Cyndrome

Posts Tagged ‘2 type diabetes’

Both all-cause and cardiovascular mortality are substantially increased in people with Type 2 diabetes compared with nondiabetics, UK researchers have shown.

They also demonstrate that duration of diabetes is an independent predictor for mortality risk and that younger women with the disease are at disproportionately increased risk for cardiovascular mortality.

Josie Evans (University of Stirling) and colleagues used record-linkage databases to identify 10,532 patients diagnosed with diabetes between 1993 and 2004. They also identified a control cohort of 21,056 nondiabetic individuals from general practice.

All patients were followed-up for a maximum of 12 years for mortality. During this time, 17.7% of diabetes patients and 14.1% of controls died. The main causes of death were diseases of the circulatory system (44.9% and 39.3%) and neoplasms (25.3% and 27.7%) for diabetic and nondiabetic participants, respectively.

The researchers calculated absolute mortality rates for subgroups of participants stratified by gender and age decile.

In all subgroups, rates of all-cause and cardiovascular mortality were “clearly” higher in diabetes patients versus controls. Similarly, all rates were higher for males than females, except for all-cause mortality in patients aged over 75 years.

Interestingly, the difference in absolute rates of all-cause mortality appeared to widen slightly among females and narrow slightly among males with increasing age. Also, widening of the absolute rates of cardiovascular mortality between diabetic and nondiabetic participants appeared to occur slightly earlier among women than men.

Further analyses revealed that the risk for all-cause mortality increased with increasing duration of diabetes, reaching a peak between 6 and 9 years, then decreased. This pattern was even more marked for cardiovascular mortality but peaked slightly earlier.

Writing in the journal Diabetic Medicine, Evans et al remark: “This study further supports the literature showing that Type 2 diabetes reduces life expectancy.”

There is a strong association between the metabolic syndrome and microvascular disease in people with Type 2 diabetes, Belgian researchers have shown.

Their analysis, which appears in the journal Diabetes & Metabolic Syndrome: Clinical Research & Reviews, suggests that the risk for microvascular complications increases in line with both the presence and severity of the syndrome.

Michel Hermans (Université catholique de Louvain, Brussels) and team studied 738 adults with Type 2 diabetes, of whom 145 had the metabolic syndrome. Participants with and without the syndrome were well-matched with respect to age and diabetes duration.

The mean number of components of the metabolic syndrome was 1.8 in those without the syndrome versus 4.0 in those with.

Body mass index, waist circumference, relative/absolute fat mass, visceral fat, conicity, insulin resistance, triglycerides, glycated hemoglobin, systolic blood pressure, and inflammatory markers were all significantly higher in those with versus without the metabolic syndrome.

With regard to macrovascular disease, the prevalence of peripheral artery disease, coronary artery disease, and cerebrovascular disease were all higher in those with the syndrome than without, at 11 vs 7%, 26 vs 10%, and 8 vs 5%, respectively.

Furthermore, the prevalence of microvascular complications increased with increasing number of components of the metabolic syndrome.

Specifically, diabetic retinopathy affected 3% of those with one component versus 26% of those with five components. For peripheral neuropathy the values were 19% and 35%, respectively, while for albuminuria the values were 6% and 32%, respectively.

Discussing their results, Hermans and co-authors note that the association with macrovascular disease is expected “as intrinsic to the current definition of metabolic syndrome.”

By contrast, “it is much debated whether establishing the presence of a metabolic syndrome in hyperglycemic states further contributes to stratifying or predicting microvascular risk.”

They say their data “indicate a strong association between metabolic syndrome and vascular disease, with respect to both macro- and microangiography in a large, mostly Caucasian, cohort of Type 2 diabetes mellitus patients of both genders.”

However they add: “Whether these risks are cumulative, potentiating or permissive will be determined in prospective studies on the natural history of microvascular disease in relation with the serial acquisition of metabolic syndrome phenotype components.”

Assessing the age and fasting blood glucose (FBG) of cardiac patients can help to reduce the need for oral glucose tolerance tests (OGTTs) to detect undiagnosed Type 2 diabetes, researchers suggest.

Guidelines recommend screening all patients with cardiovascular disease with an OGTT, but prior research suggests this may only occur in half of all patients, say the German investigators.

“The main handicap why an OGTT is not performed in daily routine might be its intensiveness in time, personnel and costs,” they suggest in the International Journal of Cardiology.

In a search for clinical markers that could be used to identify high-risk patients who would benefit most from OGTT screening, they studied the predictive value of easily available clinical markers for undiagnosed Type 2 diabetes.

OGTTs were performed in all 1215 patients without known Type 2 diabetes who presented at a heart center with known or suspected coronary artery disease for elective coronary angiography from January to October 2007.

Results showed that 31.4% of the patients had normal glucose tolerance, 50.7% had impaired fasting glucose or impaired glucose tolerance, and 17.9% were newly diagnosed with Type 2 diabetes. Therefore, 998 OGTTs did not result in the new diagnosis of undiagnosed diabetes, the team calculates.

FBG of at least 90 mg/dl and age of at least 55 years predicted undiagnosed diabetes. At these cut-off points, Type 2 diabetes could be diagnosed with a sensitivity of 81.1%, a specificity of 63.4%, and a positive predictive value of 32.5%.

“Thus, the number of subjects needed to be screened could be reduced from 1215 to 541, and costs and other resources of more than 55% of OGTTs be saved,” report Mark Lankisch (University of Witten, Dortmund) and colleagues.

They conclude: “The implementation of simple and rapid available measures as FBG and age is a helpful tool to reduce the number of OGTTs needed for the detection of so far undiagnosed Type 2 diabetes mellitis so that national and international guidelines can be followed more easily and unknown Type 2 diabetes mellitis can be detected more effectively.”

A study is underway in Europe to assess the feasibility and impact of the “chronic care model” as a framework for managing patients with Type 2 diabetes.

The trial, known as “CARAT” (The Chronic CARe for diAbeTes study), was launched in Switzerland in February 2010 and is employing a cluster randomized design. The trial design and rationale are published in the open-access journalCardiovascular Diabetology.

“Chronic conditions and multimorbidity represent the major challenge for the health care systems in the industrialized world,” explain Anja Frei (University of Zurich) and fellow CARAT investigators.

“The chronic care model provides a proactive, patient-centred, evidence-based approach to face this challenge.”

Recent studies in a range of chronic diseases have demonstrated that treatment strategies incorporating elements of the chronic care model lead to improved outcomes for both patients and healthcare systems.

To date, however, most of these studies have been performed in the USA, which has a very different healthcare system to that of Europe.

The CARAT trial aims to address this gap by adapting the chronic care model approach to the Swiss healthcare system. A total of 28 general practitioners (GPs) in Switzerland will be randomly assigned to either intervention or control; each GP will enrol 12 patients with Type 2 diabetes.

The intervention will entail the GP and practice nurse working as a team to deliver comprehensive diabetes care tailored to the needs of the individual patient; the control group will receive care as usual.

The primary endpoint is the change in glycated hemoglobin between baseline and 1 year. Secondary endpoints include control of of blood pressure, glycated hemoglobin, and low-density lipoprotein cholesterol; quality-of-life; and quality indicators of diabetes care.

“This study challenges the hypothesis that the chronic care model can be easily implemented by a practice-nurse-focused approach,” write Frei et al.

“If our results will confirm this hypothesis, the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to redesign care in Switzerland.”