Association of physical activity and sports participation with insulin resistance and non-alcoholic fatty liver disease in people with type 1 diabetes

AIM

To evaluate the association between physical activity (PA) and sports participation with insulin resistance and non-alcoholic fatty liver disease (NAFLD) in people with type 1 diabetes (T1D).

METHODS

People with T1D from a secondary and tertiary care centre were included. Questionnaire-derived PA was expressed in metabolic equivalent of task hours per week (METh/week). Insulin sensitivity was calculated with the estimated glucose disposal rate (eGDR). NAFLD was assessed by transient elastography (TE). Multivariate linear and logistic regression models were conducted, adjusted for age, sex, diabetes duration and BMI.

RESULTS

In total, 254 participants were included (men 56%, age 44 ± 14 years, diabetes duration 24 ± 14 years, median BMI 24.8 kg/m2), of which 150 participants underwent TE. Total PA (median 50.7 METh/week) was not significantly associated with insulin resistance (median eGDR 7.31 mg/kg/min) (beta -0.00, 95% CI -0.01 to 0.00) or with NAFLD (OR 1.00, 95% CI 0.99-1.01). Participating in sports was significantly associated with eGDR (beta 0.94, 95% CI 0.48-1.41) and with NAFLD (OR 0.21, 95% CI 0.08-0.56).

CONCLUSIONS

In our T1D population, we could not find any dose-dependent association between PA, insulin resistance and NAFLD. People participating in sports had a lower degree of insulin resistance and lower odds for NAFLD.

Nitrogen-Phosphorus-Potassium containing liquid fertilizer intoxication presenting with extreme hyperkalemia, metabolic acidosis and ECG changes

Liquid fertilizers are widely used for fertilizing in- and outdoor vegetation. Despite the easy accessibility and widespread use, serious intoxications are rare. This case report describes a 61-year-old woman who was treated for life-threatening hyperkalemia, metabolic acidosis and ECG changes after intentional ingestion of liquid fertilizer. Our case shows that intake of liquid fertilizer, though infrequent, can cause serious, life threatening complications.

Current treatment strategies for primary upper extremity deep venous thrombosis; a retrospective observational multicenter case series

Introduction

Current treatment strategies for primary upper extremity deep venous thrombosis (pUEDVT) range from conservative treatment with anticoagulation therapy to invasive treatment with thoracic outlet decompression surgery (TOD), frequently combined with catheter directed thrombolysis, percutaneous transluminal angioplasty, or stenting. Due to a lack of large prospective series with uniform data collection or a randomized trial, the optimal treatment strategy is still under debate. We conducted a multicenter observational study to assess the efficacy and safety of both the conservative and invasive treatment strategies for patients with pUEDVT.

Methods

We retrospectively collected data from patients treated in five vascular referral and teaching hospitals in the Netherlands between 2008 and 2019. Patients were divided into a conservative (Group 1), an invasive treatment group (Group 2) and a cross-over group (Group 3) of patients who received surgical treatment after initial conservative therapy. Follow-up consisted of outpatient clinic visits and an electronic survey. Primary outcome was symptom free survival defined as absence of any symptom of the affected arm reported at last follow-up regardless of severity, or extent of functional disability. Secondary outcomes were incidence of bleeding complications, recurrent venous thromboembolism, surgical complications, and reinterventions.

Results

A total of 115 patients were included (group 1 (N = 45), group 2 (N = 53) or group 3 (N = 27). The symptom free survival was 35.6%, 54.7% and 48.1% after a median follow-up of 36, 26 and 22 months in groups 1, 2 and 3 respectively. Incidence of bleeding complications was 8.6%, 3.8% and 18.5% and recurrent thrombosis occurred in 15.6%, 13.2% and 14.8% in groups 1-3 respectively.

Conclusion

In this multicenter retrospective observational cohort analysis the conservative and direct invasive treatments for pUEDVT were deemed safe with low percentages of bleeding complications. Symptom free survival was highest in the direct surgical treatment group but still modest in all subgroups. Perioperative complications were infrequent with no related long term morbidity. Of relevance, pUEDVT patients with confirmed VTOS and recurrent symptoms after conservative treatment may still benefit from TOD surgery. However, symptom free survival of this delayed TOD seems lower than direct surgical treatment and bleeding complications seem to occur more frequently.

Quantity of adipose tissue and adipose tissue dysfunction and the risk of cancer in individuals at high risk of cardiovascular disease

Background

Individuals with cardiovascular disease (CVD) are at increased risk of cancer compared to the general population. Adipose tissue dysfunction, as a consequence of excess adipose tissue, contributes to this risk via production of several hormones and cytokines. Whether the high risk of cancer in people with type 2 diabetes (T2D) is mainly attributable to the quantity of adipose tissue or the degree of adipose tissue dysfunction, is unknown.

Purpose

To assess the relation between the quantity of adipose tissue and adipose tissue dysfunction and the risk of cancer in a cohort of patients at high risk of CVD, with and without T2D.

Methods

10792 participants from the UCC-SMART study were included for this prospective cohort study, including 7026 individuals with a history of CVD and 1769 individuals with pre-existent T2D. The effect of quantitative measures of adiposity [BMI, waist circumference and ultrasonographically determined visceral adipose tissue (VAT)] and of the degree of adipose tissue dysfunction on the risk of cancer was assessed using Cox proportional hazards models adjusted for confounders. Adipose tissue dysfunction was quantified by metabolic dysfunction (modified metabolic syndrome criteria with waist circumference replaced by hsCRP), the estimated glucose disposal rate (eGDR, a measure of insulin resistance), and HOMA-IR (only in people without T2D). Potential effect modification by T2D was tested by adding an interaction term to the models.

Results

During a median of 8.6 (IQR 5.0–12.8) years of follow-up, 1164 individuals were diagnosed with cancer, of which 219 individuals had pre-existent T2D. Incidence rates were 14.0 and 11.6 per 1000 person-years for people with and without T2D, respectively. Increases per SD in BMI [HR 0.98 (95% CI 0.92–1.05)], waist circumference [HR 1.01 (95% CI 0.95–1.09)] and VAT [HR 1.03 (95% CI 0.97–1.10)] were not significantly associated with an increased risk of cancer. These relations were not different for people with and without T2D (p>0.05).

Metabolic dysfunction was associated with a higher risk of cancer [4–5 vs. 0–1 components: HR 1.14 (95% CI 1.03–1.25)]. The relation between eGDR and incident malignancy was different for people without T2D [HR 0.97 (95% CI 0.93–1.01)] than for people with T2D [HR 1.06 (95% CI 0.97–1.16)] (p=0.04), with this last relation being more pronounced in people with a higher amount of VAT. No significant relation was observed between HOMA-IR and the risk of cancer in people without T2D [HR 0.99 (95% CI 0.96–1.02)].

Conclusion

Adipose tissue dysfunction, assessed by the degree of metabolic dysfunction, is associated with a higher risk of cancer in people at high risk of CVD. No significant associations were observed for quantitative measures of adiposity. The higher risk of cancer among individuals with adipose tissue dysfunction warrants awareness among clinicians and emphasizes the importance of obesity prevention.

Funding Acknowledgement

Type of funding sources: None.

Patients with diffuse idiopathic skeletal hyperostosis have an increased burden of thoracic aortic calcifications

Objectives.

DISH has been associated with increased coronary artery calcifications and incident ischaemic stroke. The formation of bone along the spine may share pathways with calcium deposition in the aorta. We hypothesized that patients with DISH have increased vascular calcifications. Therefore we aimed to investigate the presence and extent of DISH in relation to thoracic aortic calcification (TAC) severity.

Methods.

This cross-sectional study included 4703 patients from the Second Manifestation of ARTerial disease cohort, consisting of patients with cardiovascular events or risk factors for cardiovascular disease. Chest radiographs were scored for DISH using the Resnick criteria. Different severities of TAC were scored arbitrarily from no TAC to mild, moderate or severe TAC. Using multivariate logistic regression, the associations between DISH and TAC were analysed with adjustments for age, sex, BMI, diabetes, smoking status, non-high-density lipoprotein cholesterol, cholesterol lowering drug usage, renal function and blood pressure.

Results.

A total of 442 patients (9.4%) had evidence of DISH and 1789 (38%) patients had TAC. The prevalence of DISH increased from 6.6% in the no TAC group to 10.8% in the mild, 14.3% in the moderate and 17.1% in the severe TAC group. After adjustments, DISH was significantly associated with the presence of TAC [odds ratio (OR) 1.46 [95% CI 1.17, 1.82)]. In multinomial analyses, DISH was associated with moderate TAC [OR 1.43 (95% CI 1.06, 1.93)] and severe TAC [OR 1.67 (95% CI 1.19, 2.36)].

Conclusions.

Subjects with DISH have increased TACs, providing further evidence that patients with DISH have an increased burden of vascular calcifications.

Distribution of cardiovascular risk in type 2 diabetes: results of an analysis using data from the CAPTURE study

Introduction

Cardiovascular disease (CVD) is the leading cause of mortality in people with type 2 diabetes (T2D). CAPTURE, a non-interventional, cross-sectional study conducted across 13 countries in 2019, collected demographic and clinical characteristics in almost 10,000 adults with T2D in primary or secondary care. Less than 25% of patients with established CVD treated with a glucose-lowering agent received an agent with demonstrated benefit in cardiovascular (CV) risk reduction, such as a glucagon-like peptide-1 receptor agonist (GLP-1 RA) or a sodium–glucose co-transporter-2 inhibitor (SGLT-2i).1 It is not known whether this is linked to estimated 10-year and lifetime CV risk.

Purpose

To estimate the CV risk distribution in the CAPTURE population using the Diabetes Lifetime-perspective prediction (DIAL) model, and to assess treatment patterns by CV risk.

Methods

The DIAL model is an externally validated competing risk adjusted model for predicting CV risk in patients with T2D, calculating absolute 10-year and lifetime risk of myocardial infarction, stroke or cardiovascular death, and life-expectancy free of a CVD event. Patient-level data from CAPTURE (age, sex, body mass index, smoking status, HbA1c, CVD history, T2D duration, clinical parameters and treatment history) were used in the DIAL model. Missing data were imputed by region using predicted mean matching. High risk was defined as 10-year risk >10%, and lifetime risk >50%.

Results

Data from 9457 patients with T2D aged 30–85 years were included in the analyses. There was a wide distribution of both 10-year and lifetime risk, with higher risk in patients with a history of CVD (n=2914) than in those without (n=6543). Among patients with a history of CVD, 96% had a 10-year risk of CVD >10% and 81% had a lifetime risk of CVD >50% (Figure). In patients with CVD and a high 10-year risk of recurrent CVD, 81% had a lifetime risk of recurrent CVD >50%. In patients without history of CVD, 14% had a 10-year risk >10% and only 1% had a lifetime risk >50% (Figure). Among patients without previous CVD but with a high 10-year risk of CVD, only 4% had a lifetime risk >50%. Of the patients with CVD, 10% received a GLP-1 RA and 18% received an SGLT-2i. Similarly, of patients with CVD and a high 10-year risk of recurrent CVD, 10% received a GLP-1 RA and 17% received an SGLT-2i. Among patients without CVD, 11% received a GLP-1 RA and 16% received an SGLT-2i, and among patients without current CVD but at a high 10-year risk of CVD, 12% received a GLP-1 RA and 16% received an SGLT-2i.

Conclusion

There is a wide distribution of CVD risk in the CAPTURE population, and only a minority of patients at high risk of CVD received a glucose-lowering agent with demonstrated benefit in CV risk reduction. Discussing with patients the 10-year and lifetime risks, and the CV benefit to be gained from interventions, can enhance shared decision making.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funded by Novo Nordisk A/S

Residual cardiovascular risk reduction guided by lifetime benefit estimation in patients with symptomatic atherosclerotic disease: effectiveness and cost-effectiveness

AIMS

To determine the (cost)-effectiveness of blood pressure lowering, lipid-lowering, and antithrombotic therapy guided by predicted lifetime benefit compared to risk factor levels in patients with symptomatic atherosclerotic disease.

METHODS AND RESULTS 

For all patients with symptomatic atherosclerotic disease in the UCC-SMART cohort (1996-2018; n = 7697) two treatment strategies were compared. The lifetime benefit-guided strategy was based on individual estimation of gain in cardiovascular disease (CVD)-free life with the SMART-REACH model. In the risk factor-based strategy, all patients were treated the following: low-density lipoprotein cholesterol (LDL-c) < 1.8 mmol/L, systolic blood pressure <140 mmHg, and antithrombotic medication. Outcomes were evaluated for the total cohort using a microsimulation model. Effectiveness was evaluated as total gain in CVD-free life and events avoided, cost-effectiveness as incremental cost-effectivity ratio (ICER). In comparison to baseline treatment, treatment according to lifetime benefit would lead to an increase of 24 243 CVD-free life years [95% confidence interval (CI) 19 980-29 909] and would avoid 940 (95% CI 742-1140) events in the next 10 years. For risk-factor based treatment, this would be an increase of 18 564 CVD-free life years (95% CI 14 225-20 456) and decrease of 857 (95% CI 661-1057) events. The ICER of lifetime benefit-based treatment with a treatment threshold of ≥1 year additional CVD-free life per therapy was €15 092/QALY gained and of risk factor-based treatment €9933/QALY gained. In a direct comparison, lifetime benefit-based treatment compared to risk factor-based treatment results in 1871 additional QALYs for the price of €36 538/QALY gained.

CONCLUSION 

Residual risk reduction guided by lifetime benefit estimation results in more CVD-free life years and more CVD events avoided compared to the conventional risk factor-based strategy. Lifetime benefit-based treatment is an effective and potentially cost-effective strategy for reducing residual CVD risk in patients with clinical manifest vascular disease.

Estimating cardiovascular disease-free life-years with the addition of semaglutide in people with type 2 diabetes using pooled data from SUSTAIN 6 and PIONEER 6

Introduction

Cardiovascular disease (CVD) is the leading cause of disability and death in people with type 2 diabetes (T2D). In a post hoc analysis of pooled data (POOLED cohort) from two phase 3, randomized CV outcomes trials, SUSTAIN 6 (NCT01720446) and PIONEER 6 (NCT02692716), the addition of the glucagon-like peptide-1 analogue semaglutide to standard of care (SoC) in people with T2D at high risk of CVD significantly reduced the risk of major adverse CVD events (3-point MACE: CV death, non-fatal stroke and non-fatal myocardial infarction).

Purpose

To estimate the effect of adding semaglutide to SoC on CVD-free life-years and 10-year CVD risk in patients with T2D by predicting individual patient-level risk of CVD events in the POOLED cohort using the DIAL CVD risk model.

Methods

The 3-point MACE hazard ratio from the POOLED cohort (N=6480; HR = 0.76 [95% confidence interval [CI]: 0.62–0.92]) was applied to the patient-level lifetime risk of CVD events derived from the DIAL model. CVD-free life-years and 10-year CVD risk were then calculated based on the age-specific risks of CVD events and non-vascular mortality, using standard actuarial methods. Both new and recurrent CVD events were considered. The DIAL model was validated by comparing the predicted and observed number of CVD events after 1 year. The DIAL model was previously developed using data from people with T2D in the Swedish National Diabetes Registry and validated across geographical regions.

Results

The DIAL model was considered valid for use in the POOLED cohort because the predicted number of CVD events at 1 year was within 5% of the number observed. Adding semaglutide to SoC was associated with a mean reduction in 10-year CVD risk of 20.0% (95% CI: 6.4–32.6%) and a mean increase of 1.72 (95% CI: 0.52–2.96) CVD-free life-years. The number of mean CVD-free life-years gained ranged from 0.62–2.91 years between age groups (Table). For a 60-year-old male with baseline characteristics matched to the average male from the POOLED cohort, adding semaglutide to SoC reduced 10-year CVD risk by 20.8% and provided 2.53 additional CVD-free life-years. The number of CVD-free life-years decreased when baseline age was increased (Figure).

Conclusions

The addition of semaglutide to SoC was associated with a gain in CVD-free life-years. This analysis helps contextualize the results of CV outcomes trials and may help to inform clinical decision-making.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novo Nordisk A/S

Prediction of 10-year and lifetime risk of cancer in individual patients with established cardiovascular disease, results from UCC-SMART and CANTOS

Background

As treatment for cardiovascular disease (CVD) has improved substantially over the last decades, more patients survive acute CVD manifestations and are at risk for developing cancer as well as recurrent CVD. Due to similar risk factors, including smoking and obesity, patients with established CVD are at higher risk for cancer.

Objectives

The aim of this study was to develop and externally validate prediction models for the estimation of 10-year and lifetime risk for total, colorectal, and lung cancer in patients with established CVD.

Methods

Data from patients with established CVD from the UCC-SMART prospective cohort study (N=7,280) were used for model development, and data from the CANTOS trial (N=9,322) were used for model validation. Predictors were selected based on previously published cancer risk prediction models or cancer risk factors, easy clinical availability, and availability in the derivation dataset (UCC-SMART cohort). A Fine and Gray competing risk-adjusted lifetime model was developed for total, colorectal, and lung cancer.

Results

Selected predictors were age, sex, smoking status, weight, height, alcohol use, antiplatelet use, diabetes mellitus, and C-reactive protein. External calibration for 4-year risks of the total cancer, colorectal cancer, and lung cancer models was good (Figure 1), and C-statistics were 0.63–0.74 in the CANTOS trial population. Median predicted lifetime risks in CANTOS were 26% (range 1%-52%) for total cancer, 4% (range 0%-13%) for colorectal cancer, and 5% (range 0%-37%) for lung cancer.

Conclusions

Lifetime and 10-year risk of cancer can be estimated with easy to measure variables in patients with established CVD, showing a wide distribution of predicted lifetime risks for total cancer and lung cancer. Using these lifetime models in clinical practice could increase understanding of cancer risk and aid in emphasizing healthy lifestyle changes.

Figure 1. Calibration plots of cancer models

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University Medical Center; Additional funding: CANTOS trial was funded by Novartis Pharmaceuticals.

Predicted lifetime therapy benefit guided treatment effectively reduces residual cardiovascular risk in patients with symptomatic atherosclerotic disease

Background

Identification of patients who benefit most from further risk factor lowering may help to effectively reduce residual risk of cardiovascular disease (CVD) in patients with symptomatic atherosclerotic disease. Using the previously published SMART-REACH model, the lifetime benefit of preventive therapy can be estimated, defined as the increase in CVD-free life expectancy from preventive therapy.

Purpose

To model the effectiveness of blood pressure lowering, lipid lowering and antithrombotic therapy guided by predicted lifetime benefit rather than guideline based risk factor levels in patients with symptomatic atherosclerotic disease in terms of total gain in CVD-free lifetime and events avoided.

Methods

For all patients with symptomatic atherosclerotic disease in the UCC-SMART cohort (1996–2018), two treatment strategies were compared. The predicted lifetime benefit-guided treatment strategy was based on individual estimation of gain in CVD-free life as estimated with the SMART-REACH model. A lifetime benefit threshold of &gt;1 year additional CVD-free life per therapy was deemed worthwhile for this analysis. Therapies were selected using a stepwise algorithm resembling clinical practice.In the risk factor-based strategy all patients were treated according to the most recent ESC guidelines for patients at very high risk: treatment goal LDL-c &lt;1.8 mmol/l, systolic blood pressure &lt;140 mmHg and antithrombotic medication. Outcomes were assessed using the SMART-REACH model in combination with relative treatment effects of the prescribed therapies.

Results

In total, 7697 patients were included with coronary artery disease, cerebrovascular disease or peripheral artery disease. Treatment according to lifetime benefit would lead to an increase of 25,388 CVD-free lifeyears (95% CI 24,936–25,824), threshold-based treatment to an increase of 18,912 CVD-free lifeyears (95% CI 18,469–19,360). In the next 10 years and lifetime, 617 events (37%; 95% CI 36–37) and 1,250 (32%; 95% CI 32–33) could be avoided with lifetime benefit-based treatment and 532 (32%; 95% CI 31–32) and 989 (25%; 95% CI 25–26) with risk factor-based treatment. When treating according to lifetime benefit, more therapies would be started in younger patients, which leads to a decreased incidence of CVD in younger patients (Figure 1). In patients older than 75, the incidence of CVD was higher when treating according to lifetime benefit.

Conclusions

Residual risk reduction guided by lifetime benefit estimation results in more CVD-free lifeyears and more CVD events avoided compared to the conventional risk factor-based strategy. Treatment according to lifetime benefit may prevent events in younger patients. Although this requires a longer duration of preventive treatment, the potential gain in CVD-free life expectancy is substantial. Benefit-based treatment is an effective strategy for reducing residual CVD risk in patients with clinical manifest vascular disease.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): UMC Utrecht

External applicability of blood pressure-lowering drug trials to real-world patients with manifest cardiovascular disease

Background

Randomised controlled trials (RCTs) are the main source of evidence for clinical treatment guidelines. However, there are concerns that strict eligibility criteria for participant selection may limit applicability of trial results to real-world patients.

Purpose

To assess the applicability of blood pressure-lowering drug trials in real-world secondary preventive care in stable coronary artery disease, peripheral artery disease and cerebrovascular disease.

Methods

Eligibility criteria from the largest guideline-informing RCTs on blood pressure-lowering drugs, the EUROPA, PEACE, HOPE-PAD, PRoFESS and PROGRESS trials, were applied to three subcohorts within the UCC-SMART study with coronary artery disease (n=5155), peripheral artery disease (n=1487) and cerebrovascular disease (n=2515). Baseline differences between would-be trial eligible and ineligible patients were estimated. Differences in all-cause mortality and a composite major adverse cardiovascular event (MACE) outcome of cardiovascular death, myocardial infarction and stroke were calculated and adjusted for age, sex and cardiovascular risk factors using Cox proportional hazard models.

Results

Seventy-five percent of UCC-SMART patients with the appropriate cardiovascular disease were eligible for EUROPA, 84% for PEACE, 59% for HOPE-PAD, 17% for PRoFESS and 100% for PROGRESS. Across trials, the main reasons for UCC-SMART patients' ineligibility were age younger than 50 or 55 years and cardiovascular history. On average, eligible patients were older (range 1.4–14.6 years across trials). Incidence rates for all-cause mortality and MACE were higher for trial eligible patients (Figure 1). After adjustment for age and sex, EUROPA and PEACE eligible patients had a lower risk of mortality (EUROPA: hazard ratio (HR) 0.68 95% confidence interval (CI) 0.59–0.77, PEACE: HR 0.52 95% CI 0.43–0.64) and MACE (EUROPA: HR 0.88 95% CI 0.76–1.01, PEACE: 0.56 95% CI 0.46–0.69), while differences between HOPE-PAD and PRoFESS eligible and ineligible patients were not statistically significant.

Conclusion

The results from the landmark trials on blood pressure-lowering drugs, specifically RAASi, in patients with peripheral artery and cerebrovascular disease are widely applicable to real-world patient populations. Although the majority of coronary artery disease patients is eligible for the EUROPA and PEACE trial, the results of these trials should be applied to trial ineligible patients with caution.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): UMC Utrecht

Predicting 10-year risk of recurrent cardiovascular events andcardiovascular interventions in patients with established cardiovascular disease: results from UCC-SMART and REACH

BACKGROUND

Existing cardiovascular risk scores for patients with established cardiovascular disease (CVD) estimate residual risk of recurrent major cardiovascular events (MACE). The aim of the current study is to develop and externally validate a prediction model to estimate the 10-year combined risk of recurrent MACE and cardiovascular interventions (MACE+) in patients with established CVD.

METHODS

Data of patients with established CVD from the UCC-SMART cohort (N = 8421) were used for model development, and patient data from REACH Western Europe (N = 14,528) and REACH North America (N = 19,495) for model validation. Predictors were selected based on the existing SMART risk score. A Fine and Gray competing risk-adjusted 10-year risk model was developed for the combined outcome MACE+. The model was validated in all patients and in strata of coronary heart disease (CHD), cerebrovascular disease (CeVD), peripheral artery disease (PAD).

RESULTS

External calibration for 2-year risk in REACH Western Europe and REACH North America was good, c-statistics were moderate: 0.60 and 0.58, respectively. In strata of CVD at baseline good external calibration was observed in patients with CHD and CeVD, however, poor calibration was seen in patients with PAD. C-statistics for patients with CHD were 0.60 and 0.57, for patients with CeVD 0.62 and 0.61, and for patients with PAD 0.53 and 0.54 in REACH Western Europe and REACH North America, respectively.

CONCLUSIONS

The 10-year combined risk of recurrent MACE and cardiovascular interventions can be estimated in patients with established CHD or CeVD. However, cardiovascular interventions in patients with PAD could not be predicted reliably.

Assessing the clinical significance of echocardiograms in determining treatment of patent ductus arteriosus in neonates

BACKGROUND

To evaluate the utility of echocardiogram (ECHO) in detection and treatment of patent ductus arteriosus (PDA) and hemodynamically significant PDA (hsPDA) in preterm neonates.

METHODS

This was a retrospective case-control study of all preterm infants born or admitted to the level III Neonatal Intensive Care Unit in McMaster Children's Hospital from January 2009 to January 2013. These cases were further classified into the following sub-groups: group A) hsPDA confirmed on ECHO; and the control, group B) PDA (but not hemodynamically significant) confirmed on ECHO. Patients without an ECHO were excluded from all analyses. The primary outcome was incidence of treatment for PDA.

RESULTS

PDA treatment was administered in 83.3% and 11.2% of patients in groups A and B respectively (P < 0.05). Among patients with a hsPDA within group A, 17% did not receive treatment, while 11% of patients with non-hemodynamically significant PDA received treatment for the PDA. Within the cohort of patients who received treatment for a hsPDA, gestational age below 35 weeks as well as murmurs heard on auscultation were both found to be predictors of treatment.

CONCLUSION

While the ECHO remains the gold standard for detecting pathological PDA, there is evidence that other traditional clinical measures continue to guide clinical practice and treatment decisions. Further research is required to gain an understanding of how clinical measures and ECHO may be used in conjunction to optimize resource utilization.

The relation between healthy lifestyle changes and decrease in systemic inflammation in patients with stable cardiovascular disease

BACKGROUND AND AIMS

Pharmacological lowering of inflammation has proven effective in reducing recurrent cardiovascular event rates. Aim of the current study is to evaluate lifestyle changes (smoking cessation, weight loss, physical activity level increase, alcohol moderation, and a summary lifestyle improvement score) in relation to change in plasma C-reactive protein (CRP) concentration in patients with established cardiovascular disease.

METHODS

In total, 1794 patients from the UCC-SMART cohort with stable cardiovascular disease and CRP levels ≤10 mg/L, who returned for a follow-up study visit after median 9.9 years (IQR 5.4-10.8), were included. The relation between changes in smoking status, weight, physical activity, alcohol consumption, a summary lifestyle improvement score and change in plasma CRP concentration was evaluated with linear regression analyses.

RESULTS

Smoking cessation was related to a 0.40 mg/L decline in CRP concentration (β-coefficient -0.40; 95%CI -0.73,-0.07). Weight loss (per 1SD = 6.4 kg) and increase in physical activity (per 1 SD = 48 MET hours per week) were related to a decrease in CRP concentration (β-coefficients -0.25; 95%CI -0.33,-0.16 and -0.09; 95%CI -0.17,-0.01 per SD). Change in alcohol consumption was not related to CRP difference. Every point higher in the summary lifestyle improvement score was related to a decrease in CRP concentration of 0.17 mg/L (β-coefficient -0.17; 95%CI -0.26,-0.07).

CONCLUSIONS

Smoking cessation, increase in physical activity, and weight loss are related to a decrease in CRP concentration in patients with stable cardiovascular disease. Patients with the highest summary lifestyle improvement score have the most decrease in CRP concentration. These results may indicate that healthy lifestyle changes contribute to lowering systemic inflammation, potentially leading to a lower cardiovascular risk in patients with established cardiovascular disease.

Short-term and long-term effectiveness of an e-coaching application; the INHERIT project

Background

Lifestyle e-coaching applications have the potential to be successful in changing people’s lifestyles although it is unclear whether such support would indeed help people with lower socioeconomic status (SES). The aim of the present study, conducted within the INHERIT EU project, was to investigate the effectiveness of a lifestyle e-coaching application in increasing physical activity (PA) in lower SES groups and whether such an increase is sustained after its prolonged use.

Methods

A two-site (Greece: N = 105, Netherlands: N = 89), two arm [Greece: 50 (experimental) and 55 (control), Netherlands: 45 (experimental) and 44 (control)], parallel group, randomized controlled trial proceeded in three phases over 19 weeks, comparing PA (as measured by the IPAQ questionnaire) of participants using a lifestyle e-coaching application with participants not using any such application. Inclusion criteria involved participants to be in low SES, have an age of 18-65 years and an estimated level of physical activity of less than 210 minutes/week, while they needed to possess a smartphone, willing to install the application and being fluent in Dutch or Greek.

Results

Results showed that the use of the app significantly improved participants’ PA in both countries, at 6 (Greece: p = 0.015, Netherlands: p = 0.003) and 19 weeks (Greece: p = 0.002, Netherlands: p &lt; 0.001), while the effect was even higher for low physically active participants as measured at baseline, after both time periods. Compared to the control group, after adjusting for several characteristics, the experimental group achieved a better improvement of PA at 19 weeks compared to baseline (p = 0.006) and week 6 (p = 0.007).

Conclusions

Positive effects on participants’ PA after 19 weeks were observed, with the findings suggesting that the longer the application is used, the greater the improvement of PA, while the effect was more obvious among those following a sedentary lifestyle as measured at baseline.

Key messages

E-coaching applications could be useful in promoting physical activity among people from low SES. E-coaching applications are cost effective and environmentally friendly methods of promoting physical activity. Uptake by national health systems should be examined further.

2153The relation between systemic inflammation and incident cancer in patients with stable cardiovascular disease; a cohort study

Background

Chronic systemic low-grade inflammation, measured by elevated plasma concentrations of high sensitive C-reactive Protein (CRP), is a risk factor for cardiovascular disease (CVD). There is evidence that systemic low-grade inflammation is also related to a higher risk of cancer.

Purpose

In the present prospective cohort study the relation between systemic low-grade inflammation and risk of cancer was evaluated in patients with clinically manifest vascular disease.

Methods

In total 7178 patients from the SMART cohort with manifest cardiovascular disease and plasma CRP levels ≤10 mg/L were included. Data of the cohort were linked to the Dutch national cancer registry. Cox regression models were fitted to study the relation between CRP and incident cardiovascular disease as well as incident cancer. Cancer types were classified according to anatomical location of origin, as well as histopathological subtype, irrespective of their anatomical location of origin. To adjust for potential confounding, age, sex, smoking status, packyears of smoking, and body mass index were added to the models, and additional cardiovascular risk factors, including diabetes mellitus, and systolic blood pressure.

Results

After a median follow-up time of 8.3 years (interquartile range 4.6–12.3) 1289 recurrent cardiovascular events (myocardial infarction, stroke, or vascular mortality) and 1072 incident cancer diagnoses were observed. CRP level was related to recurrent cardiovascular disease risk (HR 1.57; 95% CI 1.35–1.82) (Figure 1A), as well as risk of CVD and/or cancer (HR 1.45; 95% CI 1.29–1.62) (Figure 1B) comparing the third tertile of CRP to the first tertile. CRP concentration was related to total cancer risk (HR 1.33; 95% CI 1.13–1.55 for the third tertile of CRP compared to the first tertile) (Figure 1C). Especially incident lung cancer, independent of histopathological subtype, was related to CRP level (HR 2.64; 95% CI 1.77–3.93 for the third tertile of CRP compared to the first) (Figure 1D). No effect modification by smoking status or years of smoking cessation was observed of the relation between CRP and lung cancer (p-values for interaction >0.05). Incidence of epithelial neoplasms and especially squamous cell neoplasms were related to CRP concentration, irrespective of their anatomical location of origin (HR 1.17; 95% CI 1.08–1.27, and HR 1.11; 95% CI 1.02–1.20 for 1 mg/L higher CRP level respectively). Sensitivity analyses accounting for reverse causality by excluding patients with a cancer diagnosis within 1 and within 2 years of follow up showed similar results.

Kaplan Meier curves per CRP tertile

Conclusion

Chronic systemic low-grade inflammation, measured by plasma CRP levels ≤10mg/L, is a risk factor for incident cancer, markedly lung cancer, independent of smoking status, in patients with stable cardiovascular disease.

2180Estimating individual lifetime benefit and bleeding risk of adding rivaroxaban to aspirin for patients with stable cardiovascular disease: results from the COMPASS trial

Background

The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial has demonstrated that adding low-dose rivaroxaban to aspirin in patients with stable atherosclerotic disease on average reduces recurrence of cardiovascular disease (CVD) events, but increases the risk of major bleeding. For clinical practice, it is important to be able to weigh the absolute benefit from the intervention in terms of lower cardiovascular risk against the absolute increase in risk for major bleeding.

Purpose

The aim of this study was to estimate the individual lifetime benefit and harm of adding low-dose rivaroxaban to aspirin in patients with stable cardiovascular disease by predicting individual months free from CVD events gained and individual months free from major bleeding lost.

Methods

Analyses were based on data of patients with established CVD in the COMPASS trial (n=27,390) and SMART prospective cohort study (n=8,139). The externally validated lifetime SMART-REACH model for recurrent CVD was used to predict life expectancy free of stroke and myocardial infarction, based on the following predictors: sex, current smoking, diabetes mellitus, systolic blood pressure, total cholesterol, creatinine, number of locations of CVD, history of atrial fibrillation, and history of congestive heart failure. A new Fine & Gray competing-risk adjusted Cox proportional hazard model was derived in the COMPASS study population for prediction of life expectancy free from major bleeding, including the same predictors as the SMART-REACH model and additionally ethnicity, geographical region, and history of bleeding requiring transfusion. These lifetime estimates were then combined with hazard ratios from the COMPASS trial to estimate lifetime treatment effects from adding low-dose rivaroxaban to aspirin, expressed in terms of 1) months free from stroke or myocardial infarction gained, and 2) months free from major bleeding lost.

Results

External goodness-of-fit of the SMART-REACH model in the COMPASS study was sufficient. The newly developed major bleeding risk model also showed sufficient external goodness-of-fit in the SMART cohort. The median predicted individual gain in life-expectancy free of stroke or MI from added low-dose rivaroxaban was 16 months (range 1–48 months), while the median predicted individualized lifetime lost in terms of major bleeding was 2 months (range 0–20 months) (Figure 1A). Predicted benefit was higher than predicted harm in more than 90% of the study population. An interactive calculator for use in clinical practice will be made available (example in figure 1B).

Figure 1

Conclusions

There is a wide distribution in lifetime gain and harm from adding low-dose rivaroxaban to aspirin in individual patients with stable CVD. Using these lifetime models, benefits and bleeding risk can be weighed for and with each individual patient, to support treatment decision making in clinical practice.

P1540Major adverse limb events (MALE) and the relation with classical risk factors in patients with symptomatic cardiovascular disease

Background

Patients with symptomatic cardiovascular disease are at high risk for recurrent major adverse cardiovascular events (MACE). Major adverse limb events (MALE) are only rarely reported as a (primary) outcome in trials and cohorts although MALE often lead to significant morbidity and disability.

Purpose

The aim of this study was to determine the incidence of MALE in patients with coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD) or abdominal aortic aneurysm (AAA) and to assess to what extent the classical modifiable risk factors systolic blood pressure (SBP), smoking and non-high density lipoprotein cholesterol (non-HDL-c) affect the risk of MALE.

Methods

Patients with symptomatic vascular disease were included from the ongoing UCC-SMART cohort (1996–2017, n=8139). MALE was defined as a major amputation, peripheral revascularization or thrombolysis of the lower limb. A major amputation included all amputations at the level of the forefoot or higher due to a vascular cause. For non-HDL-c, smoking (per category: non-smoking, former smoking and current smoking) and SBP, the risk for MALE was analyzed with Cox proportional hazard models adjusted for potential confounders. All results were stratified for the presence of PAD/AAA or CAD/CVD at baseline. To calculate the population attributable fraction, non-HDL-c was dichotomized at 1.8 mmol/L and SBP at 140 mmHg.

Results

A total of 577 MALE were observed in 65,402 person-years (median follow up 7.6 years, IQR 3.9–11.7 years) (figure 1A), of which 32 major amputations. In PAD/AAA patients 413 MALE were observed (incidence rate 24.9/1000 person-years). In the CAD/CVD patients 164 MALE were observed (incidence rate 3.4/1000 person-years). The MALE risk per 1 mmol/L higher non-HDL-c was not elevated: HR 1.01 (95% CI 0.94–1.09) for patients with PAD/AAA and HR 1.03 (95% CI 0.91–1.18) for patients with CAD/CVD (figure 1B). The MALE risk per 10mmHg higher SBP was HR 1.10 (95% CI 1.05–1.15) for PAD/AAA patients and HR 1.14 (95% CI 1.06–1.22) for CAD/CVD patients. In patients with PAD/AAA the risk for MALE by former smoking was HR 1.34 (95% CI 0.92–1.97) and for current smoking HR 1.66 (95% CI 1.14–2.44). In CAD/CVD patients, this was for former smoking HR 2.98 (95% CI 1.65–5.39) and for current smoking HR 6.81 (95% CI 3.72–12.45). The population attributable fraction was 0.13 (95% CI −0.07–0.32) for non-HDL-c, 0.21 (95% CI 0.13–0.28) for SBP and 0.28 (95% CI 0.22–0.33) for current smoking.

Figure 1

Conclusions

The incidence of MALE is high in patients with PAD/AAA, and much lower in patients with CAD or CVD. Systolic blood pressure and smoking increase the risk of MALE in PAD/AAA and CAD/CVD patients, Non-HDL-c was not related to the risk of MALE. These findings confirm the importance of MALE as an outcome in patients with clinical manifest vascular disease and underline the importance of the management of classical risk factors to prevent these disabling clinical events.

Acknowledgement/Funding

None

P4990Heterogeneity of treatment effects from an intensive lifestyle weight loss intervention on cardiovascular events in patients with type 2 diabetes: data from the Look AHEAD trial

Background

The Action for Health in Diabetes trial (Look AHEAD) randomized overweight and obese patients with type 2 diabetes to either an intensive lifestyle intervention (ILI) or diabetes support and education (DSE). The trial was stopped early for futility after a median follow-up of 9.6 years due to a lack of effect on cardiovascular disease outcomes, despite beneficial effects on metabolic control and cardiovascular risk factors. Subgroup analyses identified no subgroups based on baseline characteristics with a significant treatment effect. However, traditional simple subgroup analyses have several disadvantages compared to a multivariable risk-based approach to identify heterogeneity of treatment effects (HTE).

Purpose

To explore the possible presence of HTE of an ILI on the occurrence of major cardiovascular events (4-point MACE: nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, and death from cardiovascular causes) in overweight or obese patients with type 2 diabetes mellitus, and to identify patient characteristics associated with treatment.

Methods

In 4,901 patients from Look AHEAD, a ridge penalized Cox regression model to predict treatment effect of ILI versus DSE on the risk of MACE was derived including all possible treatment-by-covariate interaction terms. Next, the ability of the model to predict HTE was confirmed by calculating hazard ratios (HR) and absolute risk change in quartiles of predicted treatment effect, thereby leaving randomization intact. Finally, baseline patient characteristics were compared between quartiles of predicted treatment effect.

Results

During a median follow-up of 9.4 years, 799 events occurred (Fig. 1A). The derived risk model showed good internal calibration, with a C-statistic for discrimination of 0.73 (95% confidence interval [95% CI] 0.71–0.73). The median estimated absolute treatment effect on 10 year risk for MACE with ILI was −1.3% and varied substantially, ranging from −39% to +43% (Fig. 1B). In quartile 1, the quartile with the highest benefit, there was a significant treatment benefit of ILI versus DSE (HR 0.64; 95% CI 0.49–0.83), while there was no effect from treatment in quartiles 2 and 3 (HR 0.81, 95% CI 0.58–1.14, and 1.13, 95% CI 0.80–1.60, respectively), and a detrimental effect in quartile 4 (HR 1.37, 95% CI 1.09–1.73) (Fig. 1C). Patient characteristics most notably associated with higher benefit of ILI were higher age, male sex, higher socio-economic status, no history of cardiovascular disease, no use of insulin, higher blood pressure, lower HbA1c, and the presence of micro-albuminuria but absence of macro-albuminuria.

Figure 1

Conclusion

This post-hoc analysis of the Look AHEAD trial shows evidence of considerable HTE of an intensive lifestyle intervention aimed at weight loss for reducing MACE. Future research into ILI for MACE risk reduction should be specifically aimed at subgroups of patients with a high likelihood of treatment benefit.

Acknowledgement/Funding

None

The effect of menaquinone-7 supplementation on vascular calcification in patients with diabetes: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Vitamin K occurs in the diet as phylloquinone and menaquinones. Observational studies have shown that both phylloquinone and menaquinone intake might reduce cardiovascular disease (CVD) risk. However, the effect of vitamin K on vascular calcification is unknown.

OBJECTIVES

The aim of this study was to assess if menaquinone supplementation, compared to placebo, decreases vascular calcification in people with type 2 diabetes and known CVD.

METHODS

In this double-blind, randomized, placebo-controlled trial, we randomly assigned men and women with type 2 diabetes and CVD to 360 µg/d menaquinone-7 (MK-7) or placebo for 6 mo. Femoral arterial calcification at baseline and 6 mo was measured with 18sodium fluoride positron emission tomography (18F-NaF PET) scans as target-to-background ratios (TBRs), a promising technique to detect active calcification. Calcification mass on conventional computed tomography (CT) scan was measured as secondary outcome. Dephosphorylated-uncarboxylated matrix Gla protein (dp-ucMGP) concentrations were measured to assess compliance. Linear regression analyses were performed with either TBR or CT calcification at follow-up as the dependent variable, and treatment and baseline TBR or CT calcification as independent variables.

RESULTS

We randomly assigned 35 patients to the MK-7 group (33 completed follow-up) and 33 to the placebo group (27 completed follow-up). After the 6-mo intervention, TBR tended to increase in the MK-7 group compared with placebo (0.25; 95% CI: -0.02, 0.51; P = 0.06), although this was not significant. Log-transformed CT calcification mass did not increase in the intervention group compared with placebo (0.50; 95% CI: -0.23, 1.36; P = 0.18). MK-7 supplementation significantly reduced dp-ucMGP compared with placebo (-205.6 pmol/L; 95% CI: -255.8, -155.3 pmol/L). No adverse events were reported.

CONCLUSION

MK-7 supplementation tended to increase active calcification measured with 18F-NaF PET activity compared with placebo, but no effect was found on conventional CT. Additional research investigating the interpretation of 18F-NaF PET activity is necessary. This trial was registered at clinicaltrials.gov as NCT02839044.

4943Remnant cholesterol increases the risk for recurrent vascular events independent of LDL-cholesterol in patients with clinical manifest vascular disease

Background

For many years, low density lipoprotein cholesterol (LDL-C) is recognized as an important risk factor for the development of atherosclerosis and cardiovascular disease. However, even with normal LDL-C levels there is a residual risk for cardiovascular disease and mortality. Previous research in patients with ischemic heart disease, diabetes mellitus type 2 (T2DM) and in the general population has shown that this residual risk could be explained by elevated plasma levels of very low density lipoprotein- (VLDL) and chylomicron-remnant cholesterol.

Purpose

We evaluated the relation between plasma levels of VLDL- and chylomicron-remnant cholesterol and recurrent vascular disease and all-cause mortality in a cohort of patients with clinical manifest arterial disease.

Methods

Prospective cohort study in 8057 patients with manifest arterial disease from the UCC-SMART study. Patients with triglyceride levels >9 mmol/L or known homozygote Apo E2 genotype were excluded. Cox proportional hazard models were used to evaluate the effect of fasting VLDL- and chylomicron-remnant cholesterol (calculated by total cholesterol - high density lipoprotein cholesterol (HDL-C) - LDL-C) on occurence of myocardial infarction (MI), stroke, vascular death, a composite endpoint (i.e. MI, stroke, vascular death) and all-cause mortality. Models were adjusted for LDL-C, current smoking, waist circumference, creatinine and systolic blood pressure. Effect modification of HDL-C and T2DM on the relation between remnant cholesterol and vascular endpoints was evaluated.

Results

Patients mean age was 60.0±10.3 years, 74% were male, 4894 (61%) had a prior history of coronary artery disease (CAD), 2445 (30%) of stroke and 1990 (25%) patients had peripheral arterial disease (PAD) or aneurysm abdominal aorta (AAA). There were 1544 vascular events and 1792 deaths during a median follow up of 8.2 (interquartile range (IQR) 4.5–12.2) years and a total follow up of 68699 person-years. For every 1 mmol/L increase in remnant cholesterol, risk for recurrent vascular events was increased in patients with manifest vascular disease (HR 1.17; 95% CI 1.05–1.31 for the composite endpoint (figure 1)). There was no effect for all-cause mortality in this population. Furthermore, there was no significant effect modification of HDL-C and the presence of T2DM on the relation between remnant cholesterol and vascular endpoints.

Figure 1

Conclusion

In patients with clinically manifest arterial disease plasma remnant cholesterol confers an increased risk for recurrent vascular events, independent of traditional risk factors such as LDL-C levels.

Arterial stiffness as a risk factor for cardiovascular events and all-cause mortality in people with Type 2 diabetes

AIM

To quantify the risk of different non-invasive arterial stiffness measurements with macrovascular disease and all-cause mortality in high-risk people with Type 2 diabetes.

METHODS

We conducted a prospective cohort study of 1910 people with Type 2 diabetes included in the Second Manifestations of ARTerial disease (SMART) study. Arterial stiffness was assessed by brachial artery pulse pressure, normal range (≥0.9) ankle-brachial index and carotid artery distension. Cox regression was used to evaluate the effects of arterial stiffness on risk of cardiovascular events (composite of myocardial infarction, stroke and vascular mortality) and all-cause mortality.

RESULTS

A total of 380 new cardiovascular events and 436 deaths occurred during a median (interquartile range) follow-up of 7.5 (4.1-11.0) years. A 10-mmHg higher brachial pulse pressure was related to higher hazard of cardiovascular events (hazard ratio 1.09, 95% CI 1.02 to 1.16) and all-cause mortality (hazard ratio 1.10, 95% CI 1.03 to 1.16). A 0.1-point lower ankle-brachial index within the normal range was related to a higher hazard of cardiovascular events (hazard ratio 1.13, 95% CI 1.01 to 1.27) and all-cause mortality (hazard ratio 1.17, 95% CI 1.04 to 1.31). A one-unit (10^-3 ×kPa^-1 ) lower carotid artery distensibility coefficient was related to a higher hazard of vascular mortality (hazard ratio 1.04, 95% CI 1.00 to 1.09) and all-cause mortality (hazard ratio 1.04, 95% CI 1.00 to 1.07).

CONCLUSION

Increased arterial stiffness, as measured by either increased pulse pressure, normal-range ankle-brachial index or carotid artery distensibility coefficient, is related to increased hazard of cardiovascular events and all-cause mortality in people with Type 2 diabetes.

Diagnosing and treating antiphospholipid syndrome: a consensus paper

INTRODUCTION

The antiphospholipid syndrome (APS) is defined by the occurrence of venous and/or arterial thrombosis and/or pregnancy-related morbidity, combined with the presence of antiphospholipid antibodies (aPL) and/or a lupus anticoagulant (LAC). Large, controlled, intervention trials in APS are limited. This paper aims to provide clinicians with an expert consensus on the management of APS.

METHODS

Relevant papers were identified by literature search. Statements on diagnostics and treatment were extracted. During two consensus meetings, statements were discussed, followed by a Delphi procedure. Subsequently, a final paper was written.

RESULTS

Diagnosis of APS includes the combination of thrombotic events and presence of aPL. Risk stratification on an individual base remains challenging. 'Triple positive' patients have highest risk of recurrent thrombosis. aPL titres > 99th percentile should be considered positive. No gold standard exists for aPL testing; guidance on assay characteristics as formulated by the International Society on Thrombosis and Haemostasis should be followed. Treatment with vitamin K-antagonists (VKA) with INR 2.0-3.0 is first-line treatment for a first or recurrent APS-related venous thrombotic event. Patients with first arterial thrombosis should be treated with clopidogrel or VKA with target INR 2.0-3.0. Treatment with direct oral anticoagulants is not recommended. Patients with catastrophic APS, recurrent thrombotic events or recurrent pregnancy morbidity should be referred to an expert centre.

CONCLUSION

This consensus paper fills the gap between evidence-based medicine and daily clinical practice for the care of APS patients.

Association between bone metabolism regulators and arterial stiffness in type 2 diabetes patients

BACKGROUND AND AIM

Osteopontin (OPN), osteonectin (ON) and osteocalcin (OC) play an important role in the development of vascular calcifications, but it is unclear whether these bone metabolism regulators contribute to the development of arterial stiffness in type 2 diabetes patients. We therefore aim to determine the relationship between plasma concentrations of OPN, ON, OC and arterial stiffness in type 2 diabetes patients.

METHODS

Cross-sectional study of 1003 type 2 diabetes patients included in the Second Manifestations of ARTerial disease (SMART)-cohort. Generalized linear models were used to evaluate the relation between plasma levels of OPN, ON and OC and arterial stiffness as measured by pulse pressure (PP), ankle-brachial index (ABI) (≥0.9), carotid artery distension and an arterial stiffness summary score. Analyses were adjusted for age, sex, kidney function, diabetes duration and diastolic blood pressure. Higher OPN plasma levels were significantly related to a lower ABI (β-0.013; 95%CI -0.024 to -0.002) and a higher arterial stiffness summary score (OR1.24; 95%CI 1.03-1.49). OPN levels were not related to PP (β 0.59; 95%CI -0.63-1.81) or absolute carotid artery distention (β -7.03; 95%CI -20.00-5.93). ON and OC plasma levels were not related to any of the arterial stiffness measures.

CONCLUSION

Only elevated plasma levels of OPN are associated with increased arterial stiffness in patients with type 2 diabetes as measured by the ankle-brachial index and arterial stiffness summary score. These findings indicate that OPN may be involved in the pathophysiology of arterial stiffness and call for further clinical investigation.

Maturity onset diabetes of the young: Seek and you will find

Maturity onset diabetes of the young (MODY) is a monogenic, autosomal dominant form of diabetes characterised by mutations in genes resulting in dysfunction of pancreatic β-cells and subsequent insulin production. We present a family with HNF1A-MODY due to a likely pathogenic mutation in HNF1A (c.59G>A, p.Gly20Glu), diagnosed a long time after the first diagnosis of diabetes. Currently 13 MODY subtypes caused by mutations in 13 genes, are known. We describe the four most prevalent forms in more detail, i.e. HNF4A-MODY, GCK-MODY, HNF1A-MODY and HNF1B-MODY, together responsible for probably 99% of MODY cases. The different forms of MODY vary in prevalence, severity of diabetes, occurrence and severity of diabetic complications and response to treatment. New tools, such as the MODY probability calculator, may be of assistance in finding those patients in whom further genetic testing for possible MODY is warranted. However, as our described family shows, a doctor's clinical eye and taking the time for a detailed family history may be equal to, or even better than, the best prediction rule.

The impact of posttraumatic stress disorder on partners and children of Australian Vietnam veterans

OBJECTIVE

This study explored the emotional and physical health of a group of families of Australian Vietnam veterans suffering posttraumatic stress disorder (PTSD). The aim was to study the impact of PTSD upon the families of the sufferers.

METHOD

The families of a random sample of Vietnam veterans receiving treatment at a specialist PTSD Unit were invited to participate in this study. Partners of the veterans and children over the age of 15 years were eligible to participate. Four self-report psychometric inventories were administered assessing psychological distress, social climate within their families, self-esteem, and a range of lifestyle issues, including physical health. A control group, consisting of a sample of volunteers, was also surveyed.

RESULTS

The partners of the Vietnam veterans showed significantly higher levels of somatic symptoms, anxiety and insomnia, social dysfunction and depression than the control group. They reported significantly less cohesion and expressiveness in their families and significantly higher levels of conflict. The partners also had significantly lower levels of self-esteem. The children of the veterans reported significantly higher levels of conflict in their families. However, the children showed no significant differences on measures of psychological distress and self-esteem from their matched counterparts.

CONCLUSIONS

These findings support overseas studies that indicate that the families of PTSD sufferers are also impacted by the disorder. In this study, the families of Australian Vietnam veterans experienced more conflict and their partners were significantly more psychologically distressed (i.e. somatic symptoms, anxiety, insomnia, social dysfunction, depression and low self-esteem) than a matched control group.

An intensive treatment program for chronic posttraumatic stress disorder: 2-year outcome data

OBJECTIVE

The present study evaluates the efficacy of a closed-cohort treatment program for chronic posttraumatic stress disorder (PTSD).

METHOD

The treatment orientation was a combined approach involving cognitive behaviour therapy and pharmacotherapy. Treatment involved an inpatient phase of 4 weeks, with group and individual follow-up sessions of at least 6-month duration. The treatment population consisted largely of Australian Vietnam veterans. Standardised psychometric measures were obtained pre-treatment, on completion of the residential phase; and at 6, 12 and 24 months post discharge from the residential program.

RESULTS

The results obtained from 64 patients demonstrate significant reductions in depression, anxiety and PTSD symptoms, maintained at 2 years post discharge from the residential phase of the treatment program.

CONCLUSIONS

This paper presents encouraging findings for treatment with this troubled population.