Does aggressive glycemic control benefit macrovascular and microvascular disease in type 2 diabetes? Insights from ACCORD, ADVANCE, and VADT.

Diabetes is increasing rapidly worldwide and frequently results in severe vascular complications. A target glycated hemoglobin of less than 7% has commonly been recommended in hopes of preventing both macrovascular and microvascular complications. Although results from trials of intensive glycemic control have generally supported the notion that lower glycated hemoglobin values reduce microvascular disease, the evidence for similar benefits for macrovascular disease has been less clear. As macrovascular disease is the major cause of morbidity and mortality in type 2 diabetes, this remains one of the more important unresolved clinical questions. Recent results from the ACCORD, ADVANCE, and VADT studies have challenged the conventional believe that lower glycated hemoglobin values should be pursued in all diabetic patients. Factors that may influence whether intensive glucose management is advisable include duration of diabetes, pre-existing macrovascular disease, hypoglycemic unawareness, and significant comorbidities. Glycated hemoglobin goals should account for these factors and be individualized for each patient.

Thoracic vertebral actinomycosis: Actinomyces israelii and Fusobacterium nucleatum.

Actinomyces spp. are considered rare pathogens in today's medicine, especially with thoracic vertebral involvement. Classic actinomycosis (50%) presents as an oral-cervicofacial ("lumpy jaw") infection. This report describes a case of spinal cord compression caused by Actinomyces israelii with the coisolation of Fusobacterium nucleatum. There are limited numbers of similar cases.

Cardiobacterium hominis endocarditis presenting as acute embolic stroke: a case report and review of the literature.

We report on a case of endocarditis attributable to Cardiobacterium hominis in a 31-year-old man who presented with acute-onset, left-sided hemiparesthesia. Magnetic resonance imaging of the brain showed acute infarctions in 2 areas of the right cerebral cortex, and a transesophageal echocardiogram revealed vegetation in a previously unrecognized bicuspid aortic valve. The patient completed a 6-week course of ceftriaxone and aspirin, with resolution of the vegetation and neurological complications. Our literature review of C. hominis endocarditis suggests that aortic-valve involvement is associated with high stroke and valve-surgery rates. Favorable outcomes and treatment success are evident with either penicillin or ceftriaxone, in combination with (if indicated) valve surgery in patients with neurological complications.

Intensive glycemic control and cardiovascular disease: are there patients who may benefit?

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Recent major publications, such as the Action to Control Cardiovascular Risk in Diabetes trial, the Advance in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation trial, and the Veterans Affairs Diabetes Trial, found that intensive glucose control in patients with T2DM did not reduce CVD outcomes. However, in this article, we review observational studies and clinical trials that, on aggregate, indicate how glucose lowering appears to reduce risks of CVD in certain subgroups, but can be harmful in other individuals. Based on available evidence, we suggest that younger patients with a shorter duration of T2DM, without CVD, and with few comorbid conditions may experience the greatest cardiovascular benefit from intensive glucose control. In contrast, more aggressive glucose lowering in older patients with a longer duration of T2DM, a history of CVD, and/or multiple comorbidities does not translate to reduced cardiovascular events, and may cause harm. The target goal and therapeutic strategy for intensive glucose control should be established for each individual after a careful review of his or her medical and psychosocial history, and should not reflect a "one-size-fits-all" approach.

Takotsubo cardiomyopathy associated with syncope.

We report an 81-year-old Japanese patient with takotsubo cardiomyopathy associated with syncope with the possibility that the latter event evoked the former condition. Initial investigations revealed elevation of cardiac enzymes and electrocardiography changes consistent with acute myocardial infarction. The patient subsequently underwent cardiac catheterization that revealed left ventricular apical ballooning and decreased left ventricular ejection fraction without significant coronary artery lesions. A marked elevation in plasma norepinephrine, as a result of baroreflex unloading associated with profound hypotension or frank baroreflex failure, may well have caused takotsubo cardiomyopathy.

Clinical experience with exenatide in predominantly Asian and Pacific Islander patients with type 2 diabetes.

Exenatide is a new injectable medication for the treatment of hyperglycemia in type 2 diabetes. Due to limited information of exenatide use in Asians and Pacific Islanders (API), we retrospectively reviewed API patients' responses to exenatide treatment and compared the efficacy and safety of treatment to Caucasian patients. A total of 92 patients (70 API, 21 Caucasians, and 1 Hispanic) with type 2 diabetes were treated with exenatide. In all patients, there was a significant decrease in A1c level, BMI, and weight after 6 months of exenatide treatment (A1c from 8.63 +/- 1.46 to 8.23 +/- 1.46; P = 0.03, BMI from 34.54 +/- 7.07 to 32.14 +/- 6.41; P < 0.01, and weight from 215.24 +/- 52.04 to 202.50 +/- 49.90; P < 0.01 at 95% CI, N = 51). However, differences in mean change of A1c level, BMI, and weight between API and Caucasian patients were not observed at 3 and 6 months of treatment. Side effects and discontinuation of exenatide treatment between API and Caucasian patients were similar. In conclusion, exenatide is an effective anti-hyperglycemic agent in API patients with responses similar to that observed for Caucasian patients.