Intensive insulin provides survival benefit in patients with type 2 diabetes after heart attack

 

May 12, 2014

The Lancet

Intensive insulin treatment prolonged life by more than 2 years in patients with diabetes after a heart attack, compared with standard treatment for diabetes, a long term follow-up trial has shown. The trial, involving 620 patients with type 2 diabetes, began in 1990. Patients who were admitted to hospital with a suspected heart attack received either intensive insulin treatment, or standard glucose-lowering treatment for one year. The purpose of the study was to determine whether the difference in treatment affected all-cause mortality in the long-term.

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Long-term follow-up of the DIGAMI 1 trial -- a landmark study of type 2 diabetes in Sweden -- shows that intensive insulin treatment prolonged life by more than 2 years in patients with diabetes after a heart attack, compared with standard treatment for diabetes, reports Dr Viveca Ritsinger from the Unit of Cardiology of the Department of Medicine, Karolinska Institute, Stockholm, Sweden and colleagues in The Lancet Diabetes & Endocrinology.

The trial, involving 620 patients with type 2 diabetes, began in 1990. Patients who were admitted to hospital with a suspected heart attack received either intensive insulin treatment (an insulin-glucose infusion for at least 24 h, followed by insulin injection four times a day for at least 3 months) or standard glucose-lowering treatment (involving insulin only rarely) for one year. The purpose of the study was to determine whether the difference in treatment affected all-cause mortality in the long-term.

In the new study, patients were followed for up to 20 years, during which time most of them died. Those who received intensified insulin treatment during the trial survived an average (median) of 2·3 years longer compared with those who received standard treatment. The effect was apparent for at least 8 years after randomisation and thereafter leveled off. Patients who were at low cardiovascular risk (less than 70 years old, no history of heart attack or congestive heart failure) and had not previously had insulin therapy when the trial started seemed to benefit the most from intensive insulin treatment.

Although the results clearly show a benefit of intensive insulin treatment after a heart attack in patients with type 2 diabetes, the effect on survival seen is probably larger than would be seen if the trial was started today. Compared with 1990, when DIGAMI 1 began, there have been many advances in conventional treatment of patients with type 2 diabetes and cardiovascular complications, such as more frequent use of medication to lower cholesterol (statins) and blood pressure (angiotensin-converting-enzyme inhibitors).

According to Denise Bonds, of the National Institutes of Health, Bethesda, MD, USA, in an accompanying Comment, the new study "points to the benefit of good glucose control even when other risk factors such as lipids or blood pressure cannot be or are not modified…it provides an important reminder of how quickly medicine is advancing, something that is often forgotten in the busy day-to-day practice of medicine. In 20 years, we have gone from few glucose-lowering therapies to over half a dozen oral therapy drugs, plus insulin, plus effective treatments to reduce the risk of elevated lipids and blood pressure. Now, the challenge is choosing the best treatment option for our patients."

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Story Source:

The above story is based on materials provided by The Lancet. Note: Materials may be edited for content and length.

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Journal Reference:

1. Viveca Ritsinger, Klas Malmberg, Anton Mårtensson, Lars Rydén, Hans Wedel, Anna Norhammar. Intensified insulin-based glycaemic control after myocardial infarction: mortality during 20 year follow-up of the randomised Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial. Lancet Diabetes Endocrinol, May 2014 DOI: 10.1016/ S2213-8587(14)70088-9

Living near foreclosed property linked to higher blood pressure

 

May 12, 2014

American Heart Association

This study provides the first evidence that foreclosed properties may increase neighbors' blood pressure. Neighborhood environment is an important social determinant of cardiovascular health, including blood pressure. The scale of the recent U.S. housing crisis has prompted the public health community to seek a better understanding of how foreclosure activity might impact health. The number of foreclosures spiked in the United States in 2007-10 when more than 6 million homeowners fell behind on their mortgages and banks took ownership of the homes, or foreclosed.

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Living near foreclosed property may increase your risk of higher blood pressure, according to new research in the American Heart Association journal Circulation.

The study provides the first evidence that foreclosed property may affect neighbors' systolic blood pressure, the top number in a blood pressure reading.

Neighborhood environment is an important social determinant of cardiovascular health, including blood pressure. The scale of the recent U.S. housing crisis has prompted the public health community to seek a better understanding of how foreclosure activity might impact health. The number of foreclosures spiked in the United States in 2007-10 when more than 6 million homeowners fell behind on their mortgages and banks took ownership of the homes, or foreclosed.

Researchers reviewed data from 1,740 participants (mostly white, 53 percent women) in 1987-2008 in the Framingham (Massachusetts) Offspring Cohort, which is part of the Framingham Heart Study. The researchers distinguished between real-estate-owned foreclosures, which are owned by lenders and typically sit vacant, and foreclosures purchased by third-party buyers, which are generally put into productive use.

Researchers found each additional foreclosed property within 100 meters (328 feet) of participants' homes was associated with an average increase of 1.71 mm Hg in systolic blood pressure. The association only applied to properties that were real-estate owned and there was no effect from foreclosed properties more than 100 meters from participants' homes.

"The increases in blood pressure observed could be due in part to unhealthy stress from residents' perception that their own properties are less valuable, their streets less attractive or safe and their neighborhoods less stable," said Mariana Arcaya, Sc.D., M.C.P., study lead author and Yerby Postdoctoral Research Fellow at the Harvard Center for Population and Development Studies in Cambridge, Mass. "Safety could also be a concern that affects their ability to exercise in these neighborhoods."

"Healthcare providers, particularly those serving neighborhoods still recovering from the recent housing crisis, should be aware of foreclosure activity as a possible source of unhealthy stress for residents," Arcaya said.

Because the study involved predominately white, middle-class, suburban neighborhoods with single-family homes, research on different populations in urban and rural settings is needed, Arcaya said.

High blood pressure affects nearly 76 million people in the United States and is a major contributor to heart disease and stroke. Risk factors include genetics, advanced age, poor nutrition and excessive body weight and alcohol consumption. Stress and other factors may also contribute to high blood pressure.

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Story Source:

The above story is based on materials provided by American Heart Association. Note: Materials may be edited for content and length.

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Journal Reference:

1. Mariana Arcaya, M. Maria Glymour, Prabal Chakrabarti, Nicholas A. Christakis, Ichiro Kawachi, and S V Subramanian. Effects of Proximate Foreclosed Properties on Individuals' Systolic Blood Pressure in Massachusetts, 1987-2008. Circulation, May 2014 DOI: 10.1161/CIRCULATIONAHA.113.006205

Low rate of adverse events associated with male circumcision during first year of life, study finds

 

May 12, 2014

The JAMA Network Journals

A low rate of adverse events was associated with male circumcision when the procedure was performed during the first year of life, but the risk was 10 to 20 times higher when boys were circumcised after infancy. "Given the current debate about whether male circumcision should be delayed from infancy to adulthood for autonomy reasons, our results are timely and can help physicians counsel parents about circumcising their sons," the researchers concluded.

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A low rate of adverse events (AEs) was associated with male circumcision (MC) when the procedure was performed during the first year of life, but the risk was 10 to 20 times higher when boys were circumcised after infancy.

The American Academy of Pediatrics has updated its MC guidance to say that the benefits justify access to the procedure for families who choose it. There has been debate about whether MC should be considered a public health action because of its potential protective effect against acquisition of human immunodeficiency virus (HIV) as suggested in three randomized controlled trials. A part of the debate surrounds the rate of AEs.

The authors selected 41 possible AEs of MC based on a literature review and medical billing codes. They used data from a large administrative claims data set and records were available for about 1.4 million circumcised males (93.3 percent as newborns).

The rate of total AEs from MC was slightly less than 0.5 percent. The rates of potentially serious AEs from MC ranged from 0.76 per million MCs for stricture of the male genital organs to 703.23 per million for repair of an incomplete circumcision. Compared with boys circumcised at younger than 1 year of age, the incidence of probable AEs was 20-fold and 10-fold greater for boys circumcised at age 1 to 9 years and at 10 years or older.

"Given the current debate about whether MC should be delayed from infancy to adulthood for autonomy reasons, our results are timely and can help physicians counsel parents about circumcising their sons," the researchers concluded.

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Story Source:

The above story is based on materials provided by The JAMA Network Journals. Note: Materials may be edited for content and length.

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Journal Reference:

1. Charbel El Bcheraoui, Xinjian Zhang, Christopher S. Cooper, Charles E. Rose, Peter H. Kilmarx, Robert T. Chen. Rates of Adverse Events Associated With Male Circumcision in US Medical Settings, 2001 to 2010. JAMA Pediatrics, 2014; DOI: 10.1001/jamapediatrics.2013.5414

Diets rich in antioxidant resveratrol fail to reduce deaths, heart disease or cancer

 

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Grapes and red wine (stock image).

A study of Italians who consume a diet rich in resveratrol -- the compound found in red wine, dark chocolate and berries -- finds they live no longer than and are just as likely to develop cardiovascular disease or cancer as those who eat or drink smaller amounts of the antioxidant.

"The story of resveratrol turns out to be another case where you get a lot of hype about health benefits that doesn't stand the test of time," says Richard D. Semba, M.D., M.P.H., a professor of ophthalmology at the Johns Hopkins University School of Medicine and leader of the study described May 12 in JAMA Internal Medicine. "The thinking was that certain foods are good for you because they contain resveratrol. We didn't find that at all."

Despite the negative results, Semba says, studies have shown that consumption of red wine, dark chocolate and berries does reduce inflammation in some people and still appears to protect the heart. "It's just that the benefits, if they are there, must come from other polyphenols or substances found in those foodstuffs," he says. "These are complex foods, and all we really know from our study is that the benefits are probably not due to resveratrol."

The new study did not include people taking resveratrol supplements, though few studies thus far have found benefits associated with them.

Semba is part of an international team of researchers that for 15 years has studied the effects of aging in a group of people who live in the Chianti region of Italy. For the current study, the researchers analyzed 24 hours of urine samples from 783 people over the age of 65 for metabolites of resveratrol. After accounting for such factors as age and gender, the people with the highest concentration of resveratrol metabolites were no less likely to have died of any cause than those with no resveratrol found in their urine. The concentration of resveratrol was not associated with inflammatory markers, cardiovascular disease or cancer rates.

Semba and his colleagues used advanced mass spectrometry to analyze the urine samples.

The study participants make up a random group of people living in Tuscany where supplement use is uncommon and consumption of red wine -- a specialty of the region -- is the norm. The study participants were not on any prescribed diet.

Resveratrol is also found in relatively large amounts in grapes, peanuts and certain Asiatic plant roots. Excitement over its health benefits followed studies documenting anti-inflammatory effects in lower organisms and increased lifespan in mice fed a high-calorie diet rich in the compound.

The so-called "French paradox," in which a low incidence of coronary heart disease occurs in the presence of a high dietary intake of cholesterol and saturated fat in France, has been attributed to the regular consumption of resveratrol and other polyphenols found in red wine.

Association between small-vessel disease, Alzheimer pathology studied

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Cerebral small-vessel disease (SVD) and Alzheimer disease (AD) pathology appear to be associated.

AD is believed to be caused by the buildup of amyloid protein in the brain and tau tangles. Previous studies have suggested that SVD and vascular risk factors increase the risk of developing AD. In both SVD and vascular dementia (VaD), signs of AD pathology have been seen. But it remains unclear how the interaction between SVD and AD pathology leads to dementia.

Authors examined the association between SVD and AD pathology by looking at magnetic resonance imaging (MRI)-based microbleeds (MB), white matter hyperintensities (WMH) and lacunes (which are measures for SVD) along with certain protein levels in cerebrospinal fluid (CSF) which reflect AD pathophysiology in patients with AD, VaD and healthy control patients. The authors also examined the relationship of apolipoprotein E (APOE) Ɛ4 genotype, a well-known risk factor for AD.

The presence of both MBs and WMH was associated with lower CSF levels of Aβ42, suggesting a direct relationship between SVD and AD. Amyloid deposits also appear to be abnormal in patients with SVD, especially in (APOE) Ɛ4 carriers.

"Our study supports the hypothesis that the pathways of SVD and AD pathology are interconnected. Small-vessel disease could provoke amyloid pathology while AD-associated cerebral amyloid pathology may lead to auxiliary vascular damage," researchers conclude.

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Story Source:

The above story is based on materials provided by The JAMA Network Journals. Note: Materials may be edited for content and length.

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Journal Reference:

1. Maartje I. Kester, M.D., Ph.D. et al. Associations Between Cerebral Small-Vessel Disease and Alzheimer Disease Pathology as Measured by Cerebrospinal Fluid Biomarkers. JAMA Neurol., May 2014 DOI: 10.1001/.jamaneurol.2014.754