Fatty liver and atherogenic dyslipidemia have opposite effects on diabetic micro- and macrovascular disease.

BACKGROUND AND AIMS: Non-alcoholic fatty liver (FL) is comorbid with obesity, metabolic syndrome and type 2 diabetes. Atherogenic dyslipidaemia (AD), frequent in FL, is associated with risk of micro- and macrovascular complications. Given the paradoxical ocular protection of FL in T2DM, we studied how FL modulates micro- and macrovascular complications as a function of AD. METHODS: Cross-sectional factorial analysis of 744 diabetic patients in whom FL, identified by ultrasonography, was present in 68%. AD, defined by low HDL-C plus elevated TG, was present in 45%. Four groups were analysed as regards cardiometabolic features, micro-/macroangiopathies, cataract and ocular hypertonia: FL[-]AD[-] (n = 171); FL[-]AD[+] (n = 66); FL[+]AD[-] (n = 235); and FL[+]AD[+] (n = 272). RESULTS: Age, gender and glycemic control were similar across groups. Prevalence of overall macroangiopathy and coronary artery disease were higher in patients with AD, irrespective of FL. Overall macroangiopathy was higher, by 64% in FL[-]AD[+] and by 38% in FL[+]AD[+]. Coronary artery disease was higher, by 128%, in FL[-]AD[+], and by 67%, in FL[+]AD[+]. (Micro)albuminuria was more frequent (+55%) in FL[-] AD[+] compared to FL[-] AD[-]. Retinopathy prevalence was 35% in FL[-], unaffected by AD. Retinopathy frequency was much lower in FL[+], irrespective of AD, decreased by -47% in FL[+]AD[-] and -32% in FL[+]AD[+] (vs. FL[-]AD[-]). Ocular hypertonia was present in 13%, and its prevalence was also markedly lower (-31%) in FL[+]. Cataract frequency was 29%, also lesser in FL[+] (24% vs. 39%), irrespective of AD. CONCLUSIONS: Multi-level eye protection in diabetes is linked to non-alcoholic fatty liver independently of atherogenic dyslipidemia.

Psychosocial functioning and health related quality of life in children, adolescents and young adults with type 1 diabetes mellitus in Congo.

OBJECTIVES: To describe the psychosocial functioning and assess the quality of life of children, adolescents and young adults with T1DM; and to identify the risk factors associated with the psychosocial experience and quality of life of these patients. MATERIAL AND METHODS: A cross-sectional, descriptive study of children, adolescents and young adults with type 1 diabetes. Symptoms of anxiety and depression, and the quality of life were assessed using the Beck's Anxiety and Depression Scales and the pedsQL diabetes module score respectively. RESULTS: A total of 74 patients were recruited. The mean age was 18 ± 4.1 years. Minimal symptoms of anxiety were noted in 51 (69%) patients, 23 (31%) had non-minimal symptoms of anxiety (mild:14, moderate: 5, severe: 4). Symptoms of depression were absent in 43 (58.1%) patients and present in 31 (41.9%) patients (mild: 19, moderate: 12). The patients total score of quality of life was 65.4. Higher socioeconomic status (p = 0.03) was a protective factor against Symptoms of anxiety, while the age above 14 years (p = 0.01) was a risk factor for symptoms of depression. The quality of life was lower in patients from low socio-economic status (p = 0.01), those with poor glycemic control (p = 0.03), and when symptoms of depression were present (p = 0.02). CONCLUSIONS: Patients with type 1 diabetes in Congo experienced a significant elevated symptoms of anxiety and depression, and a fairly good quality of life. These findings support recommendations for integrating psychosocial aspects in the management of these patients.

Rates of untreated, treated, and controlled hypertension and relationships between blood pressure with other cardiovascular risk factors in Brazzaville (Republic of the Congo): May Measurement Month 2017-Sub-Saharan Africa.

Hypertension (HT) is a growing burden worldwide, leading to over 10 million deaths each year. In Brazzaville, the prevalence of HT was 32.5% in 2004. The mortality for stroke in 2008 and heart failure in 2013 were, respectively, 24% and 20.2%. May Measurement Month (MMM) is a global initiative initiated by the International Society of Hypertension aimed at raising awareness of HT and to act as a temporary solution to the lack of screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. Blood pressure (BP) measurement, the definition of HT and statistical analysis followed the standard MMM protocol. The screening was carried out in Brazzaville, and the screening sites were distributed in different districts of the city in public places and health facilities. A total of 3842 individuals were screened during MMM17. After multiple imputations, 1576 (41.0%) had HT. About 956 (29.7%) individuals not receiving anti-hypertensive medication, were hypertensive. Four hundred and nine (66.0%) individuals receiving anti-hypertensive medication, had uncontrolled BP. Systolic and diastolic BPs after adjustment for age and sex differed significantly in association with use of anti-hypertensive medication (P < 0.0001), previous stroke (P = 0.001 for systolic), and waist circumference (P < 0.0001). MMM17 was the largest BP screening campaign undertaken in Congo. Almost one-third of screenees had untreated HT, and two-thirds of treated hypertensives were not well controlled. These results suggest that opportunistic screening can identify significant numbers with raised BP.

[Real-time tele-training for obstetrical ultrasonography in Congo Brazzaville]. / Télémédecine au Congo Brazzaville : formation continue à l'échographie obstétricale par supervision en direct.

The Republic of Congo is facing a shortage of specialists and an unequal distribution of healthcare professionals between urban and rural areas, limiting access to diagnostic ultrasonography. Besides other issues this project aims at establishing the feasibility of remote training by live teleconsultation in obstetrical ultrasonography, as a mechanism to support isolated care by untrained staff. The project includes abdominal ultrasound testing for women during all stages of pregnancy. The first results have shown that the transmission of dynamic images, at a low cost internet connection, offers the possibility of distance training of peripheral health professionals, with the real-time remote support of gynecologists.

La République du Congo fait face à une pénurie de spécialistes et leur répartition est inégale entre la capitale et les zones périphériques. La précarité financière des femmes enceintes et les difficultés logistiques engendrées par un déplacement à la capitale constituent un frein au suivi médical de la grossesse. Ce projet démontre la faisabilité d'une formation à distance à l'échographie obstétricale de professionnels de la santé grâce à une téléconsultation en direct par des gynécologues obstétriciens de Brazzaville. Le projet est encore en cours et les premiers résultats sur le terrain sont très encourageants et en démontrent la pertinence. En effet, la transmission d'images dynamiques permet à ce jour de former des professionnels de santé de périphérie en leur assurant un soutien en temps réel dans la prise en charge des patientes, grâce à des connexions internet à bas coût.

Size, density and cholesterol load of HDL predict microangiopathy, coronary artery disease and ß-cell function in men with T2DM.

The role of high-density lipoprotein cholesterol (HDL-C) as modifiable risk factor for cardiovascular (CV) disease is increasingly debated, notwithstanding the finding that small-dense and dysfunctional HDL are associated with the metabolic syndrome and T2DM. In order to better clarify the epidemiological risk related to HDL of different size/density, without resorting to direct measures, it would seem appropriate to adjust HDL-C to the level of its main apolipoprotein (apoA-I), thereby providing an [HDL-C/apoA-I] ratio. The latter allows not only to estimate an average size for HDLs, but also to derive indices on particle number, cholesterol load, and density. So far, the potential usefulness of this ratio in diabetes is barely addressed. To this end, we sorted 488 male patients with T2DM according to [HDL-C/apoA-I] quartiles (Q), to determine how the ratio relates to cardiometabolic risk, ß-cell function, glycaemic control, and micro- and macrovascular complications. Five lipid parameters were derived from the combined determination of HDL-C and apoA-I, namely HDL size; particle number; cholesterol load/particle; apoA-I/particle; and particle density. An unfavorable cardiometabolic profile characterized patients from QI and QII, in which HDLs were pro-atherogenic, denser and apoA-I-depleted. By contrast, QIII patients had an [HDL-C/apoA-I] ratio close to that of non-diabetic controls. QIV patients had better than average HDL size and composition, and in those patients whose [HDL-C/apoA-I] ratio was above normal, a more favorable phenotype was observed regarding lifestyle, anthropometry, metabolic comorbidities, insulin sensitivity, MetS score/severity, glycaemic control, and target-organ damage pregalence in small or large vessels. In conclusion, [HDL-C/apoA-I] and the resulting indices of HDL composition and functionality predict macrovascular risk and ß-cell function decline, as well as overall microangiopathic risk, suggesting that this ratio could serve both in cardiometabolic assessment and as biomarker of vascular complications.

The normal-weight type 2 diabetes phenotype revisited.

BACKGROUND: Type 2 diabetes (T2DM) is associated with obesity, insulin resistance and the metabolic syndrome (MetS). In non-diabetic populations, features of metabolic obesity (MO) are observed in a minority of normal-weight (NW) subjects. The cardiometabolic status of metabolically obese but normal-weight (MONW) individuals has not yet been phenotyped in T2DM. PATIENTS AND METHODS: Prevalence and features of MONW were analyzed in 1244 T2DM patients, in whom MONW was identified as a BMI <25.0 and a MetS score ≥3/5. Among NW (n=262; 21%), those without MetS (n=152; NW-MetS[-]) were compared to NW-MetS[+] (n=110; i.e. 42% of NW and 9% of all T2DM). RESULTS: There were no differences between groups in age; gender; diabetes duration; smoking; BP; and LDL-C. NW-MetS[+] had higher BMI; waist; fat mass; visceral fat; liver steatosis and HbA1c, and lower insulin sensitivity. Non-right-handedness was twice-higher (18%) in NW-MetS[-]. NW-MetS[+] had higher apoB100 and triglycerides, and lower HDL-C and LDL size. Macroangiopathy was present in 39% of NW-MetS[+] vs. 22% of NW-MetS[-], as coronary (23% vs. 14%) or peripheral artery disease (14% vs. 5%) and TIA/stroke (15% vs. 7%). Microangiopathy was present in 54% of NW-MetS[+] vs. 32% of NW-MetS[-], as retinopathy (25% vs. 13%); neuropathy (29% vs. 18%); and albuminuria (39% vs. 20%). CONCLUSIONS: MONW among T2DM represents a significant minority (about 1 in 10). Their cardiometabolic phenotype deserves attention due to multiple comorbidities, including a twice-higher prevalence of micro-/macrovascular damage in patients wrongly perceived at lower risk due to normal BMI. Unexpectedly, non-right-handedness was over-represented among metabolically healthy patients.

How to transform a metabolic syndrome score into an insulin sensitivity value?

BACKGROUND: The metabolic syndrome (MetS) predicts cardiovascular risk and incident type 2 diabetes mellitus. The presence of a MetS is defined by the clustering of ≥3 out of 5 cardiometabolic criteria (hyperglycemia; hypertension; enlarged waist; low high-density lipoprotein-cholesterol; and hypertriglyceridemia), each of which is connected with insulin resistance. It is not known whether the severity of MetS, ranked from the sextet of scores range [0/5 to 5/5], is linearly related to reduced insulin sensitivity (IS) and/or lesser hyperbolic product across the glycemic spectrum. PATIENTS AND METHODS: A total of 839 adults (54 normoglycemic; 785 with abnormal glucose homeostasis, among whom 711 type 2 diabetes mellitus) had insulin sensitivity assessed together with their cardiometabolic phenotype. RESULTS: There was a significant gradient according to interval-scale MetS score in insulinemia; body mass index; (visceral) fat; hepatic steatosis; and macroangiopathy. There was an inverse linear relationship between increasing MetS scores and decreased insulin sensitivity, allowing to define an insulin resistance-predicting linear equation: IS (%) = [-15.1 × MetS score] + 109.4 (R(2) = 0.221). For each MetS category, mean IS values did not significantly differ between groups of patients across the glycemic spectrum. The hyperbolic product (ß-cell function × IS) and/or its loss rate were inversely related to MetS severity. CONCLUSION: Insulin sensitivity is linearly and inversely related to MetS severity across the 6 scores. This novel way to exploit information intrinsic to the MetS criteria provides an easy and low cost means to quantify insulin sensitivity across the glycemic spectrum. Moreover, a higher MetS score is associated with lesser residual insulin secretion, and faster B-cell function loss. Copyright © 2015 John Wiley & Sons, Ltd.

Baseline diabetes as a way to predict CV outcomes in a lipid-modifying trial: a meta-analysis of 330,376 patients from 47 landmark studies.

BACKGROUND: Diabetes is a major cardiovascular risk factor. However, its influence on the rate of occurrence of cardiovascular (CV) events during a clinical trial that included a diabetes subgroup has not yet been quantified. AIMS: To establish equations relating baseline diabetes prevalence and incident CV events, based on comparator arms data of major lipid-modifying trials. METHODS: Meta-analysis of primary outcomes (PO) rates of key prospective trials, for which the baseline proportion of diabetics was reported, including studies having specifically reported CV outcomes within their diabetic subgroups. RESULTS: 47 studies, representing 330,376 patients (among whom 124,115 diabetics), were analyzed as regards the relationship between CV outcomes rates (including CHD) and the number of diabetics enrolled. Altogether, a total of 18,445 and 16,156 events occurred in the comparator and treatment arms, respectively. There were significant linear relationships between diabetes prevalence and both PO and CHD rates (%/year): y = 0.0299*x + 3.12 [PO] (p = 0.0128); and y = 0.0531*x + 1.54 [CHD] (p = 0.0094), baseline diabetes predicting PO rates between 3.12 %/year (no diabetic included) and 6.11 %/year (all patients diabetic); and CHD rates between 1.54 %/year (no diabetic) and 6.85 %/year (all patients diabetic). The slopes of the equations did not differ according to whether they were derived from primary or secondary prevention trials. CONCLUSIONS: Absolute and relative CV risk associated with diabetes at inclusion can be readily predicted using linear equations relating diabetes prevalence to primary outcomes or CHD rates.

Novel determinants preventing achievement of major cardiovascular targets in type 2 diabetes.

BACKGROUND: T2DM management requires tight control of 3 critical quality indicators to prevent vascular complications: LDL-C, SBP, and HbA1c. This study evaluated the rate of T2DM patients attaining these critical quality indicators, and the pathophysiological or cardiometabolic traits predicting goal achievement. PATIENTS AND METHODS: Cross-sectional analysis evaluating combined goal achievement (LDL-C<100 mg/dL; SBP<130 mmHg and HbA1c<7.0%) in 1005 T2DM outpatients (654 men) followed in a university hospital multidisciplinary department. Triple-goal achievers were compared to non-achievers regarding sociodemographics; anthropometrics; homeostatic model assessment (HOMA; ß-cell function (B); insulin sensitivity (S); hyperbolic product (B×S)); CV and glucose-lowering drugs; micro-/macro-vascular outcomes; and 10-year UKPDS risk. RESULTS: Eighty-eight patients (9%; ((3 targets) group) reached all goals, whereas 917 patients (91%; ((0-2 target(s)) group) missed 1, 2 or all 3 goals. Compared to (0-2 target(s)), (3 targets) had shorter diabetes duration; less familial diabetes history; lower waist/visceral fat; higher ß-cell function and hyperbolic product (B×S); lower (B×S) loss rate and less metabolic syndrome (all p<0.05). They had lower apoB and triglycerides; and a 28% prevalence of atherogenic dyslipidemia (vs. 40% in (0-2 target(s)); p 0.0398). Microangiopathy (36% vs. 53%) and 10-year CAD risk (13% vs. 18%) were also significantly lower in (3 targets). CONCLUSIONS: The subset of T2DM patients achieving all critical quality indicators are characterized by a less severe cardiometabolic phenotype, while exhibiting a less pronounced alteration of their residual ß-cell function. These differences are related to fewer microvascular outcomes and lower 10-year CV risk.