Guest guest Posted August 13, 2008 Report Share Posted August 13, 2008 1. MW - Low-Fat Diet May Not Protect Postmenopausal Women From Diabetes Risk July 30, 2008 - A low-fat diet in basically healthy postmenopausal women demonstrates no evidence of decreasing the risk for diabetes after 8.1 years, according to the results of a randomized controlled trial. . " This study was undertaken to assess the effects of a low-fat dietary pattern on incidence of treated DM among generally healthy postmenopausal women. " [48,835 post -menopausal women aged 50-79 were randomly assigned to a usual-diet comparison group or to an intervention group with a 20% low-fat dietary pattern including increased vegetables, fruits, and grains. " A low-fat dietary pattern among generally healthy postmenopausal women showed no evidence of reducing diabetes risk after 8.1 years, " the authors write. " Weight loss, rather than macronutrient composition, may be the dominant predictor of reduced risk of diabetes. " 2.%% MW - Colesevelam May Be Safe, Effective in Patients With Diabetes Receiving Insulin 7/29/08 - Colesevelam treatment seems safe and effective for improving glycemic and lipid control in patients with T2DM receiving insulin therapy, according to the results of a randomized controlled trial. " Poor glycemic control is a risk factor for microvascular complications in patients with T2, " write the researchers " Achieving glycemic control safely with insulin therapy can be challenging. " [287 subjects with T2 ;mean baseline glycated hemoglobin level 8.3%, Colesevelam therapy was associated with consistent reductions in fasting plasma glucose and fructosamine levels, glycemic-control response rate, and lipid control measures. Compared with the placebo group, the colesevelam group had a 12.8% decrease in low-density lipoprotein cholesterol concentration .. " Colesevelam treatment seems to be safe and effective for improving glycemic control and lipid management in patients with T2 receiving insulin-based therapy, and it may provide a novel treatment for improving dual cardiovascular risk factors, " the study authors write. " The use of bile acid sequestrants in the treatment of both hyperglycemia and elevated LDL-C [low-density lipoprotein cholesterol] concentrations thus comprises a novel therapeutic approach for T2. In the present trial, colesevelam was weight neutral and well tolerated, Arch Intern Med. 2008;168:. Learning Objectives for This Educational Activity 3.%% MNTD - Discovery Of Circadian Rhythm-Metabolism Link 7/27/08 UC Irvine researchers have found a molecular link between circadian rhythms - our own body clock - and metabolism. The discovery reveals new possibilities for the treatment of diabetes, obesity and other related diseases. The researchers have identified an essential protein called CLOCK that regulates the body's circadian rhythms, works in balance with another protein called SIRT1 that modulates how much energy a cell uses. " This interplay has far-reaching implications for human illness and aging, and it is likely vital for proper metabolism, " The circadian clocks are intrinsic time-tracking systems in our bodies that anticipate environmental changes and adapt themselves to the appropriate time of day. Disruption of these rhythms can profoundly influence human health and has been linked to metabolic disorders, insomnia, depression, coronary heart diseases and cancer. It is estimated that up to 15 % of our genes are regulated by these circadian clocks. This team identified in 2006 that the protein CLOCK is an essential molecular gear of the circadian machinery. Now, they have shown that the protein SIRT1 counterbalances the function of CLOCK. SIRT1 senses energy levels in the cell; its activity is modulated by how many nutrients a cell is consuming. It also helps cells resist oxidative and radiation-induced stress, and for this reason SIRT1 is known to help control the process of aging. " Because of the role these two enzymes play, changes in our sleep patterns or our diets can directly be translated into how our cells act. " The findings also suggest that proper sleep and diet could help maintain or rebuild the CLOCK-SIRT1 equilibrium and may help explain why lack of proper rest or disruption in our normal sleep patterns is known to increase hunger, which can lead to obesity and related illnesses and can accelerate the aging process. The specific interaction between CLOCK and SIRT1 also could lead to the development of drugs aimed at facilitating healthy metabolism, thereby helping to solve major social and medical problems such as diabetes and obesity. Article adapted by Medical News Today from original press release. 4.%% MW - Soft Drinks and Fruit Drinks Linked to Diabetes Risk in African American Women 7/30/08 - Regular intake of sugar-sweetened soft drinks and fruit drinks is associated with an increased risk for T2DM in African American women. Our objective was to examine the association between consumption of sugar- sweetened beverages, weight gain, and incidence of T2 in African American women. " [59,000 Af-Amer women since 1995] Higher intake of both sugar-sweetened soft drinks and fruit drinks was associated with a higher incidence of T2. The incidence rate ratio for 2 or more soft drinks per day was 1.24 - for fruit drinks 1.31 The authors write " Regular consumption of sugar-sweetened soft drinks and fruit drinks is associated with an increased risk of T2 in Af-Amer women. " While there has been increasing public awareness of the adverse health effects of soft drinks, little attention has been given to fruit drinks, which are often marketed as a healthier alternative to soft drinks. " Arch Intern Med. 2008;168: 5.%% MW - Flavoprotein Autofluorescence Measurements May Be Helpful in Diabetic Retinopathy 7/30/08 - Flavoprotein autofluorescence (FA) measurements may be clinically useful to rapidly and noninvasively identify diabetic-induced retinal metabolic tissue stress and disease severity. " Hyperglycemia induces mitochondrial [parts of the cell which produce energy] stress and apoptotic [programed] cell death in diabetic tissues soon after disease onset and before involvement can be detected by any current clinical diagnostic method, " write the researchers " Many subjects with DM may remain undiagnosed until they develop diabetic microvascular and macrovascular complications. A noninvasive method of measuring FA to detect early ocular dysfunction due to disease has been previously described. " The goal of this study was to determine, using a rapid, noninvasive clinical imaging method, whether individuals with DM have enhanced retinal FA compared with age-matched individuals without diabetes. [21 subjects and 21 contros without DM] Retinal imaging using 1-millisecond flashes of 467-nm light was compared. " Flavoprotein autofluorescence measurements may be clinically useful to rapidly and noninvasively identify diabetic metabolic tissue stress and disease severity, " they write. " Development of [this] technology is likely to result in a tool that will improve DM screening and disease management. " " Unlike glucose monitoring, elevations in FA reflect ongoing diabetic tissue damage and may provide patient and caregiver motivation for intensifying disease management, " the study authors conclude. Arch Ophthalmol. 2008;126: 6.%% MW -Oral Glucose Tolerance Test May Predict Risk for Type 2 Diabetes July 31, 2008 - The plasma glucose concentration at 1 hour during the oral glucose tolerance test (OGTT) is a strong predictor of the risk for T2DM " In longitudinal epidemiological studies, ~40% of subjects who develop T2bhave normal glucose tolerance (NGT) at baseline, indicating that there is a population of NGT subjects who are at risk for future T2, " write the researchers " Recently, we demonstrated that subjects with NGT, can be stratified into low- and high-risk categories based upon the relationship between their postload and fasting plasma glucose (FPG) concentrations. " The goal of this study was to evaluate the efficacy of 1-hour plasma glucose concentration and the metabolic syndrome to predict the risk for T2DM, using data from a study cohort of 1611 participants who were free of T2 at baseline. " The plasma glucose concentration at 1 h during the OGTT is a strong predictor of future risk for T2 A plasma glucose cutoff point of 155 mg/dL and the ATP [Adult Treatment Panel] III criteria for the metabolic syndrome can be used to stratify nondiabetic subjects into low,intermediate, and high risk groups. Diabetes Care. 2008;31: 7.%% MW - Diabetes May Increase Risk for Pneumonia-Related Hospitalization August 1, 2008 - Type 1 and type 2 diabetes are linked with an increased risk for pneumonia-related hospitalization, and poor glycemic control increases this risk, according to the results of a population-based, case-control study .. " Diabetic subjects may have increased susceptibility to pneumonia for several reasons. They are at increased risk of aspiration, hyperglycemia, decreased immunity, impaired lung function, pulmonary microangiopathy, and coexisting morbidity. " researchers say. The goals of this study were to determine whether diabetes is a risk factor for hospitalization with pneumonia and to evaluate the effect of hemoglobin A1c level on this risk. [34,329 subjects] Compared with participants without diabetes, those with DM had an adjusted [rate ratio] RR for pneumonia-related hospitalization of 1.26 For participants with T1 adjusted RR was 4.43 vs 1.23 for those with T2. DM duration of 10 years or more was associated with an increased risk. Adjusted RR was 1.22 for DM participants with a hemoglobin A1c level of less than 7%, and it was 1.60 with a hemoglobin A1c level of 9% or more vs participants without diabetes. " T1 & 2 diabetes are risk factors for a pneumonia-related hospitalization, Poor long-term glycemic control among patients with DM clearly increases the risk of hospitalization with pneumonia. " Diabetes Care. 2008;31: 8.%%Medscape Medical News - Ankle Impairments Seen in Diabetics Even Without Neuropathy Aug 1, 2008 - New research indicates that even in the absence of peripheral neuropathy, patients with long -standing DM are prone to impaired ankle function. The findings suggest that mechanisms besides neuropathy may play a role in altered foot-ankle biomechanics seen in diabetics, the lead author states The sensory and motor deficits that accompany diabetic neuropathy can compromise gait control, result in nerve degeneration causing muscle weakness and atrophy, and lead to plantar ulcers, the investigators note. Prior research has suggested that neuropathy is needed for altered foot-ankle biomechanics in diabetics, but due to various methodologic issues, definitive conclusions could not be reached. This team addressed this topic by evaluating muscle performance and ankle mobility in 46 diabetics with and without neuropathy and in 21 controls under controlled conditions.Compared to controls, ankle mobility was impaired in all of the DM patients. ... ankle mobility was reduced by 11% and 20%, respectively, in diabetics without neuropathy compared with controls. The values for diabetics with neuropathy were 20% and 21%. Further studies are needed to better understand the mechanisms responsible for the altered foot-ankle biomechanics in diabetics, the authors conclude. BMC Musculoskelet Disord. 2008;9:99. Reuters Health Information 2008. C 2008 Reuters Ltd. 9.%% MW- Diabetes, Left Ventricular Systolic Dysfunction, and Chronic Heart Failure Eur Heart J. 2008;29(10): C2008 Oxford U Press 7/29/2008 Abstract - Chronic heart failure (HF) and diabetes mellitus (DM) commonly coexist. Each condition increases the likelihood of developing the other, and when they occur together in the same patient the risk of morbidity and mortality increases markedly. We discuss the epidemiological overlap and the complex patho- physiological pathways linking the 2 diseases. The treatment of each condition is made more problematic by the presence of the other. Introduction - Chronic heart failure (HF) and diabetes (DM) are both common (and getting more so) and often occur in the same patients. DM is, however, managed by diabetologists and HF by cardiologists, with few physicians specializing in both areas. Yet there are difficulties managing these two conditions when they coexist. For example, many of the drugs used to control hyperglycaemia are relatively 'contraindicated' in HF. Population Studies. The prevalence of HF in the general population is 1-4% depending on age; around 0.3-0.5% of the general population have both HF and DM whereas ~12% of subjects with DM have HF, rising to 22% in those >64 years. Incidence of Heart Failure in Diabetics In the Framingham study ages 45-74), the risk of HF was two-fold higher in men and five-fold higher in women with DM. This effect was more apparent in those under 65 years, where the risk of developing HF was 4- and 8-fold higher in men and women, respectively, with DM.. The two most common risk factors for the development of HF are CHD [coronary heart disease] and hypertension, both of which are more prevalent in diabetics. Patients with DM that develop HF have a markedly increased mortality. Diabetics in [one] study who developed HF had a 12-fold higher annual mortality than those not developing HF numerous studies suggest DM is associated with increased risk of HF hospitalization in patients with established HF.. impaired glucose tolerance, and insulin resistance are risk factors for developing HF, independent of DM and other established risk factors. Symptoms - The presence of insulin resistance, hyperinsulinaemia [raised insulin levels], or IFG [impaired fasting glucose] are associated with lower functional capacity and more severe symptoms. Why Do Patients With Heart Failure Develop Insulin Resistance? Many mechanisms have been suggested, including sympathetic nervous system (SNS) overactivity, sedentary lifestyle, endothelial dysfunction, loss of skeletal muscle mass, and influence of cytokines such as TNF-alpha and leptin on peripheral insulin sensitivity. . . 10.%% MW - Combination of Insulin and Oral Diabetes Drugs Linked to Reduced Neuropathology 7/30/0 - A new study suggests that combination therapy with insulin and other oral antidiabetes drugs is associated with a significant reduction in the density of neuritic plaques in the brains of people with T2DM. The postmortem study compared plaques and neurofibrillary tangles in the brains of people with and without T2 matched for age at death, sex, and severity of dementia. They report that those taking the combination of insulin and other oral antidiabetic drugs had significantly fewer plaques than those taking either type of medication alone and those taking no medication, although there was no difference in the number of tangles between groups. The lead researcher cautioned that their results show only an association and don't prove causation. " But assuming that those results hold (and they are quite robust), this also points to biologic pathways in the brain, such as the insulin-receptor -signaling pathway, that might be a focus for developing new treatment strategies for Alzheimer's disease in the future. " [124 subjects with T2 and 124 controls] In a second study, they plan to look in a more basic way at protein and gene expression in the insulin-receptor-signaling pathway in the same brains they used in their current study. ICAD 2008: Alzheimer's Association International Conference on Alzheimer's Disease: Abstract O2-04-01. 11.%% Sodium-Glucose Transporter 2 Inhibitors as Potential Treatments for Diabetes: An Expert Interview Medscape Diabetes & Endocrinology. 2008; 7/31/2008 Editor's Note: The treatment of hyperglycemia in T2DM remains a challenge, and there are unmet needs for new agents that will help patients with DM reach treatment targets. Among the new classes of oral agents currently in clinical development are those that induce renal glucosuria by targeting the renal sodium-glucose transporter 2 (SGLT2). Medscape talked to R. Henry, MD, Professor of Medicine at the UC San Diego, about these novel agents and the promise they may have as a treatment for DM. Medscape: To set the stage, could you briefly review the role of the kidney in glucose homeostasis? Dr. Henry: Under normal circumstances, the kidney filters glucose in the glomerulus and into Bowman's space and the renal tubules. The amount that is filtered is related to the concentration of glucose in the blood. Under normal circumstances, when glucose is filtered and reaches the proximal tubule, it is essentially all reabsorbed there and none appears in the urine. In people with DM, with elevated blood glucose levels, there is a greater amount that is filtered because of the higher glucose concentration in the blood, and the ability of the kidney to reabsorb all of the glucose is exceeded. Therefore, glucose appears in the urine in people with elevated blood sugars; generally, the amount that appears in the urine is the amount that exceeds the kidney reabsorption capacity. When glucose appears at the proximal tubules, it is reabsorbed by 2 glucose transporters known as sodium glucose co-transporters 1 and 2: SGLT 1 and 2. [normally] about 90% of the glucose is taken up by SGLT2. Medscape: Could you describe the potential for SGLT2 inhibition in the treatment of T2? Dr. Henry: Because glucose can be elevated in the circulation of individuals with DM and the filtration of glucose by the kidneys is increased, blocking, or partial inhibition, of the major glucose transporter (SGLT2) would lead to decreased reabsorption of glucose and increased excretion of glucose into the urine. [which] would result in decreased serum glucose levels. Also, because glucose is a source of energy, it would result in the excretion of calories in the urine, which has the potential for weight loss as well. Medscape: What SGLT2 inhibitors are in clinical development now? Dr. Henry: The one that I believe is the furthest is along in development is dapagliflozin. Another is remogliflozin. . . There are a number of other SGLT2 inhibitors in development. (ADA) 68th Scientific Sessions 12.%% MW - Having One Kidney Does Not Accelerate the Rate of Development of Diabetic Nephropathy Lesions in Type 1 Diabetic Patients Diabetes. 2008;57(6):7/30/2008 Objective: Reduced nephron number is hypothesized to be a risk factor for chronic kidney disease and hypertension. This study investigated whether the rate of development of DM nephropathy lesions was different in T1DM patients with a single (transplanted) kidney compared with patients with two (native) kidneys. [3 groups: 28 T1DM kidney transplant recipients with 8-20 years of good graft function, 39 two-kidney patients with duration of T1 matched to the time since transplant in the one-kidney group, and 30 age-matched normal control subjects. Conclusions: Reduced nephron number is not associated with accelerated development of diabetic glomerulopathy lesions in T1 13.%% MW - The Role of Omega-3 Fatty Acids in Cardiovascular Disease, Hypertriglyceridaemia and Diabetes Mellitus Br J Diabetes Vasc Dis. 2008;8(3): 7/25/2008 Abstract - It has been suggested that omega-3 fatty acids confer benefit in patients with known coronary heart disease by significantly reducing all-cause mortality and the risk of sudden death caused by cardiac arrhythmias. This may be as a result of the triglyceride-lowering effect of omega-3 fatty acids at high doses. Much of the evidence in favour of omega-3 in cardiovascular disease relates to studies which looked at the effects of increased intake from dietary sources. Oily fish (such as salmon and tuna), flaxseed, canola oil and walnuts, are all rich dietary sources of omega-3 fatty acids. ...There is currently little evidence for specific benefits of omega-3 supplementation in patients with diabetes. Introduction - Omega-3 and omega-6 fatty acids are called essential PUFAs as they cannot be synthesised 'de novo' in the body and must therefore be obtained from the diet. The three major types of omega-3 fatty acids obtained from foods and used by the body, are ALA, EPA and DHA. The simpler omega-3 fatty acid ALA is converted to EPA and DHA, which are the two omega-3 fatty acids more readily used by the body and are important to maintain normal growth, development and brain function. ALA is therefore an essential nutrient. AHA recommends an intake of at least two servings of oily fish per week, in addition to vegetable oils (flaxseed, walnut, canola and soybean oils) which are rich in ALA. In patients with documented cardiovascular disease an average intake of approximately 1 g of EPA+DHA is recommended. This can be either via diet (e.g. fatty fish), or if dietary intake is insufficient then as a supplement in consultation with a physician. Mechanisms of Action - There remain many theories regarding the mechanisms of action of omega-3 fatty acids in cardiovascular disease. It is thought that they have a multi-factorial mode of action including antiarrhythmic effects, antithrombotic effects, antiatherosclerotic effects, anti-inflammatory effects, improvement in endothelial function, lowering of BP and lowering of triglyceride [TG] concentrations. The TG-lowering effects of omega-3 fatty acids are well established and are due to decreased hepatic lipogenesis. [creation by the liver of lipids] The potential antithrombogenic effects are thought to be due to reduction of platelet aggregation and secondly by changing cell membrane properties, interacting with cell signalling systems, promoting anti-inflammatory actions and causing endothelial [inner lining of blood vessels] relaxation mediated by nitric oxide. This also has the potential to promote a small blood pressure lowering effect. However, the strongest evidence seems to be related to antiarrhythmic [against irregular heart rhythms] effects. Omega-3 PUFA has been shown to decrease ventricular arrhythmias through electrical stabilization of myocytes.[heart muscle cells] There is also evidence that they reduce the risk of sudden cardiac death via increases in heart rate variability. %%Omega-3 PUFA in Diabetes Mellitus As the typically described T2 dyslipidaemia' consists of high TG and low HDL-C levels, it seems logical that supplementation with omega-3 fatty acids would confer some benefit. However, there is a paucity of evidence for the use of omega-3 PUFA in people with DM without CHD [coronary heart disease] The best evidence for omega-3 use in uncomplicated diabetes comes from a prospective study by Hu et al. The efficacy of increasing amounts of omega-3 PUFA dietary intake was studied in 5,103 female nurses diagnosed with T2 but free of cardiovascular disease at baseline. Compared with women who seldom consumed fish (< 1 serving/ month), the relative risks of CHD were 0.70 for fish consumption 1-3 times per month, 0.60 for once per week, and 0.36 for times per week. Therefore, higher consumption of fish (and therefore omega-3 intake) was associated with a trend toward a lower incidence of CHD and a significantly lower total mortality. Omega-3 and omega-6 fatty acids are critical in the structure of cell membranes and the development of the nervous system. Dietary fish oil has been shown to reduce DM induced nerve damage, There have also been isolated reports of worsening glycaemic [blood sugar] control with omega-3 PUFA use. However, the evidence is conflicting with some studies having reported a slight worsening, and others have found no changes. Montori et al performed a meta-analysis on the effects of fish oil supplementation in people with T2 in whom dietary fish oil supplementation was the only intervention. Eighteen trials were analysed and the pooled data demonstrated a statistically significant effect of fish oil on lowering TG and raising LDL-cholesterol. No statistically significant effect was observed for fasting glucose, HbA 1C , total cholesterol, or HDL-cholesterol. . It is also unclear whether omega-3 PUFA in addition to the increasingly used statin therapy and polypharmacy in patients with DM would have any additional benefit. However, given that diabetic patients have a significantly higher cardiovascular mortality after a MI, [heart attack] one may speculate that current NICE guidance recommending the use of omega-3 therapy in individuals having had a MI less than three months prior to initiation, may be particularly beneficial in this high-risk group. .Further cardiovascular morbidity and mortality studies are required in patients with diabetes using pharmacological omega-3 PUFA therapy, especially in addition to what would be considered standard therapy for patients with diabetes. The role of omega-3 PUFA pharmacological supplementation in primary prevention of cardiovascular disease and the management of hypertriglyceridiaemia alone cannot currently be recommended, but dietary increases in omega-3 PUFA consumption should be encouraged. 14.%% MW - Urinary Infections More of a Problem in Diabetic Women (Reuters Health) Jul 25 - Despite the fact that women with diabetes more often receive longer and more potent initial treatment for urinary tract infections (UTIs) than do women without DM, they are more likely to experience UTI recurrence Researchers note that women with DM have a high incidence of UTIs and a high complication rate, and there is a lack of information on how such patients are treated in routine clinical practice. This team used pharmacy dispensing data to identify more than 10,000 DM women and 200,000 controls who had received a new prescription of antimicrobial treatment for a UTI. A recurrence was defined as a second prescription between 6 and 30 days later. Compared to controls, more postmenopausal DM women received aggressive treatment. There were similar findings in premenopausal diabetic women, who also had greater UTI recurrence rate. " The results of this retrospective study suggest that diabetic women with a urinary tract infection need a longer treatment compared to non-diabetic women with an antibiotic with high tissue penetration to prevent recurrences of their UTI, However, a prospective randomized controlled trial has to be done to confirm these results. " Diabetes Care 2008;31: 15.%% MNTD - Birth Defect Three To Four Times More Likely For Infants Born To Diabetic Women, Study Says 1 Aug 2008 Pregnant women with diabetes are three to four times more likely to give birth to an infant with a birth defect than other pregnant women, according to a CDC [Centers for Disease Control] study. the AP/San Mercury News reports. The researchers listed nearly 40 kinds of birth defects found to be significantly more likely infants born to diabetic women than other infants. [13,000 births that involved a major defect compared to 5,000 randomly selected births that did not involve a major defect. Researchers asked pregnant women if they had been diagnosed with DM before or during their pregnancies. A spokesman for March of Dimes -- said the list of defects was longer than previously understood, adding, " It adds more information about the specific types of birth defects associated with pre-gestational diabetes and gestational diabetes " AP/San Mercury News, 7/30). 16.%% Ophthalmology Vol 115,Issue 8 Aug 2008 Optical Coherence Tomography Measurements and Analysis Methods in Optical Coherence Tomography Studies of Diabetic Macular Edema Participants - 263 subjects from a study of modified Early Treatment of Diabetic Retinopathy Study (mETDRS) versus modified macular grid (MMG) photocoagulation for DME and 96 subjects from a study of diurnal variation of DME. Conclusions - Central subfield mean thickness is the preferred OCT measurement for the central macula because of its higher reproducibility and correlation with other measurements of the central macula. Total macular volume may be preferred when the central macula is less important. Absolute change in retinal thickness is the preferred analysis method in studies involving eyes with mild macular thickening. Relative change in thickening may be preferable when retinal thickening is more severe. 17.%% MW Arthritis as a Potential Barrier to Physical Activity Among Adults With Diabetes -- US 2005 and 2007 MMWR. 2008;57(18): C2008 Centers for Disease Control and Prevention (CDC) 8/06/2008 Content The ADA and the Amer College of Sports Medicine agree that increasing physical activity among persons with DM is an important public health goal to 1) reduce blood glucose and risk factors for complications (e.g., obesity and hypertension) in persons with diabetes and 2) improve cardiovascular disease outcomes. Among adults with diabetes, co-occurring arthritis might present an underrecognized barrier to increasing physical activity. CDC analyzed combined 2005 and 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS). This report describes the results of that analysis, which indicated that 1) arthritis prevalence was 52.0% among adults with diagnosed DM and 2) the prevalence of physical inactivity was higher among adults with DM and arthritis (29.8%) compared with adults with DM alone (21.0%), independent of age, sex, or body mass index (BMI). The higher prevalence of physical inactivity among adults who have both diabetes and arthritis suggests that arthritis might be an additional barrier to increasing physical activity. Health-care providers and public health agencies should consider addressing this barrier with arthritis-specific or general evidence-based self-management and exercise programs. 18.%% Hot Topic: Intensive Glucose Control Does Not Improve Cardiovascular Outcomes AccessMedicine from McGraw-Hill. 2008; 8/07/2008 Cardiovascular disease is the most common cause of death in patients with T2DM and cross-sectional studies have noted that the poorer the glycemic control, the greater the cardiovascular risk. Improved glycemic control reduces or slows microvascular disease (nephropathy, retinopathy, and neuropathy) in T1 and T2 but whether improved glycemic control reduces macrovascular disease (myocardial infarction,stroke, peripheral arterial disease) in T2 has been uncertain. Surprisingly, none of 3 recently released clinical trials found that intensive glycemic control improved cardiovascular outcomes in patients with T2. While all three trials randomized patients with T2 to either intensive glycemic control (A1C <7.0%) or standard therapy (A1C 7.0-8.4%), the patient population and the approach to treatment differed substantially...None of the three trials showed a reduction in macrovascular or cardiovascular deaths in the intensive glycemic group. In ACCORD, but not the other two trials, a greater number of deaths in the intensive glycemic group caused the trial to be stopped early (Gerstein et al, 2008). The excessive mortality was due to a greater number of deaths from cardiovascular disease, but the explanation for this finding is not clear-neither thiazolidinedione usage, hypoglycemia, heart failure, nor weight gain appeared to explain the excessive mortality. In all three trials, the patient's DM treatment regimen was chosen by the individual physician so many patients in both treatment arms received the same combination of glucose-lowering agents. Thus, the trials compared the effect of glycemic control and not how that difference in glycemic control was achieved. Based on these studies, it will be difficult to determine whether one form of glucose-lowering therapy is associated with a better or worse outcome. In all three trials, severe hypoglycemia (requiring medical assistance) and weight gain were more common in the intensive glycemic group. How should these new results alter the management of patients with diabetes? Comprehensive diabetes care, involving a multifaceted therapeutic approach that targets control of blood pressure and lipids, aspirin use, smoking cessation, weight loss, exercise, and glycemic control, remains the foundation for the care of the individual with type 2 diabetes (see ). Achievement of recommended goals for these nonglycemic risk factors remains elusive and should be aggressively pursued in all patients with T2. Such a multifactorial intervention improves the clinical outcomes in patients with T2 and microalbuminuria . Glycemic control should continue to be a critical component of therapy for T2 ..However, this new information does not support aggressive lowering the glycemic goal beyond the currently recommended A1C of <7.0% in patients with long-standing type 2 diabetes and known or suspected cardiac disease. In patients with relatively recent onset T2 without cardiovascular disease (not the patient population studied in these three trials), the optimal glycemic goal is uncertain. In such patients, it may be appropriate to target an A1C <7.0%, which can sometimes be achieved with weight loss, exercise, and one or two oral agents. In patients with T1DM the benefits of intensive glycemic control on both microvascular disease and on long-term cardiovascular outcomes is clear and the glycemic goal should remain as near to normoglycemic as can be safely achieved (<7.0% or lower). 19.%% MW -Impact of Diabetes on Outcomes in Patients With Low and Preserved Ejection Fraction Heart Failure: An Analysis of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Programme Eur Heart J. 2008;29(11): C2008 Oxford University Press 08/01/2008 [7599 patients with symptomatic HF [heart failure]and a broad range of EF.[ejection fraction] .. There were notable differences in both baseline characteristics and outcomes between diabetics and non-diabetics. These differences were amplified when EF category was considered-the most striking contrasts were between low EF HF patients with DM and preserved EF HF patients without DM. . patients with DM were more often females and of non-European ethnicity than HF patients without diabetes. DM patients were more likely to be overweight or obese than non-diabetics. They were also less likely to be current smokers. Patients with DM had more signs and symptoms of HF and worse functional status than non-diabetics in both the low and preserved EF groups. Regardless of EF, patients with DM had a higher prevalence of hypertension, myocardial infarction, coronary artery bypass grafting, and stroke than patients without diabetes. The prevalence of hypertension in patients with preserved EF and DM(79%) was nearly double that in patients with low EF and no diabetes (44.0%)..DM was an independent risk factor for each component of this combined outcome in patients with both low and preserved EF HF. .In conclusion, we report the effect of diabetes on CV morbidity as well as mortality in a large cohort of concurrently enrolled patients with both preserved and low EF HF treated with contemporary medications. We found diabetes to be an independent predictor of CV morbidity and mortality in patients with chronic symptomatic HF, in those with preserved and low EF HF. The relative risk of CV death or hospitalization due to HF conferred by diabetes was significantly greater in those with preserved when compared with low EF HF, and the increase in absolute risk was substantial and similar in both types of HF. 20.%% MW -Immunomodulation by Mesenchymal Stem Cells Diabetes. 2008;57(7): 08/01/2008 Abstract - Mesenchymal stem cells (MSCs) are pluripotent stromal cells that have the potential to give rise to cells of diverse lineages. [they] can be found in virtually all postnatal tissues.This article focuses on recent advances that have broadened our understanding of the immunomodulatory properties of MSC and provides insight as to their potential for clinical use as a cell-based therapy for immune-mediated disorders and, in particular, T1DM What Are Mesenchymal Stem Cells? More than a century ago, the presence of progenitor cells in the bone marrow with the capability of differentiating to bone were identified. Although studies highlighting the differentiation capabilities of MSC into various cell lineages including bone, cartilage, and adipose tissue have been described over the past decade, some investigators argue that the " stemness " of MSCs is lacking, proposing instead to use the term " multipotent mesenchymal stromal cells " . .whereas the exact functions of MSCs within tissues remain largely unknown,they appear to exert different functions in specific tissues where they reside. For instance, in bone marrow, they are reported to represent the precursor cell for tissues that support hematopoiesis. [development of blood cells] In other tissues, upon receiving appropriate biological signals during tissue injury or inflammation, they may differentiate into specialized cells and play a pivotal role in tissue repair and/or control of inflammation. MSC literature is lacking in reports on the use of MSCs in animal models of DM.[however] Lee et al. used immunodeficient recipient mice chemically rendered diabetic to study the effect of human MSCs (hMSCs) in the development of diabetes. Infusion of hMSCs reduced glycemic levels and increased peripheral insulin levels. Human DNA infused as hMSCs was detected in the pancreas as well as in the kidney. In pancreata from hMSC-treated diabetic mice, the islets appeared larger compared with islets from untreated diabetic mice. Clinical Trials Using MSCs in Humans - A limited but growing number of follow-up studies involving MSCs have been reported since, most aimed at taking advantage of the plasticity of MSCs to treat a disease. These clinical studies have demonstrated promising results in treating patients with cancer, in promoting heart tissue recovery from massive myocardial infarction, and in improving the recovery of patients after amyotrophic lateral sclerosis,[lou Gehrigs disease] Juvenile Diabetes Research Foundation recently announced its intent to fund the commercial entity Osiris to evaluate the immunomodulatory effects of Prochymal, a formulation of immunomodulatory adult bone marrow- derived MSCs, for the purpose of improving disease management in individuals with T1DM While MSC-based cell therapy is clearly promising and has been used in multiple disease scenarios with no unforeseen events (at least to date), whether any long-term complications arise from this strategy remains uncertain. Thus, MSC-based cell therapy still faces many hurdles, in particular addressing the safety issues, before widespread clinical applicability becomes feasible. In addition to the general challenges any cell-based therapy face, there are additional issues specific to MSCs .. . Abbreviations: DM - diabetes Mellitus;T1DM - type 1 diabetes mellitus T2DM - type 2; BP - blood pressure; MI [myocardial infarction or heart attack] ;HTN - hypertension; ADA - Amer Diabetes Asso; AFB - Amer Foundation for the Blind ; FDA Federal Drug Administration; JH - s Hopkins ; MW Medscape Web MD; NIH - National Institutes of Health; VA - Veterans Administration. MNTD- Medical News Today Definitions - Dorlands 31st Ed and Google. Disclaimer, I am a BSN RN but not a diabetic or diabetic educator. Reports are excerpted unless otherwise noted. This project is done as a courtesy to the blind/visually impaired and diabetic communities. Dawn Wilcox Coordinator The Health Library at Vista Center contact above e-mail or thl@... Quote Link to comment Share on other sites More sharing options...
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