Inter-relationship of risk factors and pathways associated with chronic kidney disease in patients with type 2 diabetes mellitus: a structural equation modelling analysis.

OBJECTIVES: Diabetes mellitus is the most common cause of chronic kidney disease (CKD); however, the inter-relationships and pathogenetic mechanisms among risk factors are still largely unknown. Structural equation modelling (SEM) was applied to test a hypothesis of causal pathways related to CKD in patients with type 2 diabetes mellitus (T2DM). STUDY DESIGN: This is a prospective observational study. METHODS: A total of 3395 patients with T2DM were enrolled in this study. A hypothesised SEM was applied to assess associations among demographic data, diabetic self-management behaviours, diabetes control, lifestyle, psycho-social, chronic inflammation factors, anthropometric and metabolic variables simultaneously and the risk of CKD. RESULTS: Demographic data (including education, marital status and mini-mental state examination score) (-0.075), white blood cell count (0.084), high blood pressure (0.144), World Health Organisation (WHO) 5 well-being index (-0.082), diabetes control (0.099), triglyceride (0.091) and uric acid (0.282) levels had direct effects on the risk of CKD. The final model could explain 26% of the variability in baseline CKD status. In addition, the same direct and specific indirect factors at baseline CKD status analysis contributed to the risk of CKD at the 12-month follow-up. The final model could explain 31% of the variability in the risk of CKD at the 12-month follow-up. CONCLUSIONS: This study investigates associations between factors obtained from real-world daily practice and CKD status simultaneously and delineates the potential pathways and inter-relationships of the risk factors that contribute to the development of CKD in patients with T2DM.

Stress fracture of the ulna associated with bisphosphonate therapy and use of walking aid.

We report a case of a stress fracture of the ulna secondary to long-term bisphosphonate therapy and walking cane. Physicians need to have a high index of suspicion of stress fractures occurring in patients complaining of chronic upper limb pain if they are on bisphosphonate therapy and are using walking aids. Stress fractures of the upper extremities are rare and are usually associated with athletes; however, a few recent case reports have shown an association between stress fractures of the upper extremities and the use of walking aids. The association between increased incidence of upper extremity stress fractures and the use of both bisphosphonates and walking aids in patients has not been well studied, with only one previously reported case. Here, we report a case of a complete stress fracture of the ulna in a 77-year-old female, premorbidly ambulant with walking cane, on long-term bisphosphonates without any pre-existing medical conditions which could result in secondary causes of bone loss. Investigations did not reveal any causes of pathological fracture. This fracture is attributed to the use of long-term bisphosphonate therapy in conjunction with the use of a walking cane. This case highlights the importance of entertaining the possibility of such fractures occurring in any patient who is on bisphosphonate therapy presenting with stress fractures of the upper extremity.

Mechanical properties and the laminate structure of Arapaima gigas scales.

The Arapaima gigas scales play an important role in protecting this large Amazon basin fish against predators such as the piranha. They have a laminate composite structure composed of an external mineralized layer and internal lamellae with thickness of 50-60 µm each and composed of collagen fibers with ~1 µm diameter. The alignment of collagen fibers is consistent in each individual layer but varies from layer to layer, forming a non-orthogonal plywood structure, known as Bouligand stacking. X-ray diffraction revealed that the external surface of the scale contains calcium-deficient hydroxyapatite. EDS results confirm that the percentage of calcium is higher in the external layer. The micro-indentation hardness of the external layer (550 MPa) is considerably higher than that of the internal layer (200 MPa), consistent with its higher degree of mineralization. Tensile testing of the scales carried out in the dry and wet conditions shows that the strength and stiffness are hydration dependent. As is the case of most biological materials, the elastic modulus of the scale is strain-rate dependent. The strain-rate dependence of the elastic modulus, as expressed by the Ramberg-Osgood equation, is equal to 0.26, approximately ten times higher than that of bone. This is attributed to the higher fraction of collagen in the scales and to the high degree of hydration (30% H(2)O). Deproteinization of the scale reveals the structure of the mineral component consisting of an interconnected network of platelets with a thickness of ~50 nm and diameter of ~500 nm.

Modulation of macrophage activation by ammonium metavanadate.

The molecular basis of the immunotoxic effect of ammonium metavanadate on signal transduction involved in macrophage activation was studied in resident peritoneal macrophages (PEM) and a murine macrophage-like cell line, J774. A fourfold elevation in cytosolic free calcium levels was observed within 10 s following lipopolysaccharide (LPS) stimulation of the non-vanadate-exposed controls both in vitro and in vivo; the levels returned to prestimulation values within 70 s. Exposure to phorbol ester (PMA) did not result in any appreciable change in cytosolic free calcium levels. Compared to untreated controls, treatment with vanadate caused a significant elevation in basal cytosolic calcium levels. Such elevation was not enhanced further by LPS. LPS stimulation of macrophages also resulted in a significant elevation of membrane-associated protein kinase C (PKC) activity, which was, however, inhibited in a dose-dependent manner by vanadate in both in vitro and in vivo studies. Exposure to PMA also resulted in a significant elevation of membrane-associated PKC activity; vanadate treatment at lower levels did not cause downregulation, indicating that vanadate at these levels interfered with the receptor-mediated events rather than the enzyme directly. Vanadate at higher exposure levels inhibited the activity even in PMA-stimulated macrophages. No significant difference occurred in cytosolic PKC activities in control macrophages; vanadate treatment at lower levels resulted in a significant elevation of cytosolic PKC activities following stimulation with LPS or PMA, indicating that vanadate might be interfering with the translocation process.