Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Comparison of ceftibuten vs. amoxicillin/clavulanic acid as antibiotic prophylaxis in cholecystectomy and/or biliary tract surgery

A randomized, comparative, prospective clinical trial was carried out at a tertiary care center to compare the efficacy of two antibiotic regimens in the prophylaxis of postoperative infection in patients undergoing biliary tract surgery. One hundred patients undergoing cholecystectomy or biliary tract exploration were randomly allocated to one of the following antibiotic regimens: the standard regimen of three doses of amoxicillin/clavulanic acid (1000/200 mg) given by intravenous infusion, or a single dose of ceftibuten (400 mg) given orally. Patients were monitored during their stay in the hospital and over a 2 week period as outpatients. Fifty adult patients were included in each group. Mean age was 49 years, and sex distribution was 82 women and 18 men. The groups were comparable in terms of demographic characteristics and comorbidity. There were no cases of postoperative infection in the ceftibuten group, but five cases of infection occurred in the amoxicillin/clavulanic acid group (P < 0.05). No adverse effects were observed with either antibiotic. The treatment cost per patient was significantly lower for ceftibuten. The results indicate that ceftibuten is well tolerated and more effective than amoxicillin/clavulanic acid for prophylaxis following gallbladder and biliary tract surgery. In addition, ceftibuten has the advantage of being more cost-effective and easier to administer than amoxicillin/clavulanic acid so it could be considered as an alternative for antibiotic prophylaxis in these types of surgical procedures.

Toxic pseudomembranous colitis in a patient with ulcerative colitis

Toxic colitis is a severe disease that may be caused by several inflammatory and/or infectious diseases. Ulcerative colitis is one of the most frequent causes of toxic colitis in the United States. Toxic megacolon complicating Clostridium difficile colitis is a rare occurrence with significant morbidity and mortality.

CASE REPORT

A 52-year-old male presented with rectal bleeding and tenesmus. He had been treated for amebiasis with metronidazole, and had improved. Two weeks later, symptoms recurred, and he was referred to our hospital. A sigmoidoscopy and biopsies demonstrated mucosal ulcerative colitis. He underwent treatment with systemic prednisone, mesalamine, and hydrocortisone enemas with adequate response. He was asymptomatic for 2 months, but later presented with a tender abdomen and rectal bleeding. Plain abdominal and thorax films showed colonic distention and free intraperitoneal air. Emergency laparotomy was performed, and an inflamed and distended colon, with free inflammatory liquid in the peritoneum, was found. A total abdominal colectomy with temporary ileostomy and Hartmann's pouch was performed. The histopathology analysis demonstrated a Clostridium difficile pseudomembranous colitis.

CONCLUSION

The presence of toxic megacolon due to Clostridium difficile in patients with ulcerative colitis is a rare complication that may be suspected in patients with initial relapse who are on antibiotics.

[Surgical treatment of anorectal fistulas. A 17-year experience at the Instituto Nacional de la Nutrición "Salvador Zubirán"]

INTRODUCTION

Surgical treatment for anorectal fistula may be difficult because of the risk of recurrence, prolonged healing or anal incontinence following the operation.

OBJECTIVE

To analyze the experience with the surgical management of ano-rectal fistula during a period of 17 years.

PATIENTS AND METHODS

The medical records of 105 patients with anorectal fistulas were reviewed retrospectively, with analysis of demographic and clinical data, operative treatment, and results.

RESULTS

There were 73% men and 27% women. Mean age was 45 years. 86% had an underlying chronic disease, most frequently diabetes mellitus (21%) and obesity (14%). No anatomic classification of the fistulous tract was done in 86% of cases, and inter-sphincteric tracts were the most frequent type in the classified cases. In 90% of cases, treatment was fistulectomy. Complications occurred in 13% of cases, mainly delayed healing (6.5%). Recurrent disease was documented in 11 cases (10%), and the majority were treated with a new fistulectomy. There were no cases with anal incontinence following the operation.

CONCLUSIONS

The necessity of performing the anatomic classification of ano-rectal fistula should be emphasized. Fistulectomy was the most frequent surgical procedure.

Acute hyperleptinemia does not modify insulin sensitivity in vivo in the rat

Insulin resistance is associated with hyperleptinemia, whilst exposure of hepatoma cells and isolated adipocytes to high concentrations of leptin has been demonstrated to result in attenuated insulin response and a reduced suppression of gluconeogenesis. To determine the acute metabolic effects of hyperleptinemia, we measured whole body glucose uptake (WBU) and hepatic glucose production rate (HGP) in rats using the euglycemic hyperinsulinemic clamping technique. Anesthetised male rats received recombinant murine leptin (1 microg/min) or vehicle into the jugular vein for 90 min. After 30 min of leptin infusion, insulin was infused to a level of 70 microU/ml and a variable-rate glucose infusion was adjusted to maintain blood glucose levels to 4-4.5 mmol/l. Glucose infusion rates during clamping were not different between leptin-infused and control rats, and there were no significant effects on the HPR or WBU measured using [6-(3)H]glucose under basal or clamped conditions. In summary, our data demonstrate that acute hyperleptinemia in normal weight Wistar rats does not appear to reduce insulin sensitivity, in vivo, or to affect HPR under clamp conditions.

Inhibition of food response to intracerebroventricular injection of leptin is attenuated in rats with diet-induced obesity

The fat-derived hormone, leptin, is thought to regulate adipose tissue mass by acting on the brain to reduce food intake and increase thermogenesis. We have produced obesity in rats more than 8 weeks old by feeding a high-calorie diet and have then examined the inhibitory effect of intracerebroventricularly injected recombinant murine leptin on their food intake versus control rats. In control rats, randomized injections of leptin (0.5, 2.0, or 10.0 microg) or sterile saline vehicle into the lateral ventricle produced a dose-dependent reduction in normal laboratory diet consumed 1, 4, and 24 h after the lights were turned off. However, in diet-induced obesity, the dose-dependent inhibition of food intake was observed at 1 h only, and the effect was attenuated. Switching the diet-induced obese rats to a normal laboratory diet 1 week before injections of leptin were commenced resulted in a reduction in the daily food consumption. These data suggest that rats made obese by feeding a high-calorie diet override the normal satiety effects of leptin since when they are returned to a normal laboratory diet, they reduce their calorie intake, possibly as a result of a restoration of the satiety effects of endogenous leptin. However, the fact that the hypophagic response to exogenous leptin is impaired in these rats at this time suggests some residual impairment of the satiety signal, perhaps caused by reduced receptor sensitivity and/or near total occupation of receptors by endogenous leptin molecules, levels of which are raised in plasma.

[Surgical alternatives in the treatment of chronic unspecific ulcerative colitis]

BACKGROUND

Newer techniques for surgical treatment of chronic ulcerative colitis have been developed.

PURPOSE

This review article analyzes the current surgical alternatives, attempting to define their role in the overall management of patients with chronic ulcerative colitis.

RESULTS

Non-restorative total proctocolectomy with permanent ileostomy remains as the gold-standard operation for chronic ulcerative colitis. Restorative total proctocolectomy, with or without excision of the anal transitional zone, is becoming one of the most widely used procedures for this disease. It avoids a permanent ileostomy, and permits good functional results in the majority of patients. Subtotal proctocolectomy, with a Hartmann Pouch may be an adequate procedure in patients operated upon on emergency basis, to permit an ileo-anal pouch in a subsequent operation. Colectomy with ileo-rectal anastomosis, and creation of a continent ileostomy are procedures that should be limited to selected candidates.

CONCLUSIONS

Currently, total proctocolectomy with ileo-anal pouch seems to be the operation of choice in the majority of patients, but the preoperative general status is important to define the best surgical alternative for each patient.

Expression of uncoupling protein mRNA in thermogenic or weakly thermogenic brown adipose tissue. Evidence for a rapid beta-adrenoreceptor-mediated and transcriptionally regulated step during activation of thermogenesis

A cloned cDNA sequence for the unique mitochondrial uncoupling protein of rat brown adipose tissue has been used to assay the corresponding mRNA in several situations. When thermogenesis in brown adipose tissue is stimulated (exposure of adult rats to the cold, birth) a rapid and prolonged increase in the level of uncoupling protein mRNA is observed. Such an increase can be mimicked by injection of animals with a new beta-adrenoreceptor agonist BRL 26830A. Conversely it is known that mice and rats with genetic or surgical obesity have a weakly thermogenic brown adipose tissue with a reduced norepinephrine turnover. A reduced level of uncoupling protein mRNA was measured in obese fa/fa rats 10 days or 10 weeks old and in obese rats with a lesion of the ventromedial hypothalamic area but not in obese ob/ob mice. Moreover, exposure of obese animals to cold or dosing with BRL 26830A strikingly increased the level of uncoupling protein mRNA. Measurement of the relative concentration of nascent Ucp transcripts in nuclei isolated from brown adipose tissue indicates that Ucp gene is acutely (within 15 min) regulated at the level of transcription and is controlled via activation of beta-adrenoreceptors of plasma membrane. Ucp gene transcription is decreased in obese fa/fa rats but can be fully and rapidly turned on after injection of BRL 26830A.