Cardiac Autonomic Dysfunction Predicts Outcomes in Diabetes

Among patients with stable CAD and type 2 diabetes, measures of autonomic function--such as heart-rate recovery after exercise--may help predict the risk of short-term adverse cardiovascular events as per a study.

A second study reports that autonomic dysfunction is strongly linked with a greater risk of severe hypoglycemia in patients with type 2 diabetes.

The best way to avoid it is to have intensive glucose control with hemoglobin A1cs that are definitely below 7.5 and ideally below 7. On the other hand, if you have [HbA1c] levels above 8, certainly above 9, you have a very high likelihood of having the problem [within] 10 or more years.

The two studies were published online August 19, 2013 in Diabetes Care.

Test

· The patients performed a test on an exercise bicycle, which allowed the researchers to determine their heart-rate recovery, defined as the drop in heart rate from the rate at maximal exercise to the rate one minute after stopping the exercise.

· Blunted heart-rate recovery after exercise: defined as a drop in heart rate of less than 21 beats per minute--had a 1.69-fold greater risk having a cardiovascular event than their peers.

· Holter: Blunted heart-rate turbulence (<3.4 ms/R-R interval) had a 2.08-fold increased risk of an event

· Low heart-rate variability (<110 ms) had a 1.96-fold greater risk of having a cardiovascular event.

· Heart-rate variability at three times: during a Valsalva maneuver, deep breathing, and going from lying down to standing. 

There is insufficient evidence linking diabetes drugs with increase risk of cancer and as per FDA, doctors can continue to confidently prescribe all approved drugs for the management of the diabetes, as per a joint consensus statement released by American College of Endocrinology and American Association of Clinical Endocrinologist.  The statement was released on 20^th August, 2013.  Recently some reports have linked incretin drugs with pancreatic cancer and lantus insulin with cancer.  As per the statement both diabetes and obesity may increase the risk of certain cancer, therefore, it is difficult to say that the drugs are linked to it.  

High blood glucose linked to dementia even without diabetes

Higher blood glucose levels, shy of the diabetic range, increase the risk for dementia in adults, new data from the longitudinal Adult Changes in Thought (ACT) study suggest by Paul K. Crane, MD, associate professor of medicine at the University of Washington School of Medicine, Seattle. The study is published in the August 8 issue of the New England Journal of Medicine.

Among participants without diabetes, higher average glucose levels within the preceding 5 years were associated with increased risk for dementia.

At a glucose level of 115 mg/dL, as compared with 100 mg/dL, the adjusted hazard ratio for dementia was 1.18.

Higher average glucose levels were also related to an increased risk for dementia in those with diabetes. At a glucose level of 190 mg/dL, as compared with 160 mg/dL, the adjusted hazard ratio for dementia risk was 1.40.

Artificial sweeteners can cause diabetes

Consumption of non-caloric, artificially sweetened beverages is associated with an increased risk for obesity, type 2 diabetes, metabolic syndrome and cardiovascular disease.

This counterintuitive result reflects negative consequences of interfering with learned relationships between sweet tastes and typical postingestive outcomes, which may result in impaired ability to compensate for energy provided when caloric sweeteners are consumed.

The study by Dr Susan E Swithers at Purdue University, West Lafayette, IN published in July issue of Trends in Endocrinology & Metabolism found an elevated risk for weight gain and obesity, metabolic syndrome, type 2 diabetes, coronary heart disease, and hypertension in those who consumed ASBs. No decreased risk for weight gain or increased body fat percentage was associated with ASB intake.

Elderly new onset diabetes a new sub group of diabetes

Elderly patients with new-onset diabetes and poor sugar control (HbA1c of 7.5% or higher) are linked with increased mortality risk. There is no U-shaped risk pattern, unlike that reported for elderly patients with long-standing diabetes.

In a study published in July edition of Diabetes Care, patients with the highest levels of HbA1c also were least likely to undergo a coronary revascularization procedure.

The findings are totally different from the results in elderly with long-standing diabetes.

The researchers conducted a retrospective observational study of data from a cohort of 2994 individuals (48% males) living in the Sharon-Shomron District, Israel, who were insured by a large provider.

The study subjects were 65 years or older when they were newly diagnosed with diabetes in 2003 or 2004. The patients were assumed to have type 2 diabetes, since type 1 diabetes is very rare at this age, and only 0.1% to 3% of the patients were receiving insulin therapy.

The patients were followed for 7 years or until they reached a study outcome: coronary revascularization — PCI or CABG — or mortality.

At baseline, patients had a mean age of 75.6 years. They were stratified into 4 groups, based on their average HbA1c levels during follow-up: less than 6.5% (n=1580), 6.5% to 6.99% (n=611), 7% to 7.49% (n=367), and 7.5% or greater (n=436).

During a mean follow-up of 5.54 years, 1173 participants (39.17%) died. All-cause mortality rates were 41%, 32%, 36%, and 46%, in the 4 groups.

Compared with participants in the group at lowest risk of dying (those with an average HbA1c level of 6.5% to 6.99%), patients in the group with the highest HbA1c levels (>7.5%) had a significant increased mortality risk.

These findings differ from a previous large, retrospective cohort study of patients older than 50 who had long-standing diabetes and intensive hypoglycemic treatment, where researchers reported finding a U-shaped risk pattern, and an HbA1c level of about 7.5% was associated with the lowest all-cause mortality (Lancet. 2010;375:481-489).

The difference in mortality patterns between our finding and the aforementioned study underscores the need to differentially treat elderly patients with new-onset [diabetes] and elderly patients with long-standing disease.

During follow-up, 285 participants (9.51%) underwent PCI or CABG. The rate of coronary revascularization was highest in the patients with an average HbA1c level of 6.5% to 6.99% and lowest in the patients with an HbA1c level of 7.5% or higher.

This inverse relationship may be the result of a protective effect of revascularization against mortality, or the patients with the highest levels of HbA1c may have received suboptimal medical treatment for various reasons. (Source Medscape)

New India Assurance company has decided to stop charging additional premium for those with diabetes and hypertension under its revised health insurance policy.

1. The state-owned insurer has also withdrawn a clause from its policy that excluded cover for ailments caused by tobacco consumption. The new health insurance policy, however, continues to exclude cirrhosis of lever caused by alcoholism. The earlier practice of having a four-year cooling period for pre-existing conditions will continue. This means that if a diabetic buys a policy, the coverage for diabetes related hospitalization will begin only after four years.

2.      Several US and Canadian companies have stopped clinical trials in India following an amendment to the rules which makes it mandatory for companies and educational institutions to meet all medical expenses of those who volunteer for clinical trials.

The new Drugs and Cosmetics (First Amendment) Rules, 2013, states that for an injury/illness, occurring to a clinical trial subject, he or she shall be given free medical management as long as required. "This does not specify what type or cause of injury. Thus a trial participant may be involved in a traffic accident or assaulted by someone, but under the open-ended clause, the trial sponsor has to cover all costs.

Another clause calls for financial compensation to be paid over and above costs of medical management in the case in the event of any illness, considered trial-related. But there is no clarity on what constitutes trial-related injury. Again any medication cannot work all the time. A person whose cancer was not stopped from progressing may claim compensation under this clause even though the treatment was effective during the trial.

We must also make a distinction between death of a patient during a clinical trial and death due to clinical trial. Patients who participate in clinical trials already have a disease which could be mild or serious. The death of a patient in a clinical trial could be due to various reasons, including a natural progression of the disease, new diseases, age-related disorders, or an unrelated complication. Patients who participate in a clinical trial receive greater degree of medical care than they would have under regular treatment because of the high level of investigations and patient management that a clinical study protocol requires.

According to the ministry of health, 89 deaths were attributed to clinical trials between 2005 and 2012 of which compensation was paid in 82 cases. [TOI excerpts]
3.      Less than a fortnight after rejecting pleas for lowering the age of juveniles from 18 years to 16 years in heinous crimes, the Supreme Court on Wednesday agreed to hear a PIL arguing that a juvenile's culpability should be determined on his mental maturity rather than physical age. Additional solicitor general Siddhartha Lutheran opposed the PIL and informed a bench of Chief Justice P Sathasivam and Justices Rojana P Desai and Ranjan Gogoi that on July 17, the apex court had decided a bunch of petitions rejecting pleas to lower the age of juveniles to 16 years.