Providing Evidence for Subclinical CVD in Risk Assessment

When the MESA (Multi-Ethnic Study of Atherosclerosis) began, the Framingham risk score was the preferred tool for 10-year global coronary heart disease risk assessment; however, the Framingham risk score had limitations including derivation in a homogenous population lacking racial and ethnic diversity and exclusive reliance on traditional risk factors without consideration of most subclinical disease measures. MESA was designed to study the prognostic value of subclinical atherosclerosis and other risk markers in a multiethnic population. In a series of landmark publications, MESA demonstrated that measures of subclinical cardiovascular disease add significant prognostic value to the traditional Framingham risk variables. In head-to-head studies comparing these markers, MESA established that the coronary artery calcium score may be the single best predictor of coronary heart disease risk. Results from MESA have directly influenced recent prevention guidelines including the recommendations on risk assessment and cholesterol-lowering therapy. The MESA study has published its own risk score, which allows for the calculation of 10-year risk of coronary heart disease before and after knowledge of a coronary artery calcium score.     

对2型糖尿病合并亚临床甲状腺功能减退的临床特征分析

目的 探讨2型糖尿病合并亚临床甲状腺功能减退的临床特征分析.方法 择取2019年9月—2020年9月期间来该院就诊的64例2型糖尿病患者,按照是否为合并亚临床甲状腺功能减退分组,分别为实验组32例与参照组32例.实验组为2型糖尿病合并亚临床甲状腺功能减退患者,参照组为单纯的糖尿病患者患者,将两组糖尿病患者的慢性并发症发...     

Progress in National and Regional Guidelines Development and Deployment for the Clinical Prevention and Control of CVD and Diabetes in Africa

Successful efforts to reduce cardiovascular disease in many countries have come as a result of both population based interventions and individually guided interventions. Guidelines serve two purposes directed at the promotion of the individually guided interventions. First, they serve as a method to summarize approved and successful life-style and medical interventions to reduce the burden of cardiovascular disease. Second, they guide health providers on how to identify those at high risk for cardiovascular disease and who might benefit from the available interventions. However, guidelines have been increasingly complex and at times contradictory from one body to another or they may not exist at all in certain countries. This paper will review the current status of guidelines for the region as well as for individual countries. Guidelines for the prevention of CVD as a whole will be evaluated as well as guidelines for individual risk factors such as hypertension, cholesterol, and diabetes. Finally, this paper will address the pitfalls of individual risk factor based guidelines as opposed to the absolute risk approach integrating multiple risk factors into one comprehensive set of guidelines.     

Clinical and Subclinical Autoimmune Thyroid Disease in Adult Celiac Disease

Our aim was to investigate the occurrence of clinical and subclinical autoimmune thyroid disease in 79 patients with celiac disease as reflected in thyroid function, antibodies, and ultrasound. Since subclinical thyroid diseases are common in the population, 184 nonceliac controls were also studied. Normal thyroid function combined with positive antibodies and marked hypoechogenicity was considered subclinical disease. Autoimmune thyroid disease was observed in 13.9% of celiac patients and in 2.1% of controls (P = 0.0005); and subclinical disease in 10.1% and 3.3%, respectively (P = 0.048). The mean thyroid gland volume was 8.3 ml in celiac patients and 10.4 ml in controls (P = 0.007). Hypoechogenicity was found in 73% of celiac patients and in 42% of controls (P < 0.0001). Positive thyroid antibodies were associated with hypoechogenicity in celiac patients but not in controls. In conclusion, the occurrence of both clinical and subclinical autoimmune thyroid disease was increased in celiac disease; subclinical thyroid disease indicates regular surveillance.     

Clinical and Subclinical Leaks After Low Colorectal Anastomosis: A Clinical and Radiologic Study

Purpose This study was designed to examine the natural history of subclinical leaks and their effect on bowel function and quality of life and to evaluate water-soluble contrast enema features that predict anastomotic healing after leaks. Methods Consecutive patients who underwent low rectal anastomosis were followed up postoperatively for leaks. All leaks were confirmed radiologically with CT scanning and water-soluble contrast enema imaging. Water-soluble contrast enemas were serially repeated to identify healing. Characteristics on initial water-soluble contrast enema were correlated with observed healing. Postoperatively, patients were required to fill in a quality of life and a bowel function questionnaire. Results A total of 138 patients underwent low rectal anastomosis procedures with a median follow-up period of 26 (interquartile range, 19–37) months. There were 23 documented leaks of which 13 (9 percent) presented clinically and 10 (8 percent) presented subclinically. Ileostomy closure was possible in 4 of 13 (30 percent) patients with a clinical leak and all 10 (100 percent) patients with a subclinical leak. Median quality of life scores were lower for patients with clinical leaks and no ileostomy closure (P = 0.03). Bowel function for subclinical leak patients and clinical leak patients with ileostomy closure were similarly impaired. The presence of a cavity (P = 0.01) and a stricture (P = 0.01) at the anastomotic site were unfavorable radiologic features associated with nonhealing. Conclusions Subclinical leaks are more benign in their natural history compared with clinical leaks. Quality of life and bowel function is no better in patients with a subclinical leak compared with patients with a clinical leak who have ileostomy closure. Anastomotic leaks may resolve if favorable radiologic features are present. Presented at the Tripartite Colorectal Meeting, Dublin, Ireland, July 5 to 7, 2005. Reprints are not available.     

Intravascular Coagulation in Acute Leukemia: Clinical and Subclinical Abnormalities

Fifteen patients with acute leukemiawere found to have evidence of ageneralized hemostatic disorder.These patients could be divided intothree groups. The first group consistedof three patients with increased fibrinogen catabolism without clinical orlaboratory evidence of intravascularcoagulation. The second group of fivepatients had laboratory evidence ofintravascular coagulation withoutclinically evident bleeding or thrombosis. The third group of seven patients developed symptomatic intravascular coagulation characterizedby bleeding, renal failure, and poorresponse to platelet transfusions.Laboratory evidence for intravascularcoagulation in these patients includedfalling plasma fibrinogen and factor Vlevels and elevated serum levels offibrinogen degradation products.Heparin therapy resulted in clinicalimprovement in all seven patients.Rising plasma fibrinogen and factorV levels correlated with a beneficialclinical response to heparin. Increasedfibrinogen catabolism, asymptomaticintravascular coagulation, and symptomatic intravascular coagulation formpart of a spectrum of generalizedhemostatic disorders in acute leukemia.

Submitted on February 29, 1972 Revised on May 10, 1972 Accepted on May 17, 1972     

The Association Between Endocan Levels and Subclinical Atherosclerosis in Patients With Type 2 Diabetes Mellitus

Background

Proinflammatory conditions induced by circulating factors in diabetes play a pivotal role in endothelial dysfunction and related vascular complications. Endothelial cell-specific molecule-1 or endocan is a dermatan sulfate proteoglycan secreted primarily by the vascular endothelium. Although endocan has been shown to be a potential biomarker in coronary heart disease, its role in the pathogenesis of atherosclerosis (AS) in diabetes remains unclear. In this study, we investigated the correlation between serum endocan levels and subclinical AS in patients with type 2 diabetes mellitus (T2DM).

Vitamin D Deficiency: Subclinical and Clinical Consequences on Musculoskeletal Health

Vitamin D is an important contributor to musculoskeletal health through its well-established key role in calcium and phosphorus metabolism. The association between vitamin D and various muscle disease outcomes appears promising. However, the role of vitamin D extends well beyond this traditionally labeled effect on muscle and bone health (eg, as a modulator of cell growth and immune function). While further research is needed (as there are still divergent opinions regarding these extraskeletal effects of vitamin D), strong, convincing evidence supports the benefits of vitamin D in promoting bone growth and maintenance, and this has been acknowledged in the recent Institute of Medicine report. However, it should be recognized that the research on vitamin D is still an emerging field, and it is beyond the scope of this paper to include more than a brief review of the published work.     

多因素干预对新诊断2型糖尿病患者亚临床动脉粥样硬化的影响

目的 探讨多因素干预对新诊断2型糖尿病患者亚临床动脉粥样硬化发生的影响.方法 采用平行、开放的前瞻性研究,对141例新诊断2型糖尿病患者以强化控制血糖、血压、血脂、体重等多种危险因素的干预迭标措施,探讨多因素干预以及代谢综合征评分的变化对6年后亚临床动脉粥样硬化发生的影响.结果 多因素干预1年后新诊断2型糖尿病患者的代谢综合征总评分改善(P<0.01),干预1年后代谢综合征评分仍≥2分者,6年后亚临床动脉粥样硬化发病率高于0～1分者(P<0.05);干预1年后仍有2分者,6年后74.1%(20/27)发生亚临床动脉粥样硬化,仍有3分者100%(6/6)发生亚临床动脉粥样硬化.Logistic回归分析显示,经年龄、性别校正后,干预1年后代谢综合征总评分为干预6年时亚临床动脉粥样硬化发生的独立危险因素(OR=1.89,95%CI 1.19～3.01,P<0.01);且干预1年后是否有中心性肥胖为干预6年后亚临床动脉粥样硬化发生最为显著的影响因素(OR=2.45,95%CI 1.19～5.07,P<0.05).结论 新诊断2型糖尿病患者早期代谢因素的干预效果可预测其长期亚临床动脉粥样硬化的发生,而中心性肥胖是促其发生的重要因素.     

Alpha-Lipoic Acid Improves Subclinical Left Ventricular Dysfunction in Asymptomatic Patients with Type 1 Diabetes

BACKGROUND: Oxidative stress plays an important role in the development of diabetic cardiomyopathy. Alpha-lipoic acid (ALA) is a powerful antioxidant that may have a protective role in diabetic cardiac dysfunction. AIM: We investigated the possible beneficial effect of alpha-lipoic acid on diabetic left ventricular (LV) dysfunction in children and adolescents with asymptomatic type 1 diabetes (T1D). SUBJECTS AND METHODS: Thirty T1D patients (aged 10-14) were randomized to receive insulin treatment (n = 15) or insulin plus alpha-lipoic acid 300 mg twice daily (n = 15) for four months. Age and sex matched healthy controls (n = 15) were also included. Patients were evaluated with conventional 2-dimensional echocardiographic examination (2D), pulsed tissue Doppler (PTD), and 2-dimensional longitudinal strain echocardiography (2DS) before and after therapy. Glutathione, malondialdhyde (MDA), nitric oxide (NO), tumor necrosis factor-alpha (TNF-alpha), Fas ligand (Fas-L), matrix metalloproteinase 2 (MMP-2), and troponin-I were determined and correlated to echocardiographic parameters. RESULTS: Diabetic patients had significantly lower levels of glutathione and significantly higher MDA, NO, TNF-alpha, Fas-L, MMP-2, and troponin-I levels than control subjects. The expression of transforming growth factor beta (TGF-beta) mRNA in peripheral blood mononuclear cells was also increased in diabetic patients. Significant correlations of mitral e''/a'' ratio and left ventricular global peak systolic strain with glutathione, MDA, NO, TNF-alpha, and Fas-L were observed in diabetic patients. Alpha-lipoic acid significantly increased glutathione level and significantly decreased MDA, NO, TNF-alpha, Fas-L, MMP-2, troponin-I levels, and TGF-beta gene expression. Moreover, alpha-lipoic acid significantly increased mitral e''/a'' ratio and left ventricular global peak systolic strain in diabetic patients. CONCLUSION: These findings suggest that alpha-lipoic acid may have a role in preventing the development of diabetic cardiomyopathy in type 1 diabetes.     

2型糖尿病患者血糖波动与亚临床动脉粥样硬化的关系

目的探讨2型糖尿病患者血糖波动与亚临床动脉粥样硬化的关系。方法170例年龄35～70岁、病程在1年以内、无亚临床动脉粥样硬化的2型糖尿病患者随机分为4组,分别给予不同的药物方案治疗。定期复查空腹血糖、早餐后2h血糖、糖化血红蛋白和血管彩色超声等指标,共随访3年。结果3年结束时,4组之间血糖波动指标比较差异无显著性(P>0.05),4个血糖波动指标的分层分析显示,亚临床动脉粥样硬化发生率均随血糖波动的增加而呈升高的趋势,尚未达到统计学差异。Logistic回归分析显示,亚临床动脉粥样硬化的发生与吸烟、高血脂、高龄、腹型肥胖、早餐后2h血糖与空腹血糖差值波动有关,而不同的干预方式对亚临床动脉粥样硬化的发生有影响(P<0.001)。结论早餐后2h血糖与空腹血糖差值波动大是2型糖尿病患者亚临床动脉粥样硬化的危险因素之一,吸烟、高血脂、高龄、腹型肥胖均是2型糖尿病患者亚临床动脉粥样硬化的危险因素。     

Subclinical Left Ventricular Longitudinal and Radial Systolic Dysfunction in Children and Adolescents with Type 1 Diabetes Mellitus

Introduction: There are few studies of subclinical systolic dysfunctions in children and adolescents with type 1 diabetes mellitus (DM), and so the available data are limited. The aim of this study was to determine early echocardiographic signs of LV systolic dysfunction in children and adolescents with type 1 DM using two‐dimensional speckle tracking echocardiography (2DSTE). Material and Methods: The study included 84 children and adolescents with type 1 DM and 32 sex‐, age‐, and body mass index–matched healthy subjects. The LV functions were assessed using conventional echocardiography, tissue Doppler imaging, and 2DSTE. Results: The results showed LV diastolic dysfunction as reflected by significantly increased A‐wave velocity, decreased E/A ratio, and increased early filling deceleration time in the patients with diabetes (P = 0.02, P = 0.029, and P = 0.04; respectively). Compared with the control group, patients with diabetes showed significantly lower values for longitudinal systolic strain and strain rate in most segments of the LV; for radial strain values of the LV; for lateral circumferential strain and posterior and anterolateral circumferential strain rate of the LV; and for global longitudinal and radial strain of the LV. Global longitudinal and radial strain values of the LV were significantly lower among patients with poor glycemic control than in the control group. Conclusion: In addition to diastolic dysfunction, LV longitudinal and radial function was found to be impaired in asymptomatic children and adolescents with type 1 DM who have normal LV ejection fraction by 2DSTE. Glycemic control may be the main risk factor for alteration of myocardial function.     

Development and Pilot Evaluation of Literacy-Adapted Diabetes and CVD Education in Urban,Diabetic African Americans

Background  Despite prevalent low literacy nationally, empirical research on the development and testing of literacy-adapted patient education remains limited. Objective  To describe procedures for developing and evaluating usability and acceptability of an adapted diabetes and CVD patient education. Design  Materials adaptation for literacy demand and behavioral activation criteria, and pre-/post-test intervention evaluation design. Participants  Pilot sample of 30 urban African-American adults with type 2 diabetes with Below Average literacy (n = 15) and Average literacy (n = 15). Measurements  Wide Range Achievement Test (WRAT-3, Reading), assessment of diabetes and CVD knowledge, and patient rating scale. Results  Reading grade levels were: >12th, 30%; 10th–12th, 20%; 7th–9th, 10%; 4th–6th grade, 10%; and ≤3rd grade or unable to complete WRAT-3, 30%. Education materials were modified to a reading level of ≤4th grade. Knowledge improved for Below Average (2.7 to 4.7, p = 0.005) and Average (3.8 to 5.7, p = 0.002) literacy groups, with up to a ten-fold increase, at post-education, in the number of participants responding correctly to some content items. The print materials and class received maximum usability and acceptability ratings from patients. Conclusions  Development of patient education meeting very low literacy criteria was feasible, effective for knowledge acquisition, and highly acceptable irrespective of literacy level.     

Subclinical Sacroiliitis in Inflammatory Bowel Disease: A Clinical and Follow-up Study

The aim of this study was to evaluate the clinical features, evolution and reliability of spondyloarthropathy criteria in a subset of patients with subclinical sacroiliitis and inflammatory bowel disease (IBD). All patients with IBD (n 62) attending a gastroenterology clinic from a referral centre were included to assess the prevalence of articular involvement. Patients were evaluated according to a specific protocol designed for the study, which included epidemiological and clinical variables, physical examination and radiological assessment. Only those with subclinical sacroiliitis were followed prospectively for 4 years. This group was visited every 6 months with the same initial protocol. Sacroiliac joints were studied using frontal and oblique X-ray views and graded according to New York criteria. HLA B27 typing was performed by serological methods in all patients and in 80 healthy controls. The reliability of Amor and ESSG criteria for spondyloarthropathy was evaluated. Fifteen patients (24%) presented with isolated subclinical sacroiliitis. In this group a higher frequency of peripheral arthritis and erythema nodosum was observed (p= NS compared to those without sacroiliitis). Most cases (60%) were grade II unilateral sacroiliitis. Three patients were HLA B27+ (p>0.05 compared to healthy controls). The resultant sensitivity of Amor’s and ESSG criteria ranged from 40% to 46%. An unexpectedly high freuqency (9.5%) of psoriasis was observed in the whole group. There is a high prevalence of isolated subclinical sacroiliitis in IBD. This may represent a forme fruste of enteropathic ankylosing spondylitis, a stunted form of axial involvement because of therapy, or a third category of rheumatic disease associated with IBD. It may also represent a common characteristic of spondyloarthropathies, rather than a specific finding of IBD. The recently developed spondyloarthropathy criteria are not particularly helpful for the diagnosis of this milder form of spondyloarthropathy. Received: 17 November 1999 / Accepted: 22 March 2000