Association of Strict Versus Lenient Cholesterol Lowering with Cardiac Outcomes, Diabetes Progression and Complications, and Mortality in Patients with Diabetes Treated with Statins: Is Less More?

INTRODUCTION

Whereas some guidelines recommend statin use to achieve low-density lipoprotein cholesterol (LDL-C) goal < 70 mg/dL for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in patients at higher risk, others recommend against a target LDL-C level. Achieving a target level < 70 mg/dL commonly requires the use of high intensity statins, which has been associated with higher risk of diabetes progression. The objective of this study is to assess the association of strict (≤ 70 mg/dL) versus lenient (> 70 to100 mg/dL) LDL-C lowering on major adverse cardiovascular events (MACE), diabetes progression, diabetes microvascular complications, and total mortality in patients with diabetes.

METHODS

This was a retrospective propensity score (PS)-matched study from a national cohort of, predominantly male, veterans diagnosed with diabetes without prior cardiovascular disease (from fiscal years 2003-2015), who were initiated on a statin. We created PS to match strict (mean LDL-C during follow-up ≤ 70 mg/dL) versus lenient (mean LDL-C during follow up > 70-100 mg/dL) using 65 baseline characteristics including comorbidities, risk scores, medication classes usage, vital signs, and laboratory data. Outcomes included MACE, diabetes progression, microvascular diabetes complications, and total mortality.

RESULTS

From 80,110 eligible patients, we PS-matched 21,294 pairs of statin initiators with strict or lenient LDL-C lowering. The mean (SD) age was 64 (9.5) years and mean (SD) duration of follow-up was 6 (3) years. MACE was similar in the PS-matched groups [6.1% in strict versus 5.8% in lenient; odds ratio (OR): 1.06; 95% confidence interval (95% CI) 0.98-1.15, P = 0.17]. Diabetes progression was higher among the strict vs lenient group (66.7% in strict versus 64.1% in lenient; OR 1.12; 95% CI 1.08-1.17, P < 0.001). There was no difference in microvascular diabetes complications (22.3% in strict versus 21.9% in lenient; OR 1.02; 95% CI 0.98-1.07, P = 0.31) and no difference in total mortality (14.6% in strict versus 15% in lenient; OR 0.97; 95% CI 0.92-1.02, P = 0.20).

CONCLUSION

Strict compared with lenient lowering of LDL-C with statins in men with diabetes without preexisting ASCVD did not decrease the risk of MACE but was associated with an increased diabetes progression. Clinicians should monitor their patients for diabetes progression upon escalating statins to achieve LDL-C levels ≤ 70 mg/dL.

Five-Year Follow-Up of Diabetic Complications and Geriatric Alterations in French Older Patients with Type 2 Diabetes According to Treatment Modalities: The Observational Prospective GERODIAB Cohort

BACKGROUND

Little is known about clinical events occurring in older patients with type 2 diabetes mellitus according to their therapeutic modalities based on the prescription of insulin and/or oral antidiabetic drugs.

OBJECTIVE

The aim of this study was to compare the complications of diabetes and geriatric alterations that occurred according to three therapeutic modalities prescribed over 5 years.

METHODS

A total of 616 patients from the GERODIAB cohort (mean age 77.1 years) were divided into three groups: an insulin-only group (n = 200), a group receiving insulin and one or more oral antidiabetic drug (n = 169), and an oral antidiabetic drug group without insulin (n = 247). We compared the diabetic complications and geriatric alterations that occurred over 5 years in patients without these pre-existing complications.

RESULTS

At inclusion, there was a significant difference between glycosylated hemoglobin values, and between the frequencies of most diabetic complications and geriatric alterations, with higher frequencies in the insulin group and lower frequencies in the oral antidiabetic drug group. At the end of the follow-up, there was still a significant difference between the mean glycosylated hemoglobin of the three groups (mean for all patients 7.4 ± 0.8%). The frequencies of new clinical events were high and they were generally higher in the insulin group. They were not significantly different between the three groups, with the exception of four events: heart failure, retinopathy, transfer to a nursing home (more frequent in the insulin group), and hypoglycemia (more frequent in the insulin + oral antidiabetic drug group). Some frequencies of the total diabetic complications (including complications at inclusion and at the follow-up) in the oral antidiabetic drug group were close to those in the insulin group, although only at inclusion. Mortality was higher in the insulin group and lower in the oral antidiabetic drug group.

CONCLUSIONS

The increased frequency of hypoglycemia in the insulin + oral antidiabetic drug group raises doubts about the value of continuing a secretagogue drug when insulin is introduced. As the vast majority of patients were not yet receiving antidiabetic drugs with cardiovascular action, our results on heart failure could help in conducting specific studies on these drugs in older patients with type 2 diabetes.

CADD Studies in the Discovery of Potential ARI (Aldose Reductase Inhibitors) Agents for the Treatment of Diabetic Complications

The lack of currently available drugs for treating diabetes complications has stimulated our interest in finding new Aldose Reductase inhibitors (ARIs) with more beneficial biological properties. One metabolic method uses aldose reductase inhibitors in the first step of the polyol pathway to control excess glucose flux in diabetic tissues. Computer-aided drug discovery (CADD) is key in finding and optimizing potential lead substances. AR inhibitors (ARI) have been widely discussed in the literature. For example, Epalrestat is currently the only ARI used to treat patients with diabetic neuropathy in Japan, India, and China. Inhibiting R in patients with severe to moderate diabetic autonomic neuropathy benefits heart rate variability. AT-001, an AR inhibitor, is now being tested in COVID-19 to see how safe and effective it reduces inflammation and cardiac damage. In summary, these results from animal and human studies strongly indicate that AR can cause cardiovascular complications in diabetes. The current multi-center, large-scale randomized human study of the newly developed powerful ARI may prove its role in diabetic cardiovascular disease to establish therapeutic potential. During the recent coronavirus disease (COVID-19) outbreak in 2019, diabetes and cardiovascular disease were risk factors for severely negative clinical outcomes in patients with COVID19. New data shows that diabetes and obesity are among the strongest predictors of COVID-19 hospitalization. Patients and risk factors for severe morbidity and mortality of COVID- 19.

[Difficulties and prospects of standardized management of type 1 diabetes]

Type 1 diabetes patients require lifelong dependence on insulin therapy. It is a long-term challenge for patients to effectively deliver exogenous insulin to maintain glucose levels within the individual's target range as safely as possible for preventing the development and progression of diabetes complications. The management of type 1 diabetes involves multidisciplinary collaboration, referral from different hospitals, and effective diabetes education and management for patients and family members. Compared with the more mature diseases management system in the United States and the United Kindom, the standardized management of type 1 diabetes patients in China started late. Moreover, there are still some difficulties at present. Whereas, with the exploration and efforts of the hospitals at all levels for the management of type 1 diabetes patients, standardization of type 1 diabetes management will gradually step forward and truly realize the lifelong management for patients.

Biogenic integrated ZnO/Ag nanocomposite: Surface analysis and in vivo practices for the management of type 1 diabetes complications

In this research, a milk thistle seed extract (MTSE)-rich medium was used as a capping and reducing agent for the one-pot biosynthesis of ZnO/Ag (5 wt%) nanostructure. The sample was systematically characterized through various techniques and its strong biomolecule‒metal interface structure was supported by the results. The efficacy of the derived nanostructure (MTSE/ZnO/Ag) was evaluated in vivo on the basis of its therapeutic effects on the main complications of Type 1 diabetes (hyperglycemia, hyperlipidemia, and insulin deficiency). For this purpose, the changes in the plasma values of fasting blood glucose, total cholesterol, total triglyceride, high-density lipoprotein cholesterol, and insulin in alloxan-diabetic Wistar male rats were compared with those in healthy and untreated diabetic controls after a treatment period of 16 days. The antidiabetic results of MTSE/ZnO/Ag were compared with those obtained from pristine ZnO, MTSE, and insulin therapies. The health conditions of the rats with Type 1 diabetes were significantly enhanced after treatment with MTSE/ZnO/Ag (p < 0.05), which is owing to the enhanced interface structure and participatory functions of the united compartments of MTSE/ZnO/Ag.

Hypoglycemia awareness and burden among hospitalized patients at high risk for hypoglycemia

BACKGROUND

Hypoglycemia, a common complication of insulin therapy in patients with diabetes, is associated with increased hospital morbidity and mortality. Hypoglycemia may be underrecognized in hospitalized patients due to impaired counter regulation or reduced recognition. Beta blocker (BB) use may also affect hypoglycemia recognition.

AIM

To characterize hypoglycemia unawareness and patient perceived hypoglycemia burden in hospitalized patients.

MATERIALS AND METHODS

Over a 2-month period, we prospectively identified non-critically ill cognitively intact hospitalized insulin-requiring patients who were undergoing bedside glucose monitoring. Participants were included if they reported any episode of hypoglycemia in the 30 days prior to admission and either had no BB use or were on stable BB for 90 days. Hypoglycemia unawareness was assessed using the Clarke score and burden of hypoglycemia was assessed with the (TRIM-HYPO) score.

RESULTS

Of the 46 participants, 20 were not taking a BB and 26 were taking a BB. Predictors of hypoglycemia during admission included glucose coefficient of variation and hospital length of stay. Nine participants (20%) had hypoglycemia unawareness (Clarke score ≥4). Participants with a history of coronary artery disease were less likely to have impaired awareness. Burden of hypoglycemia was associated with more hypoglycemia and longer hospital length of stay. There were no differences in measures of hypoglycemia unawareness or burden according to BB use.

CONCLUSIONS

BB use was not related to hypoglycemia unawareness, or burden in hospitalized high risk patients. Hypoglycemia burden may identify patients at higher risk of hypoglycemia during admission.

Paradox of glycemic management: multimorbidity, glycemic control, and high-risk medication use among adults with diabetes

INTRODUCTION

Glycemic targets and glucose-lowering regimens should be individualized based on multiple factors, including the presence of comorbidities. We examined contemporary patterns of glycemic control and use of medications known to cause hypoglycemia among adults with diabetes across age and multimorbidity.

RESEARCH DESIGN AND METHODS

We retrospectively examined glycosylated hemoglobin (HbA_1c) levels and rates of insulin/sulfonylurea use as a function of age and multimorbidity using administrative claims and laboratory data for adults with type 2 diabetes included in OptumLabs Data Warehouse, 1 January 2014 to 31 December 2016. Comorbidity burden was assessed by counts of any of 16 comorbidities specified by guidelines as warranting relaxation of HbA_1c targets, classified as being diabetes concordant (diabetes complications or risk factors), discordant (unrelated to diabetes), or advanced (life limiting).

RESULTS

Among 194 157 patients with type 2 diabetes included in the study, 45.2% had only concordant comorbidities, 30.6% concordant and discordant, 2.7% only discordant, and 13.0% had ≥1 advanced comorbidity. Mean HbA_1c was 7.7% among 18-44 year-olds versus 6.9% among ≥75 year-olds, and was higher among patients with comorbidities: 7.3% with concordant only, 7.1% with discordant only, 7.1% with concordant and discordant, and 7.0% with advanced comorbidities compared with 7.4% among patients without comorbidities. The odds of insulin use decreased with age (OR 0.51 (95% CI 0.48 to 0.54) for age ≥75 vs 18-44 years) but increased with accumulation of concordant (OR 5.50 (95% CI 5.22 to 5.79) for ≥3 vs none), discordant (OR 1.72 (95% CI 1.60 to 1.86) for ≥3 vs none), and advanced (OR 1.45 (95% CI 1.25 to 1.68) for ≥2 vs none) comorbidities. Conversely, sulfonylurea use increased with age (OR 1.36 (95% CI 1.29 to 1.44) for age ≥75 vs 18-44 years) but decreased with accumulation of concordant (OR 0.76 (95% CI 0.73 to 0.79) for ≥3 vs none), discordant (OR 0.70 (95% CI 0.64 to 0.76) for ≥3 vs none), but not advanced (OR 0.86 (95% CI 0.74 to 1.01) for ≥2 vs none) comorbidities.

CONCLUSIONS

The proportion of patients achieving low HbA_1c levels was highest among older and multimorbid patients. Older patients and patients with higher comorbidity burden were more likely to be treated with insulin to achieve these HbA_1c levels despite potential for hypoglycemia and uncertain long-term benefit.

Impact of SGLT Inhibitors on Multiple Organ Defects in Diabetes

INTRODUCTION

Diabetes leads to multiple organ defects and cellular dysfunctions such as increased expression of sodium-glucose like transporters (SGLTs). These transporters contribute to glucose homeostasis through glucose reabsorption in the proximal renal tubule. When inhibited, it results in reduced hyperglycemia, increased glucosuria and decreased HbA1c.

AIMS

This review article summarizes the positive and adverse effects of the three main SGLT inhibitors used in Europe, on different organs with the aim of providing useful information to clinicians in order to select the adapted SGLT inhibitor in regard to patient health problems.

DISCUSSION

Recently, SGLT pharmacological inhibitors have been developed to manage hyperglycemia in diabetic patients. SGLT inhibitors like canagliflozin, dapagliflozin, empagliflozin were approved by the Food and Drug Administration (FDA) in 2013 for use in Europe. Beyond their impact on glucose re-uptake by the kidney, these inhibitors exert beneficial pleiotropic effects. Nevertheless, several studies have recently warned the scientific community regarding adverse effects of these agents. Therefore, clinicians should consider these effects to adapt the treatment regarding patients' health.

CONCLUSION

The use of SGLT inhibitor in the treatment of type 2 diabetes should be considered with the perspective of general health state of the patient. In fact, SGLT inhibitors promote pleiotropic effects, among which some are beneficial for certain organs while some are deleterious.

Study design choices for evaluating the comparative safety of diabetes medications: An evaluation of pioglitazone use and risk of bladder cancer in older US adults with type-2 diabetes

AIM

The aim of the study was to empirically demonstrate the effect of varying study designs when evaluating the safety of pioglitazone in treating bladder cancer.

METHODS

We identified Medicare beneficiaries above 65 years of age with diabetes between 2008 and 2015 and with classified exposure (at least two claims within 180 days) to glucose-lowering drugs (GLD), pioglitazone or another drug. The effects of varying the following study design parameters on bladder cancer risk were assessed: use of a new vs existing drug, choice of referent (all non-users and users of GLDs, non-insulin GLDs and DPP-4s) and whether or not censoring accounted for treatment change. We used the Cox proportional hazards model to obtain adjusted HRs and 95% CIs.

RESULTS

We included 1,510,212 patients classified as pioglitazone users (N = 135,188) or non-users (N = 1,375,024). Users had more diabetic complications than non-users, but fewer than insulin users. The HR ranged from 1.10 (1.01-1.20) to 1.13 (0.99-1.29) when censoring ignored treatment change, suggesting a weak association or none between pioglitazone and bladder cancer, probably under-estimating risk. However, the HR was 1.20 (1.01-1.42) when cohorts were restricted to new users, censored upon treatment change, and when DPP-4 was used as the referent, suggesting an increased risk of bladder cancer associated with pioglitazone.

CONCLUSIONS

The continued demand for new GLDs indicates the need for more robust observational methods to improve the value of generating real-world evidence in equipping clinicians to make informed prescribing decisions. Although there is no one-size-fits-all approach, we recommend active comparator new user study designs that compare therapeutically equivalent drugs and account for treatment changes during follow-up to present the least biased comparative safety estimates.

Predictors for repeated hyperkalemia and potassium trajectories in high-risk patients - A population-based cohort study

Understanding predictors and trajectories of increased potassium may inform testing and treatment of hyperkalemia. We examined predictors for repeated hyperkalemia among patients after first-time renin angiotensin system inhibitor (RASi) prescription, chronic kidney disease (CKD), or chronic heart failure (CHF); and we also examined potassium trajectories in these patients after their first hyperkalemia event. We used Danish population-based registries to identify all patients with first-time RASi prescription, incident CKD, or incident CHF (2000–2012). For patients with a first hyperkalemia event, potassium trajectories over the following 6 months were examined. The predictors associated with repeated hyperkalemia were assessed, with repeated hyperkalemia defined as a potassium test >5.0 mmol/L after the first event within 6 months. Overall 262,375 first-time RASi users, 157,283 incident CKD patients, and 14,600 incident CHF patients were included. Of patients with a first hyperkalemia event, repeated hyperkalemia within 6 months occurred in 37% of RASi users, 40% with CKD, and 49% of patients with CHF. Predictors included severe hyperkalemia, low eGFR, diabetes, and spironolactone use. In all cohorts, the median potassium levels declined over 2–4 weeks after a hyperkalemia event for the first time, but reverted to levels higher than before the initial hyperkalemia event in those who had repeated hyperkalemia. Following hyperkalemia, discontinuation of RASi and spironolactone was common in the RASi and CHF cohorts. Repeated hyperkalemia was common among the explored cohorts. The first hyperkalemia event was an indicator of increased median potassium levels. Predictors may identify patients likely to benefit from intensified monitoring and intervention.

The Association of Biochemical Hypoglycemia with the Subsequent Risk of a Severe Hypoglycemic Event: Analysis of the DCCT Data Set

OBJECTIVE

To evaluate the association of biochemical hypoglycemia with subsequent severe hypoglycemia (SH) events using the Diabetes Control and Complications Trial (DCCT) data set.

RESEARCH DESIGN AND METHODS

The frequency of biochemical hypoglycemia (percentage of values <70 and <54 mg/dL [3.9 and 3.0 mmol/L) was assessed using DCCT blood glucose concentrations measured at a central laboratory from seven finger-stick samples (7-point testing: pre- and 90-min postmeals and at bedtime) collected during 1 day every 3 months. SH events required a change in mental status necessitating the involvement of another individual to provide treatment. A Poisson model accounting for repeated measures from each participant was used to assess the association of biochemical hypoglycemia frequency, computed from the 7-point finger-stick data, with the development of SH events.

RESULTS

The risk of SH during a 3-month period was substantially higher (P < 0.001) when there was at least one hypoglycemic blood glucose value in the preceding 7-point profile, with similar results seen for both the 70 mg/dL (rate ratio = 3.0 [95% confidence interval: 2.6-3.3]) and 54 mg/dL (rate ratio = 2.7 [95% confidence interval: 2.4-3.1]) thresholds.

CONCLUSIONS

The occurrence of biochemical hypoglycemia <70 or <54 mg/dL is associated with an increased risk of SH. For this reason as well as the deleterious effects of hypoglycemia on glucose counter-regulation and hypoglycemia awareness, cognition, quality of life, and arrhythmias, it is important in diabetes management to avoid hypoglycemic glucose levels as much as possible.

Analysis of the characteristics of patients with diabetes mellitus who attend a tertiary hospital emergency department for a hypoglycemic event

INTRODUCTION AND OBJECTIVE

Hypoglycemia associated to insulin or other glucose-lowering agents is one of the most common causes of visits to the emergency department for adverse drug reactions. The study objective was to analyze the characteristics of patients with diabetes mellitus (DM) who attend a tertiary hospital emergency department for a hypoglycemic event.

PATIENTS AND METHODS

A 3-year retrospective analysis was conducted of patients with DM who attended the emergency department of Hospital Universitari de Bellvitge for a hypoglycemic event. An analysis was made of epidemiological and diabetes-related characteristics, prevalence of chronic diabetic complications and other comorbidities, the glucose-lowering treatment and the result of the hypoglycemic episode.

RESULTS

Of the 149 hypoglycemic events analyzed, 81.9% occurred in patients with type 2 DM. Mean age of patients with type 2 DM was 75.4 years. DM duration was longer than 10 years in 69.4% of patients. The prevalence rates of chronic kidney disease and cognitive decline were 38.5% and 19.7% respectively in patients with type 2 DM. Insulin with or without other concomitant glucose-lowering agents was associated to 78.7% of episodes in type 2 DM patients. The remaining 21.3% were associated to oral hypoglycemic agents, mainly glibenclamide. After the event, 13.4% of patients required hospital admission, and in 36.8% of these hypoglycemia was associated to use of glibenclamide.

CONCLUSIONS

A majority of hypoglycemic events occurred in elderly patients with type 2 DM, with a high prevalence of associated comorbidities and treated with insulin and sulfonylureas, particularly glibenclamide.

Review of pentosidine and pyrraline in food and chemical models: formation, potential risks and determination

Pyrraline and pentosidine are advanced Maillard reaction products derived from the reaction of glucose with the lysine amino group on proteins. They have been implicated in uremia, diabetes, and related complications, including inflammation, retinopathy, and nephropathy. This review focuses on the formation mechanism, human potential risks, and detections of pentosidine and pyrraline and lays the foundation for further study of pentosidine and pyrraline. © 2017 Society of Chemical Industry.

Renal function after intravitreal administration of vascular endothelial growth factor inhibitors in patients with diabetes and chronic kidney disease

The present study aimed to determine whether intravitreal administration of vascular endothelial growth factor inhibitors is associated with deterioration of renal function, as seen with systemic administration, in patients with diabetes and chronic kidney disease. Estimated glomerular filtration rates before and after 160 intravitreal injections of vascular endothelial growth factor inhibitors (aflibercept, bevacizumab or ranibizumab) were compared in 69 patients with diabetes and with a baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 . We also determined the incidence of acute kidney injury. The data showed no significant difference in the estimated glomerular filtration rate before and after vascular endothelial growth factor inhibitor administration in all patients and in patient subgroups based on each inhibitor. Furthermore, no episodes of acute kidney injury occurred. In conclusion, intravitreal administration of vascular endothelial growth factor inhibitors is unlikely to be associated with a deterioration of renal function in patients with diabetes and chronic kidney disease.

Adverse glycaemic effects of cancer therapy: indications for a rational approach to cancer patients with diabetes

Diabetes and cancer are common, chronic, and potentially fatal diseases that frequently co-exist. Observational studies have reported an increased risk of cancer in patients with diabetes. Furthermore, many patients with cancer already have diabetes, or develop hyperglycaemia as a consequence of the tumor or of cancer therapies, and coexisting diabetes confers a greater risk of mortality for many malignancies. Managing oncologic patients with diabetes is often complicated, since the co-existence of diabetes and cancer poses several complex clinical questions: what level of glycaemic control to achieve, which therapy to use, how to deal with glucocorticoid therapies and artificial nutrition, how diabetes complications can affect cancer management, which drug-drug interactions should be taken into account, or even how to manage diabetes at the end of life. In the clinical setting, both at hospital and at home, there are little agreed, evidence-based guidelines on the best management and criteria upon which clinical decisions should be based. A practical solution lies in the implementation of care networks based on communication and ongoing collaboration between Oncologists, Endocrinologists, and the nursing staff, with the patient at the centre of the care process. This manuscript aims to review the current evidence on the effect of cancer therapies on glucose metabolism and to address some of the more common challenges of diabetes treatment in patients with cancer.

Cardiovascular safety trials of incretin-based drugs: What do they mean?

Incretin-based dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists are newer choices of antidiabetic medications that are now most widely used worldwide. Preclinical study results suggest that the two drugs potentially exert benefits to prevent onsets and/or progressions of diabetes-related complications, such as myocardial infarctions and strokes. Outcomes of five clinical trials to evaluate the cardiovascular (CV) safety of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonist have been recently reported. The heart failure findings of the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53 (SAVOR-TIMI53) are unexpected and very concerning; results of the Examination of Cardiovascular Outcomes with Alogliptin vs Standard of Care (EXAMINE), the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) and the Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA) encourage neutral CV safety profiles of incretin-based drugs in individuals with type 2 diabetes and established CV diseases or multiple CV risks. Furthermore, the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) results show the benefits of liraglutide in preventing CV events in a similar study population. Despite the many preclinical studies showing the beneficial effects of incretin-related drugs, most CV safety trials of incretin-based drugs, except for LEADER, did not show benefits for CV events. It is important to recognize that CV safety trials were carried out to meet the US Food and Drug Administration guidance to assess CV safety of all new antidiabetic drugs; they were not designed to assess their benefits for CV events. Therefore, the long-term potential benefit, as well as even the safety, of incretin-based drugs for certain CV outcomes has not been definitively established, and requires evaluation in more specific and more relevant trials. If the need for CV safety trials would be determined based on an individual drug's safety data during its earlier development as well as its mechanism of action, resources could be saved for carrying out such clinical trials.

Glucocorticoid use and its association with skeletal health among U.S. adults with diabetes

AIMS

Determine the prevalence of glucocorticoid use in U.S. adults with diabetes and whether prevalence is associated with reduced skeletal health, as measured by fracture history and bisphosphonate use.

METHODS

Participants were age≥20years from the cross-sectional National Health and Nutrition Examination Survey (1999-2010; N=15,661). Diabetes was determined by self-report, fasting plasma glucose ≥126mg/dL (≥6.99mmol/L), or A1c ≥6.5% (≥47.5mmol/mol) (n=4539). Prevalences of fractures and bisphosphonate use were determined by diabetes status and glucocorticoid use. Logistic regression was stratified by sex and assessed the effect of glucocorticoid use and diabetes associated with fractures and bisphosphonates.

RESULTS

The age-standardized prevalence of glucocorticoid use was higher among persons with diabetes (3.2% vs. 2.0% without diabetes, p=0.001). Among adults with diabetes, the prevalence of fractures was significantly higher among those taking glucocorticoids vs. those not (38.3% vs. 26.1%, p=0.048). The prevalences of fractures and bisphosphonate use were generally similar in those with and without diabetes when stratified by glucocorticoid use. In logistic regression analysis among men, the combination of diabetes and glucocorticoid use (compared to those with neither) was highly associated with bisphosphonate use, while adjusting for demographic factors. Among women, having diabetes and glucocorticoid use increased the odds of fractures, while adjusting for demographic factors and menopause.

CONCLUSIONS

The prevalence of fractures was greater for those with diabetes taking glucocorticoids versus those not taking glucocorticoids. This study provides a national framework for further research on elucidating these associations.

Healing effects of sumac (Rhus coriaria) in streptozotocin-induced diabetic rats

Context Sumac [Rhus coriaria L. (RC) (Anacardiaceae)] is used as a folk medicine in the treatment of diabetes in Turkey. Objective This study investigates the in vivo healing and protective effects of lyophilized extract sumac against streptozotocin (STZ)-induced diabetic complications. Materials and methods Toxicity test was conducted in three different dosages (250, 500 and 1000 mg/kg of plant extracts, respectively). Six groups of seven rats each were used in experiments. Groups were designed as Normal control, Diabetic (DM), DM + AC-20 mg/kg, DM + Extract-100 mg/kg, DM + Extract 250 mg/kg and DM + Extract 500 mg/kg group. Experimental diabetes [50 mg/kg, intraperitoneal (i.p.)] was induced by STZ. The effects of oral administration of the extract for 21 d on the level of serum glucose, insulin, C-peptide, lipid profile (LP), hepatic and renal damage biomarkers (HRDB), diabetic serum biomarkers (DSB), glycosylated haemoglobin (HbA1c), antioxidant defence system constituents (ADSCs), malondialdehyde (MDA) and α-glucosidase activity in small intestine tissue were evaluated. Results The extract decreased the levels of blood glucose in diabetic groups (an average of 31%). Triglyceride, total cholesterol, high-density lipoprotein and low-density lipoprotein levels were balanced by plant extract (500 mg/kg) supplementation in the diabetic group. Decreased levels of aspartate aminotransferase (89%), alanine aminotransferase (91%), lactate dehydrogenase (35%), alkaline phosphatase (47%), creatinine (25%) and urea (29%) were detected in plant extract (500 mg/kg) supplemented diabetic group. Additionally, a considerable increase in the HRDB, DSB, LP, MDA and fluctuated ADSC levels were restored in RC-extract supplemented groups. Conclusion RC lyophilized extract has a healing effect on diabetes and diabetes-related complications.

Strong inhibition of the polyol pathway diverts glucose flux to protein glycation leading to rapid establishment of secondary complications in diabetes mellitus

BACKGROUND

Polyol pathway and protein glycation are implicated in establishing secondary complications in diabetes. Their relative contribution to the process needs to be evaluated. It is essential to understand why some aldose reductase inhibitors (ARIs) trials are successful while some have failed and to study their effect on protein glycation.

METHODS

Aldose reductase (AR) was assayed using xylose as substrate; protein glycation was evaluated using total and specific fluorescence, fructoseamine and protein bound carbonyl content (PCO) measurements. Long term studies were carried out on streptozotocin induced diabetic rats for evaluation of urine parameters, tissue fluorescence. Anti-cataract action was studied by lens culture studies.

RESULTS

Epalrestat, a commercial ARI was also found to possess potent glycation inhibitory action. Long term experiments revealed strong protein glycation with higher concentration of citronellol (ARI) demonstrating shift in glucose flux. Treatment with epalrestat and limonene revealed improved urine parameters and tissue fluorescence. Lens culture studies revealed cataract formation at higher inhibition of AR while no lens opacity was observed at lower citronellol concentration and with limonene and epalrestat.

CONCLUSION

Strong inhibition of AR shifts the glucose flux to protein glycation causing damage. ARIs possessing protein glycation inhibition are more useful in amelioration of secondary complications.

Comparative Study of the Antioxidant Effects of Metformin, Glibenclamide, and Repaglinide in Alloxan-Induced Diabetic Rats

Diabetes mellitus is one of the serious global health problems affecting a significant proportion of both developed and developing countries. Overproduction of free radicals and oxidative stress has been associated with the development of diabetic complications. In the present study, the antioxidant effects of metformin (MET), glibenclamide (GLI), and repaglinide (REP) were evaluated in alloxan-induced diabetic rats. The findings from this study may possibly help in understanding the efficacy of these standard drugs in managing the complications arising from diabetes mellitus (DM). Alloxan (130 mg/kg BW) was administered as a single dose to induce diabetes. Four (4) groups of rats (n = 6) were used; group 1 served as diabetic control while groups 2, 3, and 4 were the diabetic test groups that received MET (25 mg/kg), GLI (2.5 mg/kg), and REP (0.5 mg/kg), respectively. The result of the study showed significant (p < 0.05) improvement in the altered antioxidant enzymes (SOD, CAT) and GSH concentration in diabetic treated rats compared with the diabetic control group. MET and REP produced significant effect on the MDA concentration while GLI showed insignificant reduction in the MDA concentration compared with the diabetic control. Findings from this study suggest that the administration of MET, GLI, and REP exerts significant antioxidant effects in alloxan-induced diabetic rats, thus contributing to the protective effect against oxidative stress-induced damage during diabetic complications.

Mechanism Investigation of the Improvement of Chang Run Tong on the Colonic Remodeling in Streptozotocin-Induced Diabetic Rats

Previous study demonstrated that Chang Run Tong (CRT) could partly restore the colon remodeling in streptozotocin- (STZ-) induced diabetic rats. Here we investigated the mechanisms of such effects of CRT. Diabetes was induced by a single injection of 40 mg/kg of STZ. CRT was poured into the stomach by gastric lavage once daily for 60 days. The remodeling parameters were obtained from diabetic (DM), CRT treated diabetic (T1, 50 g/kg; T2, 25 g/kg), and normal (Con) rats. Expressions of advanced glycation end product (AGE), AGE receptor, transforming growth factor-β1 (TGF-β1), and TGF-β1 receptor in the colon wall were immunochemically detected and quantitatively analyzed. The association between the expressions of those proteins and the remodeling parameters was analyzed. The expressions of those proteins were significantly higher in different colon layers in the DM group (P < 0.05, P < 0.01) and highly correlated to the remodeling parameters. Furthermore, the expressions of those proteins were significantly decreased in the T1 group (P < 0.05, P < 0.01) but not in the T2 group (P > 0.05). The corrective effect on the expressions of those proteins is likely to be one molecular pathway for the improvement of CRT on the diabetes-induced colon remodeling.

Association between comorbidities and dementia in diabetes mellitus patients: population-based retrospective cohort study

AIMS

Most diabetes mellitus (DM) patients have several comorbidities; the correlation of these comorbidities with dementia in DM requires clarification.

METHODS

Using claims data from Taiwan National Health Insurance, we identified 33,709 DM adults before the year 2000 and randomly selected 67,066 non-DM patients matched by sex and age. Subjects were followed until diagnosis with dementia, excluded due to death/withdrawal from the insurance program, or followed until 2011. We compared the incidence and hazard ratio (HR) for dementia in both cohorts.

RESULTS

Comorbidities were more prevalent in DM patients, including hypertension, hyperlipidemia, stroke, coronary artery and/or kidney disease. The HR was higher for the DM cohort with comorbidities than those without: 1.88 vs. 1.46 with hypertension; 1.56 vs. 1.39 with hyperlipidemia; 1.73 vs. 1.37 with coronary artery disease; 2.36 vs. 2.29 with stroke and 1.88 vs. 1.50 with kidney disease. The HR for dementia in diabetics rose from 1.41 in those without comorbidities to 2.49 in those with ≥4 comorbidities. In the DM cohort, HR was 1.22 for non-insulin-users and 1.41 for insulin-users, and 1.49 for type 1 DM and 1.23 for type 2 DM.

CONCLUSION

Diabetic patients have an elevated risk of dementia, and comorbidity increases this risk.

Expression of SIRT1 and oxidative stress in diabetic dry eye

OBJECTIVE

To explore the expression of SIRT1 with oxidative stress and observe physiological and pathological changes in the corneas as well as the association between SIRT1 and oxidative stress of diabetic dry eyes in mice.

METHOD

Forty-eight C57BL/6Jdb/db mice at eight weeks of age were divided randomly into two groups: the diabetic dry eye group and the diabetic group. An additional forty-eight C57BL/6J mice at eight weeks of age were divided randomly into two groups: the dry eye group and the control group. Every mouse in the dry eye groups (diabetic and normal) was injected with scopolamine hydrobromide three times daily, combined with low humidity to establish a dry eye model. After the intervention, phenol red cotton string tests and corneal fluorescein staining were performed. In addition, HE staining and immunofluorescence were done. Expression of SIRT1 in the cornea was examined by real-time PCR and Western Blot and expression of FOXO3 and MnSOD proteins was detected by Western Blot.

RESULTS

At one, four, and eight weeks post intervention, all of the groups except the controls showed significant decreases in tear production and increases in the corneal fluorescein stain (P<0.05 vs control). Between the experimental groups, the diabetic dry eye group had the least tear production and the highest corneal fluorescein stain score (P<0.05). As the disease progressed, all of the experimental groups showed obviously pathological changes in HE staining, particularly the diabetic dry eye group. In the 1(st) and 4(th) week, the expression of SIRT1, FOXO3, and MnSOD were significantly higher in the diabetic DE and DM groups but lower in the DE group compared to the controls (P<0.05). In the 8(th) week, the expression of SIRT1, FOXO3, and MnSOD was significantly down-regulated in the diabetic DE group and the DM group (P<0.05). Immunofluorescence showed similar results.

CONCLUSION

In the condition of diabetic dry eye, tear production declined markedly coupled with seriously wounded corneal epithelium. Oxidative stress in the cornea was enhanced significantly and the expression of SIRT1 was decreased.

[Effect of moxibustion with ignited Zhuang-medicine medicated-thread on interstitial cells of Cajal in gastric antrum in diabetic gastroparesis rats]

OBJECTIVE

To observe the effect of Zhuang-medicine medicated-thread moxibustion therapy on interstitial cells of Cajal (ICC) in the gastric antrum of diabetic gastroparesis (DGP) rats, so as to investigate its mechanism underlying improving DGP.

METHODS

Sprague-Dawley (SD) male rats were randomly divided into 3 groups: control (n = 30) , model (n = 30) and moxibustion (n = 30). The DGP model was established by intraperitoneal injection of streptozotocin (STZ) and by feeding the rats with high fat-sugar forage. Zhuang-medicine medicated-thread moxibustion was applied to "Zhongwan" (CV 12), bilateral "Pishu" (BL 20), "Weishu" (BL 21), "Neiguan" (PC 6) and "Zusanli" (ST 36) once per day, for 3 weeks except weekends. The gastrointestinal propulsion rate and weight of stool in 24 h were determined, and c-kit (a marker for ICC) expression of the gastric antrum tissue was measured by immunohistochemistry.

RESULTS

The stool weight was significantly higher in the model group than in the control group (P < 0.01), but the rate of gastrointestinal propulsion and the rate of c-kit immunoreaction (IR) positive cells in the gastric antrum tissue were significantly lower in the model group than in the control group (P < 0.01). After moxibustion, the increased stool weight and the decreased gastrointestinal propulsion rate and decreased c-kit IR-positive cell rate were reversed (P < 0.01).

CONCLUSION

Zhuang-medicine medicated-thread moxibustion therapy can improve gastrointestinal function in DGP rats, which may be associated with its effect in up-regulating the expression of c-kit IR-positive ICC.

[Endotoxin theory of atherosclerosis]

The involvement of bacterial lipopolysaccharides in the induction of atherogenesis is postulated. The excess of bacterial lipopolysaccharides (endotoxin aggression) is observed in the general blood circulation of volunteers with the presence of atherosclerotic risk factors (obesity, diabetes, stress, pathology of haemostasis, kidney, intestines, etc.). The results allow to be optimistic about the prospects for preventing the development and progression of atherosclerotic pathology.

Intramuscular risk at insulin injection sites--measurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous insulin therapy

BACKGROUND

Intramuscular (IM) injection can increase insulin absorption, causing hypoglycemia. Available needle lengths today are 4-12.7 mm for pens and 6-12.7 mm for syringes. We describe the distance (D) from skin surface to muscle fascia at injection sites for subcutaneous (SC) insulin therapy and recommend needle lengths to reduce IM injection risk.

MATERIALS AND METHODS

At two locations in the United States, skin and SC fat thicknesses were measured by ultrasound at the abdomen, arm, thigh, and buttock in diverse adults (body mass index [BMI] range, approximately 19-65 kg/m²) with diabetes (n=341 with one or more paired skin and SC measurement, permitting calculation of D). The natural log of D by body site, BMI, and gender were analyzed using a mixed model to estimate IM risk.

RESULTS

D varied significantly by body site, BMI, and gender (each P<0.001), increasing with higher BMI and in women. Median D ranged from 10.9 mm (95% confidence interval, 10.3, 11.6) at the thigh to 16.9 mm (15.9, 18.1) at the buttock. Minimum D was <3 mm at the thigh and <5 mm elsewhere. When inserted 90° without pinch-up, the most commonly used needle worldwide (8 mm) has estimated IM risks of 25% and 9.7%, respectively, in the thigh and abdomen, versus 1.6% and 0.1%, respectively, with a 4 mm needle. A 45° insertion reduces, but does not eliminate, IM risk with longer needles.

CONCLUSIONS

Gender, BMI, and body site affect D; when combined with needle length and insertion angle, these factors permit detailed estimates of IM insulin injection risk. Such risk varies across sites, appears greatest at the thigh, is unnecessarily increased with 8 mm and 12.7 mm needles, and is greatly reduced with shorter-length needles and good injection technique.

Remote ischemic preconditioning for prevention of contrast-induced acute kidney injury in diabetic patients

INTRODUCTION

There are some clinical trials showing that short-term ischemia in one organ can protect different organs against higher intensity and longer ischemic insult. We designed a study to assess whether remote ischemic preconditioning (RIPC) on one organ can decrease the rate of contrast-induced acute kidney injury (AKI) in diabetic patients who undergo coronary artery angiography (CAA).

MATERIALS AND METHODS

This randomized control trial included 96 diabetic patients who were candidates for CAA. Exclusion criteria were congestive heart failure and complications during CAA. All of the patients received 1000 mL of normal saline before CAA. The RIPC group underwent 3 cycles of 5-minute ischemia in their right arm. Serum creatinine was measured before and 24 hours after CAA.

RESULTS

Contrast-induced AKI was reported in 5 cases in the control group and 1 case in the RIPC group (P = .13, odds ratio, 5.4). The differences in serum creatinine level before and after the procedure was significantly lower in RIPC group than that in the control group (P = .04, odds ratio, 0.08). Serum creatinine rise significantly correlated with contrast dose (P = .02) and a history of hypertension (P = .02) in both groups.

CONCLUSIONS

Ischemic preconditioning had a protective effect on contrast-induced AKI in our study. Since this method is harmless and cost effective, further studies on patients with chronic kidney disease is required to evaluate addition of ischemic preconditioning to our clinical practice for prevention of contrast-induced AKI.

Subchronic effects of inhaled ambient particulate matter on glucose homeostasis and target organ damage in a type 1 diabetic rat model

Epidemiological studies have reported associations between particulate matter (PM) and cardiovascular effects, and diabetes mellitus (DM) patients might be susceptible to these effects. The chief chronic injuries resulting from DM are small vascular injuries (micro-vascular complications) or large blood vessel injuries (macro-vascular complications). However, toxicological data regarding the effects of PM on DM-related cardiovascular complications is limited. Our objective was to investigate whether subchronic PM exposure alters glucose homeostasis and causes cardiovascular complications in a type 1 DM rat model. We constructed a real world PM2.5 exposure system, the Taipei Air Pollution Exposure System for Health Effects (TAPES), to continuously deliver non-concentrated PM for subchronic exposure. A type 1 DM rat model was induced using streptozotocin. Between December 22, 2009 and April 9, 2010, DM rats were exposed to PM or to filtered air (FA) using TAPES in Taipei, Taiwan, 24h/day, 7days/week, for a total of 16weeks. The average concentrations (mean [SD]) of PM2.5 in the exposure and control chambers of the TAPES were 13.30 [8.65] and 0.13 [0.05]μg/m(3), respectively. Glycated hemoglobin A1c (HbA1c) was significantly elevated after exposure to PM compared with exposure to FA (mean [SD], 7.7% [3.1%] vs. 4.7% [1.0%], P<0.05). Interleukin 6 and fibrinogen levels were significantly increased after PM exposure. PM caused focal myocarditis, aortic medial thickness, advanced glomerulosclerosis, and accentuation of tubular damage of the kidney (tubular damage index: 1.76 [0.77] vs. 1.15 [0.36], P<0.001). PM exposure might induce the macro- and micro-vascular complications in DM through chronic hyperglycemia and systemic inflammation.

The synergistic effects of HIV, diabetes, and aging on cognition: implications for practice and research

Thanks to highly active antiretroviral therapy, many people infected with HIV will likely live into old age. Although this is a welcome prognosis, new issues are emerging that may complicate the ability to successfully age in this clinical population. HIV and aging independently are related to cognitive impairments, so there are concerns that those aging with HIV may be more at risk of such cognitive impairments. Moreover, highly active antiretroviral therapy itself can create metabolic disorders, such as prediabetes and/or frank type 2 diabetes, which have also been linked to poorer cognitive functioning. Thus, concerns increase that, as people age with HIV and develop comorbid metabolic disorders that may lead to type 2 diabetes, they will be at triple risk of developing cognitive impairments that can impair everyday functioning and reduce quality of life. This article explores these issues and provides implications for practice and research.

Decreased neuronal bursting and phase synchrony in the hippocampus of streptozotocin diabetic rats

Diabetic encephalopathy is one of the complications of diabetes. Cognitive dysfunction is the main consequence. Previous findings from neuroanatomical and in vitro electrophysiological studies showed that the structure and function of the hippocampus is impaired in diabetes, which may underlie the cognitive dysfunction induced by diabetes. However the study of electrophysiological abnormality of hippocampal neurons in intact networks is sparse. In the current study, we recorded the spontaneous firing of neurons in hippocampal CA1 area in anesthetized streptozotozin (STZ)-diabetic and age-matched control rats. Profound reduction in burst activity was found in diabetic rats. Compared to control rats, the intra-burst inter-spike intervals were prolonged significantly in diabetic rats, while the burst ratio and the mean number of spikes within a burst decreased significantly. Treatment with APP 17-mer peptide retarded the effects of diabetes on these parameters. In addition, the average PLV of diabetic rats was lower than that of control rats. These findings provide in vivo electrophysiological evidence for the impairment of hippocampal function in STZ-diabetic rats, and may have some implications in the mechanisms associated with cognitive deficits in diabetes.

The impact of insulin type on severe hypoglycaemia events requiring inpatient and emergency department care in patients with type 2 diabetes

AIMS

To evaluate the risk from different insulin types on severe hypoglycaemia (SHG) events requiring inpatient (IP) or emergency department (ED) care in patients with type 2 diabetes.

METHODS

Type 2 diabetes patients newly started on insulin in a large commercial claims database were evaluated for SHG events. Patients were classified into an insulin group based on their most frequently used insulin type. Multivariable Cox models assessed the association between insulin type and the risk of SHG events.

RESULTS

We identified 8626 patients (mean age 53.5 years; 55% female) with type 2 diabetes followed for an average of 4.0 years after insulin initiation. Of these, 161 (1.9%) had a SHG event at an average of 3.1y after insulin initiation. Patients with SHG events were slightly older (56.4 vs. 53.4 years), used a similar number of OADs (1.1 vs. 1.2) but had more co-morbidities compared with those without SHG events. In multivariate Cox models, premixed insulin (HR 2.12; p<0.01), isophane insulin (NPH) (HR 2.02; p<0.01), and rapid acting insulin (HR 2.75; p<0.01) had significantly higher risks of SHG events compared with glargine. No statistically significant difference in SHG events was seen with detemir (HR 1.20; p=0.73).

CONCLUSIONS

Among patients with type 2 diabetes, the use of newer basal insulin analogues was associated with lower rates of SHG events requiring IP or ED care compared with users of other insulin formulations. Future research should examine the impact of hypoglycaemia events of different severity levels.

Beneficial effects of Brassica juncea on cognitive functions in rats

CONTEXT. Brassica juncea (BJ; Linnaeus) Czern & Coss (Brassicaceae), commonly known as Indian mustard, are enriched in redox-active polyphenols with antidiabetic activities. Diverse other health benefits of this edible plant have been described in classical Ayurvedic texts.

OBJECTIVE

The reported experiments were designed to assess therapeutic potential of a methanol extract of BJ leaves for treatment of cognitive disorders associated with diabetes or caused by central cholinergic dysfunctions.

MATERIALS AND METHODS

Elevated plus-maze and active- and passive-avoidance tests were used to assess anti-amnesic potentials of BJ (100, 200 and 400 mg/kg/day, p.o., for 10 days) in alloxan diabetic or scopolamine-challenged rats. Treatment effects on brain acetylcholinesterase (AChE), superoxide dismutase (SOD) and catalase (CAT) activities were quantified in behavioral tested animals.

RESULTS

Anti-amnesic efficacy of all three tested BJ doses against scopolamine-induced amnesia was almost equal in all behavioral tests. Such efficacy of the extract in diabetic rats was increased always with its increasing doses. All treatments of BJ dose dependently decreased the elevated level of AChE, and significantly increased the SOD and CAT levels in brain homogenates of scopolamine-challenged and diabetic rats. Minimal effective oral daily doses of BJ in all tests were 100 mg/kg/day for 10 consecutive days.

DISCUSSION AND CONCLUSION

Our observation indicates that BJ could be a therapeutic option for treatment of cognitive disorders associated with diabetes, or caused by cholinergic deficit and brain oxidative status. They also indicate that the bioactive constituents or mode of actions involved in observed effects of the extract in scopolamine-challenged or diabetic rats are most probably not the same.

An unusual case of Butcher's Broom precipitating diabetic ketoacidosis

BACKGROUND

Herbal medicines are readily available and commonly perceived to be relatively harmless. Butcher's Broom is used in various medicinal preparations and contains substances having α-adrenergic-stimulating properties.

OBJECTIVE

Our aim was to report a case of toxicity associated with Butcher's Broom in a diabetic patient.

CASE REPORT

A 39-year-old woman developed diabetic ketoacidosis 5 days after beginning therapy with Butcher's Broom for mild ankle swelling. Her diabetic ketoacidosis was complicated by hyperkalemia and acidosis with a pH of 7.02. After management with intravenous fluid, insulin, and calcium gluconate, her condition stabilized and she was discharged several days later.

CONCLUSIONS

This case represents a small but potentially serious public health concern in a diabetic woman taking Butcher's Broom.

The metabolic and mitogenic properties of basal insulin analogues

CONTEXT

Retrospective, observational studies have reported an association between diabetes treatment with insulin and a higher incidence of cancer.

OBJECTIVE

Overview the literature for in vitro and in vivo studies of the metabolic and mitogenic properties of basal insulin analogues and assess the implications for clinical use.

METHODS

Relevant studies were identified through PubMed and congress abstract database searches; data on metabolic and mitogenic signalling in relation to insulin treatment of diabetes are included in this review.

RESULTS

The balance of evidence shows that although some analogues have demonstrated mitogenic potency in some in vitro studies in cancer cell lines, these findings do not translate to the in vivo setting in animals or to the clinical setting in humans.

CONCLUSIONS

The current consensus is that there is no clinical or in vivo evidence to indicate that any commercially available insulin analogue has carcinogenic effects. Large-scale, prospective clinical and observational studies will further establish any potential link.

Prevalence and clinical characteristics of unremembered nocturnal eating in diabetic subjects: Kurume sleep trouble in obesity and metabolic disorders (KUSTOMED) study

Nighttime food intake is associated with weight gain and higher HbA1c levels. We experienced night eaters who have no memory of their nocturnal eating in the morning. In this study, the curious night eating behavior was designated as "unremembered nocturnal eating syndrome (UNES)". We screened 1,169 patients with diabetes for sleep quality and abnormal eating behavior at night using the Pittsburgh Sleep Quality Index questionnaire with an additional question regarding UNES. When abnormal nocturnal eating behavior was noted, detailed clinical information was extracted from interviews with the patients. We identified 9 patients who experienced UNES. They had a higher BMI compared with subjects who reported no such episodes. Among them, 6 patients who consumed food at night without memory 2-5 times per month or more had significantly higher HbA1c levels. Continuous glucose monitoring in a patient with type 1 diabetes revealed an abrupt elevation of glucose levels from midnight when some foods were consumed. Eight of the 9 patients were taking benzodiazepine and/or non-benzodiazepine hypnotic agents when they experienced the episodes. The prevalence of UNES was 0.8% in all subjects and 4% in those taking hypnotic drugs. The ratio of hypnotic drug use in subjects with UNES was significantly higher than for individuals without UNES (89% vs. 17%, p<0.0001). Although UNES seems to be etiologically heterogeneous, hypnotics-induced parasomnia and/or anterograde amnesia may be associated with the behavior. UNES is not rare in diabetic patients on hypnotic medicine and may be a hidden cause of unexpected morning hyperglycemia.

Unrecognized and unappreciated secondary causes of osteoporosis

There are a substantial number of secondary causes of osteoporosis that can be identified through appropriate evaluation. Unrecognized celiac disease, Monoclonal gamopathy of undetermined significance (MGUS), impaired renal function, diabetes mellitus, and renal tubular acidosis are just a few of the more common secondary causes of osteoporosis. Through targeted laboratory tests, many secondary causes of osteoporosis can be identified.

Can persistent organic pollutants and plastic-associated chemicals cause cardiovascular disease?

During the last decade, associations between persistent organic pollutants (POPs), such as polychlorinated biphenyls, dioxins and pesticides, and cardiovascular (CV) risk factors and overt CV disease (CVD) have been reported in humans. Recently, associations between plastic-associated chemicals (PACs), such as bisphenol A and phthalates, and CVD have also begun to emerge. Several approaches to evaluating such associations have been used: accidents with a high level of exposure, occupational exposure studies, geographical studies of subjects living near a contaminated area and traditional case-control or cohort studies with measurements of circulating levels of different environmental contaminants in the general population. Exposure to POPs has consistently been associated with diabetes using all the approaches described above, including prospective studies. The evidence regarding associations between exposure to POPs and other CV risk factors, such as hypertension, obesity and lipids, is less strong and is mainly based on cross-sectional data. Associations between overt CVD and POPs have been reported using all the above approaches, but prospective data from population-based studies are still lacking to provide firm evidence of an important and independent role of POP exposure in the pathogenesis of CVD. Nevertheless, taken together, current evidence suggests that further longitudinal and experimental studies should be conducted to investigate the effect of exposure to both POPs and PACs, such as bisphenol A and phthalates.

Risk of death and cardiovascular outcomes with thiazolidinediones: a study with the general practice research database and secondary care data

Objective

To describe the likely extent of confounding in evaluating the risks of cardiovascular (CV) events and mortality in patients using diabetes medication.

Methods

The General Practice Research Database was used to identify inception cohorts of insulin and different oral antidiabetics. An analysis of bias and incidence of mortality, acute coronary syndrome, stroke and heart failure were analysed in GPRD, Hospital Episode Statistics and death certificates.

Results

206,940 patients were identified. The bias analysis showed that past thiazolidinedione users had a lower mortality risk compared to past metformin users. There were no differences between past users of rosiglitazone and pioglitazone (adjusted RR of 1.04; 95% CI 0.93–1.18). Current rosiglitazone users had an increased risk of death (adjusted RR 1.20; 95% CI 1.08–1.34) and of hospitalisation for heart failure (adjusted RR of 1.73; 95% CI 1.19–2.51) compared to current pioglitazone users. Risk of mortality was increased two-fold shortly after starting rosiglitazone. Excess risk of death over 3 years with rosiglitazone was 0.3 per 100 in those aged 50–64 years, 2.0 aged 65–74, 3.0 aged 75–84, and 7.0 aged 85+. The cause of death with rosiglitazone was more likely to be due to a disease of the circulatory system.

Conclusions

Higher risks for death (overall and due to cardiovascular disease) and heart failure were found for rosiglitazone compared to pioglitazone. These excess risks were largest in patients aged 65 years or older. The European regulatory decision to suspend rosiglitazone is supported by this study.

Opium consumption and coronary atherosclerosis in diabetic patients: a propensity score-matched study

There is a traditional belief among Eastern people that opium may have ameliorating effects on cardiovascular risk factors, especially diabetes; thus, it is widely used among diabetic patients. We attempted to investigate the association of opium consumption with coronary artery disease (CAD) in diabetic patients. A cross-sectional study was conducted on diabetic patients undergoing coronary angiography in our center. Out of 1925 diabetic patients included in the study, 228 were opium users, and the remaining 1697 non-opium users were used as a pool of potential comparators. Propensity scores were used to match the 228 opium consumers with 228 matched comparators for age, sex, and smoking status. The Gensini score and extent score were respectively used to assess the angiographic severity and extent of CAD. The mean Gensini score (86.9 ± 62.7 vs. 59.6 ± 43.4, p < 0.0001) and extent score (7.1 ± 2.9 vs. 5.9 ± 2.9, p < 0.0001) were significantly higher in opium user diabetic patients than in non-opium users. After adjustment for potential confounders, a dose-response relationship was observed between dose of opium and the Gensini score ( β = 0.27, p = 0.04). There were no significant differences between the routes of opium administration (inhalation vs. oral) regarding the severity and extent of CAD. In conclusion, exposure to opium in diabetic patients may be positively associated with the risk of CAD, and with the angiographically determined severity and extent of the disease. Furthermore, dosage of opium consumption may correlate with severity of CAD.

A U-shaped relationship between plasma folate and pancreatic cancer risk in the European Prospective Investigation into Cancer and Nutrition

Folate intake has shown an inverse association with pancreatic cancer; nevertheless, results from plasma measurements were inconsistent. The aim of this study is to examine the association between plasma total homocysteine, methionine, folate, cobalamin, pyridoxal 5'-phosphate, riboflavin, flavin mononucleotide and pancreatic cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). We conducted a nested case-control study in the EPIC cohort, which has an average of 9.6 years of follow-up (1992-2006), using 463 incident pancreatic cancer cases. Controls were matched to each case by center, sex, age (± 1 year), date (± 1 year) and time (± 3 h) at blood collection and fasting status. Conditional logistic regression was used to calculate the odds ratios (OR) and 95% confidence intervals (CI), adjusting for education, smoking status, plasma cotinine concentration, alcohol drinking, body mass index and diabetes status. We observed a U-shaped association between plasma folate and pancreatic cancer risk. The ORs for plasma folate ≤ 5, 5-10, 10-15 (reference), 15-20, and > 20 nmol/L were 1.58 (95% CI=0.72-3.46), 1.39 (0.93-2.08), 1.0 (reference), 0.79 (0.52-1.21), and 1.34 (0.89-2.02), respectively. Methionine was associated with an increased risk in men (per quintile increment: OR=1.17, 95% CI=1.00-1.38) but not in women (OR=0.91, 95% CI=0.78-1.07; p for heterogeneity <0.01). Our results suggest a U-shaped association between plasma folate and pancreatic cancer risk in both men and women. The positive association that we observed between methionine and pancreatic cancer may be sex dependent and may differ by time of follow-up. However, the mechanisms behind the observed associations warrant further investigation.

Myoglobin-H2O2 catalyzes the oxidation of β-ketoacids to α-dicarbonyls: mechanism and implications in ketosis

Acetoacetate (AA) and 2-methylacetoacetate (MAA) are accumulated in metabolic disorders such as diabetes and isoleucinemia. Here we examine the mechanism of AA and MAA aerobic oxidation initiated by myoglobin (Mb)/H(2)O(2). We propose a chemiluminescent route involving a dioxetanone intermediate whose thermolysis yields triplet α-dicarbonyl species (methylglyoxal and diacetyl). The observed ultraweak chemiluminescence increased linearly on raising the concentration of either Mb (10-500 μM) or AA (10-100 mM). Oxygen uptake studies revealed that MAA is almost a 100-fold more reactive than AA. EPR spin-trapping studies with MNP/MAA revealed the intermediacy of an α-carbon-centered radical and acetyl radical. The latter radical, probably derived from triplet diacetyl, is totally suppressed by sorbate, a well-known quencher of triplet carbonyls. Furthermore, an EPR signal assignable to MNP-AA(•) adduct was observed and confirmed by isotope effects. Oxygen consumption and α-dicarbonyl yield were shown to be dependent on AA or MAA concentrations (1-50 mM) and on H(2)O(2) or tert-butOOH added to the Mb-containing reaction mixtures. That ferrylMb is involved in a peroxidase cycle acting on the substrates is suggested by the reaction pH profiles and immunospin-trapping experiments. The generation of radicals and triplet dicarbonyl products by Mb/H(2)O(2)/β-ketoacids may contribute to the adverse health effects of ketogenic unbalance.

Angiotensin II plays a critical role in diabetic pulmonary fibrosis most likely via activation of NADPH oxidase-mediated nitrosative damage

Diabetic patients have a high risk of pulmonary disorders that are usually associated with restrictive impairment of lung function, suggesting a fibrotic process (van den Borst B, Gosker HR, Zeegers MP, Schols AM. Chest 138: 393-406, 2010; Ehrlich SF, Quesenberry CP Jr, Van Den Eeden SK, Shan J, Ferrara A. Diabetes Care 33: 55-60, 2010). The present study was undertaken to define whether and how diabetes causes lung fibrosis. Lung samples from streptozotocin-induced type 1 diabetic mice, spontaneously developed type 1 diabetic OVE26 mice, and their age-matched controls were investigated with histopathological and biochemical analysis. Signaling mechanism was investigated with cultured normal human lung fibroblasts in vitro. In both diabetes models, histological examination with Sirius red and hemotoxylin and eosin stains showed fibrosis along with massive inflammatory cell infiltration. The fibrotic and inflammatory processes were confirmed by real-time PCR and Western blotting assays for the increased fibronectin, CTGF, PAI-1, and TNFα mRNA and protein expressions. Diabetes also significantly increased NADPH oxidase (NOX) expression and protein nitration along with upregulation of angiotensin II (Ang II) and its receptor expression. In cell culture, exposure of lung fibroblasts to Ang II increased CTGF expression in a dose- and time-dependent manner, which could be abolished by inhibition of superoxide, NO, and peroxynitrite accumulation. Furthermore, chronic infusion of Ang II to normal mice at a subpressor dose induced diabetes-like lung fibrosis, and Ang II receptor AT1 blocker (losartan) abolished the lung fibrotic and inflammatory responses in diabetic mice. These results suggest that Ang II plays a critical role in diabetic lung fibrosis, which is most likely caused by NOX activation-mediated nitrosative damage.

Topical metal chelation therapy ameliorates oxidation-induced toxicity in diabetic cataract

Oxidative stress plays a critical role in cataractogenesis, the leading cause of blindness worldwide. Since transition metals generate reactive oxygen species (ROS) formation, metal chelation therapy has been proposed for treatment of cataracts. However, the effectiveness of most chelators is limited by low tissue penetrability. This study is the first to demonstrate that the topically applied divalent metal chelator ethylenediamine tetraacetic acid (EDTA) combined with the carrier and permeability enhancer methyl sulfonyl methane (MSM) ameliorates both oxidation-induced lens opacification and the associated toxic accumulation of protein-4-hydroxynonenal (HNE) adducts. Both in vitro (rat lens culture) and in vivo (diabetic rats), EDTA-MSM (1) significantly reduced lens opacification by about 40-50%, (2) significantly diminished lens epithelial cell proliferation and fiber cell swelling in early stages of cataract formation in vivo, and (3) notably decreased the levels of protein-HNE adducts. These findings have important implications specifically for the treatment of cataract and generally for other diseases in which oxidative stress plays a key pathogenic role.

Successful treatment of methimazole-induced severe aplastic anaemia in a diabetic patient with other co-morbidities

A 55-year-old Filipina with Grave's disease, diabetes, hypertension, bronchial asthma, Parkinson's disease and a history of adverse drug reaction to penicillin consulted due to high-grade fever and sore throat. Patient was diagnosed with aplastic anaemia secondary to methimazole and was treated with high-dose granulocyte colony stimulating factor, thrombopoietin and mesterolone. Antibiotics used included levofloxacin, clindamycin, amikacin and fluconazole. Due to bleeding and slow recovery of blood parameters, 30 units of platelets and 7 units of packed red blood cells were transfused during her 22-day admission. This case presents a life-threatening adverse drug reaction in a patient with co-morbid conditions that complicate recovery and limit one's therapeutic options.

Inhaled insulin forms toxic pulmonary amyloid aggregates

It is well known that interfaces, such as polar-nonpolar or liquid-air, play a key role in triggering protein aggregation in vitro, in particular the aggregation of peptides and proteins with the predisposition of misfolding and aggregation. Here we show that the interface present in the lungs predisposes the lungs to form aggregation of inhaled insulin. Insulin inhalers were introduced, and a large number of diabetic patients have used them. Although inhalers were safe and effective, decreases in pulmonary capacity have been reported in response to inhaled insulin. We hypothesize that the lung air-tissue interface provides a template for the aggregation of inhaled insulin. Our studies were designed to investigate the harmful potential that inhaled insulin has in pulmonary tissue in vivo, through an amyloid formation mechanism. Our data demonstrate that inhaled insulin rapidly forms amyloid in the lungs causing a significant reduction in pulmonary air flow. Our studies exemplify the importance that interfaces play in protein aggregation in vivo, illustrating the potential aggregation of inhaled proteins and the formation of amyloid deposits in the lungs. These insulin deposits resemble the amyloid structures implicated in protein misfolding disorders, such as Alzheimer's and Parkinson's diseases, and could as well be deleterious in nature.