Impact of Anaemia on HbA1c Interpretation Among Normogylcaemic Individuals With Diabetes Mellitus: A Clinical Laboratory Observational Study

BACKGROUND AND AIM

Over the past decades, glycosylated haemoglobin (HbA1c) has been a gold standard for monitoring diabetes control over a long period, relative to blood glucose level (BGL) which measures short-term results. It is speculated that anaemia and factors that induce haemolysis may cause falsely elevated HbA1c leading to 'false positive' interpretations. This study aimed to investigate how anaemia impacts HbA1c.

METHODS

This was a pathology-based observational pilot study using archived data of diabetic subjects monitored with both BGL and HbA1c in regional New South Wales (NSW), Australia. A total of 28,487 cases of blood glucose results were pooled and those with HbA1c and anaemia results were evaluated for correlation with the BGL results. Data collection was limited to de-identified information from the laboratory information system, hence details on the ethnicity and medical history were unavailable. Descriptive frequencies and Pearson correlations were performed.

RESULTS

In the pooled data, 53.36% of individuals were females, and 50.54% had BGL ≥5.6 mmol/L. In the pilot dataset, the majority (64.86%) were males, 18.92% with BGL ≤5.6 mmol/L and 67.57% had HbA1c (≥6.5%). In the entire dataset, BGL was moderately and positively correlated with HbA1c (r = 0.6), whereas in the subset of individuals with normo-BGL and anaemia, the correlation was negative (r = -0.2).

DISCUSSION

This pilot investigation observed a pertinent issue, which is a negative correlation between glycaemia and HbA1c in patients with anaemia. HbA1c was falsely increased despite normal blood glucose levels in individuals with anaemia. This advances the speculation that anaemia falsely increases HbA1c. Therefore, caution is necessary while interpreting HbA1c results for patients with anaemia, and new methods for interpretation are required.

Barriers to management of diabetes foot ulcer: Experiential note from a setting with free medical services

The imperative need for behavioral agreement to overcome barriers of self-management of diabetes foot complication was recently articulated. A few journals have done parallel publications, which thereby stresses the significance of the issue. This article is to add to the "Overcoming barriers to self-management: the person-centred diabetes foot behavioural agreement". It presents experiential note with four tabulated cases of clients who have access to free state-of-the-art medical service; and non-adherence as a barrier to self-management is not due to affordances. It is to draw attention to the deliberately non-adherent patients where behavioral agreement process should be really driven by the client as in the real context of person-centered therapy.

Aeromedical retrievals for gastrointestinal disorders in rural and remote Australia: the need for improved access to specialist advice

The Royal Flying Doctor Service (RFDS) provides medical care to populations without access to traditional health-care services. From 2014 to 2018 the RFDS conducted 6007 (≈1201/year) aeromedical retrievals for gastrointestinal (GI) disorders. More detailed research is needed to determine specific GI disorders that contributed to this caseload, and in particular inform whether the establishment of a GI specialist service is justified.

Barriers in determining prevalence of type 2 diabetes mellitus among postpartum GDM: The research and retraining needs of healthcare professionals

AIM

A large percentage of gestational diabetes (GDM) are undiagnosed, and prevalence of postpartum type 2 diabetes (T2DM) is unknown, especially in developing countries. This study assessed barriers to GDM diagnosis and postpartum follow-up; to determine educational needs.

MATERIALS AND METHODS

This was a clinical observational study of records and procedures of antenatal services at two hospitals. Laboratory and medical records were reviewed for availability of data on anthropometrics, blood glucose, gestational age, urinalysis, and lipid profile for GDM register. Antenatal clinic protocol was observed for GDM diagnosis. BMI was derived and data were analyzed using SPSS version 20.

RESULTS

Critical barriers attributable to health systems included lack of screening for blood sugar as part of routine antenatal protocol, and lack of GDM registers at both facilities. There was 6.5% registration of pregnancies in first trimester, 22% pre-pregnancy obesity, and 2.6% high blood pressure. Positive glucosuria cases were not followed-up for GDM diagnosis.

CONCLUSIONS

There is neither concerted effort to diagnose GDM, nor systematic records of screening and postpartum follow-up. The gap in diabetology knowledge and practice calls for re-training of antenatal healthcare professionals. GDM screening checklist needs to be established and positive results entered into GDM registers for proper management during and after delivery.

Evaluation of ADL and BMI in the management of diabetes mellitus at secondary and tertiary health facilities

AIMS

Physical activities of daily living (ADL) constitutes one of diabetes management options. This study aimed to assess the extent that ADL and BMI are evaluated among diabetes patients in hospital practice.

METHOD

This was a clinical observational baseline study in two hospitals. Audit of medical files was performed to assess if BMI and occupations were recorded (N = 112). Afterwards, 'N = 38' who consented to participate in prospective study were conveniently sampled to assess ADL in relation to accessible metabolic syndrome tests. A validated questionnaire was used to collect data, which were analysed using SPSS version 20.

RESULTS

Audit shows 55/112 of clients' occupation were taken, of which 31% has BMI record. Those with lipid profile results are without blood pressure and vice versa. In the cross-sectional assessment, 74% are in physically demanding ADL occupations, but affirmed inactivity is 98% on leisure exercise. Further, 47% have BMI >25 kg/m² and were consistently less active on all leisure ADL relative to those with BMI <25 kg/m² (p < 0.02).

CONCLUSION

This report highlights oversight in clinical practice, whereby accessible metabolic syndrome parameters and occupation of clients living with diabetes are being assessed inconsistently. This implies an unmet need in the integration BMI and occupational information to improve diabetes self-management.

Diet and lifestyle habits: Association with cardiovascular disease indices in a Nigerian sub-population

BACKGROUND

There is inadequate evidence regarding the pattern of unhealthy lifestyle behaviours in Nigeria hence the aim of this study was to assess the pattern of lifestyle-related habits that predispose to risk of cardiovascular disease (CVD) indices in a Nigerian population.

METHODS

A population-based cross-sectional study was carried out on 422 apparently healthy males and females ≥18 years old. The World Health Organisation (WHO) STEPwise questionnaire was used to collect information on tobacco use or smoking habits, alcohol consumption and dietary habits. Logistic regression analysis was employed.

RESULTS

22.8% and 30.2% of participants indicated that someone smoked in their home and/or in closed areas at workplace, respectively, in the past 30 days. 225/422 admitted to taking alcohol including 72% within the past 12 months. 52.8% of the participants consumed <5 servings of fruits and/or vegetables each day. Results further showed that participants with <5 servings of fruits and/or vegetables (OR: 1.06, CI: 1.01-1.13, p = 0.028) and high level of alcohol consumption (OR: 1.85, CI: 1.18-2.88, p = 0.007) were more likely to have hypertension.

CONCLUSIONS

The relatively high prevalence of alcohol consumption and apparent unhealthy diet are of huge concern given the increasing prevalence of CVD indices in the population.

Prediabetes and cardiovascular complications study (PACCS): international collaboration 4 years' summary and future direction

Objective

The prediabetes and cardiovascular complications studies proposes to develop a screening protocol for diabetes cardiovascular risk, and strategies for holistic management amongst others. Over 500 participants were recruited in the first 2 years of rural community research screening. Specific for this report, various published findings were reviewed. The objective is to summarize research outcomes and itemize limitations as they constitute basis of future directions.

Results

Affordability and availability are major confounding behavioural change wheel factors in the rural community. 4.9% prevalence of prediabetes, which may be lower or non-significantly different in urban areas. Hyperglycaemia co-morbidity with dyslipidaemia (5.0%), obesity (3.1%) and hypertension (1.8%) were observed. Limitation of the study includes participants being mostly over 60 years old, which has created impetus for the Global Alliance on Chronic Diseases agenda on vulnerability of older adults to diabetes being a new direction of the collaboration. Other directions in Australia and Nepal focus on patients with chronic kidney disease with or without cardiovascular complications. This report highlights the need to translational research.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-3017-7) contains supplementary material, which is available to authorized users.

Outpatient cardiac rehabilitation: Effects on patient improvement outcomes

OBJECTIVE

To determine if the Cardiac rehabilitation (CR) program had positive effects on the patient medically as well as effects on pathological risk factors, functional capacity, and mental health; and the extent to which targets for blood pressure (BP) control in patients with hypertension (HT) and diabetes mellitus (DM) are achieved.

METHODOLOGY

CR participant data was collected from 1st June 2014 until 31st December 2015 (19 months), which included: demographics, medical history, social history, medications, lipid profiles and anthropometric measurements. Additional data was collected on The Patient Health Questionnaire (PHQ-9) factors, and on the participants 6min walk test (6MWT). Study participants were eligible to participate in the study if they attended 10 or more CR program sessions out of 12 at the Calvary Public Hospital Canberra.

RESULTS

Seventy nine (79) participants participated in the study. Significant reductions in BP (n=79) (p=<0.05), blood LDL cholesterol levels (n=26) (p=<0.05), and improvements in participants PHQ-9 scores (n=79) (p=<0.001), and their 6MWT (n=78) (p=<0.001) were noted. Participants were also able to better manage their medication (p=<0.05). Importantly, results indicated that significant improvements (p=<0.05) were made in DM patients (n=18) diastolic BP, physical ability and depression and anxiety.

CONCLUSION

A CR program can reduce risk factors associated with CVD, and improves mental health and physical fitness of participants.

RESULTS

Indicated that the CR program reduces DM patient risk factors through improved physical fitness and reductions in depression and anxiety, leading to reduced risk of future cardiovascular and renal disease.

Cardiovascular disease risk factors in a Nigerian population with impaired fasting blood glucose level and diabetes mellitus

Background

Diabetes is a risk factor for cardiovascular diseases (CVDs) and there are reports of increasing prevalence of prediabetes in Nigeria. This study therefore characterised CVDs risk factors in subjects with impaired fasting glucose (IFG) and diabetes.

Methods

Data from 4 population-based cross-sectional studies on 2447 apparently healthy individuals from 18 - 89 years were analysed. Anthropometric, blood pressure and biochemical parameters were collected and classified. Individuals with IFG (prediabetes) and diabetes were merged each for positive cases of dyslipidaemia, high blood pressure (HBP) or obesity. Optimal Discriminant and Hierarchical Optimal Classification Tree Analysis (HO-CTA) were employed.

Results

Overall prevalence of IFG and diabetes were 5.8% (CI: 4.9 – 6.7%) and 3.1% (CI: 2.4 – 3.8%), respectively. IFG co-morbidity with dyslipidaemia (5.0%; CI: 4.1 – 5.8%) was the highest followed by overweight/obese (3.1%; CI: 2.5 – 3.8%) and HBP (1.8%; CI: 1.3 – 2.4%). The predicted age of IFG or diabetes and their co-morbidity with other CVD risk factors were between 40 – 45 years. Elevated blood level of total cholesterol was the most predictive co-morbid risk factor among IFG and diabetes subjects. Hypertriglyceridaemia was an important risk factor among IFG-normocholesterolaemic-overweight/obese individuals.

Conclusion

The higher prevalence of co-morbidity of CVD risk factors with IFG than in diabetes plus the similar age of co-morbidity between IFG and diabetes highlights the need for risk assessment models for prediabetes and education of individuals at risk about factors that mitigate development of diabetes and CVDs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3910-3) contains supplementary material, which is available to authorized users.

Maximum accuracy obesity indices for screening metabolic syndrome in Nigeria: A consolidated analysis of four cross-sectional studies

BACKGROUND

In sub-Saharan Africa, there is no precise use of metabolic syndrome (MetS) definitions and risk factors screening indices in many clinical and public health services. Methods proposed and used in Western populations are adopted without validation within the local settings. The aim of the study is to assess obesity indices and cut-off values that maximise screening of MetS and risk factors in the Nigerian population.

METHOD

A consolidated analysis of 2809 samples from four population-based cross-sectional study of apparently healthy persons≥18 years was carried out. Optimal waist circumference (WC) and waist-to-height ratio (WHtR) cut points for diagnosing MetS and risk factors were determined using Optimal Data Analysis (ODA) model. The stability of the predictions of the models was also assessed.

RESULTS

Overall mean values of BMI, WC and WHtR were 24.8±6.0kgm(-2), 84.0±11.3cm and 0.52±0.1 respectively. Optimal WC cut-off for discriminating MetS and diabetes was 83cm in females and 85cm in males, and 82cm in females and 89cm in males, respectively. WC was stable in discriminating diabetes than did WHtR and BMI, while WHtR showed better stability in predicting MetS than WC and BMI.

CONCLUSION

The study shows that the optimal WC that maximises classification accuracy of MetS differs from that currently used for sub-Saharan ethnicity. The proposed global WHtR of 0.50 may misclassify MetS, diabetes and hypertension. Finally, the WC is a better predictor of diabetes, while WHtR is a better predictor of MetS in this sample population.

Anthropometric indices: How they compare in screening of cardio- metabolic risks in a Nigerian sub-population

BACKGROUND

The current anthropometric indices used for diagnosis of cardio-metabolic syndrome (CMS) in sub-Saharan Africa are those widely validated in the western world. We hereby aim to compare the sensitivity and specificity of these tools in identifying risk factors for CMS.

METHOD

The study assessed body mass index (BMI), waist circumference (WC) and waist-to-height ratio (WHtR). Statistical analyses were performed to determine the sensitivity and specificity of WHtR in comparison with WC cut-off points recommended by the International Diabetes Federation (IDF) and the Third Adult Treatment Panel (ATPIII) as well as BMI cut-offs prescribed by the World Health Organisation (WHO).

RESULT

WHtR had the highest area under the receiver operating characteristic (ROC) curve in screening CMS. WHtR >0.5 also showed highest sensitivity in both genders in identifying CMS and clusters of >2 CMS risk factors, but with lowest specificity and positive likelihood ratio (LR+). ATPIII WC cut-off revealed lowest sensitivity and highest specificity in screening CMS and >2 CMS risk factors in males (p<0.000l). IDF WC-threshold had the more stable sensitivity and specificity in males (p<0.0001) but not in females.

CONCLUSION

WHtR>0.5 is more sensitive than WC and BMI recommended values in screening for CMS, but with the least positive likelihood ratio. However, more studies in other nations of sub-Saharan Africa are needed to assure evaluation of different cut points that will yield optimal specificity and sensitivity. This will help curb the problem of over-diagnosis of CMS risk factors and increase better health outcome of the population.

Association of physical activity with metabolic syndrome in a predominantly rural Nigerian population

AIMS

Physical activity is an essential determinant of health. However, there is dearth of evidence regarding prevalence of physical activity in developing countries, especially its association with metabolic syndrome risk factors. This study assessed the association of physical activity with metabolic syndrome in a Nigerian population.

MATERIALS AND METHODS

A cross-sectional study was carried out on apparently healthy persons who are ≥ 18 years old. The World Health Organisation (WHO) Global Physical Activity Questionnaire (GPAQ) was used to collect five domains of physical activity. Participants were classified as physically active or inactive based on meeting the cut-off value of 600 MET-min/week. Metabolic syndrome was diagnosed using the Joint Scientific Statement on Harmonizing the Metabolic Syndrome criteria.

RESULTS

Overall prevalence of physically active individuals was 50.1% (CI: 45.6-54.7%). Physical inactivity is significantly more in females (p<0.01) and among participants >40 years old (p<0.0001). Whereas individuals with metabolic syndrome appeared more likely to be physically active (OR=1.48, CI: 0.71-3.09); physical inactivity showed to exist more among participants who were living in urban area (OR=6.61, CI: 3.40-12.85, p<0.001). Participants with prediabetes (OR=1.69, CI: 0.62-4.61) and diabetes (OR=1.91, CI: 0.65-5.63) were more likely to be physically inactive as compared to other metabolic syndrome risk factors.

CONCLUSION

The high prevalence of physical inactivity in this study population is a clear indication that concerted efforts to improve physical activity may be required. However, it seems that metabolic syndrome is not improved by being physically active. This suggests that interventions directed at physical activity alone may not produce optimal efficacy in this study population.

Metabolic syndrome and prediabetes in ndokwa community of Nigeria: preliminary study

BACKGROUND

Global prevalence of metabolic syndrome (MS) and diabetes is increasing, but the reference ranges for MS indices have yet to be established for sub-Saharan African countries. As part of the international research collaboration agenda for Prediabetes and Cardiovascular Complications Study (PACCS), a pilot study was conducted in one of the Ndokwa communities of Nigeria in 2013.

AIM

The study was to obtain preliminary indication of prevalence and reference values of MS in the rural communities of a low-mid income country.

MATERIALS AND METHODS

Seventy-four volunteer participants were recruited, after public lectures in high schools and churches in the community. Body mass index (BMI), blood pressure and waist circumference (WC), blood glucoselevel, and lipid profile were measured. Percentage prevalence MS was determined using commonest three criteria (Third Adult Treatment Panel (ATP III) 2001, International Diabetes Federation (IDF) 2005, and World Health Organization (WHO) 1999).

RESULTS

When individual indices of MS are considered separately; the males seem healthier than females. However, the prevalence of high-density lipoprotein (HDL) cholesterol was higher in males than in females. Equal 3% prevalence of MS was seen in both genders using the WHO standard. Other criteria show prevalence of 8% females and 11% males (ATP III), 5% females and 8% males (IDF 2005 European), and 14% females and 17% males (IDF 2005 Ethnic).

CONCLUSION

The prevalence of MS is higher in males than females; and relative to ATP III 2001 criteria, either the IDF 2005 European may underestimate MS, or the ethnic specific could overestimate the prevalence. Hence, it is important to define the criteria to be used.

Cardiovascular risks in prediabetes: preliminary data on "vasculopathy triad"

Background:

Subclinical cardiovascular disease is inherent in complications of diabetes mellitus. It occurs before the obvert manifestation of cardiovascular disease complication in diabetes, and involves vasculopathy triad or three major vascular events comprising stasis, endothelial dysfunction, and atherothrombosis.

Aim:

This study was to examine evidence of vasculopathy triad in prediabetes, biomarkers of stasis, endothelial dysfunction, and atherothrombosis in prediabetes were compared with apparently healthy group.

Materials and Methods:

Eighty-one participants with results for plasma D-dimer, homocysteine, and whole blood viscosity were selected from a research database. The participants consisted of control (n = 44) and prediabetes (n = 37) based on clinical history and laboratory results.

Results:

Multivariate analysis shows a significantly higher level of vasculopathy in prediabetes than in the control group (P > 0.0001). Blood viscosity (P < 0.04) and homocysteine (P < 0.03) are significantly higher in prediabetes than in controls. Average levels for plasma D-dimer are also higher in prediabetes than in control, but not statistically significant in this particular analysis.

Conclusion:

This study suggests a novel application of known idea, vasculopathy triad that could be used for assessment of subclinical cardiovascular disease in prediabetes.

Can Computer Meridian Diagnostic be useful in diagnosis and management of diseases?

The need for the development of appropriate guidelines for effective or safe use of antioxidants and herbs has always been a concern, especially for the alternative medicine practices. Computer Meridian Diagnostic (CMD) is one of emerging computer-based diagnostic technologies available to alternative medicine practitioners. However, case report of the agents monitored with CMD is uncommon; and concerted effort to bring this into conventional medical practice is yet to be. This hypothesis builds on an anecdotal observation of anti-stress effect monitored with CMD, with a view to highlight a potential tool that requires expatiation, as well as proof of concept and validation studies for possible integration in conventional and traditional medicine practices for therapeutic monitoring.

Serum bilirubin and lipoprotein-a: how are these associated with whole blood viscosity?

BACKGROUND

It has been demonstrated that oxidative stress can induce red blood cell rigidity and haemolysis, which in turn can cause hyperviscosity and hyperbilirubinaemia, respectively. However, haemolysis may be associated with a low level of haemoglobin, which reduces whole blood viscosity (WBV). Bilirubin can behave as antioxidant or oxidant, and one uncharted course for diagnostic pathology is how or whether bilirubinaemia and viscosity are associated. Further, oxidative stress is now being assessed using lipoprotein-a (Lp(a)), among other things but whether it is associated with blood viscosity has not been established.

AIM

This study investigates the association and correlation of haemoglobin level and WBV with serum Lp(a) and bilirubin levels in a general population of patients.

MATERIALS AND METHODS

Sixty-eight cases that were tested for Lp(a), concomitantly with full blood count and liver function, in our archived clinical pathology database were used in this study. WBV levels were determined using a validated formula. Multivariate and univariate analyses as well as correlation were performed.

RESULTS

WBV was found to be significantly associated with bilirubin (P<0.02), but not with Lp(a). Haemoglobin concentration was inversely correlated with Lp(a) (P<0.04), but not with bilirubinaemia.

CONCLUSION

This pilot study suggests that hyperbilirubinaemia and hyperviscosity are associated and positively correlated. Consideration of whether serum bilirubin (as an indirect index of oxidative stress) can be used in combination with WBV (as index of macrovascular effect of oxidative stress) to assess oxidative damage is recommended.

Assessment of diabetic macrovascular complications: a prediabetes model

Prediabetes is a condition that requires early intervention against diabetic macrovascular complications. This study aims to assess whether or not the likelihood of diabetes macrovascular complications occurring in prediabetes can be better estimated by a model combining a set of conventional and emerging biomarkers, with a view to improving cardiovascular disease (CVD) screening in individuals with elevated blood glucose levels associated with prediabetes. A total of 71 participants (female/male: 32/39) were divided into two groups - the prediabetic group (preDM: n=34) and the diabetic with cardiovascular complications group (DM+CVD: n=37). Blood glucose level (BGL), blood pressure (BP), total cholesterol (TC), high-density lipoprotein (HDL) and TC:HDL ratio, erythrocyte oxidative stress (as determined by reduced glutathione [GSH], malondialdehyde and methaemoglobin levels) and vascular events (D-dimer, homocysteine and whole blood viscosity) were measured. Statistical analysis was by binomial logistic regression modelling with forward likelihood ratio step procedures. A combination of BGL, BP, erythrocyte GSH and TC gave the best group identifications, with 28/34 (82.4%) and 29/37 (78.4%) members correctly identified in the preDM and DM + CVD groups, respectively. Six of the 34 (17.6%) prediabetes individuals were logistically identified as having diabetic macrovascular complications, but clinically did not qualify for CVD intervention under current screening models. The authors propose that a combination of BGL, BP, erythrocyte GSH and TC can provide a clinically acceptable standard for identifying CVD risk in individuals with prediabetes. This model provides a tool for early identification and targeted intervention in individuals with subclinical diabetes who are at risk of CVD.

Low serum creatinine levels as risk factor of diabetes mellitus: prediabetes considerations

OBJECTIVE

It has been reported that low serum creatinine level is a risk factor of diabetes. We hypothesize that should this be true, serum creatinine levels would be lower and more prevalent in prediabetes than in normal individuals.

MATERIALS AND METHODS

1017 glucose tolerance tests performed at South West Pathology Service of the New South Wales Health, Australia, in 2008 were sorted into normal (control), prediabetes and diabetes based on decisive interpretation. All cases with creatinine results in the control (n=48), diabetes (n=18) and prediabetes (n=36) groups were selected.

RESULTS

Mean levels of serum creatinine levels in the controls (80 +/- 32 micromol/L), diabetes (82 +/- 26 micromol/L) and prediabetes (82 +/- 23 micromol/L) were not statistically significantly different. The prevalence of low levels of serum creatinine is less in prediabetes (11%) than in the control (23%).

CONCLUSION

Further studies using a larger number and adjusting for confounding factors is needed to ascertain the role of low serum creatinine level as a risk factor of diabetes.

Position paper for health authorities: archived clinical pathology data-treasure to revalue and appropriate

Archived clinical pathology data (ACPD) is recognized as useful for research. Given our privileged de-identified ACPD from South West Pathology Service (SWPS), attempt is made to estimate what it would cost any researcher without such privilege to generate the same data. The Ethics Committee of the Area Health Service approved a request for Dr. Uba Nwose to use de-identified ACPD acquired by the SWPS for clinical laboratory-based translational biomedical science research. 10-years (1999-2008) have been pooled to constitute the database. Data include blood sugar, cholesterol, D-dime, ESR, glucose tolerance, haematocrit, HbA 1 c, homocysteine, serum creatinine, total protein and vitamins [C & E] amongst others. For this report, the bulk-billed-cost of tests were estimated based on number and unit price of each test performed. AU$ 17,507,136.85 is the cost paid by Medicare in the period. This amount is a conservative estimate that could be spent to generate such 10-years data in the absence of ACPD. The health/pathology service has not given any financial research grant. However, the support-in-kind is worth more than celebrated competitive research grants. It calls for revaluatrion by academic, research and scientific institutions the use ofACPD. For the countries where such provision is non-existent, this report provides a 'Position Paper' to present to the directorates or institutes of health authorities to appropriate the value of ACPD and approve of their use as a research treasure and resource management tool.

Obstructive sleep apnea management with interactive computer technology and nutrition: two case reports

We present two cases of obstructive sleep apnea (OSA) in which one of the subjects was managed with virtual scanning, which is a computer interactive diagnostic and therapeutic technology, and the other was treated with nutrition. We propose an oxidative stress concept as the biochemical basis of the two management options. It is important to consider the validity of virtual scanning Technology (which can be used to manage sleep apnea noninvasively) and to determine whether oxidative stress is the biochemical basis for this technology. It will be beneficial to develop a framework for integration into clinical practice.

Oxidative damage indices for the assessment of subclinical diabetic macrovascular complications

Subclinical cardiovascular disease (SCVD), including complications in diabetes, is associated with oxidative damage and precedes future cardiovascular disease (CVD). Hence, assessment and management of oxidative damage is imperative. This study investigates biomarkers associated with CVD, diabetes and oxidative stress in order to determine a set of indices that could be useful to assess oxidative damage in diabetic macrovascular pathogenesis. A total of 266 participants were selected and divided into seven groups (control, family history of diabetes, prediabetes, prediabetes with CVD, diabetes mellitus [DM], DM+CVD and CVD) based on clinical history/status. Blood glucose (BG) level, erythrocyte glutathione (GSH), malondialdehyde, methaemoglobin, D-dimer, homocysteine, blood viscosity and cholesterol profile were determined. Factorial MANOVA and independent univariate analyses were performed. Prevalence of significant biomarkers was assessed following a 3.5-year retrospective study. Multivariate analysis showed statistically significant differences between groups (P < 0.0001) with post hoc tests identifying a statistically significant association for BG level (P < 0.0001), GSH (P < 0.0001), D-dimer (P < 0.02) and total cholesterol (P < 0.0001). Of the subjects who showed hyperglycaemia-associated progression in clinical and biochemistry status, 89% had low-level GSH and 44% had high-level D-dimer. Four individuals exhibited prediabetic status at some stage and would qualify for macrovascular disease intervention. The results of this study suggest that BG level, D-dimer, GSH and total cholesterol contribute significantly to a diabetic oxidative damage panel of markers that could assist in evidence-based pharmacological intervention with anti-aggregation and/or antioxidant agents against future CVD in diabetes.

Cardiovascular risk assessment in prediabetes: A hypothesis

There are screening programs for future risk of cardiovascular disease (CVD) complications in diabetes, but not in subclinical diabetes. There is little or no risk and no differences between genders when a man or woman at age below 50 years presents blood pressure below 140/90 mmHg and total cholesterol/HDL less down 7.0. In the current screening programs, a hypothetical apparently non-diabetic and non-smoking person aged 49 years old; who present blood pressure 140/90 mmHg, fasting blood sugar 5.8 mmol/L and total cholesterol/HDL 6.5 has no risk of future CVD and does not require any intervention. However, by counting numbers, the person has two risk factors, hyperglycaemia and hyperlipidaemia. Furthermore, considering smoking as a factor and the propensity for hyperglycaemia-induced oxidative stress being a smoker-like effect of hyperglycaemia toxicity, the person actually has three risk factors, which qualifies the person for intervention. The issue is that a prediabetes sufferer is treated like a healthy person in the current screening programs. The problem here is that risk of CVD in prediabetes is inadequately assessed. We present a hypothesis that employs a combination of blood glucose level and an index of oxidative damage to improve CVD screening in prediabetes. We propose a longitudinal study to repeat the whole lipid modelling exercise in order to develop a separate model chart for the screening of future CVD in people with diagnosed or undiagnosed prediabetes. The proposal would also serve for people with undiagnosed diabetes.

Erythrocyte oxidative stress in clinical management of diabetes and its cardiovascular complications

Diabetes mellitus is a chronic disease in its own right and is also regarded as a cardiovascular risk factor as well as a cardiovascular disease, due to its ability to progress to a stage of cardiovascular co-morbidity. The pathophysiology of cardiovascular complications in diabetes is reported to involve hyperglycaemia-induced oxidative stress. The erythrocyte has an array of endogenous antioxidants involved in quenching oxidant production and the exponential chain reactions in diabetes. When the erythrocyte is oxidatively stressed, as demonstrated by depleted reduced glutathione and/or increased malondialdehyde in its cell membrane, the risk of diabetes progression and its cardiovascular sequelae, including atherosclerosis and coronary artery disease, is increased. Virtually all studies that determined erythrocyte malondialdehyde and glutathione in diabetes show consistently increased and reduced levels, respectively. Furthermore, cardiovascular complications of diabetes are reported to commence at the prediabetes stage. Current coronary artery disease screening programmes based on the presence of two or more risk factors are failing to identify those with increased risk of diabetes and cardiovascular complications, thereby limiting early interventions. Screening that includes erythrocyte oxidative stress determination may provide an additional marker for both preclinical and advanced disease. In this review, a concise description of the involvement of erythrocyte oxidative stress in diabetes mellitus and its cardiovascular sequelae is presented. Antioxidant action and interaction in the erythrocyte are also described, with emphasis on why current coronary artery disease screening markers cannot be regarded as erythrocyte oxidative stress markers.

D-dimer identifies stages in the progression of diabetes mellitus from family history of diabetes to cardiovascular complications

AIM

The aim of the study was to ascertain whether there is variation in the fibrinolytic/coagulation component of diabetes associated with disease progression to macrovascular complications and whether D-dimer can discriminate such variation.

METHODS

A total of 343 participants were selected based on clinical status and divided into 7 groups: control, family history of diabetes, pre-diabetes with/without CVD, diabetes with/without CVD and CVD only. Plasma D-dimer was tested. Statistical analysis was performed on log normalised data by ANOVA, Fisher's LSD post hoc test. After the initial analysis, data were classified and re-analysed by quartiles, interquartile range and 95(th) percentile.

RESULTS

An overall significant difference between groups (p<0.002) and a steady rise in D-dimer levels that became increasingly higher than control as the disease progressed from pre-diabetes to cardiovascular complications was observed. A statistically significant difference was observed between control versus diabetes (p<0.0005). Analysis of data by quartiles and percentiles gave qualitatively similar results, but a greater significant difference between control versus pre-diabetes at 3rd quartile and interquartile range (p<0.014).

CONCLUSION

We report changes in D-dimer levels that may indicate diabetes disease progression to macrovascular complications. Using D-dimer in conjunction with other biomarkers to identify stages of disease progression, commencing from pre-diabetes and continuing to development of asymptomatic and clinical cardiovascular disease in diabetes mellitus, is worthy of consideration.

Changes in the erythrocyte glutathione concentration in the course of diabetes mellitus

This study aims to evaluate the significance of the changes of erythrocyte reduced glutathione (GSH) in the course of diabetes mellitus including the pre-diabetes stage and cardiovascular disease co-morbidity. A total of 222 participants (female:male, 107:115) were selected and their erythrocyte GSH levels were measured. The participants were divided into four groups: (i) control; (ii) those with blood glucose level > or =5.6 mmol/l but < 6.9 mmol/l as pre-diabetes mellitus with no other pathology; (iii) diabetes without co-morbidity; and (iv) those with diabetes mellitus and cardiovascular disease. Statistical analysis was by ANOVA followed by a Fisher's LSD post hoc test. We observed that GSH concentration was significantly different between groups (P < 0.04). The Fisher's post hoc test indicated significant differences in erythrocyte GSH levels between the pre-diabetes mellitus and diabetes mellitus groups compared to control (P < 0.005 and P < 0.05, respectively). A statistically significant change (P < 0.001) involving an initial fall followed by a rise in erythrocyte GSH levels was observed when diabetes mellitus and diabetes mellitus+cardiovascular disease groups were combined and assessed with respect to period of diabetes. We conclude that oxidative stress is already present in the pre-diabetes stage as determined by the fall in GSH, representing the initial phase of oxidative stress in diabetes mellitus progression. This finding provides evidence that antioxidant markers such as GSH could be a useful tool for pre-diabetes mellitus screening.