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Background Transferring results obtained in cardiovascular outcome trials (CVOTs) to the real-world setting is challenging. We herein transposed CVOT results to the population of patients with type 2 diabetes (T2D) seen in routine clinical practice and who may receive the medications tested in CVOTs. Methods We implemented the post-stratification approach based on aggregate data of CVOTs and individual data of a target population of diabetic outpatients. We used stratum-specific estimates available from CVOTs to calculate expected effect size for the target population by weighting the average of the stratum-specific treatment effects according to proportions of a given characteristic in the target population. Data are presented as hazard ratio (HR) and 95% confidence intervals. Results Compared to the target population (n = 139,708), the CVOT population (n = 95,816) was younger and had a two to threefold greater prevalence of cardiovascular disease. EMPA-REG was the CVOT with the largest variety of details on stratum-specific effects, followed by TECOS, whereas DECLARE and PIONEER-6 had more limited stratum-specific information. The post-stratification HR estimate for 3 point major adverse cardiovascular event (MACE) based on EMPA-REG was 0.88 (0.74–1.03) in the target population, compared to 0.86 (0.74–0.99) in the trial. The HR estimate based on LEADER was 0.88 (0.77–0.99) in the target population compared to 0.87 (0.78–0.97) in the trial. Consistent results were obtained for SUSTAIN-6, EXSCEL, PIONEER-6 and DECLARE. The effect of DPP-4 inhibitors observed in CVOTs remained neutral in the target population. Conclusions Based on CVOT stratum-specific effects, cardiovascular protective actions of glucose lowering medications tested in CVOTs are transferrable to a much different real-world population of patients with T2D.

Type 2 diabetes (T2D) is a risk factor for metabolic dysfunction-associated fatty liver disease (MAFLD), which is becoming the commonest cause of chronic liver disease worldwide. We estimated MAFLD prevalence among patients with T2D using the hepatic steatosis index (HSI) and validated it against liver ultrasound. We also examined whether glucose-lowering medications (GLM) beneficially affected HSI.We collected data from 46 diabetes clinics (n = 281,381 T2D patients), extracted data to calculate HSI and validated it against ultrasound-detected hepatic steatosis. We then examined changes in HSI among patients with a follow-up visit within 1 year after initiating newer GLMs.MAFLD (defined by HSI 36, i.e., a high probability of steatosis) was present in 76.3% of the 78,895 included patients, while only 2.7% had HSI 30 (low probability of steatosis). After age- and sex-adjusting, higher HSI was associated with higher prevalence of chronic kidney disease (odds ratio 1.35; 95%CI 1.22-1.51) and macroangiopathy (odds ratio 1.18; 95%CI 1.07-1.30). Among 2,179 subjects in the validation cohort, the prevalence of MAFLD was 67.8% and was greater in those with high HSI. Performance of HSI for ultrasound-detected MAFLD was moderate (AUROC 0.70), yet steatosis prevalence was threefold higher among subjects with HSI 36 than among those with HSI 30. Notably, HSI declined significantly ~ 6 months after initiation of dapagliflozin or incretin-based therapies, but not gliclazide.About three quarters of patients with T2D have HSI values suggestive of MAFLD, a condition associated with macroangiopathy and nephropathy. Treatment with dapagliflozin or incretin therapies might improve MAFLD in T2D.

Measurement and monitoring of blood glucose levels in hospitalized patients with portable glucose meters (PGMs) is performed widely and is an essential part of diabetes monitoring, despite the increasing evidence of several interferences which can negatively bias the accuracy of measurements. The purpose of this study was to evaluate the effect of the hematocrit on the analytical performances of different PGMs as compared with a reference laboratory assay.The effect of various hematocrit values (approximiately 0.20, approximiately 0.45 and approximiately 0.63 L/L) were assessed in three whole blood specimens with different glucose concentration (approximiately 1.1, approximiately 13.3, and approximiately 25 mmol/L) by using six different commercial PGMs. The identical samples were also tested with the laboratory reference assay (i.e., hexokinase). The percentage difference from the laboratory assay (%Diff) was calculated as follows: % Diff = average PGM value - value from laboratory assay x 100 / value from laboratory assay.The %Diff of the six different PGMs were rather broad, and comprised between 56.5% and -34.8% in the sample with low glucose concentration (approximiately 1.1 mmol/L), between 40% and -32% in the sample with high glucose concentration (approximiately 13.3 mmol/L), and between -50% and 15% in the sample with very high glucose concentration (approximiately 25 mmol/L), respectively. It is also noteworthy that a very high hematocrit value (up to 0.63 L/L) generated a remarkable negative bias in blood glucose (-35%) as measured with the laboratory assay, when compared with the reference sample (hematocrit 0.45 L/L).The results of this analytical evaluation clearly confirm that hematocrit produces a strong and almost unpredictable bias on PGMs performances, which is mainly dependent on the different type of devices. As such, the healthcare staff and the patients must be aware of this limitation, especially in the presence of extreme hematocrit levels, when plasma glucose assessment with the reference laboratory technique might be advisable.

Cardiovascular autonomic neuropathy in diabetes is associated with a high risk of mortality, which makes its early identification clinically important. An easy method for identification of subjects with autonomic dysfunction would be of clinical benefit. We evaluated the autonomic function in 28 diabetic patients and 21 control subjects recording 12 min time series of heart period (RR) and systolic arterial pressure (SAP, Finapres) during supine rest and 60 degrees head-up tilt. The power of the high (respiratory) and low (LF approximately 0.1 Hz) frequency oscillations was quantified by spectral analysis. The central frequency of the LF oscillations (LF_freq), phase shift, and the transfer function gain between RR interval and SAP fluctuations were provided by cross-spectral analysis, and measured at the point of maximal coherence. In the supine position 15 patients (LF-) displayed atypical LF variability with the LF_freq being shifted towards lower frequencies (about 0.06 Hz). They also showed larger phase angle, lower values or even absence of coherence and smaller transfer function gain between RR and SAP fluctuations. 13 patients (LF+) and the controls showed the LF_freq around 0.1 Hz, higher coherence and transfer function gain values. The orthostatic maneuver induced the expected changes in the spectral parameters (increase in the LF components of both RR and SAP and decrease in the HF variability of RR) into the LF+ patients and all the control subjects and abnormal response in the other 15 LF-patients. These findings indicate that diabetic subjects with uncharacteristic response to the orthostatic test present abnormal LF variability already in the supine position. Crossspectral parameters while supine may be used for the identification of these subjects.

OBJECTIVE: Although cardiovascular syndrome X was described many years ago, its causes are still unclear. Many studies have addressed the autonomic function, whereas others have investigated the coronary reserve. The purpose of this study was to investigate the correlations between parasympathetic dysfunction and coronary flow reserve deficiency. BASIC METHODS: Eleven consecutive women suffering from cardiovascular syndrome X were enrolled in the study. All the patients underwent the analysis of heart rate and blood pressure variability, the cold face test and noninvasive evaluation of the coronary flow reserve by transthoracic echocardiography. Comparison was made with healthy volunteers. RESULTS: Seven patients (64%) showed vagal impairment in the analysis of heart rate and blood pressure variability and a pathological response to the cold face test, whereas four patients (36%) did not show significant differences from the control group. In these three groups, patients with and without vagal impairment and controls, there was a difference in the mean diastolic coronary velocity reserve (1.94+/-0.48; 3.73+/-0.95, 2.88+/-0.55, P=0.0005) and in maximal diastolic velocity reserve (2.00+/-0.48, 3.26+/-0.64, 2.65+/-0.57, P=0.0047). Post-hoc analysis demonstrated that the mean and maximal diastolic velocity reserves of the patients with vagal impairment seemed to be reduced compared with those of the other groups (P

Granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) sensitise nerves to mechanical stimuli experimentally and may induce bone and muscle pain when used as supportive drugs. G-CSF and GM-CSF produced endogenously by tumour cells can cause paraneoplastic leucocytosis. Whether paraneoplastic leucocytosis is associated with changes in pain sensitivity is not yet clear. We report on a patient with advanced-stage thyroid cancer who developed extreme leucocytosis within a period of 4 weeks (103 000 white blood cells/mm(3)), composed mostly of neutrophils and eosinophils. Parallel to this leukemoid reaction, allodynia and hyperalgesia developed in the absence of tissue inflammation. The course of disease of an elderly male with advanced stage metastatic thyroid cancer with new onset neuropathic pain followed by the development of extreme leucocytosis in a leukemoid reaction suggests paraneoplastic release of myeloid CSFs. The coincidence of pain sensitisation and extreme leucocytosis suggests a causal contribution of G-CSF and GM-CSF.