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22 Clinical Rounds OB.GY N.

N E W S • March 15, 2008

Metabolic Syndrome Adds Smoking May Raise Risk of

To Diabetes Stroke Risk Developing Neuropathic Pain
BY ROBERT FINN patients and 38% of the patients with B Y F R A N L O W RY havior, and people who smoke are in-
San Francisco Bureau metabolic syndrome; cortical strokes ac- Orlando Bureau volved in more dangerous behavior, or
counted for 15% and 13% of the strokes, situations where they suffer more back

atients with both type 2 diabetes and respectively; and intracerebral hemor- O R L A N D O — In a community sample injuries,” he said. “At any rate, our find-
metabolic syndrome have strokes rhage accounted for the remaining 2% of 205 adults with chronic pain of any ing just gives one more reason for doc-
an average of 3.5 years earlier than and 5% of the strokes. A multivariate type, neuropathic pain was documented tors to tell their pain patients to quit
do those who have type 2 diabetes alone, analysis revealed no statistically signifi- in almost two-thirds of those who smoking.”
according to a study. cant differences between the groups in smoked, compared with one-third of In another study from the Mayo Clin-
There were no significant differences stroke subtypes. those who did not smoke, Dr. Todd G. ic, Dr. Susan Moeschler reported that fe-
between diabetes patients with and with- The results emphasize the importance Call reported at the annual meeting of males attending the Mayo Clinic’s pain
out metabolic syndrome in the type of of aggressive management of patients the American Academy of Pain Medi- center had higher pain intensity scores if
stroke, with lacunar stroke predominating with both metabolic syndrome and type 2 cine. they smoked, compared with female
in both groups, wrote Imtiaz M. Shah and diabetes because of their high vascular risk “The results were a little bit of a sur- nonsmokers and smoking and non-
colleagues from Ayr (Scotland) Hospital state, the investigators wrote. They also prise to us, but it appears that smoking smoking males.
(Diabetes Res. Clin. Prac. 2008;79:e1-4). noted that lacunar stroke has been associ- seems to confer a greater risk of neuro- Compared with 131 female nonsmok-
The retrospective study involved 151 ated with endothelial dysfunction, and pathic pain. We’re not quite sure why ers, the 14 female smokers were more
patients with metabolic syndrome and that ACE inhibition, angiotensin receptor that is. It’s too early to say. The study re- likely to be unemployed and less likely to
type 2 diabetes, and a control group of 92 blockade treatment, and statins have all ally wasn’t designed to look at that, but have completed high school.
patients with diabetes alone. All patients been shown to reverse endothelial dys- it’s worth looking into further,” Dr. Call Smokers also reported greater pain
had experienced a stroke between Sep- function. of the Mayo Medical School, Rochester, intensity, which was more likely to in-
tember 1996 and August 2004. Patients The investigators stated that they had no Minn., said in an interview. terfere with their mood, personal rela-
were considered to have metabolic syn- conflicts of interest. ■ Dr. Call and his colleagues sought to tionships, sleep, and enjoyment of life,
drome if they had two or more of the fol- validate a method of screening for neu- according to Borderline Personality In-
lowing additional risk factors: obesity, low ropathic pain in adults with chronic pain ventory subscales. Among the 85 men in
HDL cholesterol, elevated triglycerides, or Metabolic Syndrome Associated living in the community. the study, 22 of whom were smokers,
hypertension. With Earlier Occurrence of They identified a subset of adults with smoking status was not related to any de-
Patients with metabolic syndrome ex- Stroke in Diabetic Patients self-reported nerve pain, and confirmed mographic, pain intensity, or mood in-
perienced their stroke at an average of 71.7 Age (years) the diagnosis according to scores on the terference differences.
years of age, compared with 75.2 years self-reported Leeds Assessment of Neu- “These findings suggest that female
among the control group, a statistically sig- 71.7 ropathic Symptoms and Signs pain scale smokers with painful conditions have
nificant difference. Other than the defin- and select ICD-9-CM codes associated greater affective distress than other male
ing characteristics of metabolic syndrome, with neuropathic pain on chart review. smokers and other subsets of patients,”
the only other significant difference be- They also assessed smoking status. Dr. Moeschler said.
tween the groups was in the proportion Neuropathic pain was confirmed in 75 Dr. Call and colleagues’ study was
taking statins, which was 40% among pa- of the 205 patients. The remaining 130 supported by an unrestricted grant from

tients with metabolic syndrome and 24% patients had chronic, nociceptive pain. AstraZeneca Pharmaceuticals LP and
among the control group. Type 2 diabetes Type 2 diabetes
Overall, 13% of the participants smoked, the U.S. National Institutes of Health. Dr.
Lacunar stroke, an indication of small- plus metabolic alone but among patients in the neuropathic Call said he had no financial conflicts of
vessel disease, was responsible for 44% of syndrome (n = 92) pain subset, 21% were smokers. interest.
strokes in both control patients and 44% (n = 151) Dr. Call speculated that there might be Dr. Moeschler and colleagues’ study
of strokes in patients with metabolic syn- Source: Diabetes Research and Clinical something about nicotine that causes was supported by institutional funds
drome. Transient ischemic attacks ac- Practice chronic ischemia or nerve damage. from the Mayo Clinic’s Department of
counted for 39% of the strokes in control “Or perhaps it’s more a matter of be- Anesthesia. ■

Insulin Restriction May Shorten Life Span in Type 1 Diabetes

BY BRUCE K. DIXON Women reporting insulin restriction showed distinct Causes of death for 16 of 163 women reporting ap-
Chicago Bureau clinical differences from those reporting appropriate in- propriate insulin use included cancer (1), cardiac events
sulin use. (11), diabetic ketoacidosis (1), sepsis (2), and unknown

W omen with type 1 diabetes who take less insulin than

prescribed may be raising their risk of complications
and shortening their life spans, researchers reported.
At baseline, insulin restricters were significantly
younger (aged 32 vs. 36 years) and had higher hemoglo-
bin A1c values (9.6% vs. 8.3%). However, there were no
causes (1), Dr. Goebel-Fabbri noted in an interview.
Comparisons of both groups of deceased women
found that those who had restricted insulin died at a sig-
Because of various psychosocial variables, more than differences between the two groups with regard to base- nificantly younger age, and had higher baseline hemo-
half of adult patients do not achieve the American Dia- line body mass index (BMI) or diabetes duration, the au- globin A1c values, poorer diabetes self-care behaviors, in-
betes Association’s glycemic targets, explained Ann E. thors said. creased levels of diabetes-specific distress, and higher
Goebel-Fabbri, Ph.D., of the Joslin Diabetes Center and Predictably, insulin restricters reported significantly scores on measures of bulimia and other eating disorder
Harvard Medical School, both in Boston, and her associ- lower scores on the baseline measure of diabetes self-care symptoms, the scientists reported.
ates. Chief among the implicated variables are general behaviors, and they scored higher on baseline measures Compared with their living counterparts, deceased in-
psychological distress, diabetes-specific distress, fear of hy- of diabetes distress; fear of hypoglycemia; general psy- sulin restricters at baseline had higher BMI and hemo-
poglycemia, concern about weight gain, and related eat- chological symptoms; eating disorder symptoms, such as globin A1c values and reported more symptoms of bu-
ing-disorder behaviors. bulimia; and the Eating Disorders Inventory, the re- limia and higher levels of diabetes-specific distress.
In this 11-year study, the largest to examine the long- searchers explained. “These data suggest that mortality associated with in-
term effect of insulin restriction on the morbidity and In addition, women who said at baseline that they re- sulin restriction occurred in the context of eating disor-
mortality of women with type 1 diabetes, insulin re- stricted insulin were significantly more likely to report der symptoms, rather than other psychological distress,”
striction at baseline conveyed more than a threefold in- nephropathy and foot problems at follow-up, the re- the authors said. They added that these patients require
crease in the relative risk of death, said the authors (Di- searchers said, adding that self-reported rates of retinopa- careful monitoring and would benefit from in-depth
abetes Care 2008;31:1-5). thy, neuropathy, and cardiovascular complications at fol- evaluations by a mental health professional, ideally one
At baseline, the cohort included 234 women aged 13- low-up did not differ between groups. with specialized training in diabetes. “Unfortunately,
60 years who had had a diagnosis of type 1 diabetes for Causes of death for 10 of 71 women reporting insulin such specialty services are rarely available to individuals
at least 1 year, and who agreed to be followed up. Of restriction included perforated bowel with gastroparesis with type 1 diabetes,” they said.
those, 26 women died during the study period. (1), cancer (1), cardiac events (3), hypoglycemia (1), renal The researchers recommended that clinicians screen
Mean age at follow-up was 45 years, with a range of 24- failure (2), sepsis (1), and suicide in the context of their type 1 diabetes patients by routinely asking them if
72 years. retinopathy-related blindness (1). they follow their insulin prescriptions. ■