Association Between Sustained Glycated Hemoglobin Control and Healthcare Costs.

OBJECTIVE: To examine the relationship between sustained glycemic control and health care costs among patients with diabetes with an initial hemoglobin A1c≥9%. STUDY DESIGN/METHODS: We conducted a retrospective analysis of administrative data from patients with diabetes and initial poor HbA1c control enrolled in a large health plan in Hawai'i (n=1304). We used propensity scores to identify a comparable cohort based on age, gender, type of coverage, diabetes duration, number of medications, location of residence, comorbidity conditions, and morbidity level. We examined the relationship between reduced A1c values and costs in the same year as well as the impact of achieving sustained A1c control (at < 7%)for three years on changes in health care costs using generalized linear models. RESULTS: In cross-sectional comparisons, the average annual direct medical costs for patients withHbA1c less than 7% was $14,821 compared to $12,108 for the matched sample of patients with A1c greater than or equal to 7%, for a difference of $2,713 95%CI[$285, $5,140]. In contrast, when we examined the change in cost from 2006 to 2009 for patients who had sustained levels of A1c at <7% for all three years, we found that total cost care for patients with sustained control decreased by $2,207 compared to a $3,006 increase for patients without sustained control, for a difference of -$5,214, 95%CI[-$10,163, -$264]. CONCLUSION: Our study suggests that while reducing hemoglobin A1c levels to target goals may not immediately result in cost reductions, sustained A1c control were associated with lower costs in a three-year time frame.

Technetium-99m-ECD SPECT in antiphospholipid antibody syndrome: a drastic improvement in brain perfusion by antiplatelet therapy.

We present a case of antiphospholipid antibody syndrome (APS) with repeated transient ischemic attacks (TIAs). Magnetic resonance imaging showed multiple cerebral infarcts and ischemic changes in the cerebral white matter. Cerebral angiographies showed no abnormalities. Technetium-99m-ethyl cysteinate dimer (Tc-99m-ECD) brain SPECT showed multiple decreased perfusion areas, which were more extensive than the lesions demonstrated on MRI. After treatment with an antiplatelet agent, the patient subsequently recovered from the TIAs. Although no interval changes were observed by MRI after therapy, follow-up Tc-99m-ECD SPECT revealed a marked improvement in brain perfusion. This is the first imaging report of remarkable post-therapy improvement in brain perfusion in APS cases.

Hydrogen peroxide and hydroxyl radical involvement in the activation of caspase-3 in chemically induced apoptosis of HL-60 cells.

Apoptosis of HL-60 cells induced by actinomycin D, H7, or daunorubicin was shown to involve the activation of caspase-3-like protease, 2 h after the addition of these drugs, based on microassay of enzyme activity by high-performance liquid chromatography. Catalase and a spin trap, N-t-butyl-alpha-phenylnitrone, which effectively inhibited the apoptosis induced by these drugs, also inhibited the activation of caspase-3-like protease. These results suggest that hydrogen peroxide and the hydroxyl radical are common mediators of caspase-3 activation caused by these chemicals, with apparently different functional mechanisms. Based on mitochondrial activity determined by oxygen consumption, complexes I, II, and IV were inhibited by actinomycin D. H7 inhibited complexes I and IV, 1 and 1.5 h respectively, after the addition of the drug to HL-60 cells. Daunorubicin inhibited complex IV, 1.5 h after the addition of the drug to HL-60 cells. Inhibition of complex IV by actinomycin D, H7, and daunorubicin were almost fully restored by the addition of cytochrome c. The release to the cytosol of cytochrome c by these drugs was also demonstrated by Western blot analysis. Addition of catalase inhibited the depression of complex IV activity induced by actinomycin D and H7. These observations indicate a direct relationship between hydrogen peroxide and the release of cytochrome c during apoptosis caused by actinomycin D, H7, and daunorubicin.

Ectodomain shedding of epidermal growth factor receptor ligands is required for keratinocyte migration in cutaneous wound healing.

Keratinocyte proliferation and migration are essential to cutaneous wound healing and are, in part, mediated in an autocrine fashion by epidermal growth factor receptor (EGFR)-ligand interactions. EGFR ligands are initially synthesized as membrane-anchored forms, but can be processed and shed as soluble forms. We provide evidence here that wound stimuli induce keratinocyte shedding of EGFR ligands in vitro, particularly the ligand heparin-binding EGF-like growth factor (HB-EGF). The resulting soluble ligands stimulated transient activation of EGFR. OSU8-1, an inhibitor of EGFR ligand shedding, abrogated the wound-induced activation of EGFR and caused suppression of keratinocyte migration in vitro. Soluble EGFR-immunoglobulin G-Fcgamma fusion protein, which is able to neutralize all EGFR ligands, also suppressed keratinocyte migration in vitro. The application of OSU8-1 to wound sites in mice greatly retarded reepithelialization as the result of a failure in keratinocyte migration, but this effect could be overcome if recombinant soluble HB-EGF was added along with OSU8-1. These findings indicate that the shedding of EGFR ligands represents a critical event in keratinocyte migration, and suggest their possible use as an effective clinical treatment in the early phases of wound healing.

Epiregulin, a novel member of the epidermal growth factor family, is an autocrine growth factor in normal human keratinocytes.

Epiregulin is a new member of the epidermal growth factor (EGF) family purified from conditioned medium of NIH-3T3 clone T7. Some EGF family growth factors play essential roles in human keratinocytes in an autocrine manner. We show here that epiregulin is another autocrine growth factor for human keratinocytes. Epiregulin stimulated human keratinocyte proliferation under both subconfluent and confluent culture conditions in the absence of exogenous EGF family growth factors. Immunoprecipitation of [(35)S]methionine-labeled conditioned medium revealed a 5-kDa band corresponding to epiregulin. Northern blot analysis detected a 4. 8-kilobase transcript of epiregulin, and the addition of epiregulin up-regulated epiregulin mRNA synthesis. Furthermore, an anti-epiregulin blocking antibody reduced DNA synthesis by 25%. Epiregulin up-regulated the mRNA levels of heparin-binding EGF-like growth factor (HB-EGF), amphiregulin, and TGF-alpha. In turn, the addition of EGF, HB-EGF, amphiregulin, and TGF-alpha increased epiregulin mRNA levels. These results demonstrate that epiregulin acts as an autocrine growth factor in human epidermal keratinocytes and is part of auto- and cross-induction mechanisms involving HB-EGF, amphiregulin, and TGF-alpha. The mRNA expression profile resulting from induction of differentiation with high calcium and fetal calf serum revealed the differential expression of epiregulin, HB-EGF, amphiregulin, and TGF-alpha in keratinocytes. This indicates that these four growth factors have distinct, non-redundant biological functions.

Evaluation of oxidative stress based on lipid hydroperoxide, vitamin C and vitamin E during apoptosis and necrosis caused by thioacetamide in rat liver.

After 12 h of thioacetamide (500 mg/kg body weight) administration to rats, the activity of caspase-3-like protease in the liver increased significantly compared to that in the control group. In plasma, the activity of caspase-3 was barely detectable in the control rat, but had increased significantly after 24 h of drug administration along with a dramatic increase in GOT. These results indicate that thioacetamide causes apoptosis in the liver by activating caspase-3, which is released to plasma by successive necrosis. At 24 h, the concentration of liver lipid hydroperoxides, a mediator of radical reaction, was 2.2 times as high as that of control rats. After 12 and 24 h of thioacetamide administration, the liver concentrations of vitamins C and E decreased significantly. The decrease of antioxidants and formation of lipid hydroperoxides 24 h after thioacetamide administration support the view that extensive radical reactions occur in the liver during the necrotic process.

Age-dependent changes in lipid peroxide levels in peripheral organs, but not in brain, in senescence-accelerated mice.

The tissue concentration of lipid peroxides was determined in the brain, heart, liver, lung and kidney of accelerated senescence-prone (SAMP-8) and -resistant (SAMR-1) mice at 3, 6 and 9 months of age by a method involving chemical derivatization and high performance liquid chromatography. The level of lipid peroxides in the brain did not show an age-dependent change, but at each age the brain level of lipid peroxides was significantly higher in SAMP-8 than in SAMR-1. In contrast, the lipid peroxide levels in the peripheral organs showed increases with aging in both strains, and they were significantly higher in SAMP-8 than in SAMR-1 at both 3 and 6 months of age (except at 3 months of age in the kidney). These results suggest that increased oxidative stress in the brain and peripheral organs is a cause of the senescence-related degeneration and impairments seen in SAMP-8.

[Oxidative stress and vitamins].

The importance of specific determination of key molecules involved in radical reaction is discussed in the evaluation of oxidative stress in animal tissues. As an effective index of oxidative stress, the concentration of lipid hydroperoxides, which is determined by a specific and sensitive method developed by the authors, is discussed firstly. The efficiency of the indicator is demonstrated by several results that it increases in tissues of aged, vitamin C-deficient, vitamin E-deficient, iron-overloaded, or streptozotocin-induced diabetic rats. The other indicator, tissue vitamin C, which is also determined by a specific and sensitive method developed by the authors, is discussed. Based on the method, the profile of vitamin C decrease in tissues of ODS rats, which cannot synthesize the vitamin inherently, was determined and the in vivo interaction between vitamin C and vitamin E was demonstrated for the first time. The roles of oxidative stress in diabetes mellitus, atherosclerosis, and cell death (necrosis and apoptosis) were also discussed.

Involvement of hydrogen peroxide and hydroxyl radical in chemically induced apoptosis of HL-60 cells.

Effects of three kinds of antagonists against reactive oxygen species were evaluated at the same time in chemically induced apoptosis of human leukemic HL-60 cells. Apoptosis of HL-60 cells induced by actinomycin D, H7, 1-beta-D-arabinofuranosylcytosine, and daunorubicin was inhibited significantly by radical scavengers (vitamin E, N-acetyl-L-cysteine, and mercaptoethanol), catalase, and a spin trap, N-t-butyl-alpha-phenylnitrone. These results suggest that hydrogen peroxide and hydroxyl radical are common mediators of apoptosis caused by these chemicals with apparently different functional mechanisms. The consumption of vitamin E to inhibit apoptosis induced by actinomycin D was undetectable, suggesting that the generation of reactive oxygen species during apoptosis was not very extensive. Radicals were suggested to be a mediator of apoptosis of HL-60 cells induced by cisplatin based on the observations that the above inhibitors, except catalase, effectively inhibited apoptosis by the drug.

Change in tissue concentrations of lipid hydroperoxides, vitamin C and vitamin E in rats with streptozotocin-induced diabetes.

The tissue concentration of lipid hydroperoxides, which was determined by a specific method involving chemical derivatization and HPLC, increased significantly in the heart, liver, kidney and muscle of diabetic rats 8 weeks after the intraperitoneal injection of streptozotocin compared with that of the control group. These results demonstrate that an enhanced oxidative stress is caused in these tissues by diabetes. Vitamin C concentrations of the brain, heart, lung, liver, kidney and plasma of the diabetic rats decreased significantly after 8 weeks compared with those of the control group. Vitamin E concentrations of the brain, heart, liver, kidney, muscle and plasma of the diabetic rats increased significantly after 4 weeks compared with the control group. After 8 weeks, an elevation in vitamin E concentration was observed in the heart, liver, muscle and plasma of the diabetic rats.

Facile degradation of apolipoprotein B by radical reactions and the presence of cleaved proteins in serum.

A facile cleavage of peptide bonds of apolipoprotein B (apoB) by radical reaction is reported. When human LDL was subjected to oxidative damage using Cu2+, extensive degradation of apoB was observed based on immunoblotting. The degradation of apoB was inhibited by radical scavengers (beta-mercaptoethanol, butylated hydroxytoluene, and probucol) and promoted by a radical initiator [2, 2'-azobis(2-amidinopropane)dihydrochloride]. When human serum was treated with Cu2+, a similar cleavage pattern of apoB was observed. The cleaved apoB proteins were also detected in normal serum on the basis of immunoblots. These results suggest that apoB is highly reactive toward radicals in vitro and in vivo, with reaction resulting in the cleavage of peptide bonds.

Changes in the level of sialic acid in plasma, brain and liver of inherently scorbutic rats during vitamin C and E deficiencies.

The plasma level of sialic acid (NeuAc) in inherently scorbutic [Osteogenic Disorder Shionogi (ODS)] rats was increased by 21 days of vitamin C deficiency. The brain content of NeuAc was decreased by deficiencies of these vitamins. The NeuAc level in the liver was not affected significantly by these deficiencies.

Increase of lipid hydroperoxides in the rat liver and kidney after administering ferric nitrilotriacetate.

Two hours after an intraperitoneal injection of ferric nitrilotriacetate to rats at a dose of 15 mg of Fe/kg of body weight, the level of lipid hydroperoxides, which was determined by a specific method involving chemical conversion into 1-naphthyldiphenylphosphine oxide and HPLC, had increased significantly in the liver (from 190.1 +/- 58.8 of the control to 467.1 +/- 175.8 pmol/mg of protein) and kidney (from 181.8 +/- 52.3 of the control to 405.9 +/- 22.7 pmol/mg of protein). These results demonstrate that oxidative stress was transiently increased by an iron overload in these tissues.

Increase of lipid hydroperoxides in liver mitochondria and inhibition of cytochrome oxidase by carbon tetrachloride intoxication in rats.

The cellular localization of lipid hydroperoxides was determined for the first time in mitochondria, microsomes and cytosol of rat liver using a specific method involving chemical derivatization and HPLC. Mitochondria contained the highest level of hydroperoxides. After 6h of intragastric administration of carbon tetrachloride (CCl4) to rats (2 ml/kg body weight), the concentration of lipid hydroperoxides increased significantly in liver mitochondria and cytochrome oxidase activity was inhibited to 35% of the control rats. The mitochondrial content of haem a decreased to 60% of the control at 12h of CCl4 administration. In vitro reaction of mitochondria with CCl4 caused inactivation of cytochrome oxidase. These observations suggested that cytochrome oxidase and haem a in mitochondria were targets of CCl4.

Interactions between vitamin C and vitamin E are observed in tissues of inherently scorbutic rats.

To investigate in vivo interactions between antioxidant vitamins C and E, sparing effects of vitamin C on vitamin E as well as those of vitamin E on vitamin C were evaluated using inherently scorbutic [Osteogenic Disorder Shionogi (ODS)] rats. Rats were divided into four groups (control, vitamin E-deficient, vitamin C-deficient and simultaneously vitamins C and E-deficient). The levels of vitamins C and E in tissues were determined at 0, 14 and 21 d of deficiency. On d 14, the vitamin E concentration in plasma, liver, brain and lung of the vitamin C-deficient group was significantly lower than that of the control, in agreement with the literature concerning the sparing of vitamin E by ascorbate. The vitamin E concentration of the vitamin C-deficient group also was significantly lower in plasma, heart, liver, lung and kidney than that of the control group on d 21. On the basis of two-way ANOVA, significant interactions between vitamins C and E were observed on d 21 for vitamin E concentration in these tissues. The ascorbate level in plasma, heart, liver, muscle and kidney of the vitamin E-deficient group was significantly lower than that of the corresponding control group on d 21. Significant interactions between vitamins C and E were observed on d 21 for vitamin C concentration in these tissues. These results suggest a sparing effect of vitamin E on vitamin C, an effect that was observed for the first time in this study. These results suggest that the interaction between vitamins C and E exists in vivo and that the extent of the interaction depends on the tissue. Thiobarbituric acid reactive substances (TBARS) in plasma and liver of the vitamin C-deficient rats were significantly higher than those of the control and the vitamin E-deficient groups on d 21, suggesting that the deficiency of vitamin C caused a larger increase in oxidative stress than the deficiency of vitamin E. TBARS of the liver in rats deficient in both vitamins C and E were significantly higher than those in all other groups, suggesting an additive effect of the deficiencies of vitamins C and E on hepatic TBARS. These data suggest that in vivo, vitamins E and C interact, and each can exert sparing effects in the absence of the other.

Possible involvement of radical reactions in desialylation of LDL.

The role of oxidatively modified LDL in the pathogenesis of atherosclerosis has been well documented. These studies have focused on modifications of lipid and protein parts of LDL. Recently desialylated LDL has received attention in relation to atherosclerosis and coronary artery disease. We examined the possible involvement of radical reactions in desialylation of LDL. Human LDL was subjected to oxidative damage using Cu2+ ion. As the conjugated dienes monitored by absorption at 234 nm increased, the content of sialic acid decreased steadily. Both the elevation of conjugated diene and the decrease of sialic acid were inhibited by beta-mercaptoethanol, a typical radical scavenger. Besides, both butylated hydroxytoluene and a nitrogen atmosphere inhibited the decrease of sialic acid. These inhibition experiments suggested that sialic acid moieties in LDL were reactive toward radicals.

Increase of lipid hydroperoxides in tissues of vitamin E-deficient rats.

The level of lipid hydroperoxides was determined by a newly developed method in rat tissues of vitamin E deficiency, which was a good in vivo model of enhanced radical reactions. In the heart, lung and kidney, the level of lipid hydroperoxides increased significantly as early as 4 weeks after feeding on a tocopherol-deficient diet compared with that of the control group. After 8 weeks of the deficiency, similar results were obtained. These results indicate that the lipid hydroperoxide is available as an extremely sensitive indicator of lipid peroxidation in these organs, because it takes several months to detect manifestations of the vitamin deficiency based on conventional indices.