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Higher mortality in diabetic women and nonfasting triglyceride levels
Diabetes Care in the 21st century: Where have we been?
New bedside way in Reducing mortality in diabetic men and women.
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P Dileep Kumar, MD Port Huron Hospital
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dileepkumarp{at}yahoo.com P Dileep Kumar
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The paper by Gregg et al about the higher mortality in diabetic women is intriguing. In addition to the sex differences in the pathophysiology of coronary artery disease and the treatment bias attributed to the poorer prognosis in women, additional risk factors may be at play. One recent report indicated that nonfasting triglyceride levels independently predicted myocardial infarction, coronary artery disease and death particularly in women(1). An elevated nonfasting triglyceride level indicates high amounts of atherogenic triglyceride rich remnant lipoproteins. Another recent study(2) showed that nonfasting triglyceride levels were associated with incident cardiovascular events independent of traditional risk factors. The issue of postprandial lipemia is also emerging as an under- recognized atherogenic factor in patients with diabetes mellitus(3). The authors did not explore the relation of the nonfasting triglyceride levels and morbidity and mortality in the present cohort. The current thrust of anti hyperlipidemic treatment is geared towards reducing the cholesterol (both total and low density lipoprotein) burden. More studies are required to elucidate any role nonfasting triglyceride levels might play in the increased morbidity of diabetic women. This issue may be specifically targeted in future epidemiological and therapeutic trials. 1. Nordestgaard BG, Benn M, Schnohr P, Tybjaerg-Hansen A. Nonfasting triglycerides and risk of myocardial infarction, ischemic heart disease, and death in men and women. JAMA. 2007 ;298:299-308. 2. Bansal S, Buring JE, Rifai N, Mora S, Sacks FM, Ridker PM. Fasting compared with nonfasting triglycerides and risk of cardiovascular events in women. JAMA. 2007;298:309-16. 3. Pastromas S, Terzi AB, Tousoulis D, Koulouris S. Postprandial lipemia: An under-recognized atherogenic factor in patients with diabetes mellitus. Int J Cardiol. 2007 Aug 7; [Epub ahead of print http://www.internationaljournalofcardiology.com/article/PIIS0167527307010790/abstract] Conflict of Interest:None declared |
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saad sakkal, MD.FACP.FACE Metabolic Care Center
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ssakkal{at}mail2doctor.com saad sakkal
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Improvement in diabetes processes of care and intermediate outcomes between 1988-2006 have been dismal (1). In “NHANES” surveys, poor glycemic control (HgbA1C > 9%) continue to be the norm with a non significant decrease in 3.9% of patients only (1).Now we even have more hard facts :Women with diabetes are still dying as before. This scandalous non-significant change in HgbA1C ,and ,the little change in mortality in women with diabetes occurred during unparallel time in which three major revolutions occurred nearly simultaneously: First, improved technology of blood glucose self testing with outstanding data collection systems including continuous blood glucose monitoring. Second, improved technology of many new interventions like insulin pumps, novel insulin’s, oral hypoglycemic agents, and, better success in transplantation. . Third, an explosion of knowledge base and prove of the value of good glycemic control on outcome as published in widely publicized ,resource intensive, expensive academic trials lasting for years ( DCCT , UKDSP , YAMAMOTO , DPP ). Physicians and patients alike feel frustrated by this dismal failure and both are beginning to ask what is the reason and what could be done? Other stakeholders like insurance companies, business, and the government are suggesting a variety of solutions of unproven nature. The government proposes “Pay For Performance” with the newest acronym “P4P” directing future payments for care. This proposal is already beginning to worry physicians predicting decrease in reimbursement with troubled days ahead . I believe the diabetic community has been lead astray and has not been looking at reality with evidence based medicine that already exists showing the solution of the problem.!: Here is a chronic disease characterized by huge data and numbers management challenging the time of every provider and patient alike: data of diabetic manifestations, complications, outcome measures, diagnostic results, medications, exercise , activity , nutrition and meals , stress and other lifestyle factors influence ,etc. The only reasonable manner by which such a disease could be handled is to use computing power to treat effectively, especially since computing has been used to solve the most difficult challenges from cell biology to space exploration ,so why not diabetes therapy?. It is almost intuitive that it should be used to help since such a computer software exist.!(2).if we did not hear about it where have we been? 1) Saaaddine JB et al. “A Diabetes Report Card for the United States: Quality of Care in the 1990’s.” Ann Intern Med 136:565-574, 2002 2) Albisser AM,et al. “Diabetes Intervention in the Information Age.” Medical Informatics 1996;21: 297-316. Conflict of Interest:None declared |
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Sergio Stagnaro, Researcher Biophysical Semeiotics Research Laboratory
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dottsergio{at}semeioticabiofisica.it Sergio Stagnaro
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Sirs, The conclusion of this interesting article invite all of us to consider the 3 key findings: 1) Reductions in mortality occurred among diabetic men but not among diabetic women; 2) disparities in mortality rates between women with and without diabetes have worsened; and 3) the female-over-male advantage in mortality rates among the diabetic population has been eliminated. First of all, so-called diabetes “complications” begin really decades befor disease on-set. Glucose and lipid metabolism impairement worsens BUT not brings about such as complications (1-5). The presence of subclinical disease substantially increased the risk of subsequent CHD for participants with hypertension, diabetes mellitus, or elevated C-reactive protein". Notoriously, subclinical, and consequently dangerous, coronary heart disease is very prevalent among older individuals, is independently associated with risk of CHD , and substantially increases the risk of CHD among individuals with hypertension or diabetes mellitus. In following, I suggest - once again - an useful, reliable and easy clinical manoeuvre, that allows doctor to recognize both CAD Real Risk and silent CAD (1-3). This brief paper proved to be really useful in my 50-year-long clinical experience, also in order to the bed-side recognizing heart ischaemic disease before cardiac pathology occurs. Moreover, it is well known that patients with coronary artery disease (CAD) may have no symptoms at all for many years or decades and that the electrocardiographic features of ischaemia may be induced by exercise without accompaning angina (1). (For further information: See web site http://www.semeioticabiofisica.it, Practical Applications). In other words, we need a clinical tool reliable in rapid detecting CAD, even clinically silent, initiating from CAD “real risk”, doctor can now utilize in his day-to-day practice (1). I think surely that one method is "Myocardial Ischaemic Biophysical- Semeiotic Preconditioning", described elsewhere(1-3). From the tehnical viewpoint, doctor has to know, at least, the auscultatory percussion of the stomach, described even in old acàdemic books of two last centuries (Rasario IX edition). Briefly, in healthy individuals, digital pressure of mean intensity, applied upon heart cutaneous projection area, brings about the so-called gastric aspecific reflex (= in the stomach, fundus and body are dilated; on the contrary, antral-pyloric region contracts) after an age-dependent latency time of 8 sec., that lasts less than 4 sec. (= parameter value of paramount significance since it parallels the efficicacy of coronary microvessel Microcirculatory Funcional Reserve). A second, successive evaluation after an interval of 5 sec. exactly, provokes the identical reflex, but after lt. of 12 sec. or more: physiological myocardial preconditioning, typeI. On the contrary, in patients involved by CAD, even silent, i.e. subclinical,latency time persists identical in both evaluations, or results clearly reduced in the second one, in relation with disease seriousness: type II and respectively type III preconditioning. Of course, biophysical semeiotic preconditioning evaluation, really more complex than it appears in the above brief description, can be applied to all others biological systems, with favourable influences on primary prevention and diagnosis (1-5). 1) Stagnaro-Neri M., Stagnaro S. Deterministic Chaos, Preconditioning and Myocardial Oxygenation evaluated clinically with the aid of Biophysical Semeiotics in the Diagnosis of Ischaeemic Heart Disease even silent. Acta Medica Mediterranea 13, 109-116, 1997. 2) Stagnaro S. A clinical efficacious maneouvre, reliable in bed-side diagnosing coronary artery disease, even initial or silent, as well as "heart coronary risk". 3rd Virtual International Congress of Cardiology, FAC,2003, http://www.fac.org.ar/tcvc/marcoesp/marcos.htm 3) Stagnaro Sergio. Newborne-pathological Endoarteriolar Blocking Devices in Diabetic and Dislipidaemic Constitution and Diabetes Primary Prevention. The Lancet. March 06 2007. http://www.thelancet.com/journals/lancet/article/PIIS0140673607603316/comments?totalcomments=1 4) Stagnaro Sergio Endothelial cell function can ameliorate under safer drugs, such as Melatonin-Adenosine. BMC Cardiovascular disorders. 2004 http://www.biomedcentral.com/1471-2261/4/4/comments 5) Stagnaro S. Pre-Metabolic Syndrome: Locus primary prevention. NYAS web site. 1999 http://www.memberconnections.com/olc/membersonly/NYAS/mboards.html Conflict of Interest:None declared |
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