Incidence Of Macrovascular Complications Research Articles

Bone marrow mesenchymal stem cell and mononuclear cell combination therapy in patients with type 2 diabetes mellitus: a randomized controlled study with 8-year follow-up.

To investigate the long-term effects of combining bone marrow mesenchymal stem cells (MSCs) with mononuclear cells (MCs) in the treatment of type 2 diabetes mellitus (T2DM). T2DM patients were divided into the combination group (Dual MSC + MC, n = 33), the mononuclear cell group (MC-Only, n = 32) and the control group (Control, n = 31). All groups were treated with insulin and metformin. The Dual MSC + MC group additionally received MSC and MC infusion and the MC-Only group additionally received MC infusion. The patients were followed up for 8 years. The primary endpoint was the C-peptide area under the curve (C-p AUC) at 1 year. This study was registered with clinicaltrial.gov (NCT01719640). A total of 97 patients were included and 89 completed the follow-up. The area under the curve of C-peptide of the Dual MSC + MC group and the MC-Only group was significantly increased (50.6% and 32.8%, respectively) at 1 year. After eight years of follow-up, the incidence of macrovascular complications was 13.8% (p = 0.009) in the Dual MSC + MC group and 21.4% (p = 0.061) in the MC-Only group, while it was 44.8% in the Control group. The incidence of diabetic peripheral neuropathy (DPN) was 10.3% (p = 0.0015) in the Dual MSC + MC group, 17.9% (p = 0.015) in the MC-Only group, and 48.3% in the Control group. The combination of MSC and MC therapy can reduce the incidence of chronic diabetes complications and improves metabolic control with mild side effects in T2DM patients.

The long-term effect of bariatric/metabolic surgery versus pharmacologic therapy in type 2 diabetes mellitus patients: A systematic review and meta-analysis.

Metabolic/bariatric surgery as a treatment for obesity and related diseases, such as type 2 diabetes mellitus (T2DM), has been increasingly recognised in recent years. However, compared with conventional pharmacologic therapy, the long-term effect (≥ 5years) of metabolic surgery in T2DM patients is still unclear. This study aimed to evaluate the diabetes remission rate, incidence of diabetic microvascular complications, incidence of macrovascular complications, and mortality in T2DM patients who received metabolic surgery versus pharmacologic therapy more than 5years after the surgery. Searching the database, including PubMed, Embase, Web of Science, and Cochrane Library from the inception to recent (2024), for randomised clinical trials (RCTs) or cohort studies comparing T2DM patients treated with metabolic surgery versus pharmacologic therapy reporting on the outcomes of the diabetes remission rate, diabetic microvascular complications, macrovascular complications, or mortality over 5years or more. A total of 15 articles with a total of 85,473 patients with T2DM were eligible for review and meta-analysis in this study. There is a significant long-term increase in diabetes remission for metabolic surgery compared with conventional medical therapy in the overall pooled estimation and RCT studies or cohort studies separately (overall: OR=4.58, 95% CI: 1.89-11.07, P<0.001). Significant long-term decreases were found in the pooled results of microvascular complications incidence (HR=0.57, 95% CI: 0.41-0.78, P<0.001), macrovascular complications incidence (HR=0.59, 95% CI: 0.50-0.70, P<0.001) and mortality (HR=0.53, 95% CI: 0.53-0.79, P=0.0018). Metabolic surgery showed more significant long-term effects than pharmacologic therapy on diabetes remission, macrovascular complications, microvascular complications incidence, and all-cause mortality in patients with T2DM using currently available evidence. More high-quality evidence is needed to validate the long-term effects of metabolic surgery versus conventional treatment in diabetes management.

Microvascular complications of obesity and diabetes-Role of bariatric surgery.

Bariatric surgery in people with obesity can lead to long-term remission of type 2 diabetes mellitus (T2DM) and a reduction in the incidence of macrovascular complications. The impact of bariatric surgery on microvascular complications is less clear. In this narrative review, we sought to evaluate the effect of bariatric surgery on microvascular complications in patients with and without diabetes. The risk of developing microvascular complications is increased in people with obesity, and this is amplified in those with T2DM. The impact of metabolic surgery on microvascular complications is limited to a subgroup analysis of studies or statistical modeling to predict the glycemia-independent effect of bariatric surgery. While bariatric surgery halts the progression of retinopathy in those with minimal retinopathy, it may worsen in those with advanced retinopathy. Bariatric surgery improves proteinuria and major renal outcomes, regardless of the severity of renal impairment. Bariatric surgery in patients with obesity with or without diabetes is associated with an improvement in neuropathic symptoms and regeneration of small nerve fibers. In conclusion, bariatric surgery is associated with an improvement in microvascular complications. Further studies are needed to elucidate the underlying mechanisms for the favorable effect of bariatric surgery on microvascular outcomes.

1372-P: Micro and Macro Complications Three-Year Follow-up in LANDMARC—Longitudinal Nationwide Study on Real-World Outcomes of Type 2 Diabetes in India

Microvascular and macrovascular complications were evaluated during the 3 years (yrs) of LANDMARC, a prospective observational study (CTRI/2017/05/008452) that included participants with T2D on ≥2 antihyperglycemic medications. Out of 6222 evaluable participants (mean baseline age: 52.1 yrs, T2D duration: 8.6 yrs and A1C: 8.05%), 5273 participants completed the 3-yr follow-up. The mean A1C decreased by 0.68% (p&amp;lt;0.0001) in 3 yrs. Microvascular complications were noted in 18.02% (1121/6222) of participants, while the incidence of macrovascular complications was 3.29% (205/6222). Neuropathy was the most commonly reported complication (baseline: 11.8% and 3-yrs: 14.8%). The 3-yr results indicate slightly higher complications among those who were overweight, but the difference was non-significant (p=0.8380); and significantly higher complications among those with suboptimal glycemic control (p&amp;lt;0.0001) or having CV risk factors (p&amp;lt;0.0001) (Table). The most common macrovascular complication was MI. A total of 37 CV deaths were reported, with majority being sudden deaths (n=24), followed by fatal myocardial infarction (MI, n=10), coronary artery procedure (n=2), and stroke (n=1). These results offer insights into disease progression and suggest the need for controlling risk factors and timely treatment adjustment in participants with T2D. Disclosure N.Rais: Advisory Panel; Bayer Consumer Care AG, Board Member; Abbott, Biocon. A.Sugumaran: Employee; Sanofi. A.Satpathy: Employee; Sanofi. A.Gadekar: Employee; Sanofi. S.K.Menon: Employee; Sanofi. R.Neogi: Employee; Sanofi. D.Chodankar: Employee; Sanofi. C.Trivedi: None. S.Wangnoo: None. A.H.Zargar: None. K.Kumar: None. A.K.Das: n/a. S.R.Joshi: Advisory Panel; Biocon, Zydus Cadila, Torrent Pharmaceuticals Ltd, Franco India, Consultant; Glenmark Pharmaceuticals, Twin Health, Speaker's Bureau; Abbott Nutrition, Sanofi, Abbott, Novo Nordisk, Lupin Pharmaceuticals, Inc. A.Mithal: Advisory Panel; Eris Lifesciences Ltd., Consultant; Glenmark Pharmaceuticals, Lupin Pharmaceuticals, Inc., USV Private Limited, Research Support; Sanofi, Speaker's Bureau; Novo Nordisk, Boehringer-Ingelheim, AstraZeneca, Sun Pharmaceutical Industries Ltd., Novartis. S.Kalra: Speaker's Bureau; Abbott, Bayer Inc., Novo Nordisk, Sanofi. A.Unnikrishnan: Speaker's Bureau; Sanofi, AstraZeneca, Boehringer-Ingelheim, Intas Pharmaceuticals Ltd. H.Thacker: None. B.Sethi: None. S.Chowdhury: None. Funding Sanofi India

1168-P: Complications in the Second Year of LANDMARC—Longitudinal Nationwide Study on Real-World Outcomes of Type 2 Diabetes in India

Macrovascular and microvascular complications were evaluated during the first 2 years of LANDMARC, a 3-year prospective observational study (CTRI/2017/05/008452) that included participants with T2D on ≥2 antihyperglycemic medications. Out of 6234 evaluable participants (mean baseline values - age: 52.1 years, T2D duration: 8.59 years and A1C: 8.05%) , 5318 participants completed the 2-year follow-up. The mean A1C decreased by 0.58% (baseline: 8.05%) in 2 years. The microvascular complications were frequent in 17.6% participants (1096/6234) ; while the incidence of macrovascular complications was 1.1% participants (66/6234) . Neuropathy was the most commonly reported complication (baseline: 11.8% and 2-years: 14.4%) . Overall, complications were more common in participants with BMI ≥23 kg/m2, A1C ≥7% or having CV risk factors (Table) . A total of 41 deaths were reported; of which 30 deaths were attributed to CV causes (sudden death [n=19], myocardial infarction [n=9], stroke [n=1], and coronary artery procedure [n=1]) . The 2-year results indicate more complications among those who were overweight, or with suboptimal glycemic control or having CV risk factors. Neuropathy was the predominant T2D complication. These results offer insights into disease progression and suggest the need for controlling risk factors and timely treatment adjustment in participants with T2D. Disclosure N. Rais: None. A.K. Das: Advisory Panel; Boehringer Ingelheim International GmbH, Novo Nordisk, Roche Diagnostics, Sanofi. Speaker's Bureau; Dr. Reddy’s Laboratories Ltd., Lupin Pharmaceuticals, Inc., USV Private Limited. S. Joshi: Advisory Panel; Abbott, Boehringer Ingelheim International GmbH, Dr. Reddy’s Laboratories Ltd., Eli Lilly and Company, Novo Nordisk, Roche Diabetes Care. Consultant; Biocon, Glenmark Pharmaceuticals, Sanofi, USV Private Limited. A. Mithal: Advisory Panel; Eris Lifesciences Ltd. Consultant; Glenmark Pharmaceuticals, Lupin Pharmaceuticals, Inc., USV Private Limited. Speaker's Bureau; Abbott Diabetes, AstraZeneca, Biocon, Boehringer Ingelheim International GmbH, Dr. Reddy’s Laboratories Ltd., Novartis AG, Novo Nordisk, Sanofi. S. Kalra: Speaker's Bureau; Boehringer Ingelheim International GmbH, Novo Nordisk A/S, Sanofi. A. Unnikrishnan: Advisory Panel; Intas Pharmaceuticals Ltd. Speaker's Bureau; Abbott, AstraZeneca, Boehringer-Ingelheim, Sanofi. Other Relationship; Novo Nordisk, Serdia Pharmaceuticals (India) Pvt. Ltd., Torrent Pharmaceuticals Ltd. H. Thacker: None. B. Sethi: None. S. Chowdhury: None. A. Nair: None. S. Mohanasundaram: Employee; Sanofi. V. Salvi: Employee; Sanofi. D. Chodankar: Employee; Sanofi. C. Trivedi: None. S. Wangnoo: None. A.H. Zargar: Advisory Panel; Sanofi. Speaker's Bureau; AstraZeneca, Biocon, Boehringer Ingelheim International GmbH, Intas Pharmaceuticals Ltd., Janssen Pharmaceuticals, Inc., Lupin Pharmaceuticals, Inc., Novo Nordisk, USV Private Limited. K. Kumar: None. Funding Sanofi, India

Risk of macrovascular complications in statin-treated patients developing diabetes

AimsTo assess the risk of macrovascular complications in patients developing diabetes from statin treatment. MethodsIn this population-based cohort study, 40,409 participants who began to receive statin therapy between 2000 and 2012 were enrolled in to the study group, and another 1:1 matched adults without statin treatment during the same period served as the control group. Both groups were followed up to identify individuals who later developed diabetes. After a follow-up identification of diabetes, diabetes and non-diabetes cohorts were subjected to an analysis for the risk of macrovascular events between diagnosis of diabetes and December 31, 2013. ResultsCompared with individuals without statin therapy, statin-treated patients had a higher risk of developing diabetes (adjusted hazard ratio: 2.46; 95% confidence interval: 2.37–2.57). Compared with statin-treated patients without diabetes, statin-treated participants developing diabetes had a higher overall incidence of macrovascular complications (adjusted hazard ratio: 1.74; 95% confidence interval: 1.62–1.88). Moreover, compared with that of other diabetogenic statins, patients taking pravastatin had a lower risk of developing diabetes (adjusted hazard ratio: 0.63; 95% confidence interval: 0.55–0.73) and macrovascular events (adjusted hazard ratio: 0.64; 95% confidence interval: 0.42–0.98). ConclusionsAccording to these findings, prescribing statins that have a neutral effect on glucose homeostasis may be advisable for Asian populations.

Real-World Data on the Incidence of Macrovascular Complications in Japanese Patients with Type 2 Diabetes: The Sitagliptin Registration Type 2 Diabetes-Juntendo Collaborating Project.

IntroductionType 2 diabetes is associated with vascular complications that deteriorate the quality of life and decrease the life expectancy of individuals. We previously reported the efficacy of sitagliptin for glucose control in patients with type 2 diabetes in the Sitagliptin Registration Type 2 Diabetes-Juntendo Collaborating Project (SPIRITS-J). Through the results of the SPIRITS-J study, we expected that optimal comprehensive management of type 2 diabetes according to current clinical practice guidelines in addition to achieving individualized glycemic goals would reduce macrovascular complications and all-cause mortality in Japan. The aim of this study was to evaluate this hypothesis.MethodsWe investigated the clinical outcomes prospectively in the extended SPIRITS-J study and compared these to previous Japanese cohort studies in the era before widespread use of guidelines. The primary clinical outcome was a composite of myocardial infarction (MI), stroke, and all-cause mortality.ResultsMean duration of follow-up was 3.5 ± 1.3 years. The crude incidence of the primary outcome per 1000 person-years was 13.9 (non-fatal MI 1.44, non-fatal stroke 4.22, all-cause mortality 8.79 per 1000 person-years, respectively). It is noteworthy that the incidence of MI in the SPIRITS-J study was very much lower than that in a previous Japanese cohort study. In multivariate analysis, both the history of coronary artery disease and low-density lipoprotein cholesterol (LDL-C) were independently associated with incidence of primary clinical outcome.ConclusionThe extended SPIRITS-J study demonstrated that optimal comprehensive management in patients with type 2 diabetes according to the recent practice guidelines has succeeded in preventing macrovascular complications in Japan. This study suggests that more intensive LDL-C-lowering therapy is important for further prevention of macrovascular complications even in Japanese patients with type 2 diabetes (UMIN 000004121).Electronic supplementary materialThe online version of this article (10.1007/s13300-019-0626-2) contains supplementary material, which is available to authorized users.

A long-term quality-of-care score for predicting the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus

AimsThe aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications. MethodsUsing Taiwan’s Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999–2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1c), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications. ResultsOf the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28–0.45). ConclusionsGood quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients.

Long term outcomes and mortality among patients enrolled in a structured primary care-led diabetes programme

Introduction: Limited data exists, internationally and in Ireland, on long-term outcomes among people with diabetes who are managed in primary care. The Midlands Diabetes Structured Care Programme takes a multifaceted approach to primary-care-led management, encompassing evidence-based strategies to integrate diabetes management within general practice (clinical integration) and with other disciplines (professional integration), including patient registration and recall, regular diabetes review visits, active role of the practice nurse in coordination and ongoing management, multidisciplinary specialist access (e.g. nurse specialists, dietetics, ophthalmology, chiropody), professional education, and remuneration. Our aim was to examine mortality, complications and clinical outcome targets among patients with diabetes enrolled in the programme since its establishment in 1998. Methods: Data were collected in 1998 and 2015, on patient outcomes (mortality (2015), complications (2008–2015), and clinical parameters (1998, 2015)), among patients with diabetes (≥18 years) registered with participating practices. Data were extracted from patient notes by clinical nurse specialists using a paper-based data collection form. Using Stata, chi-square tests were used to test differences in clinical outcomes over time and to examine baseline factors associated with mortality. Results: Overall 376 patients (10 practices) were followed up to 2015. Among survivors (n=192, 51%), 23% (n=30) had experienced a macrovascular complication; primarily heart failure (n=9, 7%) or CVA (n=7, 5%), and 2% (n=1) had a minor amputation. In 1998, 15% (n=14) had retinopathy, increasing to 72% (n=118) by 2015. The proportion of patients with a recommended blood pressure target ( Discussion: The findings indicate the progress which has been made in clinical outcomes among patients enrolled since the initiation of the programme. Conclusions: The proportion of patients meeting targets increased over time. There was a high incidence of macrovascular complications. The proportion of patients with retinopathy had increased over time, reflecting the increasing age of the cohort, and potentially improvements in screening during the study period. Lessons learned: Improvements in the clinical profile of patients enrolled in the programme since its inception suggests primary-care-led diabetes management can perform favourably in the long-term. The incidence and prevalence of complications indicates the importance of effective management and achieving clinical outcome targets. Limitations: Changes observed in patient outcomes cannot be attributed directly to the programme and may reflect improvements in clinical guidance, self management, and medication during the study period. Suggestions for future research: Future work should explore factors associated with mortality and survival in this cohort, including establishing cause of death to facilitate comparisons the national population.

The association of depressive symptoms and diabetes distress with glycaemic control and diabetes complications over 2\xa0years in newly diagnosed type 2 diabetes: a prospective cohort study

Aims/hypothesisWe examined the associations between depressive symptoms and diabetes distress with glycaemic control and diabetes complications over 2 years, after diagnosis of type 2 diabetes.MethodsIn a multi-ethnic, primary care cohort (n = 1735) of adults, all with recent (<6 months) diagnosis of type 2 diabetes, we measured the associations between depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) and diabetes distress (Problem Areas in Diabetes [PAID] score ≥40), with change in 2 year HbA1c as the primary outcome and with incident rates of diabetes complications as secondary outcomes. Multivariate models were used to account for potential confounders.ResultsOf the 1651 participants (95.2%) of the total primary care cohort with available baseline PHQ-9 and PAID scores, mean ± SD age was 56.2 ± 11.1 years, 55.1% were men and 49.1% were of non-white ethnicity; 232 (14.1%) and 111 (6.7%) had depressive symptoms and diabetes distress, respectively. After adjustment for confounders, depressive symptoms were not associated with worsening HbA1c. After adjustment for age, sex, ethnicity, vascular risk factors and diabetes treatments, depressive symptoms were associated with increased risk of incident macrovascular complications (OR 2.78 [95% CI 1.19, 6.49], p = 0.018) but not microvascular complications. This was attenuated (p = 0.09) after adjustment for IL-1 receptor antagonist concentration. Diabetes distress was not associated with worsening HbA1c or incident complications.Conclusions/interpretationIn the first 2 years of type 2 diabetes, the effect of depressive symptoms and diabetes distress on glycaemic control is minimal. There was, however, an association between depressive symptoms and incidence of macrovascular complications. Elevated innate inflammation may be common to both depression and macrovascular diabetes complications, but these findings require replication.

Utility of the waist-to-height ratio, waist circumference and body mass index in the screening of metabolic syndrome in adult patients with type 1 diabetes mellitus

BackgroundThe incidence of macrovascular complications and morbidities associated to metabolic syndrome are increasing in patients with type 1 diabetes mellitus (T1DM). The combination of T1DM with features of insulin resistance similar to that of type 2 diabetes (T2DM), sometimes called “double diabetes”, has been associated with central obesity. Since the most methods to accurately detect body fat and insulin resistance are not readily available, we propose that certain indirect indexes for detecting obesity as waist-to-height ratio, waist circumference and body mass index, may be useful when screening for metabolic syndrome in patients with T1DM.MethodsWe performed a transversal evaluation (clinical and biochemical) in all the patients of the T1DM Clinic (n = 120). We determined the presence of metabolic syndrome according to the Joint Statement Criteria by the American Heart Association/ National Heart Lung and Blood Institute and the International Diabetes Federation and the utility of certain anthropometric indexes for predicting double diabetes was evaluated.ResultsThirty seven percent of the patients were considered to have metabolic syndrome using these criteria (n = 30). These patients were significantly older (p = 0.002), have a higher glycated hemoglobin (p = 0.036), cholesterol (p < 0.012) and triglyceride concentration (p < 0.01) as well as body mass index (p = 0.004), waist circumference (p = 0.01) and waist-to-height ratio (p < 0.01) than the group without metabolic syndrome. Also their c-HDL is lower (p < 0.01). A value of 0.52 for waist-to-height ratio correctly classified the largest number of patients (68% of correctly classified) well as the waist circumference (66% of correctly classified) with an adequate specificity and sensibility. Meanwhile the most precise body mass index value only classified correctly to 61% of patients.ConclusionOur data show that waist circumference and waist-to-height ratio indexes are useful to predict the presence of metabolic syndrome in adult patients with type 1 diabetes mellitus.

Prediction of mortality and macrovascular complications in type 2 diabetes: validation of the UKPDS Outcomes Model in the Casale Monferrato Survey, Italy

The United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model can be used to estimate the lifetime occurrence of major diabetes-related complications in order to calculate health economic outcomes. The aim of the study was to assess the performance of the model by comparing the predicted and observed mortality and the incidence of macrovascular complications in an Italian population-based cohort with type 2 diabetes. We used data from the Casale Monferrato Survey, a cohort enrolled in 1988 and surveyed in 1991 (n = 1,967) to assess the prevalence of cardiovascular risk factors. In 2000, a new survey included all the members of the original cohort who were still alive (n = 860), and in addition all individuals identified with a new diagnosis of type 2 diabetes since 1993 (n = 2,389). We compared the mortality predicted by the model for the 1991 survey over the subsequent 17-year period with the observed risk. The following outcomes were analysed in the 2000 survey: myocardial infarction (MI), other ischaemic heart disease, stroke, congestive heart failure (CHF) and amputation. For all-cause mortality, the predictions from the model at 5 and 10 years (23% and 47%, respectively) were identical to the observed risks. At 15 years, the risk of death was slightly overestimated (an estimate of 67% vs 64% observed, 95% CI 61%, 66%). The performance of the model was best for patients with a recent history of disease (duration <6 years). Among the complications, the predicted cumulative incidences of MI and CHF were very close to those observed. External validation is essential to assess the accuracy of simulation models. The UKPDS Outcomes Model satisfactorily predicted a set of actual incidences of mortality and complications in an Italian diabetes cohort up to a duration of approximately 12 years. The longer term performance of such models should be carefully evaluated.

Determining the Relationship Between Homocysteinemia and Biomarkers of Inflammation, Oxidative Stress and Functional Kidney Status in Patients with Diabetic Nephropathy

Summary Background: One of the leading causes of terminal renal failure is diabetic nephropathy. The aim of this study was to determine the relationship between homocysteine levels and the biomarkers of renal function, inflammation and oxidative stress, as well as the incidence of macrovascular complications in patients with diabetic nephropathy. Methods: Sixty-four patients with diabetic nephropathy were included in this study. They were divided according to their homocysteine levels into two groups: hyperhomocysteinemic (HHcy, n=47) and normohomocysteinemic patients (NHCy, n=17). The re sults were compared to a control group (n=20) with normal renal function and without diabetes. Besides homocysteine, cystatine C, creatinine, urea, albuminuria, creatinine clearance, lipid status parameters, apolipoprotein A-I and B, lipo protein (a), CRP, fibrinogen, oxidative LDL were determined using appropriate methods. The incidence of macro vascular diabetic complications was also determined. Results: The results indicate that the level of renal dysfunction is greater in HHcy than in NHcy patients (p&lt;0.05). In HHcy patients levels of oxLDL were also higher compared to NHcy patients (119.3±140.4 vs. 71.4±50.8 ng/mL, disp&lt; 0.05) as well as fibrinogen levels (4.3±1.3 vs. 3.7±0.8 g/L, p&lt;0.05). The in cidence of macrovascular complications is more frequent in HHcy than in NHcy patients (55.3. vs. 35.3 %, p&gt;0.05), and in patients with macroalbuminuria compared to patients with microalbuminuria (65% vs. 39%, p&lt;0.05). Conclusions: It can be concluded that HHcy is significantly present in patients with diabetic nephropathy, especially if there is greater reduction of renal function. Besides that, significantly higher concentrations of inflammatory (fibrinogen) and oxidative stress (oxLDL) markers were present in HHcy patients with diabetic nephropathy compared to NHcy patients.Therefore in diabetic nephropathy patients it is useful to regularly monitor the levels of homocysteine, as well as inflammatory and markers of oxidative stress.

The predictive value of TNF-α and IL-6 and the incidence of macrovascular complications in patients with type 2 diabetes

Some inflammation factors have been shown to accelerate type 2 diabetes macrovascular complication (T2DMC). The study investigates the variation of TNF-α and IL-6 levels during the progression of T2DMC to explore their predictive value in the incidence of T2DMC. All participants were divided into two groups, type 2 diabetes mellitus (T2DM) and non-diabetes (ND) group. TNF-α and IL-6 were analyzed with enzyme immunoassay. All participants were followed up by carotid Doppler, Doppler of lower extremities, head CT and 64-row multislice spiral CTA. The incidence of macrovascular atherosclerosis in T2DM was significantly higher than that in ND group (P < 0.05). The levels of TNF-α and IL-6 in both groups with atherosclerosis increased annually. In patients who had atherosclerosis with diabetes, measured levels of TNF-α and IL-6 were significantly higher than those in patients with atherosclerosis without diabetes (P < 0.05). The levels of TNF-α and IL-6 in T2DMC and ND group with atherosclerosis was significantly higher than that in two groups without atherosclerosis (P < 0.05). Patients with T2DM were divided into four groups according to their HbA1C level. There was a strong positive correlation between the levels of TNF-α and IL-6 and HbA1C (P > 0.05). The TNF-α and IL-6 levels can be used as predictors for atherosclerosis development. Compared with non-diabetic atherosclerosis, TNF-α and IL-6 have stronger predictive value in diabetic atherosclerosis development. One reason for hyperglycemia increasing atherosclerosis is to activate inflammatory cells and relives of inflammatory factors. Hyperglycemia can trigger inflammation, which is a quality-effect relationship reaction.

Relationship between level of circulating modified LDL and the extent of coronary artery disease in type 2 diabetic patients

The impact of diabetes on health is due almost entirely to a series of complications that characterise the disease. It is associated with an increased incidence of macrovascular complications including coronary artery disease (CAD). The aim of the present study is to evaluate the possible relationship between the circulating levels of the modified derivatives of low-density lipoprotein (LDL) and the development of angiopathy in type 2 diabetic patients with CAD. The status of the antioxidant defences and the role of supplementation with antioxidant combinations are also studied in these patients. The study was conducted on three groups: group I (controls); group II (type 2 diabetic patients without complications – CAD[–]); and group III (including type 2 diabetic patients with stable CAD – CAD[+]). Patients in group III received adjunct treatment of antioxidant tablets for three months. The results of the present study clearly indicated that there was excessive exposure to oxidative stress in diabetic patients. The increase in free radicals was coupled with disturbance in free radical scavengers, particularly the glutathione system. The disturbance was more prominent in CAD(+) patients. The study has shown alteration in the lipid profile in diabetic groups, where the oxidised LDL (ox-LDL) levels were significantly higher than in control subjects. Diabetics with CAD had higher levels of ox-LDL than did patients without CAD. The intima/media thickness (IMT) of the carotid artery was within clinically accepted normal values if the ox-LDL level was below 100–110 u/L. Once the ox-LDL exceeded this range, IMT increased sharply with the increase in plasma ox-LDL. It seems that the level of ox-LDL should be kept below an upper limit of the 100–110 u/L range in order to avoid the serious atherosclerotic effects of this factor. The results demonstrate that plasma levels of ox-LDL correlate with the extent of coronary artery disease in type 2 diabetic patients and suggest that elevated levels of ox-LDL, can serve as an independent and significant predictor for future cardiac events in type 2 diabetic patients with CAD.

Where thiazolidinediones will fit.

Individuals with type 2 diabetes have two defects: insulin resistance, which occurs in the first stages of disease progression, and pancreatic beta-cell failure, which occurs later in the disease. Insulin resistance is the major pathological defect. During the course of the disease, insulin levels are initially elevated to compensate for the increased insulin resistance and then decline as the disease progresses and beta-cells become less responsive. It is necessary to change antidiabetic therapies to address this progression. Current management of type 2 diabetes follows a stepwise treatment program of diet and exercise, monotherapy with oral antidiabetic agents, combination oral therapy and, ultimately, combination therapy with insulin to control blood glucose levels. While control of blood glucose will reduce the risk of microvascular complications, such as microalbuminuria and retinopathy, the incidence of macrovascular complications is not significantly reduced. The introduction of the thiazolidinediones (TZDs) or 'glitazones', a class of agents that offer effective glycemic control and work through the reduction of insulin resistance, offers a new strategy in the management of this condition. These agents have beneficial effects on the pancreatic beta-cell and, in addition, may have potential benefits on the macrovascular complications that commonly occur in these patients.

Provider Profiling and the Provider Support Report

Diabetes mellitus is a chronic disease that accounts for a significant proportion of national health care expenditures. Over the past decade, several studies have documented that control of blood glucose levels will decrease the incidence of microvascular complications and treatment of co-morbidities will decrease the incidence of macrovascular complications. These findings have been collected and disseminated by the American Diabetes Association in the Standards of Care. Despite this evidence, performance of appropriate screening tests and treatment of diabetes and its co-morbidities remains suboptimal. Lovelace Healthcare Innovations has developed the methodology to measure performance of providers. We have taken this data, converted it into useful feeback data and used it as part of a disease managemnt program to improve performance of providers at Lovelace Health Systems. The methodology and outcomes will be described.

Selected aspects of ACE inhibitor therapy for patients with renal disease: impact on proteinuria, lipids and potassium.

Overt proteinuria is often accompanied by hypercholesterolemia and is associated with increased lipoprotein(a) levels. These lipid abnormalities are probably involved in the high incidence of macrovascular complications associated with diabetic nephropathy and possibly other kinds of non-diabetic proteinuric renal disease. Over the last decade many studies have shown that ACE inhibitors can reduce urinary protein excretion but little attention was paid to the impact of this form of therapeutic intervention on the lipid profile. In this article we review our recent data showing that fosinopril administration was associated with significant decreases in both urinary protein excretion, serum total cholesterol levels, and plasma lp(a) levels. The use of ACE inhibitors in patients with renal impairment can result in the development of hyperkalemia as a result of suppression of angiotensin II-driven aldosterone secretion by the adrenal gland. Inhibition of aldosterone secretion may depend on the degree of inhibition of angiotensin II formation in the circulation and also locally in the adrenal gland. Because the various ACE inhibitors exhibit different degrees of ACE inhibition at the tissue level, we have postulated that angiotensin II-dependent aldosterone production will be inhibited to a lesser degree by agents that have low tissue affinity for the adrenal gland. The implication of this theoretical concept for the development of hyperkalemia in patients with impaired renal function treated with ACE inhibitors is discussed.