Linda Peckel

Death from acute stroke has dropped by as much as 55 percent, shows a population study published in 

The decline, according to the authors who were led by Olena Seminog, University of Oxford, United Kingdom, is probably driven by improvements in stroke care. Even though there appears to be fewer deaths from stroke, stroke event rates increased among 35 to 54 year old men and women.

“The increase in stroke event rates in young adults is a concern. This suggests that stroke prevention needs to be strengthened to reduce the occurrence of stroke in people younger than 55 years,” the authors wrote.

The British study is based on a review of trends in stroke events and mortality from a national database of 759,869 adults who were admitted for or died from stroke during the period from 2000 to 2010.

Several important trends emerged: Death from acute stroke declined across all age groups, which included substantial reductions in mortality during the first 30 days following the event. And, more than half of all patients over age 85 who presented with stroke in 2001 died within the first 30 days, which decreased to 34 percent among men and 38 percent among women by 2010.

Although women in the cohort had higher rates of stroke events (55.1 percent) and stroke deaths (61.5 percent), total reductions in mortality were also moderately greater in women compared to men (reduced from 128/100,000 in 2001 to 72/100,000 in 2010 and 140/100,000 in 2001 to 74/100,000 in 2010, respectively).

The greatest reduction by age group was among those aged 35 to 54. Improvements in both event rates and survival from stroke were equally important in reducing death from stroke in people over age 85, while reduction of stroke mortality was the more significant factor in younger people, as stroke events rates increased by 2 percent each year from the age of 34.

The increase in the occurrence of stroke, observed in both men and women from ages 34 to 55 was of particular concern to the investigators. “This suggests that stroke prevention needs to be strengthened to reduce the occurrence of stroke in people younger than 55 years,” they wrote.

The authors concluded that improvements in stroke care are the major contributing factors to greater survival following acute stroke, but also noted that, “acute and long term management of such patients is expensive, and the NHS is already spending about 5 percent of its budget on stroke care. By focusing on prevention and reduci¬¬ng the occurrence of stroke, major resources can be conserved.”

Seminog OO, Scarborough P, Wright FL, Rayner M, Goldacre MJ.

 “Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults.”

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Death from acute stroke has dropped by as much as 55 percent, shows a population study published in BMJ.

Stroke Survival Much Improved Since 2000

Late-in-life weight gain or weight loss appears to be associated with an increased risk of dementia, shows a Korean study of 67,219 men and women between 60-79 years old.

The study, which was published earlier this month in 

, found that a weight change of more or less than 10 percent body mass index (BMI) over two years is associated with a 20 percent increased risk of dementia as compared to men and women who maintained their BMI over the same period.

“Our study demonstrated the detrimental effects of weight gain and loss on dementia in an elderly population,” wrote the authors who were led by Jin-Won Kwon, M.D., of Kyungpook National University, Korea.

The association between late-in-life weight gain and dementia didn’t appear to apply to men and women who had a  high BMI of more than 25 kg at the beginning of the study. However, a low BMI of less than 18.5 kg was associated with a significant increase in the risk of dementia in men, but not women.

The entire group was followed for an average 5.3 years.

4,887 men and 6,685 women developed dementia during the 5.3-year follow-up period.

51 percent of study participants were men.

Body mass index measures were documented for two years.

More women than men had BMIs higher than 25 kg:  40.2 percent of women compared to 28.9 percent of men.

Modifiable risk factors varied by sex-men were more likely to be smokers and consume alcohol, while women had a higher prevalence of hypercholesterolemia, hypertension, and congestive heart failure.

 "Cognitive function in diabetic patients"

The authors attributed the main impact of weight gain on 

to an increase in fat mass that provokes chronic inflammation leading to neurodegenerative changes. They suggested that the association between pre-existing middle-age obesity and lower dementia risk, could be due to the survivor effect.

Weight loss in later years, the authors wrote, suggests the presence of underlying preclinical dementia or other conditions that may influence cognitive function. Cardiometabolic risk factors, including hypertension, congestive heart failure, diabetes mellitus and high fasting blood sugar, were found to be significant risk factors for dementia. Diabetes patients with a high fasting blood sugar had a 1.6-fold higher risk of developing dementia. And, a sedentary lifestyle, smoking, and frequent drinking were also associated with the risk of dementia.

Regular moderate exercise at least three times weekly reduced the risk of developing dementia, the authors found.

“Our results suggest that continuous weight control, disease management, and the maintenance of a healthy lifestyle are beneficial in the prevention of dementia, even later in life,” they wrote.

1. Park S, Jeon SM, Jung SY, Hwang J, Kwon JW. 

“Effect of late-life weight change on dementia incidence: a 10-year cohort study using claim data in Korea.”

 2019;9:e021739. doi: 10.1136/bmjopen-2018-021739.

Dementia Tied to Late-in-Life Weight Gain and Loss

A single course of treatment with teplizumab delayed the development of 

 in at-risk teens and children, shows a study presented at the American Diabetes Association annual meeting earlier this month.

The study, by Kevan Herold, M.D., of Yale University, was a phase two randomized, placebo-controlled, double-blind trial of teplizumab, a novel monoclonal antibody. It included 76 patients (mean age 18 years) who had a relative with 

, but hadn’t developed the condition. The study participants had at least two autoantibodies and abnormal results of an oral glucose-tolerance test at baseline. They were assigned to a single 14-day course of teplizumab or placebo with follow-up testing every six months.

Less than half of the participants who received teplizumab (43 percent) were diagnosed after 48 months, while 72 percent of those who received placebo developed diabetes on an average of two years. This translated into annual rates of diagnosis of type 1 diabetes of 14.9 percent per year for teplizumab compared to 35.9 percent for those taking the placebo.

“The people who enrolled in the study didn’t have diabetes and don’t see physicians for care of diabetes. They don’t take insulin, don’t follow a diet or do any of the other things that people with diabetes need to do,” Dr. Herold said. “I am hoping this result will generate discussion about how to implement this preventative approach. Now that we have a treatment for delay and possibly prevention should we screen a larger group (those in the trial were relatives), even the general population.”

The treatment effect was greatest after the first year. During year one, diabetes was diagnosed in only three of 44 participants (7 percent) in the teplizumab group, but in 14 of 32 participants (44 percent) in the placebo group. The treatment effect diminished overall after three years.

Neighborhood Disadvantage Impacts Type 1 Diabetes

“We can’t really say that the treatment effect wanes after two or three or even more years in a given individual,” Dr. Herold said. “We can say that as a group there is waning of the effect but in our previous trial (AbATE) there was a group that showed very robust responses and a group that did not. It could be that those who have not developed diabetes by three years will continue to be diabetes free or they could lose any clinical benefit. We certainly need to follow the participants to figure this out.”

Currently, an estimated 1.5 million young adults in the U.S. have been diagnosed with type 1 diabetes. Immune therapies that target preservation of beta function have shown the most promise in patients with recent-onset clinical type 1 diabetes. By modifying the function of CD-8 and T lymphocytes that promote the destruction of beta cells, teplizumab has been shown to reduce the loss of beta cell function for long as seven years following diagnosis of type 1 diabetes.

“Our data suggest that responses to teplizumab differ on the basis of characteristics of the participants. The absence of one type 1 diabetes–associated MHC allele, HLA-DR3, but the presence of HLA-DR4, as well as the absence of anti-ZnT8 antibodies identified the persons most likely to have a response,” Dr. Herold said. Larger studies are warranted, he said.

Herold KC, Bundy BN, Long SA, et al. “An Anti-CD3 Antibody, Teplizumab, in Relatives at Risk for Type 1 Diabetes.” 

. 2019 Jun 9. doi: 10.1056/NEJMoa1902226.

Perdigoto AL, Preston-Hurlburt P, Clark P, Long SA, et al. “Treatment of type 1 diabetes with teplizumab: clinical and immunological follow-up after 7 years from diagnosis.” 

. 2019;62:655-664. doi: 10.1007/s00125-018-4786-9.

A single course of treatment with teplizumab delayed the development of type 1 diabetes in at-risk teens and children, shows a study presented at the American Diabetes Association annual meeting earlier this month.

Treatment Delays Onset of Diabetes in At-Risk Populations

Diabetes complications in young adults with type 2 diabetes are occurring in unusually high rates, researchers reported at the American Diabetes Association annual meeting held earlier this month in San Francisco.

The study, presented by Philip S. Zeitler, M.D., Ph.D., of Children’s Hospital Colorado, showed extensive development of severe renal, cardiac, eye, nerve and pregnancy complications in less than a decade of diagnosis.

are not being as vigorously managed as these data suggest is needed,” Dr. Zeitler stated in a press release, noting that in particular, less than half of participants were being treated for

 or high lipid levels that were already clinically evident. “Since these individuals are battling the disease at a younger age, they are experiencing life-changing health consequences caused by 

at the earliest stages of adulthood,” suggesting they will require even more intense management as they age.

The study, called Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY), included 517 participants (mean age 25 years). The average time since diagnosis was 12 years. More than half had 

, more than 60 percent had high blood pressure, and about 40 percent showed evidence for early diabetic kidney disease. Diabetic retinal disease was also evident in 50 percent of the group. Early signs of diabetic nerve disease were associated with poor glucose control in one-third of the group.

One quarter of the 306 pregnancies in the group had preterm deliveries and of 236 known outcomes, 25 percent resulted in miscarriage or fetal death.

Interesting T2DM: Peds Obesity & AHA Guides

Dr. Zeitler observed that acceptance of the need for more aggressive therapies in young adults appears to be split.

“Those providers who work with these kids and keep up with the research are probably coming around to more aggressive treatment. The barrier is the intrinsic resistance that occurs in people taking care of youth who hesitate to add medications for kids who are so young and don’t seem like they should need more meds. The fact is that the evidence base is lacking and the choice to treat blood pressure and/or lipids aggressively has to be supported by extrapolation of adult data and some providers are, not unreasonably, hesitant to do this extrapolation and start medications that aren’t proven to be needed,” he said.

Dr. Zeitler pointed to the ADA guidelines published in December 2018 as a good place for providers to look for a reasonable approach to 

of young adults with type 2 diabetes based on current knowledge. 

The National Institutes of Health has committed to start a new study to address prevention and effective interventions for youth-onset type 2 diabetes, Dr. Zeitler said. 

Linda Peckel

Articles

Stroke Survival Much Improved Since 2000

Dementia Tied to Late-in-Life Weight Gain and Loss

Treatment Delays Onset of Diabetes in At-Risk Populations

Young Adult Type 2 Diabetes Increasingly Associated with Serious Complications