Category Archives: Heart Disease

Common Test Could Help Predict Early Death In Diabetes

High levels of calcified ‘plaque’, a strong indicator of coronary heart disease, can be measured by a special ‘gated’ CT scan that costs just over $200

WHILE vascular disease is common in the general population, it is twice as common in people with diabetes. At least 60 percent of diabetes patients – even those on dialysis for kidney failure – ultimately die of a vascular event, such as heart attack or stroke. However, questions about why so many diabetes patients die early have remained unanswered in the medical community’s understanding of the disease.

Diabetes is associated with many other medical problems so identifying a way to determine who is at highest risk and who needs the most intensive medical monitoring and care is especially important. Now new findings reveal that a common test may be useful in predicting early death in individuals with diabetes. The study appears in the May issue of Diabetes Care.

Dr. Donald W. Bowden

“People with diabetes are already at high risk of developing heart disease and experiencing an early death,” said Donald W. Bowden, Ph.D., the director of the Center for Diabetes Research at Wake Forest Baptist Medical Center and lead investigator in a press statement. “With this study, we’ve discovered that we can identify a subset of individuals within this high risk group who are at even higher risk, and the means to do this is already widely available in the form of a computed tomography (CT) scan – a relatively inexpensive and non-invasive test.”

For the Diabetes Heart Study, Bowden and colleagues have been following nearly 1,500 patients with diabetes in North Carolina for about 13 years, gathering data on various aspects of the disease and how it affects individual health. As original study participants began to die, the researchers sought to understand why.

“When we reviewed the data last year, we were shocked by the number of participants who had already died during this study,” Bowden said. “We wanted to find out if there were any predictors of who would succumb versus those who are still living. In a group of people who are already at high risk, we were looking for a way to identify which individuals were at even higher risk for early death, with the goal of finding interventions or ways to focus medical care and attention toward those individuals at highest risk.”

A high coronary artery calcium (CAC) score is known to be a strong indicator of coronary heart disease. The score provides a measure of how much coronary artery disease, or calcified ‘plaque’ is present in the blood vessels of the heart. Plaque plays a major role in heart attacks and other vascular events and can be measured by taking a special ‘gated’ CT scan which, in comparison to typical CT scans, uses very few X-rays, does not require any injections and generally takes less than 10 minutes to perform. (At Wake Forest Baptist, the test costs just over $200 and some insurance companies will cover the exam in appropriate situations, informs the press statement.).

Within the diabetes-affected population, there is a very wide range of calcified plaque buildup in the arteries and the heart, from individuals with none at all, to people whose entire vessels are nearly completely calcified. The researchers separated more than 1,000 study participants into five groups, according to the amount of calcified plaque they had in their blood vessels at the beginning of the study. The health of those participants was then followed for an average of 7.4 years before researchers compared the data from those who died during the study to those who are still living.

“We saw a dramatic risk of dying earlier in the people with highest levels of calcified plaque in their blood vessels,” Bowden said. “When comparing the group with the highest amount of plaque to the group that had the lowest amount of calcified plaque, the risk of dying was more than six times greater in the group with high levels of calcified plaque. The difference in risk that we revealed is striking. It’s in a group of people who are already at risk, but the CAC level really rather dramatically differentiates risk between people within this high risk group. This finding could have novel clinical implications.”

“The striking magnitude of the risk suggests very strongly that other research samples should be evaluated, especially in individuals with diabetes,” he said.

Source: Wake Forest Baptist Medical Center


Limiting Cholesterol Levels May Minimize Inflammation and Reduce Type 2 Diabetes Risk

Study will make possible new target therapies that help predict susceptibility to the metabolic condition and perhaps prevent diabetes

BY stimulating the enzyme cholesteryl ester hydrolase (CEH) to remove more cholesterol from cells, it may be possible to limit inflammation, improve insulin sensitivity and reduce an individual’s type 2 diabetes risk, claims a group of researchers from Virginia Commonwealth University School of Medicine. The results of the study have been published online in the Journal of Biological Chemistry.

Cholesterol has long been known to increase inflammation levels, and inflammation is well regarded as a risk factor for type 2 diabetes. Yet the researchers noted that few treatments for type 2 diabetes specifically target high cholesterol levels. It is hoped that the study will make possible new target therapies that help predict susceptibility to the metabolic condition, and perhaps prevent diabetes in the future.

“Although diabetes and heart disease often co-exist, current management of diabetes does not necessarily include cholesterol and/or inflammation control,” said lead researcher Shobha Ghosh, PhD. “These studies provide the first evidence that targeting fat tissue inflammation as well as elimination of cholesterol from the body may be emerging new strategies to prevent diabetes.”

For the study, the team analyzed the effect of turning up the expression of a gene that regulates CEH levels in a group of mice. The results showed that even when fed a high-fat diet, these mice had lower levels of inflammation and were more sensitive to the effects of insulin.

The results held true despite the fact that mice still gained significant weight from being fed the high-fat diet. Ghosh explained CEH appeared to cause low-density lipoprotein cholesterol molecules to exit cells, where they could then be neutralized by high-density lipoprotein cholesterol cells and taken to the liver for processing.

Ghosh said that these findings suggest that taking steps to control cholesterol levels in individuals with other risk factors for type 2 diabetes may be an effective treatment strategy. Additionally, they reveal that stimulating the genes that regulate CEH levels in the body may be one of the surest ways to control cellular cholesterol levels and limit fat’s pro-inflammatory effects.

From Endocrine Today

Related story: Arterial Plaques May Be Reduced By Increasing the Amount of a Key Enzyme in Cells Storing Cholesterol

Apples Reduce Bad Cholesterol (LDL) By 23%, Increase Good Cholesterol (HDL) By 4%, Finds New Study

APPLES are truly a “miracle fruit” that convey benefits beyond fiber content. Bahram H. Arjmandi of Department of Nutrition, Food and Exercise Sciences at The Florida State University in Tallahassee has found that eating an apple or two a day appears to lower levels of cholesterol and two other markers associated with plaques and inflammation in artery walls.

In his study, postmenopausal women who ate an apple a day gained heart healthy benefits and even lost weight in a study from food science researchers. In six-months, women age 45 to 65, lowered dangerous LDL cholesterol, raised beneficial HDL cholesterol levels and lost a few pounds from consuming dried apples. The study shows apples could be a heart healthy snack for everyone; not just women.

Indeed, the findings are of great interest to diabetics who must maintain tight control of their blood sugar levels every day. Uncontrolled diabetes puts them at greater risk for heart disease.

Arjmandi’s recent research is the first to evaluate the long-term cardioprotective effects of daily consumption of apple in postmenopausal women, says a news release. The results of the study, which were presented at Experimental Biology 2011 on April 12 in Washington, DC, should be considered preliminary as they have not yet undergone the “peer review” process, in which outside experts scrutinize the data prior to publication in a medical journal.

Arjmandi reported that “incredible changes in the apple-eating women happened by 6 months ‒ they experienced a 23% decrease in LDL cholesterol. The daily apple consumption also led to a lowering of lipid hydroperoxide levels and C-reactive protein in those women.  “I never expected apple consumption to reduce bad cholesterol to this extent while increasing HDL cholesterol or good cholesterol by about 4%,” he said.

Though the study used dried apples for convenience, Arjmandi said fresh are likely to be even better. And it doesn’t matter if they’re green, red, or golden. “Any varieties of apples are good,” he said.

Yet another advantage is that the extra 240 calories per day consumed from the dried apple did not lead to weight gain in the women; in fact, they lost on average 1.5kg (3.3lb). “Reducing body weight is an added benefit to daily apple intake” he said. Part of the reason for the weight loss could be the fruit’s pectin, which is known to have a satiety effect.

This study randomly assigned 160 women ages 45-65 to one of two dietary intervention groups: one received dried apples daily (75g/day for 1 year) and the other group ate dried prunes every day for a year. Blood samples were taken at 3, 6 and 12-months.

Experts said the study’s results were consistent with previous evidence that apples do indeed live up to the famous adage about keeping the doctor away.

“When we look at the whole composite of human studies and animal studies and in vitro lab studies, when you look at the active components in apples and apple juice, there’s definitely benefit,” Dianne A. Hyson, PhD, RD, a nutritionist and researcher at the University of California at Davis was quoted as saying in a WebMD Health News report.

Hyson, who was not involved in the current research, recently completed a review of 80 studies, published since 2005, on the health benefits of apples, and she said that in addition to their cardiovascular benefits, there’s some evidence that apples help regulate blood sugar and control appetite, protect against cancer, and safeguard the lungs.

Another key, Dyson said, is eating the whole fruit, rather than looking for individual components in supplements. “Most of the time, in many studies, the whole is better than the sum of its parts,” she said. As far as how much to eat, just follow the apple-a-day adage, though Arjmandi said two-a-day might be even better. “That’s doable and practical and people like apples,” he said.

The next step in confirming the results of this study is a multi-investigator nationwide study.

Source: Experimental Biology 2011 Onsite Newsroom


Diabetes Management: Tight Cholesterol, BP Control Does Little Good for Diabetics

Lower isn’t always better in diabetes management. In fact, pushing too hard may not help, and may actually hurt in some cases. This has been proved, once again, by the landmark Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, results released last week reveal. Indeed, the new lipid and blood pressure results round out the negative portrait of aggressive risk factor management in diabetes patients.

(ACCORD is one of the largest studies ever conducted in adults with type 2 diabetes who were at especially high risk of cardiovascular events, such as heart attacks, stroke, or death from cardiovascular disease.  The multicenter clinical trial tested three potential strategies to lower the risk of major cardiovascular events: intensive control of blood sugar, intensive control of blood pressure, and treatment of multiple blood lipids. The lipids targeted for intensive treatment were high density lipoprotein (HDL) cholesterol and triglycerides, in addition to standard therapy of lowering low density lipoprotein (LDL) cholesterol. Read the Questions & Answers about the ACCORD Trial here.)

According to received wisdom, intensive blood pressure and blood fat management could drive down diabetics’ higher risks of heart problems. But results from the ACCORD trial prove that when it comes to traditional measurements of heart disease risk, a blood pressure target of 120 mm Hg rather than the general population standard of 140 did not reduce nonfatal heart attacks, nonfatal strokes or death from cardiovascular causes.

Likewise, adding the cholesterol-busting drug fenofibrate to standard statin therapy did not reduce the chances of major adverse cardiovascular events. Indeed, tribal behavior by physicians that is no doubt driven by the big pharma marketing machinery, has raised concerns about the ramifications of recommending costly medications that don’t confer real benefits to patients. (See my post ‘Increased Use of Fibrates in US Could Be A Triumph Of Marketing Over Medicine’ here.)

Both studies ‒ part of the complex ACCORD trial ‒ were presented at the American College of Cardiology meeting in Atlanta, Ga. and released simultaneously online in the New England Journal of Medicine.

[A third part of this research ‒ one which examined intensive lowering of blood sugar to see if this had a positive effect ‒ was prematurely halted in 2008 because it turned out that patients receiving this approach actually had an increased, instead of decreased, risk of death. (See a related post ‘Aggressive Diabetes Therapy May Raise Death Risk’ here.)]

As for the newly released findings, the lipid arm of ACCORD included 5,518 patients with high risk of heart problems because of cardiovascular disease or at least two risk factors. LDL, or bad, cholesterol levels had to be between 60 and 180 mg/dL; HDL, or good cholesterol, levels had to be under 50 mg/dL or 55 mg/dL for women and blacks; and triglycerides had to be under 750 mg/dL if the patients were not on any therapy, or 400 mg/dL otherwise. Patients either received fenofibrate or a placebo in addition to statins.

What the researchers found was that lipid and triglyceride levels responded as expected. Despite this, however, the patients appeared to receive no benefit when it came to major heart problems such as heart failure, stroke and nonfatal heart attacks.

Meanwhile, the  blood pressure portion of ACCORD compared a strategy of keeping systolic blood pressure under 120 mm Hg to one of under 140 mm Hg in 4,733 diabetes patients with high risk of cardiovascular events because of clinical or subclinical heart disease or at least two risk factors. In this trial, treatment effectively lowered blood pressure. But again, there was no impact on aspects of patient health including death risk, death related to heart problems and nonfatal heart attacks.

ABC News reported that the U.S. Food and Drug Administration will conduct a full review of findings from the ACCORD study. An FDA spokesperson said the agency planned to include a review of the labeling and indications for fenofibric acid (Trilipix) ‒ even though the trial used fenobrate (TriCor). Asked about the timing of the announcement, the spokesperson said the FDA was attempting to be more proactive.

Both Trilipix and TriCor are marketed by Abbott, and Trilipix is “the active metabolite of TriCor,” according to Dr. Marshall Elam of the Memphis VA Medical Center. Elam, who was involved in the design of the lipid treatment arm of ACCORD said that “neither TriCor nor Trilipix has a label indication for cardiovascular disease.”

In a statement released after the ACCORD results were reported, but before the FDA said it would conduct a review of the ACCORD findings, Abbott said the data from the ACCORD Lipid trial “supports the appropriate patient type and current treatment guidelines for fibrates. The top-line results of the study were widely expected, given that two-thirds of patients in the trial would not be recommended for fibrate therapy under current guidelines.”

Wake-up Call: 50% Adult Americans Face Serious Health Risk

Nearly 50 percent of all adult Americans have high cholesterol, high blood pressure or diabetes. All conditions increase the risk of cardiovascular disease. Diabetics, of course, are at greater risk of having the other two conditions as well, and heart disease is one of the most common complications resulting from poor diabetes management.

A report released online Monday by the national Centers for Disease Control and Prevention said nearly 13 percent Americans have at least two of the conditions and three percent have all three, sharply increasing their risk. Of those with at least one condition, 15 per cent have not been diagnosed.

(Diabetes affects 8.3 percent of Americans of all ages, and 11.3 percent of adults aged 20 and older, according to the National Diabetes Fact Sheet for 2011. About 27 percent of those with diabetes—7 million Americans—do not know they have the disease. Prediabetes affects a whopping 35 percent of adults aged 20 and older.)

“The number that really surprises me is the penetration of these conditions into the U.S. population,” said Dr. Clyde Yancy of Baylor University Medical Center, president of the American Heart Association. “When that number is nearly 50%, that’s a huge wake-up call.” It means there are a large number of people “who think they are healthy…but are working under a terrible misconception.”

The data come from the ongoing National Health and Nutrition Examination Survey, which releases new figures every two years. The survey consists of interviews conducted in participants’ homes, standardized physical examinations given to some participants and laboratory tests using blood and urine specimens.

“This report is so timely and important because it crystallizes exactly what the burden is,” Yancy said. “It tells us the challenge we now face that could stress and potentially defeat any healthcare system we could come up with.”

Personal responsibility plays a big role in creating these three health problems, he said. “This trio begins with a quartet of smoking, a junk diet, physical inactivity and obesity. Those are all things we can do something about.”

Though researchers should be able to use the new data to plan interventions, “the main thing here is for people to be aware that they have these conditions and know that lifestyle modifications and medications can control them and reduce their risk for cardiovascular disease,” said epidemiologist Cheryl D. Fryar of the CDC’s National Center for Health Statistics, one of the study’s authors.

Aggressive Diabetes Therapy May Raise Death Risk

The BIG news of the day is that intensive blood sugar control doesn’t benefit people with both type 2 diabetes and heart disease.  In fact, intensive treatment to lower blood sugar is linked to increased mortality, according to a long-running study whose findings were published today.

This reminds me of a discussion that I participated in a TuDiabetes forum a couple of week ago. The issue being discussed was A1c/eAG levels. I had written: “My diabetologist says that diabetics have higher eAG than normal, healthy individuals. Indeed, he says that it is better for diabetics to have an eAG of ~ 180 than ~ 140. He says in his experience diabetics who try to emulate normal eAG levels suffer more complications – cardio, renal, vascular, optho – than those with slightly higher values. He cites the example of a few patients (now age 80+) who have remained at 200+ for 30 years!”

Clinical trials now seem to have validated anecdotal evidence. The New England Journal of Medicine reported today that according to the latest analysis from the long-running ACCORD study, trying to maintain the blood sugar levels typical of people without diabetes can increase the risk of death for people with type 2 diabetes and heart disease by 19 percent.

ACCORD stands for Action to Control Cardiovascular Risk in Diabetes. This study was designed to assess whether intensive blood sugar interventions to bring A1C levels to under 6 percent would benefit people with type 2 diabetes and heart disease.

A1C is a long-term measure of blood sugar control, and the A1C level provides about two to three months of average blood sugar levels. A level of under 6 percent, which is considered normal or non-diabetic, can be difficult for someone with diabetes to achieve.

This brings me to the outlook of many TuDiabetes members (many of who take their management very seriously). Replying to my response mentioned above, one member wrote: “I disagree with the idea that lower blood sugar levels cause more complications….The largest intervention study to date, the DCCT pretty conclusively found that risks of “all” complications could be decreased by reducing blood sugars. Data from the DCCT conclusively substantiated that down to below 7% (154 mg/dl eAG). Further studies have found additional support that additional risk reductions occur all the way down to A1cs of even 5.5%. The American Association of Clinical Endochrinologists in fact suggests that patients “Encourage patients to achieve glycemic levels as near normal as possible without inducing clinically significant hypoglycemia”.”

Another quipped: “If your diabetologist is implying that averaging 180 is okay (over the Renal Threshold), then he desperately needs to go on a high-fiber diet.”

Fair enough. All of agree that BS levels should be as close to normal as possible. But do we have to adopt an aggressive approach to diabetes management just because the doctors says so? Ground Zero observations have revealed that many diabetics do NOT suffer complications. (See my earlier post on this here.)

It should not be forgotten that aggressive insulin therapy also necessitates the need of continuous monitors, a luxury most diabetics cannot afford (given the high cost of testing strips). In India where I live, only a minuscule number of people test BS on a daily or even weekly basis. The norm is to test fasting and post-prandial levels only when one visits a diabetologist, which is not more than 2-3 times in a year. (My diabetologist says most of his patients turn up only when they’re really sick.)

Of course I’m guilty of poorly paraphrasing my diabetologist’s observations. But essentially he’s right and the recent ACCORD study validates a diabetologist’s long experience of treating a variety of patients in a (clinically) ‘hostile’ environment.

It is interesting to note how the ACCORD study reached its conclusions. The people recruited for the study were between 40 and 79 years old, and their A1C levels were above 7.5 percent at the start of the study. Study volunteers were randomly assigned to either intensive blood sugar control or to a standard diabetes program striving for levels of 7 percent to 7.9 percent.

The study began in 2001 and was halted in February 2008 when researchers realized that people in the intensive treatment group had an increased risk of dying. By then, the intensive treatment group had received 3.7 years of treatment aimed at lowering their A1C levels to below 6 percent.

Achieving such tight blood sugar control often required numerous interventions, such as lifestyle changes along with medication, multiple medications or insulin therapy.

The analysis includes five years of data. For the intensive group, that meant an average of 3.7 years of intense treatment, followed by 1.3 years of standard therapy.

At the time the study was stopped, the intensive therapy group experienced a 21 percent reduction in the risk of heart attacks, but a 21 percent increase in the risk of all-cause mortality.

After five years, the researchers found that the risk of heart attacks was still decreased by 18 percent, but the increased risk of all-cause mortality also persisted. People in the intensive therapy group had a 19 percent increased risk of dying of any cause.

The study’s lead author, Dr. Hertzel C. Gerstein, the Population Research Health Institute Chair in Diabetes Research at McMaster University in Hamilton, Canada, said many researchers have tried to tease out why intensive blood sugar control might up the risk of death, and so far, no one has succeeded. Causes that have been ruled out include low blood sugar levels (hypoglycemia) and the rapid change in blood sugar levels.

“This study really reminds us that we always need to be prudent. Even if we think something is the right thing to do, sometimes we may have findings that are unexpected,” said Gerstein.

“This study confirms the results of the ACCORD trial over the full duration of the study,” said Dr. Vivian Fonseca, president-elect of medicine and science for the American Diabetes Association.

“Overall, this means that the recommendations of the American Diabetes Association hold true. In general, people with diabetes should aim for an A1C goal of less than 7 percent, but clearly individualization is important. One size does not fit all,” said Fonseca.

And, the findings suggest that people with type 2 diabetes and heart disease shouldn’t attempt to achieve an A1C below 6 percent, the study authors said.

Gerstein and Fonseca noted that the ACCORD findings should not be generalized for everyone with diabetes. People with type 1 diabetes and those with type 2 diabetes and no history of heart disease were not included in this study.

“There is no reason to change current guidelines because of this study, and this study certainly doesn’t support ignoring glucose control. We saw benefits in eye disease and many other outcomes with good control,” said Gerstein.

More information

To learn more about the connection between diabetes, heart disease and stroke, go to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases

Aspirin May Help Diabetics With Kidney Disease Avoid Heart Complications

A new study from a team of Japanese researchers at the Nara Medical University shows that low daily doses of aspirin may help reduce risk of heart disease in patients who have both type 2 diabetes and kidney disease.

Heart disease, as we all know, is the most common cause of death for individuals who have type 2 diabetes because persistently high levels of blood sugar in the veins causes inflammation that leads atherosclerosis, which is a hardening of the arteries that causes the heart to work harder, eventually causing it to wear out.

The research, published in the journal Diabetes Care, concludes that there appears to be a strong relationship between diabetes-induced kidney disease and aspirin therapy. If future studies bear out these results, aspirin could provide a simple solution to a major problem that affects millions of people.

“The current study demonstrated that low-dose aspirin therapy reduced the risk of atherosclerotic events in type 2 diabetic patients,” the researchers wrote in their report.

For the study, researchers gave a group of more than 2,500 participants who had type 2 diabetes and kidney disease either an 81 mg daily dose of aspirin, a 100 mg daily dose or no aspirin at all. The researchers then tracked the participants’ medical records for nearly five years. During this time they checked for instances of stroke, heart disease and peripheral artery disease.

They found that individuals who were in either of the groups that received aspirin had significantly fewer atherosclerosis-related incidences than those who did not receive aspirin.

“The current study demonstrated that low-dose aspirin therapy reduced the risk of atherosclerotic events in type 2 diabetic patients,” the researchers conclude.

Depression Sufferers Live With Higher Risk of Diabetes

Depression can heighten the risk of developing type 2 diabetes as the mental illness also increases the likelihood of obesity and failing to take enough exercise, a study carried out by the German Diabetes Association (DDG) has shown, reports DPA.

Bouts of depression can also lead to higher levels of the stress hormone cortisol in the blood. Cortisol, also known as hydrocortisone, counteracts insulin and contributes to type 2 diabetes, which is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency.

It is recommended that those suffering from depression undergo tests for the disease as they are 11 times more likely to suffer vascular complications than people battling diabetes alone. The risk of damage to arteries, which could lead to a heart attack, is between two and five times as high.

According to the DDG, not only are people with depression at increased risk of developing type 2 diabetes, those with diabetes are also at increased risk of developing depression.

The consequences can be serious as treatment for diabetes requires the active involvement of the patient. “Depression is a major barrier in such instances,” explains Bernhard Kulzer, chairman of the DDG’s psychology council.

Complications that can result from improperly managed type 2 diabetes include renal failure, blindness and arterial disease, including coronary artery disease. The DDG recommends that diabetics suffering from depression undergo psychological treatment.

Diabetes: Shortage Of Vascular Surgeons In India Costs 80,000 Limbs Every Year

India has less than 100 vascular surgeons since the establishment of the first department of vascular surgery in 1978. The states of Orissa, Madhya Pradesh, Bihar and Manipur don’t have any vascular surgeon.

No government-run hospital in the country’s capital New Delhi, including the premiere All India Institute of Medical Sciences, has a department of vascular surgery. Chennai and Bangalore in the southern states of Tamil Nadu and Karnataka respectively, with 20 surgeons each, are slightly better off.

Only last year, the number of seats for post-graduate degree in vascular surgery in the country was raised from four to eight in medical colleges. Including diploma holders, the country produces only 16 vascular surgeons yearly. This, experts feel, should be trebled in two years.

“A large number of people wheeled in for amputations are either trauma victims or long-term diabetics. At least 40% of people with decade-long diabetes develop vascular problems. In a country where more than 40 million people are estimated to have diabetes, the number of people estimated to have vascular problems is large. Add to this road accident victims day and you know why there is a need to produce a greater number of vascular surgeons,” says Dr Sekar, who is also the president of the Vascular Society of India. Though there are no clear statistics on amputations, it is estimated that at least one lakh people lose a limb every year. Of these, nearly, 80,000 amputations are avoidable.

Sakthiraj Ekambaram, 29, a chronic smoker, complained of pain every time he walked for more than 20 minutes. “I had to stop for a couple of minutes and walk again. The doctor sent me to the gym,” he said. Luckily, Sakthiraj, decided to consult a vascular surgeon for the wound that did not heal for long. “That is when I discovered that the blood supply to my legs was very low. My feet were cold unlike other parts where blood flowed and I did not have good sensation on my feet. I underwent a procedure that saved my legs,” he said. But not all patients are as lucky has Sakthiraj, says Dr Sekar.

Pulling out the case sheets of a 40-year-old patient, he continues, “A chronic diabetic, this patient had one of his limbs amputated last year. This year, he had his other leg amputated too. Almost 50% of diabetics who go in for amputation of one limb, lose their second limb in another year. A vascular disease is an indicator of a heart disease because if there are blocks in the leg, there can be blocks in the heart too,” says Dr Sekar.

“When people are disabled, the burden is high on the family and the government,” says Dr Ravul Jindal, the only qualified vascular surgeon in Chandigarh. “Some patients who can afford the treatment are referred to doctors in other states. The others undergo amputation surgeries. These are done by general surgeons or orthopedic surgeons to prevent infection from spreading to other parts of the body,” says Dr Jindal.

The society is now waging an aggressive war with the Union health ministry and at least ten state governments urging them to start new departments in vascular surgery. Vascular surgeons say they consider several options before deciding to remove a limb.

“The blood vessels in the legs and hands are just like arteries and veins in the heart. If there is a block in arteries of the heart, it can reduce supply of blood and cause heart attack, which is death of the heart muscle. When similar things happen on the leg, it leads to death of muscles in the leg. They begin to rot (gangrene). Just like the heart, we have options of using balloons to remove blocks by a procedure called angioplasty, place drug coated thin wires in the vessels to prevent clots or even do a by-pass graft,” says Dr Paresh Pai, consultant vascular surgeon at Mumbai’s Lilavati Hospital. “But on most occasions, patients are refered to us very late. We want to create awareness among doctors and patients on foot care. For instance, if a wound remains unhealed for long, doctors should first check if there is adequate blood supply and restore it. For this, the patient should come in early,” he says.

Representatives from the association would meet Union health minister Ghulam Nabi Azad and health secretary Sujatha Rao to discuss a road map. First, they want the ministry to increase the number of seats for post-graduate degree in vascular surgery. “At present, there are only seven training centers for vascular surgery, training 12 students every year. We want them to double the number of seats in a year and increase it by at least three times by 2012,” Dr Sekar said.

Thank you Pushpa Narayan/Times of India

Controlling a Fat-Regulating Protein Dramatically Increases Insulin Sensitivity

PPARy is a protein that regulates the body’s production of fat cells. However, obesity can modify how PPARy works, leading to decreased insulin sensitivity and the development of metabolic syndrome. (Metabolic syndrome is the cluster of factors, including insulin resistance, overweight, high blood pressure, and abnormal blood sugar levels, that is a precursor to type 2 diabetes.)

But now a joint team of researchers from The Scripps Research Institute in San Diego and the Dana-Farber Cancer Institute at Harvard University in Cambridge has found a way to control the adverse changes in PPARy brought on by obesity.

One of those changes is phosphorylation, when an enzyme called cdk5 kinase adds a phosphate group to PPARy. That addition causes PPARy to alter the expression of several genes, including one that regulates production of adiponectin, a protein essential to insulin sensitivity.

The challenge for the scientists was to find a way to change PPARy back to its normal state without inducing it to overproduce fat cells. They knew from a previous study that an agonist, a compound that makes cells respond in certain ways, interacted with the region of PPARy known to regulate fat generation. The agonist in that case was a full agonist, meaning that it was able to easily combine with a receptor in that region of PPARy and activate it to do a certain thing-in this case, not generate fat cells.

The researchers wondered if partial agonists-chemical agents that have only partial effects on certain cell receptors-could be used to counteract the insulin-suppressing effects of phosphorylation on PPARy without the side effect of ramping up fat cell production.

They found that while partial agonists did not interact with the PPARy receptor that governs fat cell production, one, called MRL24, worked extremely well in the exact region of PPARy where phosphorylation takes place. By altering and diminishing that region’s receptiveness to phosphorylation, MRL24 allowed PPARy to increase the production of adiponectin.

Those findings, which open the door to learning how to fully manipulate PPARy, could lead to drugs that reduce the risk of developing type 2 diabetes and cardiovascular problems. If PPARy can be prevented in obese people from losing its ability to direct the production of adiponectin, it could become a significant therapy in treating the effects of extreme overweight.

Thank you Patrick Totty

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