Does addressing prediabetes help to improve population health?

Peer reviewe

Connatalis syphilis = Congenital syphilis

A syphilis az elmúlt évtizedekben ismét egyre gyakrabban diagnosztizált betegség. Előretörésével számítanunk kell a congenitalis syphilis megjelenésére is. Syphilis állhat spontán, illetve habituális vetélés, halvaszülés hátterében. Az intrauterin élet során szerzett syphilisszel világra jövő újszülöttek gyakran tünetmentesek, és a fertőzés által okozott szervi károsodások csak hónapokkal vagy akár évekkel később válnak nyilvánvalóvá. A betegség megelőzhető a terhes nők szűrésével és kezelésével. Minden újszülött, aki potenciálisan syphilisszel fertőződhetett, kezelendő a megszületés napjától kezdve. A syphilis elleni kezelés szuverén szere ma is a penicillin. | Syphilis has been a re-emerging disease in the past few decades. As a consequence, the prevalence of congenital syphilis is expected to be on the rise. Maternal syphilis may be related to several pathologies, such as miscarriage, stillbirth, or congenital syphilis in the child. Infants that acquire syphilis in utero are frequently asymptomatic, and the organ damage caused by the infection may be apparent only years later. Syphilis is a curable disease, and most of its complications in the infant can be prevented by screening and treating the mother. Every newborn potentially infected should be treated with penicillin immediately starting on the day of birth

Relationship between serum calcium and CA 19-9 levels in colorectal cancer

AIM: To examine the calcium metabolism of colorectal cancer (CRC) in patients with colorectal cancer and control patients. METHODS: Seventy newly diagnosed CRC patients were included. The healthy control group was age and gender matched (n=32). Particular attention was devoted to the relationship between serum calcium of patients, and levels of AFP, CEA, carbohydrate antigen 19-9 (CA 19-9) (that could be considered as prognostic factors). Furthermore, the Ca-sensing receptor (CaSR) gene A986S polymorphism was investigated in these patients, as well as the relationship between different CaSR genotypes and the data stated above. RESULTS: A lower level of ionized calcium (also corrected for albumin) was found in the serum of CRC patients with normal 25(OH) vitamin D levels. The ionized calcium concentration was inversely correlated with the serum level of CA 19-9. There was no difference in the distribution of CaSR genotypes, between CRC patients and general population. The genotypes did not correlate with other data examined. CONCLUSION: Based on these results, lower levels of serum calcium might be a pathogenic and prognostic factor in colorectal cancer

A normoglykaemia elérésének korlátai inzulinkezelt 2-es tipusú cukorbetegekben

Insulin therapy is the most effective treatment of diabetes. It is proven to prevent microvascular disease and likely to decrease the risk of cardiovascular complications. However, these benefits are associated with a 2-3 times increased risk of hypoglycaemia and a faster weight gain compared to other antidiabetic medications. In addition, one study found elevated all-cause mortality among patients on intensive therapy (requiring more frequent insulinisation). Insulin has growth factor properties that may translate to increased mitogenicity. These factors could prevent the medical team or the patient from initiation or intensification of insulin therapy. The authors describe evidence on long-term remission related to transient intensified insulin therapy at diabetes diagnosis. The currently recommended method of insulin initiation is once daily basal insulin treatment that offers different schedules for intensification. The authors review the pharmacokinetics of analogue insulins that translate to similar efficacy to human insulins with a 20-30% lower risk of hypoglycaemia. Orv. Hetil., 2015, 156(36), 1443-1450

Trajectories of cardiometabolic risk factors before diagnosis of three subtypes of type 2 diabetes: a post-hoc analysis of the longitudinal Whitehall II cohort study

SummaryBackgroundMost clinicians acknowledge that type 2 diabetes is multifactorial and has heterogeneous characteristics, but neither prevention nor treatment is systematically stratified. To address the heterogeneity of the disease, we examined whether patients diagnosed on the basis of fasting glucose concentrations, those diagnosed on the basis of 2 h concentrations, and those diagnosed on the basis of both criteria differed in terms of pathogenesis or cardiovascular risks.MethodsRetrospectively, we analysed trajectories of cardiometabolic risk factors and 10 year cardiovascular risks in the prospective Whitehall II study cohort by use of multilevel longitudinal modelling. Participants were diagnosed by 75 g oral glucose-tolerance tests. We classified those diagnosed with type 2 diabetes into three subgroups: diagnosed on the basis of fasting glucose concentrations, diagnosed on the basis of 2 h glucose concentrations, and diagnosed on the basis of both concentrations. We also developed a classification tree for identification of individuals who are likely to have high fasting and 2 h glucose concentrations, but for whom only fasting concentrations are available.ResultsMedian follow-up was 14·2 years with 15 826 person-examinations (1991–2009). Of 10 308 individuals, 6843 were included and 6569 remained diabetes free. 274 cases of type 2 diabetes were identified: 55 had high fasting glucose concentrations only, 148 had high 2 h concentrations only, and 71 had high fasting and 2 h concentrations. At diagnosis, participants with high fasting and 2 h glucose concentrations had higher mean body-mass indices (30·9 kg/m2 [SD 5·7]) than did those with high fasting concentrations (28·4 kg/m2 [4·4]; p=0·0009) or 2 h concentrations (27·9 kg/m2 [4·9]; <0·0001). Mean glycated haemoglobin A1c concentrations were also higher in the fasting and 2 h subgroup (7·4% [1·6]) than in the fasting (5·9% [0·5]; <0·0001) or 2 h (5·9% [0·6]; <0·0001) sugroups. Additionally, the fasting and 2 h subgroup had a higher proportion of individuals with moderate or high risk of cardiovascular disease than did the fasting subgroup (p=0·02). A classic pattern of β-cell decompensation before diagnosis was noted only in the fasting and 2 h subgroup. Additionally, glucose concentrations and insulin resistance accelerated more substantially before diagnosis in the fasting and 2 h subgroup than in the fasting subgroup or the 2 h subgroup.InterpretationPatients with type 2 diabetes diagnosed on the basis of increased fasting glucose concentrations or 2 h glucose concentrations, or both, have distinct cardiometabolic risk development before diagnosis.FundingUK Medical Research Council, UK Economic and Social Research Council, British Heart Foundation, UK Health and Safety Executive, UK Department of Health, US National Heart Lung and Blood Institute, US National Institute on Aging, US Agency for Health Care Policy Research, and John D and Catherine T MacArthur Foundation

Integrated Central Blood Pressure-aortic Stiffness Risk Categories and Cardiovascular Mortality in End-stage Renal Disease

BACKGROUND: Our aim was to study the predictive power of integrated central blood pressure-aortic stiffness (ICPS) risk categories on cardiovascular (CV) mortality in end-stage renal disease (ESRD) patients. METHODS: This is a secondary analysis of a prospective study of 91 ESRD patients on hemodialysis therapy. At baseline, pulse wave velocity (PWV), central systolic blood pressure (cSBP) and central pulse pressure (cPP) were measured and patients were followed up for CV mortality for a median 29.5 months. Based on the shape of the association of each individual ICPS parameter with the CV outcome, patients were assigned ICPS scores: one point was given, if either the cSBP value was in the 3rd, or if the PWV or cPP was in the 2nd or 3rd tertiles (ICPS range: 0–3). We then evaluated the role of ICPS risk categories (average: 0–1, high: 2, very high: 3 points) in the prediction of CV outcomes using Cox proportional hazard regression analysis and compared its discrimination (Harrell’s C) to that of each of its components. RESULTS: We found a strong dose–response association between ICPS risk categories and CV outcome (high risk HR = 2.62, 95% CI: 0.82–8.43, p for trend = 0.106; very high risk HR = 10.03, 95% CI: 1.67–60.42, p = 0.02) even after adjustment for multiple potential confounders. ICPS risk categories had a modest discrimination (C: 0.622, 95% CI: 0.525–0.719) that was significantly better than that of cSBP (dC: 0.061, 95% CI: 0.006–0.117). CONCLUSIONS: The ICPS risk categories may improve the identification of ESRD patients with high CV mortality risk

Pregesztációs és gesztációs diabétesszel társuló terhesség miatt gondozott asszonyok szülést követő keresztmetszeti vizsgálata: Szövődmények és kardiovaszkuláris kockázati tényezők patogenetikája = Cross-sectional study of women cared for a pregnancy complicated by pregestational and gestational diabetes after delivery: Pathogenetics of complications and cardiovascular risk factors

1-es és a 2-es típusú cukorbetegek terhessége során romolhatnak a diabéteszes szövődmények. Kevéssé ismert azonban a terhesség hatása a betegség hosszútávú kimenetelére. Nem tisztázottak a gesztációs diabétesz (GDM) késői anyai következményei sem. Jelen vizsgálatban hasonló módszerekkel pregesztációs (1-es és 2-es típusú) diabéteszben és korábban GDM-ben szenvedő (kGDM) asszonyokat vizsgáltunk évekkel szülésük után. A terhességük előtt is cukorbeteg asszonyokban gyakori a túlsúly, a hypertonia és a dohányzás. A kGDM kohorszban összefüggést találtunk a glukóz intolerancia (GI) súlyossága és a metabolikus szindróma gyakorisága között. GI asszonyokban magasabb osteoprotegerin szinteket, az oGTT során károsodott leptinválaszt észleltünk. kGDM betegeinkben magasabb resistin és alacsonyabb adiponectin értékeket találtunk. Az adiponectin negatívan korrelált ismert CV kockázati tényezőkkel. kGDM asszonyokban fokozott CV kockázatot igazoltunk a Framingham rizikópontszám alkalmazásával kontrollokhoz képest. Károsodott volt a centrális érfali rugalmasságot jellemző carotis-femoralis pulzushullám sebesség, ill. az endothelfüggő vazodilatációt jellemző postocclusiv reaktív hyperaemia index is kGDM-ben. Független kapcsolatot találtunk a D3 vitamin szint, az inzulinérzékenység és a beta-sejt működés között. Eredményeink alapján mind a pregesztációs, mind a gesztációs diabétesz szülést követő szoros követése javasolt a szövődmények kialakulásának kivédésére, késleltetésére. | Diabetic complications can progress during pregnancy of type 1 or type 2 diabetic women. However the long term consequences of a diabetic pregnancy are not well described. Similarly there is uncertainty regarding the late maternal consequences of gestational diabetes (GDM). This study aimed to investigate women with pregestational (type 1 and type 2) diabetes and with prior gestational diabetes (pGDM) using similar methodology years after delivery. In women with pregestational diabetes high frequency of obesity, hypertension, and smoking was found. In the pGDM cohort we found a dose-response relationship between the severity of glucose intolerance (GI) and the prevalence of metabolic syndrome (MS). Among women with GI we found elevated osteoprotegerin levels and an abnormal leptin response during an oGTT. In pGDM women resistin levels were elevated, adiponectin levels decreased. Adiponectin negatively correlated with several CV risk factors. In pGDM women an elevated CV risk was proven using the Framingham risk score compared to controls. pGDM women had abnormal carotid-femoral pulse wave velocity and postocclusive reactive hyperemia index that measures endothel-dependent vasodilation. There was an independent relationship between levels of vitamin D3 and insulin sensitivity and beta-cell function. Our results support the recommendation for the follow-up of women with gestational or pregestational diabetes to prevent or delay its late complications

Effect of secular trends on age-related trajectories of cardiovascular risk factors: the Whitehall II longitudinal study 1985-2009

Secular trends in cardiovascular risk factors have been described, but few studies have examined simultaneously the effects of both ageing and secular trends within the same cohort

Midlife type 2 diabetes and poor glycaemic control as risk factors for cognitive decline in early old age: a post-hoc analysis of the Whitehall II cohort study

Background: Type 2 diabetes increases the risk for dementia, but whether it affects cognition before old age is unclear. We investigated whether duration of diabetes in late midlife and poor glycaemic control were associated with accelerated cognitive decline. Methods: 5653 participants from the Whitehall II cohort study (median age 54·4 years [IQR 50·3-60·3] at first cognitive assessment), were classified into four groups: normoglycaemia, prediabetes, newly diagnosed diabetes, and known diabetes. Tests of memory, reasoning, phonemic and semantic fluency, and a global score that combined all cognitive tests, were assessed three times over 10 years (1997-99, 2002-04, and 2007-09). Mean HbA1c was used to assess glycaemic control during follow-up. Analyses were adjusted for sociodemographic characteristics, health-related behaviours, and chronic diseases. Findings: Compared with normoglycaemic participants, those with known diabetes had a 45% faster decline in memory (10 year difference in decline -0·13 SD, 95% CI -0·26 to -0·00; p=0·046), a 29% faster decline in reasoning (-0·10 SD, -0·19 to -0·01; p=0·026), and a 24% faster decline in the global cognitive score (-0·11 SD, -0·21 to -0·02; p=0·014). Participants with prediabetes or newly diagnosed diabetes had similar rates of decline to those with normoglycaemia. Poorer glycaemic control in participants with known diabetes was associated with a significantly faster decline in memory (-0·12 [-0·22 to -0·01]; p=0·034) and a decline in reasoning that approached significance (-0·07 [-0·15 to 0·00]; p=0·052). Interpretation: The risk of accelerated cognitive decline in middle-aged patients with type 2 diabetes is dependent on both disease duration and glycaemic control. Funding: US National Institutes of Health, UK Medical Research Council. © 2013 Elsevier Ltd. All rights reserved

Real-world effectiveness of IDegLira compared with intensified conventional insulin therapy in adults with type 2 diabetes: a retrospective cohort study

Background: IDegLira is a fixed-ratio combination of insulin degludec and liraglutide with proven efficacy against simpler regimens and non-inferiority against basal-bolus insulin therapy. However, the evaluation of its real-world effectiveness is hindered by technical issues and requires further exploration. Thus we aimed to compare effectiveness of insulin degludec/liraglutide (IDegLira) versus intensified conventional insulin therapy (ICT) for type 2 diabetes in a real-world setting. Methods: This retrospective cohort study from an outpatient clinic in Hungary included people who initiated IDegLira due to inadequate glycaemic control (HbA1c > 7.0% [53.0 mmol/mol]) with oral and/or injectable antidiabetic drugs. Data were compared with a historical cohort who initiated ICT. Outcomes included HbA1c, body weight, and hypoglycaemia differences over 18 months of follow-up. Results: Data were included from 227 and 72 people who initiated IDegLira and ICT, respectively. Estimated mean difference (MD) in HbA1c at 18 months favoured IDegLira versus ICT (MD 0.60, 95% CI 0.88–0.32 [MD 6.6 mmol/mol, 95% CI 9.6–3.5]). More people reached target HbA1c ≤7.0% (53.0 mmol/mol) with IDegLira than ICT (odds ratio 3.36, 95% CI 1.52–7.42). IDegLira treatment was associated with weight loss compared with gain for ICT (MD 6.7 kg, 95% CI 5.0–8.5). The hazard ratio for hypoglycaemia comparing IDegLira with ICT was 0.18 (95% CI 0.08–0.49). Conclusions: Treatment with IDegLira over 18 months resulted in greater HbA1c reductions, weight loss versus gain, and a lower rate of hypoglycaemia versus ICT in people with type 2 diabetes