[acb-diabetics] many articles

[Patricia LaFrance-Wolf]

1.%% M 8/30 In DM, Any Protein in Urine May Signal Heart Risk
[1200pts;9yrs] The team found that any amount of measurable albumin [a
simple protein] excretion in the urine was associated with significant heart
risks in people with T2. However, the study did not prove cause & effect.
There was no link between albumin excretion levels & heart risks in a
subgroup taking drugs for high BP (ACE inhibitors) which suggests that these
drugs may help protect the hearts of DM pts with albumin in the urine &
those with normal albumin levels. AmSociety of Nephrology, news release,
Aug. 30, 

2.%% Oph 119,9 Sep 2012 Longer Axial Length Is Protective of Diabetic
Retinopathy & DME Terms: Axial length (AL).. [630 eyes] Eyes with longer AL
were less likely to have DR & a lesser risk of mild & moderate but not
severe DME.

3.%% ADA 8/31 (HealthDay News) -- Using a glycated hemoglobin (HbA1c)
threshold of =6.5 % is a specific but not sensitive early indicator of T1DM
K Vehik & team studied the use of HbA1c as an alternative criterion for
impaired glucose tolerance (IGT) for T1 in high-risk pts younger than 21yrs.
[2062pts] Across the 4 studies, the positive predictive value of HbA1c
varied from 50 to 94%. "Redefining the HbA1c threshold is recommended if
used as an alternative criterion in diagnosing T1." 

4.%%SciAm 9/4 DM, Insulin & Helicobacter Pylori (HP) Eradication
[601,441pts] HP erad- defined as [series of drugs] taken 7-14days. Pts with
T2 have a significantly higher risk of gastric cancer mortality. HP
infection is the most important etiology for G cancer & its eradication can
significantly reduce G cancer.. HP erad rates in pts with T1 & T2 are 62% &
50% respectively, which are much lower than the recom-mended 80%. Also
reinfection rate is higher in T1 & it may deteriorate metabolic control,
leading to higher insulin dosage & development of DM complications.
Conclusions -This study shows a significantly higher incidence of HP
eradication in pts with T2 & in insulin users among the DM pts. In addition,
lower socioeconomic status & use of calcium channel blockers consistently
show a higher rate of HP erad but the uses of oral anti-diabetic agents do
not. The underlying causes for the link between T2 & the use of meds & HP
eradication require further investigation. BMC Gastroenterol. 2012;12(46) 

5. %% MPD 9/5 Blood Sugar Levels Linked to Brain Loss The hippocampus, the
part of the brain involved in memory forming & the amygdala, a set of
neurons located deep in the brain's temporal lobe used in the processing of
emotions, have atrophies associated with higher fasting glucose levels. T2DM
has increasingly been recognized as a risk factor for loss of cognitive
ability with aging. The Australian team measured fasting glucose & did MRI
scans of the amygdala & hippocampus in 249 cognitively healthy pts av age
63. After an average of 4 yrs, intracranial volumes had fallen by 2.7%, but
only a small percentage of overall difference in intracranial volume could
explain the loss of volume in the hippocampus & amygdala. In contrast, after
controlling for age, sex, BMI, BP, and alcohol and tobacco use, glucose
levels accounted for 6-10% of atrophy in the amygdala & hippocampus, a
change of about 2% each year. This study indicated that control of glucose
levels modulates inflammatory responses & that pts with T2 are more likely
to be exposed to longer lasting & stronger inflammatory states. T2 also is
characterized by various abnormalities of the coagulation system,that can
raise the risk for cardiovascular events. These abnormalities also have been
caused by uncontrolled glucose in pts with pre-DM & in healthy volunteers
following experimentally induced hyperglycemia. An additional contributor is
psychological stress, which influences glucose levels. There is now strong
evidence that chronic increases in inflammatory responses, high stress
hormone levels, & abnormal blood coagulation activation are linked to
cerebral changes & associated decreases in cognitive function. Ca Source
reference: Cherbuin N, et al Neurology 2012; 

6.%% ADA 9/6 Insulin Glargine Fails to Halt Atherosclerosis Progression in
pts with DM or pre-DM at high CV risk [1184;6.2yrs] rates of CV death,
nonfatal MI or stroke were similar between the insulin glargine & standard
care groups (18.6 vs. 16.9%) the results of GRACE are concordant with those
reported from the larger ORIGIN trial in which glargine reduced the risk of
developing T2 by 28% in pts with pre-DM, but had a neutral effect on CV
outcomes. Omega-3 fatty acids reduced triglyceride levels, but also failed
to reduce the rate of CV (N Engl J Med 2012;367).

7.%% ADA 9/4 Mobile app to support T1 patients The Lilly Glucagon mobile app
is an interactive tool designed to teach caregivers how to use severe
hypoglycemia treatment Glucagon (1-mg) for injection through simulated
practice..app is available on the iTunes store as a free download for iPhone
or iPad mobile devices.

8.%% M 9/10 Increased Mortality of Patients With DM Reporting Severe
Hypoglycemia [1020adults;5yrs;T1 &T2] retrospective study. Mild hypoglycemia
was defined as symptoms managed without assistance & severe hypo as symptoms
requiring external assistance. Conclusion, hypoglycemia is common in pts
with T1 & T2, increasing in prevalence with disease duration & higher HbA1c.
Pt-reported severe hypo is associated with 3.4-fold increase in 5-year
mortality. Self-report of severe hypoglycemia is therefore an important
prognostic indicator that should be included in the clinical assessment of
each pt with DM. Diabetes Care. 2012;35(9)

9.%% M 9/12 Study looked at metabolic activation of the innate immune system
governed by interleukin(IL)-1-? which contributes to cell failure in T2.
Gevokizumab is a monoclonal anti-IL-1? antibody. The study evaluated the
safety & biological activity of Gev. in pts with T2. RCT study [98pts]
randomly assigned to Gev or placebo] Results showed that the drug was well
tolerated with no serious adverse events. There was 1 hypo event which
resulted in an insulin Rx. Conclusion this new antibody improved glycemia,
via restored insulin production & it reduced inflammation in pts with T2.
This therapeutic agent may be able to be used on a once-every-month or
longer schedule. Ca Diabetes Care 2012; 35(8) 

10.%% M 9/12 Scientists ID Gene for Insulin Sensitivity An Oxford team has
discovered the single gene that causes insulin sensitivity. This term refers
to how well the body uses the hormone insulin, to regulate glucose (sugar)
in the blood. The opposite is insulin resistance [IR], which means the body
does not use insulin properly. IR is a major feature of T2DM. The insulin-
producing cells in the pancreas may be working hard & pumping out lots of
insulin, but the body's cells no longer respond. Study leader Dr. A Gloyn
said finding a genetic cause of insulin sensitivity, gives a new window on
the biological processes involved. This understanding could be important in
developing new drugs that restore insulin sensitivity in T2. [15contrls &15
pts w Cowden syn caused by mutations in the PTEN gene]. "PTEN is a gene that
is heavily involved in processes for both cell growth & metabolism," first
author A Pal said. Results --pts with Cowden syndrome had significantly
higher insulin sensitivity as a result of heightened activity in the
insulin-signaling pathway. After expanding the comparison to more than 2,000
pts, the team confirmed that people with Cowden syn had more fat & higher
rates of obesity. This was a surprise since normally insulin sensitivity
goes with being lean. EX & a healthy diet remain the best ways to avoid DM
the team stressed. If left untreated, the disease can lead to heart disease,
stroke, nerve damage & blindness. Ca-dw N Eng J Med 9/13 

11.%% M 9/12 Hispanics May Face Higher Risk for T2 Hispanics are more likely
to store fat in their pancreas, but less likely to be able to produce more
insulin to compensate for this excess fat, putting them at higher risk for
T2 "Not all pts who are overweight or obese & who have insulin resistance go
on to develop DM" R Bergman author, said "If we can determine who is most
likely to develop DM & why, then we can make strides toward preventing it in
individuals." The team used a noninvasive medical imaging technique -
magnetic resonance spectroscopy [MRS ] to measure the amount of fat in the
organs of white, black & Hispanic pts all of whom were equally over-weight &
shared many of the symptoms of pred-DM. 26 mil in the US have DM & 79 mil
more are prediabetic. DM is the 7th-leading cause of death in the US & a
major cause of heart disease & stroke. Diab Care 9/17/12

12.%% JH 9/27 How to Get More Accurate Finger Stick Readings
Clean hands may lead to a more reliable blood glucose [BG] reading 123 pts w
DM underwent G testing on 2 drops of blood in four scenarios. (1) without
washing their hands (2) after handling fruit (3) after handling fruit, then
washing their hands (4) with pressure put on a freshly washed finger.
Results were compared with a control measurement of the average reading for
the first 2 drops after wash-ing hands. Not washing hands led to a 10% or
more difference in G level 11% of pts in the first drop & 4% in the second
drop vs controls. Handling fruit & not washing hands led to 10% or higher G
concen-trations in the first drop in 88% of pts but in only 11% on second
drop vs controls. Squeezing a freshly washed finger also caused unreli-able
readings. Our advice. Before testing your BG, it's best to wash your hands
with soap & water & dry them. Use the first drop of blood but don't squeeze
your finger to make the drop appear. If you can't wash your hands first &
you haven't been handling sugary products, it's okay to test the second drop
of blood after wiping away the first drop. study reported in DiabCare vol
34,

13.%%ADA 9/11 New Insulin Degludec-Aspart Combo May Offer Advantages T1
diabetics who took a new combo formulation of insulins degludec & aspart
(IDegAsp) [Ryzodeg] at their main meal, with insulin aspart (IAsp) at other
meals, had better nocturnal glycemic control than pts on basal-bolus therapy
with insulin detemir (IDet) & IAsp. [548pts;26wks] random assigment to Rx.
The nocturnal hypo rate was 37% lower with IDegAsp than Idet. There were
fewer daily injections with IDegAsp (3 vs 4-5) & the total insulin dose was
13% lower. However, weight gain was 1 kg greater. Dr.Hirsch added, "We can't
comment how this coformulation would perform with tighter levels of glucose
control & A1C less than 7%. Nevertheless, for some T1 pts who may do better
with a [combo as above] the same benefit of reduced nocturnal hypo can be
expected." Novo-Nordisk funded the study. Diabetes Care 2012.

14.%% MPD 9/17 Gastric Bypass Not Best for Weight Loss? A rela-tively rarely
used bariatric procedure (duodenal switch) resulted in better control of
weight & comorbidities than the gold standard gastric bypass. However DS
surgery is associated wtih higher early risks, including infection & the
need for reoperation, compared with gastric bypass. Nonetheless, the team
concluded biliopancreatic diversion with DS may be a useful alternative to
gastric bypass. Data from 1,545 DS pts & 77,406 w gastric bypass "further
studies of this procedure to determine the optimal pt selection, technique,
& longer -term risks vs outcomes are warranted." Nelson DW, et al Arch Surg
2012;147(9)

15.%% ADA 9/17 White Matter Structural Changes ID'd in Children With T1DM
Children with T1 have significant structural differences in the white matter
of their brain compared to healthy children, which correlates with
hemoglobin A1c(HbA1c) values. To examine clinical correlates of cognitive
abilities & white matter microstructural changes in [this group] T Ay & team
Stanford U School Med used diffusion tensor imaging (DTI) scans &
neurocognitive testing [22pts; age 3-10yrs;14ctrls] children with T1 had
significantly lower axial diffusivity (AD) values in the temporal & parietal
lobe regions, vs that of healthy controls. There were no significant
dirrerences between the grps in fractional anisotropy & radial diffusivity
(RD). There was a significant, positive correlation between time-weighted
HbA1c & RD within the DM group. A higher, time-weighted HbA1c value also
correlated with reduced overall intellectual functioning. In addition, white
matter structural differences (as measured by RD) were signifi-cantly
correlated with their HbA1c values. CA Sept. 10 in Diab Care

16.%% Diabetes raises risk of UTIs Patients with T2DM have a 60% increased
risk of developing a UTI, Urinary Tract Infection, compared with those
without DM, concludes new research in UK. [135,000pts; equal # cntrls;] the
adjusted 2year risk of UTI for all pts with DM was 61% higher than matched
controls. The absolute incidence of UTI among pts with DM was 46.9 per 1,000
person years, vs 29.9/1,000 person years in pts without DM. Results confirm
that pts with DM are at an increased risk of developing UTIs across all age
categories. CA J DiabComplications, online 13 Aug 2012

17.%% NatRevEndo Oct2012 Metabolic neuroimaging of the brain in DM &
hypoglycaemia - Functional neuroimaging techniques can be used to study
changes in regional brain activation, using changes in markers such as
regional cerebral perfusion & rates of glucose uptake or metabolism. These
approaches are shedding new light on 2 major health problems: the increasing
burden of T2 driven by the rising prevalence of insulin resistance & obesity
& recurrent intract-able problematic hypoglycaemia. Some pts with DM lose
awareness of being hypoglycaemic, which puts them at risk of severe hypo as
they are unlikely to take action to prevent the condition worsening.
Involvement of cortico-limbic brain, the hypothalamus & centers serving
higher executive functions has been shown in both situations & has
implications for therapy. Understanding these dysregulations could enable
the development of new interventions. Yee-Seun Cheah et al;

18.%% ADA 9/26 3 Drugs Similar in Efficacy for Neuropathic Pain in Diabetes
In the treatment of patients with chronic diabetic peripheral neuropathic
pain (DPNP), there are no significant differences in pain-relief efficacy
between amitriptyline, duloxetine, and pregabalin; however, pregabalin
improves sleep continuity and duloxetine improves daytime functioning. J
Boyle & team in UK conducted a randomized, double-blind, parallel-group
study [83 T1&2 pts w DPNP] The team found that all 3 meds improved pain
compared with placebo
but no statistically significant between-group difference was seen.
Pregabalin was associated with improved sleep continuity, while duloxetine
increased wake & reduced total sleep time. Despite its negative effect on
sleep, duloxetine improved central nervous system arousal and performance on
sensory motor tasks. Pregabalin was associated with a significantly higher
number of adverse events compared with the other drugs. In this short,
28-day dosing study, there was no evidence of improved quality of life.

19.%% M 9/25 How to Use New T2DM Diabetes Guidelines ADA/EASD Position
Statement 'Translated' for Clinicians Anne Peters, MD, CDE
Director Clinical Diabetes Programs at USC was part of the committee who
wrote the position statement. The first big position addressed was
lifestyle. Dr. P thinks that lifestyle is a cornerstone to DM care. Part of
lifestyle is putting in place a plan for EX, & if needed, a plan for weight
loss. Beyond weight loss there is always a need for some types of
medication. In the position statement, metformin was the first med named.
Metformin helps in nearly every facet of the T2 syndrome. It lowers BS
levels, & even helps reduce cardiovascular risk. However many pts experience
gastrointestinal side effects which limit its use. Dr. P states that she
normally starts a pt on a low dose & advances slowly to 50 mg for 2 wks, 100
mg for the next 2 wks. Another choice mentioned in the clinician's statement
is a sulfonylurea agent (1), a DPP-4 inhibitor (2), or a glucagon-like
peptide-1 GLP-1 receptor agonist(3), insulin(4), or a thiazolidine-dione(5)
[TZD] . For all of these agents, Dr.Peters, uses 2 different criteria. If
the main goal is to lose weight the choice would be a GLP-1 receptor
agonist. When it comes to maintaining wt & avoiding hypo, either the DPP-4
inhibitor or the GLP-1 receptor agonist will be effective. A DPP-4 inhibitor
is a little easier because it is in pill form rather than injection & has
very few side effects. If a pt's A1c is 7.5% & they want to get it below 7%,
then adding a DPP-4 inhibitor makes a lot of sense. In regards to cost, both
are expensive & have been on the market a relatively short time so we don't
have data on long-term follow-up. 
Moving on to other choices, there are sulfonylurea agents. They have been
around a long time. They are associated with reduction in both micro- &
macro-vascular events. She writes about these agents with the caveats that
they have been connected with progressive beta-cell failure. The beauty of
the sulfony agents is not only that they lower BS levels, but they are very
inexpensive & have a long- term history. These agents are useful in pts who
are very hyperglycemic or when the cost of some of these other agents is
prohibitive. TZDs (5) help preserve beta-cell function & Dr. Peters states
she tends to use them in a very low dosage. She sees a marked improvement in
blood glucose levels.. They don't cause hypo, but need to be balanced with
the risk for weight gain & fluid retention. In the US, the TZDs remain
expensive. This drug can be assoc with osteoporosis, macular edema, &
congestive heart failure. ..using a lower dose seems to produce fewer side
effects. You can add insulin at this point, Dr. P s states she may add basal
insulin to metformin. You can add almost any overnight insulin to get the
fasting blood sugar down & then continue the metformin as an oral agent. 
The next treatment step involves more complicated math because you want to
add drugs that make sense with the drugs that the pt is already taking. Dr.
P tends use lower doses of pioglitazone & sulfony agents, keeping the pt on
the 2 drugs they used initially. She tends to take away the sulfonylurea
agent but adds mealtime insulin..for the biggest meal. Additionally She
gives her pts the option of bariatric surgery, which fits in as an important
way to get pts to target on less medication. We now have enough tools, to
get patients to target BS levels. At the same time, they need to pay
attention to treating their lipids, as well as their BP, to create a
combination that hopefully will maximize lives & their overall outcomes. CA

%% Abbreviations-acronyms fup-follow up; pt - patient/participant ; 
DM - diabetes Mellitus; T1- type 1 DM;T1A -autoimmune T1; T2 - type 2; DME -
diabetic macular edema;DR - DM retinopathy; BS/BG- blood sugar/glucose;
HA1C, glycated hemoglobin A1C; BP -blood pressure; CVD - cardio-vascular
disease; IR- insulin resistance; OCT-optical coherence tomography; BCVA -
best corrected visual acuity; RYGB- Roux-en-Y gastric bypass; RCT
-Randomized controlled trial; ADA - Am Diab Ass;J- Joslin DMCenter; M-
Medscape Web MD; MA- Medline Abstract, MP- Medline Plus; MPD - Med Page
Today; NEI - Nat Eye Institute;SciA-Scientific Amer. Definitions via online
Medical dictionaries. Disclaimer, I am a BSN RN but not a diabetic or
diabetic educator. Assistant Editor: Cam Acker, 50yr DM survivor. Reports
excerpted unless otherwise noted. [translations/explanations by thl] This
project is done as a courtesy to the blind/visually impaired & diabetic
communities. Dawn Wilcox RN BSN Coordinator The Health Library at Vista
Center; an affiliate of the Stanford Hospital Health Library. contact above
e-mail or thl at vistacenter.org

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