Spuriously high prevalence of prediabetes diagnosed by HbA(1c) in young Indians partly explained by hematological factors and iron deficiency anemia.

Source: Diabetes Care. 2012 Apr;35(4):797-802. Epub 2012 Feb 8. (Original) Link

Cohort study: HbA1c had 50% sensitivity and 77% specificity for diagnosing prediabetes and diabetes but was less accurate in patients with anemia.

PMID: 22323413
OBJECTIVE: To examine the influence of glycemic and nonglycemic parameters on HbA(1c) concentrations in young adults, the majority of whom had normal glucose tolerance.

RESEARCH DESIGN AND METHODS: We compared the diagnosis of normal glucose tolerance, prediabetes, and diabetes between a standard oral glucose tolerance test (OGTT; World Health Organization 2006 criteria) and HbA(1c) concentrations (American Diabetes Association [ADA] 2009 criteria) in 116 young adults (average age 21.6 years) from the Pune Children`s Study. We also studied the contribution of glycemic and nonglycemic determinants to HbA(1c) concentrations.

RESULTS: The OGTT showed that 7.8% of participants were prediabetic and 2.6% were diabetic. By ADA HbA(1c) criteria, 23.3% were prediabetic and 2.6% were diabetic. The negative predictive value of HbA(1c) was 93% and the positive predictive value was 20% (only 20% had prediabetes or diabetes according to the OGTT; this figure was 7% in anemic participants). Of participants, 34% were anemic, 37% were iron deficient (ferritin <15 ng/mL), 40% were vitamin B(12) deficient (<150 pmol/L), and 22% were folate deficient (<7 nmol/L). On multiple linear regression analysis, HbA(1c) was predicted by higher 2-h glucose (R(2) = 25.6%) and lower hemoglobin (R(2) = 7.7%). When hematological parameters were replaced by ferritin, vitamin B(12), and folate, HbA(1c) was predicted by higher glycemia (R(2) = 25.6%) and lower ferritin (R(2) = 4.3%).

CONCLUSIONS: The use of HbA(1c) to diagnose prediabetes and diabetes in iron-deficient populations may lead to a spuriously exaggerated prevalence. Further investigation is required before using HbA(1c) as a screening tool in nutritionally compromised populations.

ACE inhibitors associated with improved in-hospital outcomes for CABG patients

Continuing angiotensin-converting enzyme (ACE) inhibitors, or adding them early after surgery, is associated with improved in-hospital outcomes for patients undergoing coronary artery bypass grafting (CABG), a study found.

In a prospective, observational study, researchers examined 4,224 patients undergoing CABG surgery. Patients were analyzed in four groups: continuation, that is, patients who were on ACE inhibitors pre- and postoperatively (21.7%, n=915); withdrawal, patients who took ACE inhibitors preoperatively but not postoperatively (21.8%, n=923); addition, patients who didn't take ACE inhibitors preoperatively but added them postoperatively (8.1%, n=343); and patients with no exposure to ACE inhibitors (48.4%, n=2,043). The primary outcome was a composite of cardiac, cerebral and renal events and in-hospital mortality. Results were published onlinepublished online June 18 by Circulation.

Compared to not using ACE inhibitors, continuous treatment with ACE inhibitors was associated with a significant reduction in the risk of nonfatal events (adjusted odds ratio [OR] for composite outcome, 0.69; P=0.009) and cardiovascular events (OR, 0.64; P=0.006). Adding ACE inhibitors after surgery compared to no use was also associated with a significantly lower risk of composite outcome (OR, 0.56; P=0.004) and cardiovascular events (OR, 0.63; P=0.04). Compared to withdrawal of ACE inhibitors, continuous treatment was associated with a lower risk of the composite outcome (OR, 0.50; P=0.001) as well as a decreased risk in cardiac and renal events (P<0.001 and P=0.005). There were no differences in in-hospital deaths or cerebral events based on ACE inhibitor usage.

The results indicate that withdrawing ACE inhibitors after CABG surgery is associated with nonfatal in-hospital events, while continuing ACE inhibitor treatment or adding it early after surgery is associated with better outcomes, the authors concluded. Given these findings, it is "alarming to learn that clinicians chose to acutely discontinue [ACE inhibitor] therapy in nearly 50% of patients following cardiac surgery. This pattern of practice was associated with major vascular complications. Acute withdrawal of [ACE inhibitor] therapy may be particularly harmful in the context of cardiac surgery….," they wrote.

Editorialistscaution that, as the study was observational, one can only note associations and not assume causation, and a randomized, controlled trial is needed. "As such, we should not yet conclude that withdrawal of [ACE inhibitors] necessarily causes increased post-operative complications," they wrote. For example, "If [ACE inhibitors] were withdrawn from patients at high risk of cardiovascular instability postoperatively, it may erroneously appear as if [ACE inhibitor] withdrawal is a cause of the postoperative cardiovascular events." Still, they said, the study is important "in that it forces providers to re-examine the practice of routinely discontinuing [ACE inhibitors] peri-operatively. Our advice to readers is to be open minded [and] stay tuned…."

Frailty Associated With Early Dialysis, Poorer Outcomes.

MedPage Today  (6/26, Phend) reports, "Acute kidney injury appears to be an increasing problem in cardiac and vascular surgeries," according to a study  published online in the CMAJ. Investigators found that "severe cases marked by need for acute dialysis after major elective surgery -- although rare -- rose year over year from a rate of 0.2% in 1995 to 0.6% in 2009." This "increase was primarily in cardiac and vascular surgeries."

Acute Kidney Injury May Be An Increasing Problem In Cardiac, Vascular Surgeries.

MedPage Today  (6/26, Phend) reports, "Acute kidney injury appears to be an increasing problem in cardiac and vascular surgeries," according to a study  published online in the CMAJ. Investigators found that "severe cases marked by need for acute dialysis after major elective surgery -- although rare -- rose year over year from a rate of 0.2% in 1995 to 0.6% in 2009." This "increase was primarily in cardiac and vascular surgeries."

Heart attacks may lead to PTSD, analysis finds

Posttraumatic stress disorder (PTSD) is relatively common among survivors of acute coronary syndrome (ACS) and is associated with worse outcomes, according to a new meta-analysis.
The analysis covered 24 observational cohort studies including more than 2,000 patients who had ACS and were assessed for PTSD at least one month after the event. Overall, 12% of the patients had clinically significant symptoms of PTSD (95% CI, 9% to 16%), although rates varied widely among the studies. The variation could be explained by differing methods of screening, authors said; studies that used a screening questionnaire found higher rates of PTSD than those that used diagnostic interviews.
Three of the studies, totaling about 600 patients, assessed the relationship between PTSD and negative outcomes (mortality and/or ACS recurrence). Combined, the studies indicated a doubling of risk for these negative outcomes associated with clinically significant symptoms of PTSD (risk ratio, 2.00; 95% CI, 1.69 to 2.37). The overall meta-analysis also found that younger age was associated with higher PTSD rates, while a more recent study publication date was associated with lower risk (perhaps due to advances in treatment, the authors said). The results were published in the June PLoS One.
Extrapolating from their findings, study authors calculated that 168,000 ACS patients in the U.S. may develop PTSD each year. Their risk for mortality and recurrence is similar to the increased risk faced by depressed patients, they noted. Although the mechanism for this relationship is not known, increased inflammation associated with PTSD may have a negative effect on the heart, the authors speculated.
They called for additional research into treatments for ACS-induced PTSD, noting that only one treatment study (a trial of cognitive behavioral therapy) was identified in their search. A unified risk stratification strategy, using previously identified risk factors, is also needed, they concluded.

Olmesartan associated with GI condition mimicking celiac disease.

The Minneapolis Star Tribune (6/22, Lerner) reports that Joseph Murray, MD, of the Mayo Clinic, "has published a study linking the drug olmesartan," a blood pressure medication whose trade name is Benicar, "to a potentially life-threatening gastrointestinal condition that mimics celiac disease." Murray, a specialist in celiac disease, discovered that olmesartan "was associated with severe nausea, vomiting, diarrhea and weight loss in a group of 22 patients from 16 states, according to a report published online in Mayo Clinic Proceedings. Some of the patients had been told -- apparently mistakenly -- that they had celiac disease, a severe intestinal disorder." Symptoms in patients improved once they discontinued olmesartan therapy.

Review: Hot water, lidocaine most effective against jellyfish stings.

Reuters (6/22, Norton) reports that according to a review of 19 studies published online June 8 in the Annals of Emergency Medicine, the topical painkiller lidocaine and hot water appear to be the most effective remedies against stings by jellyfish in North America and in Hawaii. For stings of the Portuguese man-of-war, vinegar may be useful, but will increase pain and cause further nematocyst (venom sack) discharge from the stings of other types of jellyfish. No evidence was found for the efficacy of meat tenderizer and urine against jellyfish stings. Finally, for onsite first aid, the study's lead author suggested that beachgoers carefully remove nematocysts from the skin by using a credit card edge to scrape them off. Sting victims should not use their bare hands to remove tentacles and should carefully wash the sting area with saltwater.

Man First In New England To Receive Total Artificial Heart.

In a front-page story, the Boston Globe  (6/22, A1, Kowalczyk) reports, "A retired Massachusetts high school teacher and track coach is being kept alive with an artificial heart while awaiting a transplant at Brigham and Women's Hospital, the first use of the technology in New England to replace a patient's failing heart." While "total artificial hearts have been widely used elsewhere as a 'bridge to transplant'...Boston surgeons have not embraced the devices." The Globe points out that "one drawback of the SynCardia Total Artificial Heart that" the man "received is that ­patients are typically connected to a bulky 'pneumatic driver,' which resembles a large copier on wheels." The CBS News  (6/22, Jaslow) "HealthPop" blog also covers the story.

Researchers May Be Closer To Finding A Way To Reverse Effects Of Apixaban.

MedPage Today  (6/22, Kaiser) reports, "Researchers may be closer to finding a way to reverse the effects of the novel oral anticoagulant apixaban, a factor Xa inhibitor, according to results presented in the American Heart Association's Emerging Science Series webinar." Investigators found, "using healthy donor blood...that prothrombin complex concentrates (PCCs) and activated prothrombin complex concentrates (aPCCs) better restored thrombin generation than recombinant factor VII." However, "recombinant factor VII was better at improving clotting time and clot firmness, followed by aPCC and PCC."

Normoglycemia Reversion Associated With Reduced Risk Of Progression To Full Diabetes.

MedWire  (6/22, Robertson) reports, "Individuals with prediabetes have a significantly reduced risk for progressing to full diabetes if they have a history of reverting to normal glucose regulation," according to a study  published online June 16 in The Lancet. "During a mean 5.4-year follow-up study of participants from the Diabetes Prevention Program (DPP), the investigators found that prediabetic individuals were 56% less likely to progress to diabetes if they had reverted to normal glucose regulation at least once during DPP." The study authors also pointed out that the "reduction in risk applies irrespective of how the reversion was achieved or however transiently."

Study Examines Why Type 2 Diabetes May Remit Following Gastric Bypass.

The Los Angeles Times  (6/21, Mestel) "Boosters Shots" blog reports that research presented at the annual meeting of the American Society for Metabolic and Bariatric Surgery examined factors why "people with type 2 diabetes often see their disease completely disappear" within just a few weeks of gastric bypass surgery, well before they lose substantial amounts of weight. After following 139 gastric bypass patients with diabetes for about a year, researchers found that patients whose "diabetes was so severe they were taking insulin" had a lower chance of recovery from diabetes. In addition, patients whose glucose disposition index was just "30% of normal or lower were less likely to recover." Weight before surgery and immediate weight loss following surgery did not seem to factor into whether patients achieved remission from diabetes.

        Seven Years After Weight-Loss Surgery, Many Patients Have Lower Heart Risks. HealthDay  (6/21, Dotinga) reports, "Seven years after they underwent weight-loss surgery, patients as a whole fared better on several measurements of their risk of cardiac problems, a new study finds, and many returned to normal levels." The investigators found that "after seven years, the average patient weight fell from 286 pounds to 205 pounds." Participants' "average cholesterol reading dipped from 184 to 174, LDL cholesterol dropped from 113 to 92, and triglycerides fell from 151 to 87." Additionally, participants had, on average, large declines in C-reactive protein levels. The research was scheduled to be presented at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

Bariatric Surgery May Reduce Risk Of Diabetes-Related Kidney Disease.

HealthDay  (6/21, Preidt) reports, "Weight-loss surgery may reduce the risk of kidney disease in obese people with diabetes," according to a 52-patient study scheduled for presentation at the annual meeting of the American Society for Metabolic & Bariatric Surgery. All 52 patients underwent gastric bypass surgery. Five years later, "nearly 60 percent of the patients who'd had diabetic nephropathy no longer had the condition." What's more, "only 25 percent of those who did not have diabetic nephropathy at the time of surgery eventually developed the condition," which is "about 50 percent less than the occurrence rate in people with diabetes who don't have bariatric surgery." The ABC News  (6/20, Salahi, Reddy) website also mentioned the study.

FDA: Use Of Surgical Clips Contraindicated For Kidney Donor Surgeries.

CNN  (6/21, Bonifield, Cohen) reports that Teleflex surgical clips to close the renal artery during transplant surgery are not considered safe for use during "laparoscopic kidney donor surgeries." Beginning "in 2004, transplant surgeons...began raising concerns about using clips in kidney donors, sending letters to the US Food and Drug Administration and making presentations at transplant conferences and publishing articles in medical journals." While instructions with the clip packaging "state the clips should not be used on kidney donors," such instructions are not typically kept in operating rooms and may be overlooked by surgical teams. Following the death of a patient in 2011, the fifth since 2001, "FDA issued a safety notification reminding surgeons that the clips are contraindicated for kidney donor surgeries."

Bite from lone star tick may trigger allergic reactions to meat.

On its website, ABC News (6/21, Moisse) reports, "There's a new weapon in the war on meat: a tiny tick, whose bite might be spreading meat allergies up the East Coast." According to the story, researchers report that even though a bite from a lone star tick may not seem like much, "saliva that sneaks into the tiny wound may trigger an allergic reaction to meat -- agonizing enough to convert lifelong carnivores into wary vegetarians." The story quotes Dr. Scott Commins, assistant professor of medicine at the University of Virginia in Charlottesville, as saying, "People will eat beef and then anywhere from three to six hours later start having a reaction; anything from hives to full-blown anaphylactic shock."

        CNN (6/21,Smith) notes that the food allergy "reactions vary on a case-by-case basis, sometimes with a patient experiencing a severe reaction and other times nothing at all. Doctors advise that people who are exposed to lone star ticks should be aware of the allergy, especially if they live in the country, where it could take some time to reach a hospital."

        The Huffington Post (6/21) mentions that "the American Academy of Allergy Asthma & Immunology noted on its website that, indeed, having an anaphylactic reaction to red meat that is delayed by several hours seems to be strongly linked with lone star tick bites, citing Commins' 2011 study in the Journal of Allergy and Clinical Immunology." The story also notes that the Centers for Disease Control and Prevention "recommends preventing tick bites by using DEET-containing bug repellant, washing yourself within two hours of coming inside from outdoors, doing a tick check with a mirror, looking for ticks on your gear and pets and avoiding walking in grassy, bushy areas."

Adding Blood Lipid-Related Markers May Add Little To CV Risk Prediction.

MedPage Today  (6/20, Gever) reports, "Only slight improvements in cardiovascular risk prediction were gained by adding more blood lipid-related markers to conventional factors," according to a study  published in the Journal of the American Medical Association. Investigators found that "fewer than 5% of individuals would have their risk classifications changed by including such markers as apolipoprotein A-I, apolipoprotein B, lipoprotein(a), or lipoprotein-associated phospholipase A2 (LpA-PLA2) in gauging the likelihood of major cardiovascular events." In fact, "at best, adding more lipid markers to the risk prediction equation brought 'slight improvement,' the researchers wrote."

        HeartWire  (6/20, Hughes) reports, "In an accompanying editorial  , Dr Scott Grundy (University of Texas Southwestern Medical Center, Dallas) agrees that these apolipoproteins 'do not add much to risk prediction over routine lipid measures.'" Grundy "suggests that the main reason for this is that cardiovascular disease is multifactorial and that apolipoproteins are only one set of factors among many."

People With CKD May Have Same Risk For CHD As Those Who Have Had Heart Attack.

HealthDay  (6/20, Preidt) reports, "People with chronic kidney disease may have the same level of risk for coronary heart disease as people who have previously had a heart attack," according to a study published in The Lancet. Investigators "compared the incidence of heart attacks and death among 1.3 million people in Canada with chronic kidney disease, diabetes, previous heart attack or a combination of these risk factors." The researchers found that "the risk of heart attack among people with chronic kidney disease, diabetes or both was comparable to that of people who previously had a heart attack."

        Forbes  (6/20, Husten) reports that the study authors wrote that CKD should "be added to the list of criteria defining people at highest risk of future coronary events."

Untreated Kidney Failure May Be More Prevalent Among Elderly Adults.

HealthDay  (6/20, Dallas) reports, "Untreated kidney failure is more prevalent among older adults than those who are younger," according to a study  published in the June 20 issue of the Journal of the American Medical Association. "Investigators found adjusted rates of untreated kidney failure were more than five times higher among patients aged 85 years or older than among those aged 18 to 44."

        "This held true across the range of estimated glomerular filtration rate (eGFR)," MedPage Today  (6/20, Neale) reports. The results "suggest that the incidence of advanced kidney disease in the elderly may be substantially underestimated by rates of treated kidney failure alone and that untreated kidney failure may be more common than initiation of renal replacement at older ages," the study authors wrote. An accompanying editorial  observed that the study "highlights a potentially sizable unmeasured burden of untreated kidney failure among older adults."

Hormonal contraception may slightly increase risk of heart attack, stroke.

The Huffington Post (6/14) reports, "A sweeping new Danish study" published in the New England Journal of Medicine "concludes that hormonal contraception increases the risk of heart attack and stroke, but the overall risk for individual women is very low."

        On its website, ABC News (6/14, Mahand) reports, "In the study, researchers looked at more than 1.6 million women over a period of 15 years and tracked all the contraceptive measures they took -- including the pill, the vaginal ring, intrauterine device, subcutaneous implants, skin patches and intramuscular injections." The investigators "found...that although the absolute risk of stroke and heart attacks associated with the use of contraception was low, the chances of these problems occurring was 0.9 to 1.7 times higher on estrogen at a low dose. These risks increased to a factor of 1.3 to 2.3 when a higher dose of estrogen was used."

        The Boston Globe (6/14, Kotz) "Daily Dose" blog reports that "in absolute terms the risk is very low, because young women under age 50 rarely have heart attacks or strokes."

        MedPage Today (6/14, Neale) reports, "Among other types of hormonal contraception, the vaginal ring was associated with a greater risk of thrombotic stroke (RR 2.5, 95% CI 1.4 to 4.4), but not MI. Progestin-only contraceptives and subcutaneous implants were not associated with increased risks of stroke or MI."

        WebMD (6/14, Boyles) reports, "In an editorial published with the study, Arizona State University researcher Diana B. Petitti, MD, MPH, writes that the Danish study should reassure women and their doctors about the safety of oral contraceptives." Petitti "notes that the small increase in risk could perhaps be eliminated if women with risk factors for heart attack and stroke, such as smokers and those with high blood pressure, avoided combination hormonal contraceptives." Also covering the story are Reuters (6/14, Emery), HeartWire (6/14, Nainggolan), and HealthDay (6/14, Salamon).

Study associates saturated milk fats with IBD.

Bloomberg News (6/14, Ostrow) reports that in mice, "diets high in saturated milk fats, found in processed foods and sweets, may increase the risk of developing immune disorders like inflammatory bowel disease (IBD) in those who are genetically predisposed," according to a study published online June 13 in the journal Nature. "About 60 percent of mice fed a diet high in saturated milk fats developed ulcerative colitis, an autoimmune inflammatory bowel disease, within six months, compared with about 25 to 30 percent of the animals who ate a low-fat diet or one high in polyunsaturated fats such as safflower oil," the study found. What's more, "the severity and extent of the colitis was much greater in the mice fed milk fats than those fed low-fat diets," researchers reported.

        "The University of Chicago researchers said their findings help explain why once rare immune-system-related disorders such as inflammatory bowel disease have become more common in the United States and other Westernized nations in the last half-century," HealthDay (6/14, Preidt) reports. Investigators "said their study may shed some light on why many people who are genetically prone to the condition still don't develop it and how certain environmental factors can cause inflammation in those at risk. Scientists note, however, that research with animals often fails to provide similar results in humans."

New Pop Warner football rules seek to limit contact allowed in practice.

In a front-page story, the New York Times (6/14, A1, O'Connor, Subscription Publication) reports, "In response to growing concerns over head injuries in football, Pop Warner, the nation's largest youth football organization, announced rule changes on Wednesday that will limit the amount of full-speed collisions and other contact allowed in practice." The problem "of brain injuries sustained on the football field has forced a reckoning at all levels of the sport in recent years." These "new rules, which will affect hundreds of thousands of youth football players, some as young as five years old, were seen as the latest acknowledgment that the nation's most popular sport poses dangers to the long-term cognitive health of its athletes."

        The Chicago Tribune (6/14, Smith) reports that Pop Warner coaches will now "only be allowed to have full-speed hitting -- including one-on-one blocking and tackling, contact between linemen and scrimmages -- for one-third of their weekly practice time." In the past, "there were no restrictions on contact time. Also barred are any head-to-head, full-speed blocking or tackling drills in which players start more than three yards apart."

        Bloomberg BusinessWeek (6/14, Matuszewski) reports, "Pop Warner said it's the first youth organization to limit contact in practice."

        The AP (6/14) reports, "Some parents have voiced worry about letting their children play football, and the National Sporting Goods Association and the National Federation of State High School Associations have each recorded very slight declines in participation in recent years -- though doctors are reluctant to declare the changes a trend just yet."

        The USA Today (6/14, Cherner) "Game On" blog points out that "the NFL is currently wrestling with the issue of blows to the head and facing lawsuits by thousands of retired players." The CNN (6/14, Kounang) "The Chart" blog also covers the story.

Report: Vein Grown From Patient's Own Stem Cells Successfully Transplanted.

Bloomberg BusinessWeek  (6/14, Kitamura) reports, "The first vein grown from a patient's own stem cells was successfully transplanted into a 10-year-old girl, potentially offering a way for those lacking healthy veins to undergo dialysis or heart bypass surgery." The girl "had a blockage in the vein that carries blood from the spleen and intestines to the liver." Physicians "took a 9-centimeter (3.5-inch) segment of vein from a human donor and removed all living cells, the Swedish researchers wrote in a study  in The Lancet."

        The AP  (6/14, Cheng) reports, "Using stem cells from the girl's bone marrow, scientists grew millions of cells to cover the vein, a process that took about two weeks. The new blood vessel was then transplanted into the patient." Since "the procedure used her own cells, the girl did not have to take any drugs to stop her immune system from attacking the new vein, as is usually the case in transplants involving donor tissue."

        On its website, ABC News  (6/14, Gann) reports, "While a handful of doctors around the world have had success growing blood vessels and other organs and transplanting them into patients, doctors said this is the first time a vein has been lab-grown and successfully transplanted using cells and parts taken entirely from the human body."

        The UK's Telegraph  (6/14, Adams) reports that the study "authors wrote that she had grown two inches and put on 11 pounds in weight since the first operation a year ago."

        MedPage Today  (6/14, Phend) reports that in an accompanying editorial  , Martin Birchall, MD, and George Hamilton, MD, both of University College London, contend that "the procedure is too long and complicated to ultimately succeed in the healthcare market or to be practical for larger numbers of patients." Although "promising, they wrote, 'one-off experiences such as the procedure they describe need to be converted into full clinical trials in key target populations, and delivered via straightforward, quality-controlled production processes if regenerative medicine solutions are to become widely used and accepted.'" Also covering the story are the UK's Press Association  (6/14), BBC News  (6/14, Gallagher), and Reuters  (6/14, Hirschler).