Cardiac Autonomic Neuropathy and Early Progressive Renal Decline in Patients with Nonmacroalbuminuric Type 1 Diabetes

Background and objectives

Cardiac autonomic neuropathy predicts future adverse renal outcomes in the general population. This study sought to determine its relationship with early progressive renal decline in type 1 diabetes.

Design, setting, participants, & measurements

A subset of participants with normoalbuminuria (n=204) or microalbuminuria (n=166) from the First Joslin Kidney Study underwent assessment for cardiac autonomic neuropathy using heart rate variability during baseline visits performed from January 1991 to April 1992. Cardiac autonomic neuropathy was defined as an R-R variation (mean circular resultant) <20. Participants also had baseline and follow-up measurement of eGFR. Early progressive renal decline was evaluated according to two definitions: early GFR loss (slope of eGFR estimated by cystatin C <−3.3%/year) and incident advanced CKD (stage ≥3, defined by eGFR [calculated by Modification of Diet in Renal Disease method] <60 ml/min per 1.73 m²). Association with baseline cardiac autonomic neuropathy was assessed by adjusted logistic regression and Cox proportional hazards.

Results

Among the 370 participants, 47 (13%) had baseline cardiac autonomic neuropathy, 51 (14%) had early GFR loss, and 68 (18%) had incident advanced CKD over a median 14-year follow-up. Early GFR loss occurred in 15 (32%) of the 47 patients with baseline autonomic neuropathy and in 32 (10%) of the 323 without baseline autonomic neuropathy (P<0.001). Baseline autonomic neuropathy was strongly associated with odds of early GFR loss (adjusted odds ratio, 4.09; 95% confidence interval, 1.65 to 10.12; P=0.002). Incident advanced CKD was observed in 22 (47%) of those with baseline autonomic neuropathy and 46 (14%) of those without baseline autonomic neuropathy (P<0.001). Autonomic neuropathy was independently associated with incident advanced CKD (adjusted hazard ratio, 2.76; 95% confidence interval, 1.44 to 5.30; P=0.002).

Conclusions

Cardiac autonomic neuropathy was a strong independent predictor of the long-term risk of early progressive renal decline in type 1 diabetes. Future research should explore the mechanisms by which autonomic neuropathy may be associated with renal function loss.     

Migration increase aspects of ocular patology

The authors present a case abundant in general and specific pathology, which makes up take a closer look to the pathology specific to Eastern doctors.     

Diabetes and stress hyperglycemia in the intensive care unit: outcomes after cardiac surgery

Background: Hyperglycemia is common in the post-cardiac surgery population and has been associated with increased mortality rates, surgical length of stay, and infection rates. Although hospitalized patients with diabetes are known to have more complications, recent studies in various hospital settings have reported worse outcomes in patients with stress hyperglycemia than in those with diabetes. Aim: The primary objective of this study was to analyze 30- and 90-day mortality rates in post-cardiac surgery patients with stress hyperglycemia and diabetes who were managed to achieve similar moderate blood glucose goals using the University of Michigan Hospital (Ann Arbor, MI) insulin protocol between 2005 and 2008. The secondary outcomes were rates of postoperative complications, including hypoglycemia. Methods: A standardized glucose management program was followed to treat all patients in the cardiac intensive care unit, with a blood glucose goal of 100 to 140 mg/dL. Data from 1973 patients with either diabetes or stress hyperglycemia were analyzed to identify associations between mean postoperative blood glucose levels and mortality, incidence of hypoglycemia, and complication rates. Results: Mortality rates did not differ between patients with diabetes and stress hyperglycemia (3.4 and 2.3%; P = 0.2). Rates of severe hypoglycemia were low (1%) for both groups and were not associated with an increase in mortality (P = 0.95). Other complication rates were similar between patients with diabetes and stress hyperglycemia. Conclusion: Maintaining a blood glucose range between 100 to 140 mg/dL in post-cardiac surgery patients was associated with a low mortality rate, low risk of hypoglycemia, and with complications rates that were similar in patients with diabetes and stress hyperglycemia.     

Facial asymmetry quantitative evaluation in oculoauriculovertebral spectrum

Objectives

Facial asymmetries in oculoauriculovertebral spectrum (OAVS) patients might require surgical corrections that are mostly based on qualitative approach and surgeon’s experience. The present study aimed to develop a quantitative 3D CT imaging-based procedure suitable for maxillo-facial surgery planning in OAVS patients.

Materials and methods

Thirteen OAVS patients (mean age 3.5 ± 4.0 years; range 0.2–14.2, 6 females) and 13 controls (mean age 7.1 ± 5.3 years; range 0.6–15.7, 5 females) who underwent head CT examination were retrospectively enrolled. Eight bilateral anatomical facial landmarks were defined on 3D CT images (porion, orbitale, most anterior point of frontozygomatic suture, most superior point of temporozygomatic suture, most posterior-lateral point of the maxilla, gonion, condylion, mental foramen) and distance from orthogonal planes (in millimeters) was used to evaluate the asymmetry on each axis and to calculate a global asymmetry index of each anatomical landmark. Mean asymmetry values and relative confidence intervals were obtained from the control group.

Results

OAVS patients showed 2.5 ± 1.8 landmarks above the confidence interval while considering the global asymmetry values; 12 patients (92 %) showed at least one pathologically asymmetric landmark. Considering each axis, the mean number of pathologically asymmetric landmarks increased to 5.5 ± 2.6 (p = 0.002) and all patients presented at least one significant landmark asymmetry.

Conclusions

Modern CT-based 3D reconstructions allow accurate assessment of facial bone asymmetries in patients affected by OAVS. The evaluation as a global score and in different orthogonal axes provides precise quantitative data suitable for maxillo-facial surgical planning.

Clinical relevance

CT-based 3D reconstruction might allow a quantitative approach for planning and following-up maxillo-facial surgery in OAVS patients.

     

Falls and depression in older people

BACKGROUND: Depression is one of the most common risk factors for falls, but links between falls and depression are still unclear. Few studies have examined the relationship between depression and gait alteration, which may increase the risk of fall. OBJECTIVE: This study aims to assess a possible relationship between depression, postural and gait abnormalities, and falls. METHODS: We conducted a 1-year prospective study on patients >/=70 years who were admitted to a geriatric unit for 'spontaneous' unexplained falls. Patients were tested for depression using the 30-item Geriatric Depression Scale (GDS). Their motor performances were assessed using the Mini Motor Test (MMT), which is an easy direct-observation test, validated in France, for assessment of frail old people who present with severe postural and gait impairment. This scale is composed of 4 categories of items: (1) abilities in bed; (2) quality of the sitting position; (3) abilities in the standing position, and (4) quality of gait. RESULTS: Sixty-nine patients were included. Depression was found in 46 patients (66.7%). The MMT score was higher in the non-depressed fallers (NDF) group (GDS 10; p < 0.05). The 2 groups were compared for each of the 4 items of the MMT: the difference between the DF and NDF groups was mainly explained by the impairment of postural abilities in the standing position. CONCLUSIONS: Our results support the idea that depression is associated with postural abnormalities in the standing position, which may predispose to falls. In clinical practice, more attention should be given to old fallers concerning diagnosis and treatment of associated depression.     

Determinants of Weight Gain in the Action to Control Cardiovascular Risk in Diabetes Trial

OBJECTIVE

Identify determinants of weight gain in people with type 2 diabetes mellitus (T2DM) allocated to intensive versus standard glycemic control in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

RESEARCH DESIGN AND METHODS

We studied determinants of weight gain over 2 years in 8,929 participants (4,425 intensive arm and 4,504 standard arm) with T2DM in the ACCORD trial. We used general linear models to examine the association between each baseline characteristic and weight change at the 2-year visit. We fit a linear regression of change in weight and A1C and used general linear models to examine the association between each medication at baseline and weight change at the 2-year visit, stratified by glycemia allocation.

RESULTS

There was significantly more weight gain in the intensive glycemia arm of the trial compared with the standard arm (3.0 ± 7.0 vs. 0.3 ± 6.3 kg). On multivariate analysis, younger age, male sex, Asian race, no smoking history, high A1C, baseline BMI of 25–35, high waist circumference, baseline insulin use, and baseline metformin use were independently associated with weight gain over 2 years. Reduction of A1C from baseline was consistently associated with weight gain only when baseline A1C was elevated. Medication usage accounted for <15% of the variability of weight change, with initiation of thiazolidinedione (TZD) use the most prominent factor. Intensive participants who never took insulin or a TZD had an average weight loss of 2.9 kg during the first 2 years of the trial. In contrast, intensive participants who had never previously used insulin or TZD but began this combination after enrolling in the ACCORD trial had a weight gain of 4.6–5.3 kg at 2 years.

CONCLUSIONS

Weight gain in ACCORD was greater with intensive than with standard treatment and generally associated with reduction of A1C from elevated baseline values. Initiation of TZD and/or insulin therapy was the most important medication-related factor associated with weight gain.Weight gain is a well-known consequence of the intensive treatment of type 2 diabetes mellitus (T2DM) (1). However, the definition of intensive therapy varies, and no studies have attempted near-normal glycemia, as in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Furthermore, some currently available therapies have a greater effect on weight, although the key determinants of weight gain in relation to intensive therapy remain unclear. Therefore, data from this trial could give us insight into the determinants of weight gain with intensive therapy.The ACCORD trial randomized 10,251 people with type 2 diabetes and other cardiovascular risk factors to one of two glycemic targets: 1) an intensive A1C target of <6.0%; or 2) a standard target of between 7 and 7.9% (2). Participants were followed for a mean of 3.5 years until the intervention was stopped due to increased mortality in the intensive group. During this follow-up period, weight was measured regularly, and participants in the intensive group experienced greater weight gain than participants in the standard group. The data collected in the ACCORD trial provide an opportunity to identify determinants of weight gain in people with T2DM allocated to intensive versus standard glycemic control and to assess the relationship between changes in glycemic control and changes in weight.The main outcomes of the ACCORD trial were previously reported (2). We present results on 8,929 participants (4,425 randomized to the intensive arm and 4,504 to the standard arm) with valid data at baseline and at least 2 years of follow-up. Participants who were not included did not have weights or withdrew or died during the first 2 years. In this analysis, we focus on weight gain as the dependent variable and describe the time course of weight change, its relationship to baseline characteristics and allocated treatment arm (intensive and standard), and its relationship to the postrandomization change in glycemic control (A1C) and use of glucose-lowering medications.We posed several questions regarding potential causes of weight gain during the first 2 years of the trial, and the differences in weight gain experienced by the two allocated groups. First, was weight gain explained by the baseline characteristics (including prior medications)? Second, was weight gain explained by the change in A1C? Third, was weight gain explained by postrandomization medication use? Finally, were the factors that led to the change in weight the same in the intensive and standard groups?     

Dapagliflozin and measures of cardiovascular autonomic function in patients with type 2 diabetes (T2D)

AimsSodium-glucose cotransporter-2 (SGLT-2) inhibitors reduce blood pressure without compensatory heart rate elevation, possibly by modulating sympathetic/parasympathetic activity. This may contribute to their cardiovascular benefits in type 2 diabetes (T2D). We evaluated the effects of dapagliflozin (DAPA) on measures of cardiovascular autonomic neuropathy (CAN), cardiac function, and glucose variability (GV) in T2D.MethodsPilot, randomized, two-period crossover trial comparing 12-week DAPA versus 12-week glimepiride treatment on CAN measures (cardiovascular autonomic reflex tests and heart rate variability), B-type natriuretic peptide (BNP), and GV (Abbott's Libre Pro devices) using signed rank tests and mixed models from baseline to 12 weeks within and between each period.ResultsForty-five T2D participants on metformin monotherapy (mean age 57 ± 8 years, duration 7 ± 6 years, HbA1c 7.8 ± 1.3%) were enrolled with 41 completing the trial. There were no differences in CAN indices or BNP with each drug compared to baseline and each other. Participants on DAPA demonstrated greater weight loss, reduced time in hypoglycemia, and improved GV compared to glimepiride.ConclusionsShort term treatment with DAPA did not affect CAN measures or BNP in uncomplicated and relatively healthy T2D participants. Longer prospective studies in patients with advanced disease are needed to better understand relationships between SGLT-2 inhibitors and CAN.Clinical trial registration: NCT02973477     

Design of Green Silver Nanoparticles Based on Primula Officinalis Extract for Textile Preservation

The present study aims to bring an addition to biomass resources valorization for environmental-friendly synthesis of nanoparticles. Thus, the green synthesis of silver nanoparticles (AgNPs) was performed, using a novel and effective reducing agent, Primula officinalis extract. The synthesis was optimized by monitoring the characteristic absorption bands, using UV–Vis spectroscopy, and by evaluating the size and physical stability. The phenolic consumption was established using Folin-Ciocâlteu method (1.40 ± 0.42 mg, representing ~5% from the total amount of poly--phenols) and the antioxidant activity was evaluated using chemiluminescence and TEAC methods. The optimum ratio extract to Ag ions was 1:3, for which the AgNPs presented a zeta potential value of −29.3 ± 1.2 mV and particles size of 5–30 nm. For characterization, EDS and XRD techniques were used, along with microscopy techniques (TEM). The AgNPs dispersions were applied on natural textile samples (cotton and wool), as a novel antimicrobial treatment for textile preservation. The treated fabrics were further characterized in terms of chromatic parameters and antimicrobial effect against Escherichia coli, Staphylococcus aureus, Bacillus subtilis, and Penicillium hirsutum strains. The high percentages of bacterial reduction, >99%, revealed that the AgNPs produced are a good candidate for textiles preservation against microbial degradation.