Education to increase ophthalmologic care in older onset diabetes patients: Indications from the Wisconsin Epidemiologic Study of Diabetic Retinopathy

Both physicians and diabetic persons must be educated about the need for regular ophthalmologic examinations to prevent blindness. A large population-based study of diabetic persons living in Southern Wisconsin (Wisconsin Epidemiologic Study of Diabetic Retinopathy), designed to evaluate the incidence and associated risk factors for diabetic retinopathy, provided the opportunity to evaluate an intervention to increase ophthalmologic care. As part of this study, a sample of persons less than 80 years of age with older onset diabetes of less than 15 years duration was identified and examined in both 1980–1982 and 1984–1986 (n = 619) using standardized protocols. Study subjects received educational material on diabetic eye disease, and examination findings were conveyed to each participant and their primary physician. To evaluate the effect of this intervention, a random representative sample of diabetic persons who were not selected for examination (a nonintervention control group) was identified and interviews were completed with 241 (80%) of the surviving subjects. The two study groups were similar with respect to demographic factors, employment status, medical history, and frequency of physician visits and hospitalizations, but not for income. Self-assessments of general health were also identical between the selected and nonintervention groups. Overall, both groups reported very similar patterns of ophthalmologic care, visual impairment, and knowledge of retinopathy. These results suggest that a more intensive intervention is needed to improve the ophthalmologic care patterns of the diabetic population at risk of eye disease.     

Lack of association between lipoprotein (a) concentrations and coronary heart disease mortality in diabetes: the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

Recently, considerable data have suggested that lipoprotein (a) [Lp(a)] is a strong independent risk factor for coronary heart disease. Since Lp(a) is increased in both insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM), this study examined the relationship of Lp(a) concentrations to coronary heart disease (CHD) mortality in the 4-year follow-up of the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). Twenty-four older-onset subjects and 11 younger-onset subjects who died of CHD (cases) before the age of 70 were matched by age, gender, and type of diabetes to subjects who remained alive (controls). The distribution and mean levels of Lp(a) in the cases and controls were very similar, suggesting a lack of association between Lp(a) concentrations and CHD mortality. Although the number of subjects was small, caution should be used in extrapolating results on Lp(a) relationships in nondiabetic subjects to diabetic subjects.     

Postural hypotension and labile blood pressure associated with severe hypophosphatemia

We present a patient with postural hypotension and labile blood pressure due to severe hypophosphatemia. There was no evidence for other causes of postural hypotension in our patient. The blood pressure abnormalities responded to phosphate replacement.     

Weight gain is associated with improved glycaemic control but with adverse changes in plasma lipids and blood pressure isn Type 1 diabetes.

AIMS: To assess the effects of weight gain on metabolic control, plasma lipids and blood pressure in patients with Type 1 diabetes. METHODS: Patients in the EURODIAB Prospective Complications Study (n = 3250) were examined at baseline and 1800 (55%) were re-examined a mean of 7.3 years later. Patients had Type 1 diabetes, defined as a diagnosis made before age 36 years and with a need for continuous insulin therapy within a year of diagnosis. Patients were aged 15-60 years at baseline and were stratified for age, sex and duration of diabetes. RESULTS: The change in HbA(1c) from baseline to follow-up examination was significantly more favourable in those who gained 5 kg or more during follow-up ('marked weight gain') than in patients who gained less or no weight or lost weight ('less or no weight gain'). In those with marked weight gain, there was a significantly greater rise in plasma triglycerides and total cholesterol and significantly less favourable changes in low-density lipoprotein and high-density lipoprotein cholesterol compared with those with less or no weight gain, with or without adjustment for HbA(1c). Systolic and diastolic blood pressure also rose significantly more in the group with marked weight gain. CONCLUSION: Weight gain in patients with Type 1 diabetes has adverse effects on plasma lipids and blood pressure, despite a small improvement in glycaemic control.     

Postural changes in blood pressure and incidence of ischemic stroke subtypes: the ARIC study

The relation of orthostatic blood pressure decrease, or increase, with occurrence of ischemic stroke subtypes has not been examined. We investigated the association of orthostatic blood pressure change (within 2 minutes after supine to standing) obtained at baseline (1987 to 1989) in the Atherosclerosis Risk in Communities Study with incidence of ischemic stroke subtypes through 2007. Among 12 817 black and white individuals without a history of stroke at baseline, 680 ischemic strokes (153 lacunar, 383 nonlacunar thrombotic, and 144 cardioembolic strokes) occurred during a median follow-up of 18.7 years. There was a U-shaped association between orthostatic systolic blood pressure change and lacunar stroke incidence (quadratic P=0.004). In contrast, orthostatic systolic blood pressure decrease of 20 mm Hg or more was associated with increased occurrence of nonlacunar thrombotic and cardioembolic strokes independent of sitting systolic blood pressure, antihypertensive medication use, diabetes, and other lifestyle, physiological, biochemical, and medical conditions at baseline (for nonlacunar thrombotic: hazard ratio, 2.02; 95% CI, 1.43 to 2.84; for cardioembolic: hazard ratio, 1.85, 95% CI, 1.01 to 3.39). Orthostatic diastolic blood pressure decrease was associated with increased risk of nonlacunar thrombotic and cardioembolic strokes; the hazard ratios (95% CI) associated with 10 mm Hg lower orthostatic diastolic blood pressure (continuous) were 1.26 (1.06 to 1.50) and 1.41 (1.06 to 1.88), respectively, in fully adjusted models. In conclusion, the present study found that nonlacunar ischemic stroke incidence was positively associated with an orthostatic decrease of systolic and diastolic blood pressure, whereas greater lacunar stroke incidence was associated with both orthostatic increases and decreases in systolic blood pressure.     

Orthostatic blood pressure changes and diabetes duration

To determine the prevalence and the associated clinical characteristics of orthostatic hypotension and orthostatic hypertension in patients with diabetic sensorimotor polyneuropathy (DSP).MethodsA single-center retrospective cross-sectional study was conducted on 200 DSP patients who had 3-minute orthostatic measures as part of the standard clinic evaluation. We measured the heart rate (HR) and blood pressure (BP) supine and again after 3 min of standing.ResultsThe prevalence of orthostatic hypotension was 19.5% and that of orthostatic hypertension was 23%. Subjects with orthostatic hypotension had significantly longer diabetes duration than subjects who were normotensive and those with orthostatic hypertension. Quantitatively, BP changes from supine to standing correlated with diabetes duration (R = 0.306; P = 0.0582) and age (R = 0.434; P = 0.006) in subjects with orthostatic hypotension.ConclusionsOrthostatic hypertension and orthostatic hypotension are frequent in patients with DSP. Orthostatic hypertension is associated with shorter diabetes duration than orthostatic hypotension.     

老年人的体位性血压变化和相关危险因素的初探

目的了解体位性血压异常波动在老年人群中的发生情况,探讨相关危险因素及靶器官损伤情况。方法对106例老年人进行卧位及立位3min内血压测定,根据血压变化情况分为体位性低血压（OHYPO）组、体位性高血压（OHT）组及体位性血压正常（ONT）组。分析各组的临床资料、生化指标、颈动脉超声、心脏超声检查结果。结果106例患者中,发现OHYPO组10例（9．4％）,OHT组30例（28．3％）。OHYPO组合并帕金森氏病及应用抗震颤药物者比例高于ONT组（P〈0．01）及OHT组（P〈0．05）;OHT组应用硝酸酯类药物者比例高于其他两组（P〈0．05）,该组三酰甘油高于OHYPO组（P〈0．05）,高密度脂蛋白低于ONT组（P〈0．05）;多元回归分析结果显示使用硝酸酯类药物、低高密度脂蛋白血症是体位性高血压的独立危险因素。OHT组左房内径大于ONT组（P〈O．01）,OHYPO组内生肌酐清除率低于OHT组（P〈O．05）。结论体位性血压异常波动在老年人中较常见,这可能与老年人血脂异常、合并疾病及使用药物增多相关。剧烈的血压变化对老年人左心房及肾小球滤过功能造成的损伤较明显。     

Type 1 diabetes is associated with significant changes of ACE and ACE2 expression in peripheral blood mononuclear cells

Background and aimsThe renin-angiotensin system (RAS), which is a key mediator of cardiovascular homeostasis, has two main axes. The classic one, including angiotensin-converting enzyme (ACE) and Angiotensin (Ang) II, promoting vasoconstriction, and the “alternative” one, including ACE2 and Ang1-7, with opposed actions to AngII. ACE2 has been identified as the main receptor of SARS-CoV2, whereby it enters the cells, leading to the downregulation of surface ACE2 and RAS tissue unbalance. Given that diabetes is associated with an increase in COVID-19 severity and death, we aimed at evaluating RAS expression in patients with type 1 diabetes (T1D).Methods and resultsThis is a case–control study comparing 39 T1D patients to 33 controls, with a median age of 29 and 32 years, and no comorbidities. ACE and ACE2 gene expression was assessed in peripheral blood mononuclear cells. T1D patients had higher ACE expression and circulating AngII, which were related to glucose levels. T1D patients had lower ACE2 expression. However, ACE2 expression was also related to the sex of participants, being higher in the female group. T1D women did not show the same increase of ACE2 expression that was seen in control women.ConclusionT1D promotes the increase of ACE, AngII, and ACE/ACE2, which might contribute to the higher cardiovascular risk, as well as to severe tissue injury induced by SARS-CoV2 in these patients. The ratio ACE/ACE2 does not differ between men and women with T1D, which might explain why CVD or COVID-19 do not show substantial gender differences in these patients.     

Poor glycemic control is associated with increased diastolic blood pressure and heart rate in children with Type 1 diabetes

Although higher levels of hemoglobin A1c (HbA1c) and blood pressure precede the development of nephropathy in Type 1 diabetes (T1DM), the relationship between glycemic control and cardiovascular factors early in the course of diabetes is not clear. We conducted a retrospective study from clinic data for a 1-year period in 148 children with T1DM aged 12.5+/-4.4 years who had average diabetes duration of 4.5+/-3.3 years. The influence of HbA1c and reported insulin dose on blood pressure and heart rate were analyzed in multivariate linear regression models, statistically adjusted for the effect of race, sex, age, body mass index, and duration of diabetes. There was a significant positive correlation of mean HbA1c with mean diastolic blood pressure (P<.025) and mean heart rate (P<.0004). Higher diastolic blood pressure and heart rate were associated with higher HbA1c. Increased insulin doses were also associated with increased diastolic blood pressure (P<.009) and heart rate (P<.013). Insulin dose and HbA1c were also significantly correlated (P<.001). There was no correlation between mean HbA1c and mean systolic blood pressure. Increased levels of HbA1c and insulin dose are associated with increased diastolic blood pressure and heart rate. Although within the normal range, early increases of diastolic blood pressure and heart may indicate early cardiovascular changes in response to diabetes and potentially contribute to a greater proclivity for later development of nephropathy.     

Prevalence of Diabetic Retinopathy and Cataract in Adult Patients With Type 1 And Type 2 Diabetes in Russia

AIM: The aim of the study was to identify the prevalence of diabetic retinopathy (DR) and diabetic cataract (DC) in type 1 and type 2 diabetic patients within the Russian Federation. Also, the stage of DR at the time of its identification and the proportion of new cases diagnosed with DR or DC were to be determined. METHODS: A random sample of 7,186 adult patients with diabetes was screened for DR and DC using fundoscopy and fundus photography. Levels of HbA1c, total cholesterol, triglycerides, creatinine and urinary albumin excretion rate were assessed. RESULTS: In diabetic patients, the prevalence of DR and DC was 45.9% and 30.6%, respectively. These complications appeared significantly more frequently in patients with type 1 diabetes than in type 2 diabetes. The prevalence of background, preproliferative and proliferative DR among diabetic patients was 28.1%, 8.1%, and 6.7%, respectively. Patients with DR were older, had a longer duration of diabetes, higher HbA1c, elevated plasma total cholesterol, increased triglicerides, and higher systolic BP, compared with patients without DR. Microalbuminuria and proteinuria were more prevalent among patients with DR compared with non-DR patients. CONCLUSIONS: The results showed that diabetic retinopathy and cataract are wide-spread complications among diabetic patients in Russia. However, the disease course is more aggressive and accelerated in patients with type 1 diabetes than in those having type 2 diabetes. Therefore, it is important to prevent DR by identifying diabetes and signs of retinopathy at the earliest possible stage of progression for timely and adequate retina laser coagulation or surgical treatment, compensation of carbohydrate and lipid metabolism, and normalization of blood glucose and pressure.     

Type 2 diabetes in Bangladesh and associated risk factors

This study aims at determining the impact of different background factors on type 2 diabetes. During the year 2007–2008, 12,112 registered diabetic patients of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) have been selected as the sample for this study. The variables age, sex, body mass index, marital status, place where spent three fourth of the life, educational level, occupation, economic status, smoking habit, and family history of diabetes have been considered as potential risk factors for diabetes. The dependent variable chosen was the fasting blood glucose level. Chi-square test of independence diagnosed age, place where spent at least three fourth of lifetime, body mass index, education, economic status, sibling’s having diabetes, occupation, father having diabetes, smoking habit, and sex to be significantly associated with the fasting blood glucose level. Ordinal logistic regression model was applied to detect the impact of risk factors on blood glucose level and age, body mass index (BMI), education, economic status, occupation and place where spent three fourth of the lifetime were found to be significant.     

Diabetic background retinopathy is associated with impaired coronary vasoreactivity in people with Type 1 diabetes

Aims/hypothesis We examined whether diabetic background retinopathy is associated with reduced coronary vasoreactivity in people with Type 1 diabetes.Methods A total of 21 men with Type 1 diabetes were investigated, including 9 men with background retinopathy and 12 men without retinopathy. In addition, 12 non-diabetic, age-matched subjects were studied. All subjects were non-smokers, otherwise healthy and had no other diabetic complications. Resting myocardial blood flow and hyperaemic dipyridamole-stimulated flow (dipyridamole, 0.56 mg/kg during a 4-min period), a measure of coronary vasoreactivity, were measured during euglycaemic hyperinsulinaemic clamp (1 mU·kg^–1·min^–1) using positron emission tomography and oxygen-15-labelled water.Results Resting myocardial blood flow (0.82±0.13 vs 0.96±0.23 vs 0.88±0.25 ml·g^–1·min^–1, with vs without retinopathy vs non-diabetic subjects) and coronary vascular resistance (111.2±23.4 vs 95.5±15.8 vs 101.9±31.5 mmHg·min·g·ml^–1 respectively) were not significantly different between the groups. Dipyridamole infusion induced an increase in blood flow and a decrease in coronary vascular resistance in all study subjects (p<0.001). However, dipyridamole-stimulated flow and coronary vascular resistance were blunted in diabetic patients with retinopathy (2.9±0.9 ml·g^–1·min^–1 and 34.1±11.3 mmHg·min·g·ml^–1) when compared to diabetic patients without retinopathy (4.0±1.3 ml·g^–1·min^–1, p=0.04 and 24.6±7.5 mmHg·min·g·ml^–1, p=0.03) or non-diabetic subjects (4.5±1.4 ml·g^–1·min^–1, p=0.008 and 22.2±8.7 mmHg·min·g·ml^–1, p=0.01). Myocardial flow reserve was impaired in diabetic patients with retinopathy (3.6±1.0) when compared to non-diabetic subjects (5.3±1.9, p=0.02) but not significantly reduced when compared to diabetic patients without retinopathy (4.2±1.4, p=0.2).Conclusions/interpretation Diabetic background retinopathy appears to be associated with impaired coronary vasoreactivity in young people with Type 1 diabetes.Abbreviations PET positron emission tomography - [¹⁵O]H₂O oxygen-15-labelled waterJ. Sundell and T. Janatuinen contributed equally to this work     

Dysrhythmias and blood pressure changes associated with thrombolysis

Recent technologic advances facilitate salvage of viable myocardium before the process of myocardial infarction is complete. The aim of thrombolytic agents is to restore antegrade flow of blood in occluded coronary arteries. The process of reperfusion may be dysrhythmogenic because of the heterogeneous return of electrical activity in myocardial cells. This study examined the incidence and type of dysrhythmia occurrence and the associated changes in mean arterial blood pressure (MAP) during infusion of tissue-type plasminogen activator (TPA). A retrospective chart review of 41 subjects showed that 80% of subjects experienced dysrhythmias during TPA therapy. The most common dysrhythmia was sinus bradycardia, followed by idioventricular/accelerated idioventricular rhythm, ventricular premature beats, and ventricular tachycardia/fibrillation. There was a significant difference between MAP changes when there were no dysrhythmias and MAP changes when dysrhythmias occurred (p less than 0.05). The largest change in MAP (-22.71 mm Hg) was observed when dysrhythmias occurred in those subjects with blockage of the left anterior descending artery, although there was no statistically significant difference in changes in MAP among the groups of different sites of blockage (p greater than 0.05).     

Postural change in blood pressure associated with age and systolic blood pressure. The National Health and Nutrition Examination Survey II

The prevalence of postural change in blood pressure and its association with age and systolic blood pressure were examined in data from 8,574 White nondiabetic persons aged 25-74 who participated in the second National Health and Nutrition Examination Survey (1976-1980). Postural change in blood pressure was defined as a drop of 20 mm Hg or more on change from supine to seated position. In subjects on no antihypertensive medications (n = 7,316), the prevalence of postural change in blood pressure increased with older age and with higher blood pressure levels, regardless of age. However, systolic blood pressure levels also increased with age. In logistic regression models, level of supine systolic blood pressure was strongly related to postural change in blood pressure (Relative odds (RO) = 1.59, 95% confidence interval (CI) = 1.49, 1.70 for a 10 mm Hg increase in systolic blood pressure) whereas age was not related to postural change in blood pressure (RO for age = 1.07, Cl = .89, 1.19 for a 10-year increase in age). Results were similar for those medicated for hypertension. All results were unchanged by addition of health status indicators, including reports of hospitalization and number of medical conditions, to the model. These data suggest that the age-related increase in the prevalence of postural hypotension previously reported may be partially explained by age-associated increases in systolic blood pressure.     

Albuminuria and Diabetic Retinopathy in Type 2 Diabetes Mellitus Sankara Nethralaya Diabetic Retinopathy Epidemiology And Molecular Genetic Study (SN-DREAMS,report 12)

Background

The purpose of this study was to evaluate the effects of cigarette smoke exposure before pregnancy on diabetic rats and their offspring development.

Methods

Diabetes was induced by streptozotocin and cigarette smoke exposure was conducted by mainstream smoke generated by a mechanical smoking device and delivered into a chamber. Diabetic female Wistar rats were randomly distributed in four experimental groups (n minimum = 13/group): nondiabetic (ND) and diabetic rats exposed to filtered air (D), diabetic rats exposed to cigarette smoke prior to and into the pregnancy period (DS) and diabetic rats exposed to cigarette smoke prior to pregnancy period (DSPP). At day 21 of pregnancy, rats were killed for maternal biochemical determination and reproductive outcomes.

Results

The association of diabetes and cigarette smoke in DSPP group caused altered glycemia at term, reduced number of implantation and live fetuses, decreased litter and maternal weight, increased pre and postimplantation loss rates, reduced triglyceride and VLDL-c concentrations, increased levels of thiol groups and MDA. Besides, these dams presented increased SOD and GSH-Px activities. However, the increased antioxidant status was not sufficient to prevent the lipid peroxidation observed in these animals.

Conclusion

Despite the benefits stemming from smoking interruption during the pregnancy of diabetic rats, such improvement was insufficient to avoid metabolic alterations and provide an adequate intrauterine environment for embryofetal development. Therefore, these results suggest that it is necessary to cease smoking extensive time before planning pregnancy, since stopping smoking only when pregnancy is detected may not contribute effectively to fully adequate embryofetal development.     

Postural changes in blood pressure in the general population of Cantabria (northern Spain)

OBJECTIVE: To describe the postural changes in blood pressure and correlates among the general population of Cantabria, a region in the north of Spain. METHODS: Between 2002 and 2004 blood pressure measurements were taken in a seated position and after 1 and 3 min standing on a random sample of 1178 individuals aged 18 years and above, stratified by age and sex. RESULTS: The prevalence of orthostatic hypotension was 7%, whereas 30% of the participants presented an exaggerated increase in blood pressure when standing and 36% presented one of the two alterations (postural dysregulation in blood pressure syndrome). Sixteen percent of the nonhypertensive participants presented a blood pressure figure when standing that was above or equal to 140/90 mmHg (orthostatic hypertension). In logistic regression analysis the existence of a high level of blood pressure when sitting was the only variable related to orthostatic hypotension (odds ratio: 2.407; confidence interval: 1.413-4.099). CONCLUSION: When evaluating and treating hypertensive patients, it should be taken into account that orthostatic hypotension is more frequent among those individuals who present poor levels of control of their blood pressure figures. Postural dysregulation in blood pressure syndrome is frequent among the general population, and therefore it is worthy of detailed study.