Myocardial infarct size and mortality in diabetic patients.

The mortality rate from myocardial infarction is disproportionately high in diabetic patients. One explanation for this may be that diabetic patients incur more extensive myocardial necrosis. This possibility was examined in a three part study. Firstly, peak serum aspartate aminotransferase concentrations of all diabetic and non-diabetic patients admitted with myocardial infarction over a 16 year period were compared retrospectively. Secondly, peak aspartate aminotransferase concentrations in a series of diabetic patients and controls matched by age and sex were examined retrospectively. Thirdly, creatine kinase MB release and electrocardiographic measures of infarct size were investigated prospectively in a case/control study. Although cardiac failure and death were more common in the diabetic groups, there were no significant differences in estimates of infarct size between diabetic and non-diabetic patients in any of the studies. Therefore, the high case fatality rate amongst diabetic patients is not caused by increased myocardial damage. Presumably survival is prejudiced by factors operating before the infarction.     

A cross-sectional study of echocardiographic indices, treadmill exercise capacity and microvascular complications in Nigerian patients with hypertension associated with diabetes mellitus.

Associations between hypertension and cardiovascular complications of diabetes mellitus in Nigerians, were examined in a cross-sectional study. 20 hypertensive-diabetic patients, 16 hypertensive patients, 10 non-hypertensive diabetic patients and 10 age- and sex-matched healthy controls, underwent M-mode and cross-sectional echocardiography, and Bruce-protocol treadmill exercise performance. Left ventricular (LV) mass indices (+/- SD) were significantly higher in hypertensive patients (164 +/- 12gm-2), diabetic (158 +/- 17gm-2) and hypertensive diabetic patients (125 +/- 129gm-2) compared with normal controls (111 +/- 17gm-2) p < 0.01. However, the LV mass index in the hypertensive-diabetic patients was significantly less than in hypertensive (p < 0.05) or normotensive diabetic patients (p < 0.05). Systolic cardiac contractility measured as fractional fibre shortening, was preserved in the hypertensive patients (24 +/- 4%) compared with the healthy controls (23 +/- 4%), but was depressed in diabetic patients (19 +/- 3%) and to a greater extent in the hypertensive-diabetic patients (15 +/- 4% p < 0.01). Treadmill exercise tolerance time was reduced independently in hypertension (309 +/- 73 seconds) or diabetes (321 +/- 119 seconds), p < 0.05, but was further impaired in hypertensive-diabetic patients (289 +/- 110 seconds) p < 0.01 compared to the healthy controls (490 +/- 156 seconds). The patients with hypertension and diabetes had a greater degree of proteinuria (p < 0.001) and a higher frequency of retinopathy (p < 0.001), in comparison to those with hypertension or diabetes alone.     

Hyperglycaemia and mortality of diabetic patients with candidaemia.

AIMS: To determine whether the degree of hyperglycaemia has an impact on in-hospital mortality in diabetic patients with candidaemia. METHODS: A retrospective cohort study of 87 diabetic patients with candidaemia admitted between June 1995 and June 2003 was carried out at two medical centres. Patients were stratified into two groups: those with moderate hyperglycaemia (7 days post-candidaemia mean blood glucose < 13.9 mmol/l) and those with severe hyperglycaemia (7 days post-candidaemia mean blood glucose > or = 13.9 mmol/l). A stepwise logistic regression analysis was performed to determine whether the degree of hyperglycaemia was a significant predictor of mortality. RESULTS: During the follow-up period from admission till discharge, 34 (39.1%) patients had died. Nine (69.2%) of 13 patients with severe hyperglycaemia have died while 25 (33.8%) of 74 patients with moderate hyperglycaemia have died. Multivariate analysis identified three independent determinants of death; Apache II score > or = 23 [OR 8.1, 95% CI (2.6, 25.3), P = 0.0003], mean blood glucose levels 7 days post-candidaemia > or = 13.9 mmol/l [OR 6.8, 95% CI (1.2, 38.2), P = 0.03], and mechanical ventilation [OR 6.5, 95% CI (2.21), P = 0.03]. CONCLUSION: Severe hyperglycaemia is an important marker of increased mortality among hospitalized diabetic patients with candidaemia.     

Prognostic value of pharmacological stress echocardiography in diabetic patients.

Our study was undertaken to assess the prognostic significance of pharmacological stress echocardiography in 325 diabetic patients. Pharmacological stress echocardiography was performed for diagnosis of coronary artery disease in 128 patients, and for risk stratification in 197 patients. Follow-up was 34 months. Cardiac-related death and non-fatal myocardial infarction were considered hard events. During the follow-up period, there were 38 deaths and 23 acute non-fatal myocardial infarctions. By univariate analysis, a pharmacological stress echocardiography positive response for ischaemia indicated an increased risk of cardiovascular death. However, by multivariate analysis, advanced age and peak ejection fraction <40% were the only independent predictors of cardiac death. The same peak ejection fraction (EF) <40%, rest wall motion score index and previous myocardial infarction were independent predictors of hard events. After dividing the population into two subgroups on the basis of EF at rest, only a peak EF <40% and a pharmacological stress echocardiography positive test were powerful independent predictors of cardiovascular mortality.     

Prognostic efficacy of cardiac biomarkers for mortality in dialysis patients

Background: The high prevalence of cardiovascular mortality in the end‐stage renal disease population is well established. The aim of this current study was to document the relative prognostic significance of established cardiac biomarkers troponin T (TnT), troponin I (TnI), B‐type natriuretic peptide (BNP) and N‐terminal pro‐BNP (NT‐pro‐BNP) in this population. Methods: A prospective cohort study of dialysis patients undertaken in a single tertiary centre in Australia. Relevant clinical and biochemical information was collected at entry and all patients followed up prospectively without any loss to follow up. End‐point of interest was all‐cause mortality. Statistical analysis using Cox proportional hazards was used to study relationship between competing covariates and outcome. A total of 143 patients with a mean age of 59.67 ± 15.49 years was followed up for a median duration of 30 months. Of these patients, 89.3% were white Australians of European ancestry. Twenty‐seven per cent had an established diagnosis of diabetes mellitus. The mean concentrations (±SD) of TnT, TnI, BNP and N‐terminal peptide pro‐BNP (NT‐pro‐BNP) were 0.08 ± 0.04 µg/L, 0.09 ± 0.2 µg/L, 270 ± 117 ng/L and 1434 ± 591 ng/L respectively. Results: Twenty‐eight subjects died during the period of follow up. By univariate analysis, all cardiac markers (TnT, TnI, BNP, NT‐pro‐BNP and C‐reactive protein) were significantly associated with an increase in mortality. On Cox proportionate hazards analysis, only albumin and NT‐pro‐BNP showed a significant association with mortality, with hazard ratios of 0.834, 95% confidence interval (CI) 0.779–0.893, P < 0.001, and 1.585, 95%CI 1.160–20165, P = 0.004 respectively. Conclusion: In patients with end‐stage renal failure on dialysis NT‐pro‐BNP provides greater prognostic information compared with TnT and TnI.     

Macro-microangiopathy and endothelial dysfunction in NIDDM patients with and without diabetic nephropathy

Summary The Steno hypothesis suggests that albuminuria reflects widespread vascular damage (proliferative retinopathy and severe macroangiopathy) due to a generalized vascular (endothelial) dysfunction. We assessed this concept in NIDDM (non-insulin-dependent diabetic) patients with (13 female/39 male, age 60 ± 7 years, group 1) and without (12 female/41 male, age 61 ± 7 years, group 2) diabetic nephropathy compared to matched non-diabetic subjects (7 female/15 male, age 58 ± 8 years, group 3). A 12-lead ECG was recorded and coded blindly using the Minnesota Rating Scale; the World Health Organization cardiovascular questionnaire was used to assess past and present evidence of myocardial infarction, angina pectoris, stroke, and peripheral vascular disease (digital systolic blood pressure determination). The degree of diabetic retinopathy was scored from fundus photography. The following variables were measured: transcapillary escape rate of albumin (initial disappearance of intravenously injected ¹²⁵I-labelled human serum albumin), plasma concentrations of prorenin (radioimmunoassay) and serum concentrations of von Willebrand factor (enzyme-linked immunoadsorbent assay). Prevalence of ischaemic heart disease (ECG reading) (49/20/5)% and peripheral vascular disease as indicated by reduced systolic blood pressure on big toe (69/30/14)% was significantly higher in group 1 vs group 2 (p < 0.01) and in group 2 vs group 3 (p < 0.01), respectively. The prevalence and severity of retinopathy was higher in group 1 vs 2 (p < 0.01). Transcapillary escape rate of albumin (%/h) was elevated in group 1 and 2 as compared to control subjects: 7.9 (4.3–13.7); 7.4 (3.7–16.4) vs 6.0 (3.4–8.7), (p < 0.005), respectively. Plasma prorenin activity (IU/ml) was raised in group 1 and group 2 as compared to group 3: 272 (59–2405); 192 (18–813), and 85 (28–246), p < 0.001, respectively. Serum von Willebrand factor (IU/ml)was elevated in group 1 as compared to group 2 and 3: 2.07 (0.83–4.34); 1.60 (0.30–2.99) and 1.50 (1.00–2.38), p < 0.001, respectively. Our study demonstrated that NIDDM patients with and without albuminuria had increased transcapillary escape of albumin and raised prorenin activity, whereas only those with albuminuria had increased von Willebrand factor. Patients with NIDDM may have abnormal endothelial function in the absence of albuminuria. [Diabetologia (1996) 39: 1590–1597]     

High levels of erythrocyte aldose reductase and diabetic retinopathy in NIDDM patients

Summary Erythrocyte aldose reductase was determined in 90 NIDDM patients by a two-site ELISA using recombinant human aldose reductase. The level of aldose reductase did not correlate with age, duration of diabetes, fasting blood glucose and HbA_1cof the patients. Among 38 patients with diabetes for more than 10 years, aldose reductase in those with retinopathy (including non-proliferative and proliferative) was significantly higher than in those without, while no difference in the means of the average HbA_1c, maximum and minimum blood pressure levels was observed between the two groups. The results indicate that the level of aldose reductase in the erythrocyte of diabetic patients is associated with the presence of retinopathy.Abbreviations NIDDM Non-insulin-dependent diabetes mellitus - IDDM insulin-dependent diabetes mellitus     

Prognostic markers in treated hypertensive diabetic patients. 28-month follow-up.

INTRODUCTION: Diabetes mellitus has a prevalence of about 6 to 10% in western populations, with a rising tendency due to inappropriate increases in calorie intake and decreased physical activity. In diabetic patients hypertension (HT) has a prevalence of over 60% and cerebro- and cardiovascular disease is responsible for two-thirds of the mortality in these patients. PATIENTS AND METHODS: We studied prospectively and consecutively 97 patients (age 63 +/- 8; 39-89) with treated type 2 diabetes and HT. The objective was to identify cardio- and cerebrovascular risk markers. The majority of the patients were evaluated by clinical and laboratory examination, 24h ambulatory blood pressure monitoring (ABPM), HbA1c, total cholesterol, HDL-C and triglycerides, microalbuminuria, echocardiogram (left ventricular mass index) and carotid-femoral pulse wave velocity. Later, the patients were re-evaluated using the same diagnostic methodology after a mean follow-up of 28 months. RESULTS: The population was at high risk for cardio- and cerebrovascular disease (60% dyslipidemic, 39% with previous cerebro- or cardiovascular accidents, 73% nondipper, 69% with decreased vascular distensibility [<12 m/sec] and 35% with microalbuminuria) despite treatment. Diabetes was controlled in only 55% of cases and blood pressure (BP) in 10%, although by ABPM it was controlled in 40% of cases. Simultaneous control of diabetes and HT was present in only one third of the patients. At the end of follow-up these values had not changed significantly, which can only be considered positive in respect of reduction in microalbuminuria (due to ACEIs and AIIRAs). Thirty cardio- and cerebrovascular events occurred (5 deaths), related to inadequate control of diabetes at initial evaluation (p=0.012), night-time systolic BP (SBP) and nondipper status (p=0.02) and vascular distensibility at the end of the study (p=0.03). On multiple linear regression (stepwise) analysis the only variable which was significantly associated with cardio- and cerebrovascular mortality and morbidity was night-time SBP. CONCLUSIONS: Overall analysis of the data confirmed the elevated risk of these patients and the importance of more frequent and aggressive control. The study also confirms the importance of evaluation by ABPM in these patients, which may lead to more efficacious, tailor-made treatment.     

Prognostic significance of body mass indices for patients undergoing esophagectomy for cancer

The aim of this study was to determine the role of body mass index (BMI) in a Western population on outcomes after esophagectomy for cancer. Two hundred and fifteen consecutive patients undergoing esophagectomy for esophageal cancer of any cell type were studied prospectively. Patients with BMIs > 25 kg/m were classified as overweight and compared with control patients with BMIs below these reference values. Ninety-seven patients (45%) had low or normal BMIs, 86 patients (40%) were overweight, and a further 32 (15%) were obese. High BMIs were associated with a higher incidence of adenocarcinoma versus squamous cell carcinoma (83%vs. 14%, P = 0.041). Operative morbidity and mortality were 53% and 3% in overweight patients compared with 49% (P = 0.489) and 8% (P = 0.123) in control patients. Cumulative survival at 5 years was 27% for overweight patients compared with 38% for control patients (P = 0.6896). In a multivariate analysis, age (hazard ratio [HR] 1.492, 95% CI 1.143-1.948, P = 0.003), T-stage (HR 1.459, 95% CI 1.028-2.071, P = 0.034), N-stage (HR 1.815, 95% CI 1.039-3.172, P = 0.036) and the number of lymph node metastases (HR 1.008, 95% CI 1.023-1.158, P = 0.008), were significantly and independently associated with durations of survival. High BMIs were not associated with increased operative risk, and long-term outcomes were similar after R0 esophagectomy.     

Malnutrition-related diabetes mellitus in young adult diabetic patients attending a Nigerian diabetic clinic

Although malnutrition-related diabetes mellitus (MRDM) is reported to affect about 40-50% of young adult diabetics in the Indian subcontinent and possibly other tropical and subtropical countries, anecdotal reports have suggested its relative uncommonness in Africa. The presentation of subjects (aged 15-30 years) attending a major Nigerian diabetic clinic in 1984 was therefore reviewed. The results (i) confirm previous observations on the rarity of diabetes in young adult Africans: only 45 of a total of 756 registered diabetics presented when aged 15-30 years; (ii) indicate that classical MRDM from established clinical criteria was uncommon, affecting only about 6% of the subjects, the majority of whom were either atypically or classically insulin-dependent (about 90%), although a small proportion (about 6%) appeared non-insulin-dependent. These observations suggest that diabetes in young adult Nigerians is heterogeneous in clinical presentation and aetiopathogenesis and, furthermore, that classical malnutrition-related diabetes mellitus is rarely seen, being much the least common mode of presentation, unlike the indication of the WHO Expert Committee on Diabetes Report (1985).     

Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality

BackgroundPrognostic factors of mortality in elderly patients with dementia with aspiration pneumonia (AP) are scarcely known. We determined the mortality rate and prognostic factors in old patients with dementia hospitalized due to AP.MethodsWe prospectively studied 120 consecutive patients aged ≥ 75 years with dementia admitted with AP to two tertiary university hospitals. We collected data on demographic and clinical variables and comorbidities. Oropharyngeal swallowing was assessed by the water swallow test.ResultsSixty-one (50.8%) patients were female, and mean age was 86 ± 9 years. The swallow test was performed in 68 patients, revealing aspiration in 92.6%. Patients with repeat AP (28.3%) were more-frequently taking thickeners (61.8% vs.11.6%, p < 0.0001) and were less-frequently prescribed angiotensin-converting-enzyme (ACE) inhibitors (8.8% vs. 27.9%, p < 0.001) than patients with a first episode. Hospital mortality was 33.3%; these patients had lower lymphocyte counts and higher percentage of multilobar involvement. In the multivariate model, involvement of ≥ 2 pulmonary lobes was associated with hospital mortality (OR 3.051, 95% CI 1.248 to 7.458, p < 0.01). Six-month mortality was 50.8%; these patients were older and had worse functional capacity and laboratory data indicative of malnutrition. In the multivariate model, lower albumin levels were associated with six-month mortality (OR 1.129, 95% CI 1.008 to 1.265, p < 0.03).ConclusionIn-hospital and 6-month mortality were high (one-third and one-half patients, respectively). Multilobar involvement and lower lymphocyte counts were associated with hospital mortality, and older age, greater dependence and malnutrition with six-month mortality.     

Myocardial infarct size and mortality in diabetic patients

The mortality rate from myocardial infarction is disproportionately high in diabetic patients. One explanation for this may be that diabetic patients incur more extensive myocardial necrosis. This possibility was examined in a three part study. Firstly, peak serum aspartate aminotransferase concentrations of all diabetic and non-diabetic patients admitted with myocardial infarction over a 16 year period were compared retrospectively. Secondly, peak aspartate aminotransferase concentrations in a series of diabetic patients and controls matched by age and sex were examined retrospectively. Thirdly, creatine kinase MB release and electrocardiographic measures of infarct size were investigated prospectively in a case/control study. Although cardiac failure and death were more common in the diabetic groups, there were no significant differences in estimates of infarct size between diabetic and non-diabetic patients in any of the studies. Therefore, the high case fatality rate amongst diabetic patients is not caused by increased myocardial damage. Presumably survival is prejudiced by factors operating before the infarction.