Therapeutic Advances in Diabetic Nephropathy

Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease (ESKD) in the United States. Risk factor modification, such as tight control of blood glucose, management of hypertension and hyperlipidemia, and the use of renin–angiotensin–aldosterone system (RAAS) blockade have been proven to help delay the progression of DKD. In recent years, new therapeutics including sodium-glucose transport protein 2 (SGLT2) inhibitors, endothelin antagonists, glucagon like peptide-1 (GLP-1) agonists, and mineralocorticoid receptor antagonists (MRA), have provided additional treatment options for patients with DKD. This review discusses the various treatment options available to treat patients with diabetic kidney disease.

Risky business: a scoping review for communicating results of predictive models between providers and patients

Objective Given widespread excitement around predictive analytics and the proliferation of machine learning algorithms that predict outcomes, a key next step is understanding how this information is—or should be—communicated with patients. Materials and Methods We conducted a scoping review informed by PRISMA-ScR guidelines to identify current knowledge and gaps in this domain. Results Ten studies met inclusion criteria for full text review. The following topics were represented in the studies, some of which involved more than 1 topic: disease prevention (N = 5/10, 50%), treatment decisions (N = 5/10, 50%), medication harms reduction (N = 1/10, 10%), and presentation of cardiovascular risk information (N = 5/10, 50%). A single study included 6- and 12-month clinical outcome metrics. Discussion As predictive models are increasingly published, marketed by industry, and implemented, this paucity of relevant research poses important gaps. Published studies identified the importance of (1) identifying the most effective source of information for patient communications; (2) contextualizing risk information and associated design elements based on users’ needs and problem areas; and (3) understanding potential impacts on risk factor modification and behavior change dependent on risk presentation. Conclusion An opportunity remains for researchers and practitioners to share strategies for effective selection of predictive algorithms for clinical practice, approaches for educating clinicians and patients in effectively using predictive data, and new approaches for framing patient-provider communication in the era of artificial intelligence.

Risk factor modification reduced incidence of atrial fibrillation in an 18-year prospective cohort study: a time-updated analysis

Background Although atrial fibrillation (AF) is an increasing health burden worldwide, strategies for AF prevention are lacking. This study aimed to identify modifiable risk factors (MRF) for and estimate their impact on AF risk in the midlife general population. Methods We assessed 9,049 participants who were free of prevalent AF at baseline from the Korean Genome and Epidemiology Study. Cox models with time-varying assessment of risk factors were used to identify significant MRF for incident AF. The MRF burden was defined as the proportion of times presented MRF during follow-up, based on the number of visits. Results Over a median follow-up of 13.1 years, 182 (2.01%) participants developed AF. In time-updated multivariable models accounting for changes in risk factors, three MRF including systolic blood pressure (SBP) more than 140 mmHg, obesity with central obesity, and an inactive lifestyle were significantly associated with incident AF. Compared to subjects with three MRF, those with one or no MRF had a decreased risk of AF (hazard ratio [95% CI] for one MRF, 0.483 [0.256–0.914]; and for no MRF, 0.291 [0.145–0.583]). A decreasing MRF burden was associated with reduced AF risk (hazard ratio [95% CI] per 10% decrease in SBP more than 140 mmHg, 0.937 [0.880–0.997]; in obesity with central obesity, 0.942 [0.907–0.978]; in inactivity, 0.926 [0.882–0.973]). Conclusions Maintenance or achievement of optimal MRF control was associated with decreased AF risk, suggesting that minimizing the burden of MRF might help prevent AF.

Vascular Calcification and Cardiovascular Risk in Chronic Kidney Disease: A Problem That Is Here to Stay

Cardiovascular disease is the primary cause of morbidity and mortality in chronic kidney disease (CKD) population, particularly in end stage renal disease (ESRD). This could be explained in part due to the presence of traditional cardiovascular risk factors, such as older age, hypertension, dyslipidemia and diabetes, but is also associated with nontraditional cardiovascular risk factors related to CKD, like inflammation, anemia, abnormal calcium and phosphate metabolism and extracellular fluid volume overload, which may contribute to intimal or medial wall arterial calcification. Vascular calcification (VC) is a dynamic process, resulting from the dysregulation of the balance of molecules that promote and those that inhibit this course. It is important for clinicians to both acknowledge and recognize the pathways and risk factors of VC in order to improve cardiovascular health in CKD patients. This chapter will focus on the biology of VC, the association with CKD, risk factor modification, screening and prevention of VC and cardiovascular disease in CKD patients.

Chronic Migraine Pathophysiology and Treatment: A Review of Current Perspectives

Chronic migraine is a disabling neurological disorder that imposes a considerable burden on individual and socioeconomic outcomes. Chronic migraine is defined as headaches occurring on at least 15 days per month with at least eight of these fulfilling the criteria for migraine. Chronic migraine typically evolves from episodic migraine as a result of increasing attack frequency and/or several other risk factors that have been implicated with migraine chronification. Despite this evolution, chronic migraine likely develops into its own distinct clinical entity, with unique features and pathophysiology separating it from episodic migraine. Furthermore, chronic migraine is characterized with higher disability and incidence of comorbidities in comparison to episodic migraine. While existing migraine studies primarily focus on episodic migraine, less is known about chronic migraine pathophysiology. Mounting evidence on aberrant alterations suggest that pronounced functional and structural brain changes, central sensitization and neuroinflammation may underlie chronic migraine mechanisms. Current treatment options for chronic migraine include risk factor modification, acute and prophylactic therapies, evidence-based treatments such as onabotulinumtoxinA, topiramate and newly approved calcitonin gene-related peptide or receptor targeted monoclonal antibodies. Unfortunately, treatments are still predominantly ineffective in aborting migraine attacks and decreasing intensity and frequency, and poor adherence and compliance with preventative medications remains a significant challenge. Novel emerging chronic migraine treatments such as neuromodulation offer promising therapeutic approaches that warrant further investigation. The aim of this narrative review is to provide an update of current knowledge and perspectives regarding chronic migraine background, pathophysiology, current and emerging treatment options with the intention of facilitating future research into this debilitating and largely indeterminant disorder.

Targeting residual inflammatory risk in coronary disease: to catch a monkey by its tail

Patients with coronary disease remain at high risk for future cardiovascular events, even with optimal risk factor modification, lipid-lowering drugs and antithrombotic regimens. A myriad of inflammatory pathways contribute to progression of the atherosclerotic burden in these patients. Only in the last few years has the inflammatory biology of atherosclerosis translated into clinical therapeutic options. Low-dose colchicine can provide a clinically relevant reduction in the risk for composite and individual major cardiovascular outcomes in patients with acute and chronic coronary syndromes. Among others, its anti-inflammatory effects in atherosclerosis seem to be related to neutrophil recruitment and adhesion, inflammasome inhibition, and morphological changes in platelets and platelet aggregation. Future research is aimed at further elucidating its particular mechanism of action, as well as identifying patients with the highest expected benefit and evaluating efficacy in other vascular beds. These data will help to formulate the role of colchicine and other anti-inflammatory drugs in patients with coronary disease and atherosclerosis in general in the near future.

The Treatment of Painful Diabetic Neuropathy

: Painful diabetic peripheral neuropathy (painful-DPN) is a highly prevalent and disabling condition, affecting up to one-third of patients with diabetes. This condition can have a profound impact, resulting in a low quality of life, disruption of employment, impaired sleep, and poor mental health with an excess of depression and anxiety. The management of painful-DPN poses a great challenge. Unfortunately, there are currently no Food and Drug Administration (USA) approved disease-modifying treatments for diabetic peripheral neuropathy (DPN) as trials of putative pathogenetic treatments have failed at phase 3 clinical trial stage. Therefore, the focus of managing painful-DPN other than improving glycaemic control and cardiovascular risk factor modification is treating symptoms. The recommended treatments based on expert international consensus for painful-DPN have remained essentially unchanged for the last decade. Both the serotonin re-uptake inhibitor (SNRI) duloxetine and α2δ ligand pregabalin have the most robust evidence for treating painful-DPN. Weak opioids (e.g., tapentadol and tramadol, both of which have an SNRI effect), tricyclic antidepressants, such as amitriptyline and α2δ ligand gabapentin, are also widely recommended and prescribed agents. Opioids (except tramadol and tapentadol) should be prescribed with caution in view of the lack of definitive data surrounding efficacy and concerns surrounding addiction and adverse events. Recently, emerging therapies have gained local licenses, including the α2δ ligand mirogabalin (Japan) and the high dose 8% capsaicin patch (FDA and Europe). The management of refractory painful-DPN is difficult; specialist pain services may offer off-label therapies (e.g., botulinum toxin, intravenous lidocaine,, and spinal cord stimulation), although there is limited clinical trial evidence supporting their use. Additionally, despite combination therapy being commonly used clinically, there is little evidence supporting this practice. There is a need for further clinical trials to assess novel therapeutic agents, optimal combination therapy, and existing agents to determine which are the most effective for the treatment of painful-DPN. This article reviews the evidence for the treatment of painful-DPN, including emerging treatment strategies, such as novel compounds and stratification of patients according to individual characteristics, (e.g., pain phenotype, neuroimaging, and genotype) to improve treatment responses.

Identify the patients perceived learning needs after myocardial infarction

Funding Acknowledgements Type of funding sources: None. Background Cardiovascular disease is the major trait to public health and the leading cause of death worldwide. There are over 1 million new and recurrent myocardial infarctions (MI) occur each year and 12,000 of these individuals are still living. Patients surviving from MI have to adapt to live with the heart disease and restore their quality of life. Hence health education for patients to combat the disease as secondary prevention has become very important. Health care professionals must understand the information needs of patients so that effective health education could be taken place consistently with patients’ needs, to optimize outcome of risk factor modification and lifestyle changes. Purpose This study aims to identify post MI patients" perceived learning needs and the demographic factors that influence the needs. Methods Cross-sectional design and convenience sampling method were used for this study. A questionnaire adapted from Cardiac Patient Learning Needs Inventory (CPLNI) was completed by 56 patients who were recruited from a tertiary hospital during inpatient hospitalization in Malaysia. Data from the questionnaires were analyzed using SPSS version 24. Results It was shown that patients’ perceived learning needs were highly important in all eight domains. All domains range from mean 3.52-3.66. Information in the domains of other pertinent information (sign and symptom of MI), medication as well as anatomy and physiology were highly needed by post MI patients, with mean 3.66, 3.65 and 3.64 respectively. Age was significantly related to the patients’ learning need in the domain of anatomy and physiology. Conclusion MI patients need abundant cardiac related information prior discharge, to regain and improve their life. This need should be met by delivering appropriate health education before discharge or during follow-up by health care professionals. There is a necessity to integrate this study finding into the cardiac rehabilitation content to benefit post MI patients.