced diabetes by using alloxan (50 mg/kg, i.p). Losartan (3 mg/kg, i.v) was given to rats following the L-NAME treatment. Acute hypertensive vascular injury was induced by epinephrine (40 microg/kg). The BBB disruption was quantified according to the extravasation of the Evans blue (EB) dye. L-NAME induced a significant increase in arterial blood pressure on day 14 in normoglycemic and hyperglycemic rats (p < 0.05). Losartan significantly reduced the increased blood pressure in hypertensive and diabetic hypertensive rats (p < 0.01). Epinephrine-induced acute hypertension in diabetic hypertensive rats increased the content of EB dye dramatically in cerebellum and diencephalon (p < 0.01) and slightly in both cerebral cortex (p < 0.05). Losartan treatment reduced the increased BBB permeability to EB dye in the brain regions of diabetic hypertensive rats treated with epinephrine (p < 0.05). This study indicates that, in diabetic hypertensive rats, epinephrine administration leads to an increase in microvascular-EB-albumin efflux to brain, however losartan treatment significantly attenuates this protein's transport to brain tissue.