High-Density Lipoprotein Cholesterol and the Risk of Myocardial Infarction, Stroke, and Cause-Specific Mortality: a Nationwide Cohort Study in Korea

Objective@#We aimed to investigate the relationship between high-density lipoprotein cholesterol (HDL-C) level and the risk of myocardial infarction (MI), stroke, and causespecific mortality. @*Methods@#Using the Korean National Health Insurance Service-National Sample Cohort, we identified 343,687 subjects (men, 176,243; women, 167,444) aged ≥20 years who underwent health examinations between 2009 and 2012. HDL-C levels were categorized based on the concentration with 10 mg/dL intervals, starting from levels <30 mg/dL, with levels ≥90 mg/ dL considered the highest. The endpoints of the study were newly-diagnosed MI, stroke, or mortality. We used the Cox proportional hazards model with restricted cubic splines. @*Results@#During a median follow-up of 6.0 years, the number of cases of death, MI, and stroke were 6,617, 4,064, and 3,435 in men and 3,677, 2,804, and 2,891 in women, respectively. The risk of all-cause mortality, cancer mortality, other mortality, and stroke was the lowest at HDL-C concentrations of 57–76 mg/dL in the spline curves; inverse associations with increased risk were observed at the lower HDL-C levels. In contrast, the lowest risk of cardiovascular mortality and MI was observed at the extreme high end. In men, there was a significant inverse and graded increase in hazard ratios of all outcomes in the lower HDL-C categories compared to the reference group (50–59 mg/dL). In the higher HDL-C categories, no significant increase in outcomes was observed. Women showed similar trends. @*Conclusion@#The risk of mortality, MI, and stroke was high at low HDL-C levels in the Korean general population. However, extremely high HDL-C levels were not associated with an increased risk of mortality, MI, and stroke.

Clinical Effects of Remote Glucose Monitoring and Patient-Centered Education Platform for Patients with Diabetes / 임상당뇨병

With development of the internet and smartphones, various systems have been introduced to monitor patient blood sugar remotely, and their clinical effect on diabetes management has been analyzed in different patient groups. However, these systems need to be available cost-effectively to many patients for the long term. Also, there is need for a communication platform that can easily identify a patient's blood sugar pattern and provide appropriate counseling and education. In addition, relevant educational contents must be provided so that patients maintain self-care for diabetes. With the rapid increase in diabetes patients, we must continuously develop the field of digital healthcare to efficiently monitor blood sugar and provide effective face-to-face management of these patients.

Clinical Effects of Remote Glucose Monitoring and Patient-Centered Education Platform for Patients with Diabetes / 임상당뇨병

With development of the internet and smartphones, various systems have been introduced to monitor patient blood sugar remotely, and their clinical effect on diabetes management has been analyzed in different patient groups. However, these systems need to be available cost-effectively to many patients for the long term. Also, there is need for a communication platform that can easily identify a patient's blood sugar pattern and provide appropriate counseling and education. In addition, relevant educational contents must be provided so that patients maintain self-care for diabetes. With the rapid increase in diabetes patients, we must continuously develop the field of digital healthcare to efficiently monitor blood sugar and provide effective face-to-face management of these patients.

Cardiovascular Autonomic Neuropathy Predicts Higher HbA1c Variability in Subjects with Type 2 Diabetes Mellitus

BACKGROUND: This study aimed to investigate the association between the presence and severity of cardiovascular autonomic neuropathy (CAN) and development of long-term glucose fluctuation in subjects with type 2 diabetes mellitus. METHODS: In this retrospective cohort study, subjects with type 2 diabetes mellitus who received cardiovascular autonomic reflex tests (CARTs) at baseline and at least 4-year of follow-up with ≥6 measures of glycosylated hemoglobin (HbA1c) were included. The severity of CAN was categorized as normal, early, or severe CAN according to the CARTs score. HbA1c variability was measured as the standard deviation (SD), coefficient of variation, and adjusted SD of serial HbA1c measurements. RESULTS: A total of 681 subjects were analyzed (294 normal, 318 early, and 69 severe CAN). The HbA1c variability index values showed a positive relationship with the severity of CAN. Multivariable logistic regression analysis showed that CAN was significantly associated with the risk of developing higher HbA1c variability (SD) after adjusting for age, sex, body mass index, diabetes duration, mean HbA1c, heart rate, glomerular filtration rate, diabetic retinopathy, coronary artery disease, insulin use, and anti-hypertensive medication (early CAN: odds ratio [OR], 1.65; 95% confidence interval [CI], 1.12 to 2.43) (severe CAN: OR, 2.86; 95% CI, 1.47 to 5.56). This association was more prominent in subjects who had a longer duration of diabetes (>10 years) and lower mean HbA1c ( < 7%). CONCLUSION: CAN is an independent risk factor for future higher HbA1c variability in subjects with type 2 diabetes mellitus. Tailored therapy for stabilizing glucose fluctuation should be emphasized in subjects with CAN.

Reduction of Sulfonylurea with the Initiation of Basal Insulin in Patients with Inadequately Controlled Type 2 Diabetes Mellitus Undergoing Long-Term Sulfonylurea-Based Treatment

BACKGROUND: There were a limited number of studies about β-cell function after insulin initiation in patients exposed to long durations of sulfonylurea treatment. In this study, we aimed to evaluate the recovery of β-cell function and the efficacy of concurrent sulfonylurea use after the start of long-acting insulin. METHODS: In this randomized controlled study, patients with type 2 diabetes mellitus (T2DM), receiving sulfonylurea for at least 2 years with glycosylated hemoglobin (HbA1c) >7%, were randomly assigned to two groups: sulfonylurea maintenance (SM) and sulfonylurea reduction (SR). Following a 75-g oral glucose tolerance test (OGTT), we administered long-acting basal insulin to the two groups. After a 6-month follow-up, we repeated the OGTT. RESULTS: Among 69 enrolled patients, 57 completed the study and were analyzed: 31 in the SM and 26 in the SR group. At baseline, there was no significant difference except for the longer duration of diabetes and lower triglycerides in the SR group. After 6 months, the HbA1c was similarly reduced in both groups, but there was little difference in the insulin dose. In addition, insulin secretion during OGTT was significantly increased by 20% to 30% in both groups. A significant weight gain was observed in the SM group only. The insulinogenic index was more significantly improved in the SR group. CONCLUSION: Long-acting basal insulin replacement could improve the glycemic status and restore β-cell function in the T2DM patients undergoing sulfonylurea-based treatment, irrespective of the sulfonylurea dose reduction. The dose reduction of the concurrent sulfonylurea might be beneficial with regard to weight grain.

New Technology for Type 1 Diabetes / 임상당뇨병

Type 1 diabetes is an autoimmune disease with insulin deficiency which causes microvascular complications such as retinopathy, nephropathy and neuropathy. There have been some trials to simulate the pancreatic endocrine function of insulin and glucagon for homeostatic equilibration of blood glucose, developing artificial pancreas. There are three major functional components of the modern artificial pancreas, a continuous glucose-monitoring system, an insulin-infusion pump and a control algorithm. There are commercially available continuous glucose monitoring systems with subcutaneous glucose measuring, however, there have been many attempts to develop more efficient glucose monitoring systems, including noninvasive systems. Thanks to technological advances and the miniaturization of electronics, recent advances in the accuracy and performance of these systems have placed research on the threshold of prototype commercial devices and large-scale outpatient feasibility studies. In addition, smartphone technology has created the opportunity for caregivers to receive push notification alerts and makes it possible to provide patients with advisory or decision-support systems. Even though there are still some remaining challenges to develop a successful artificial pancreas, glucose control in type 1 diabetes will be more efficient with its advent.

Refractory Graves' Disease Successfully Cured by Adjunctive Cholestyramine and Subsequent Total Thyroidectomy

The three major forms of treatment for Graves thyrotoxicosis are antithyroid drugs, radioactive iodine therapy and thyroidectomy. Surgery is the definitive treatment for Graves thyrotoxicosis that is generally recommended when other treatments have failed or are contraindicated. Generally, thyrotoxic patients should be euthyroid before surgery to minimize potential complications which usually requires preoperative management with thionamides or inorganic iodine. But several cases of refractory Graves' disease have shown resistance to conventional treatment. Here we report a 40-year-old female patient with Graves' disease who complained of thyrotoxic symptoms for 7 months. Her thyroid function test and thyroid autoantibody profiles were consistent with Graves' disease. One kind of thionamides and beta-blocker were started to control her disease. However, she was resistant to nearly all conventional medical therapies, including beta-blockers, inorganic iodine, and two thionamides. She experienced hepatotoxicity from the thionamides. What was worse is her past history of serious allergic reaction to corticosteroids, which are often used to help control symptoms. A 2-week regimen of high-dose cholestyramine improved her uncontrolled thyrotoxicosis and subsequent thyroidectomy was successfully performed. In conclusion, cholestyramine could be administered as an effective and safe adjunctive agent for preoperative preparation in patients with severe hyperthyroid Graves's disease that is resistant to conventional therapies.