Clinical Rounds

OB.GY N. N E W S • March 15, 2008

Metabolic Syndrome Adds To Diabetes Stroke Risk

Smoking May Raise Risk of Developing Neuropathic Pain

San Francisco Bureau


atients with both type 2 diabetes and metabolic syndrome have strokes an average of 3.5 years earlier than do those who have type 2 diabetes alone, according to a study. There were no significant differences between diabetes patients with and without metabolic syndrome in the type of stroke, with lacunar stroke predominating in both groups, wrote Imtiaz M. Shah and colleagues from Ayr (Scotland) Hospital (Diabetes Res. Clin. Prac. 2008;79:e1-4). The retrospective study involved 151 patients with metabolic syndrome and type 2 diabetes, and a control group of 92 patients with diabetes alone. All patients had experienced a stroke between September 1996 and August 2004. Patients were considered to have metabolic syndrome if they had two or more of the following additional risk factors: obesity, low HDL cholesterol, elevated triglycerides, or hypertension. Patients with metabolic syndrome experienced their stroke at an average of 71.7 years of age, compared with 75.2 years among the control group, a statistically significant difference. Other than the defining characteristics of metabolic syndrome, the only other significant difference between the groups was in the proportion taking statins, which was 40% among patients with metabolic syndrome and 24% among the control group. Lacunar stroke, an indication of smallvessel disease, was responsible for 44% of strokes in both control patients and 44% of strokes in patients with metabolic syndrome. Transient ischemic attacks accounted for 39% of the strokes in control

patients and 38% of the patients with metabolic syndrome; cortical strokes accounted for 15% and 13% of the strokes, respectively; and intracerebral hemorrhage accounted for the remaining 2% and 5% of the strokes. A multivariate analysis revealed no statistically significant differences between the groups in stroke subtypes. The results emphasize the importance of aggressive management of patients with both metabolic syndrome and type 2 diabetes because of their high vascular risk state, the investigators wrote. They also noted that lacunar stroke has been associated with endothelial dysfunction, and that ACE inhibition, angiotensin receptor blockade treatment, and statins have all been shown to reverse endothelial dysfunction. The investigators stated that they had no conflicts of interest. ■

Orlando Bureau

Metabolic Syndrome Associated With Earlier Occurrence of Stroke in Diabetic Patients
Age (years) 71.7 75.2

Type 2 diabetes plus metabolic syndrome (n = 151)

Type 2 diabetes alone (n = 92)

Source: Diabetes Research and Clinical Practice

O R L A N D O — In a community sample of 205 adults with chronic pain of any type, neuropathic pain was documented in almost two-thirds of those who smoked, compared with one-third of those who did not smoke, Dr. Todd G. Call reported at the annual meeting of the American Academy of Pain Medicine. “The results were a little bit of a surprise to us, but it appears that smoking seems to confer a greater risk of neuropathic pain. We’re not quite sure why that is. It’s too early to say. The study really wasn’t designed to look at that, but it’s worth looking into further,” Dr. Call of the Mayo Medical School, Rochester, Minn., said in an interview. Dr. Call and his colleagues sought to validate a method of screening for neuropathic pain in adults with chronic pain living in the community. They identified a subset of adults with self-reported nerve pain, and confirmed the diagnosis according to scores on the self-reported Leeds Assessment of Neuropathic Symptoms and Signs pain scale and select ICD-9-CM codes associated with neuropathic pain on chart review. They also assessed smoking status. Neuropathic pain was confirmed in 75 of the 205 patients. The remaining 130 patients had chronic, nociceptive pain. Overall, 13% of the participants smoked, but among patients in the neuropathic pain subset, 21% were smokers. Dr. Call speculated that there might be something about nicotine that causes chronic ischemia or nerve damage. “Or perhaps it’s more a matter of be-

havior, and people who smoke are involved in more dangerous behavior, or situations where they suffer more back injuries,” he said. “At any rate, our finding just gives one more reason for doctors to tell their pain patients to quit smoking.” In another study from the Mayo Clinic, Dr. Susan Moeschler reported that females attending the Mayo Clinic’s pain center had higher pain intensity scores if they smoked, compared with female nonsmokers and smoking and nonsmoking males. Compared with 131 female nonsmokers, the 14 female smokers were more likely to be unemployed and less likely to have completed high school. Smokers also reported greater pain intensity, which was more likely to interfere with their mood, personal relationships, sleep, and enjoyment of life, according to Borderline Personality Inventory subscales. Among the 85 men in the study, 22 of whom were smokers, smoking status was not related to any demographic, pain intensity, or mood interference differences. “These findings suggest that female smokers with painful conditions have greater affective distress than other male smokers and other subsets of patients,” Dr. Moeschler said. Dr. Call and colleagues’ study was supported by an unrestricted grant from AstraZeneca Pharmaceuticals LP and the U.S. National Institutes of Health. Dr. Call said he had no financial conflicts of interest. Dr. Moeschler and colleagues’ study was supported by institutional funds from the Mayo Clinic’s Department of Anesthesia. ■

Insulin Restriction May Shorten Life Span in Type 1 Diabetes

Chicago Bureau


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. Because of various psychosocial variables, more than half of adult patients do not achieve the American Diabetes Association’s glycemic targets, explained Ann E. Goebel-Fabbri, Ph.D., of the Joslin Diabetes Center and Harvard Medical School, both in Boston, and her associates. Chief among the implicated variables are general psychological distress, diabetes-specific distress, fear of hypoglycemia, concern about weight gain, and related eating-disorder behaviors. In this 11-year study, the largest to examine the longterm effect of insulin restriction on the morbidity and mortality of women with type 1 diabetes, insulin restriction at baseline conveyed more than a threefold increase in the relative risk of death, said the authors (Diabetes Care 2008;31:1-5). At baseline, the cohort included 234 women aged 1360 years who had had a diagnosis of type 1 diabetes for at least 1 year, and who agreed to be followed up. Of those, 26 women died during the study period. Mean age at follow-up was 45 years, with a range of 2472 years.

Women reporting insulin restriction showed distinct clinical differences from those reporting appropriate insulin use. At baseline, insulin restricters were significantly younger (aged 32 vs. 36 years) and had higher hemoglobin A1c values (9.6% vs. 8.3%). However, there were no differences between the two groups with regard to baseline body mass index (BMI) or diabetes duration, the authors said. Predictably, insulin restricters reported significantly lower scores on the baseline measure of diabetes self-care behaviors, and they scored higher on baseline measures of diabetes distress; fear of hypoglycemia; general psychological symptoms; eating disorder symptoms, such as bulimia; and the Eating Disorders Inventory, the researchers explained. In addition, women who said at baseline that they restricted insulin were significantly more likely to report nephropathy and foot problems at follow-up, the researchers said, adding that self-reported rates of retinopathy, neuropathy, and cardiovascular complications at follow-up did not differ between groups. Causes of death for 10 of 71 women reporting insulin restriction included perforated bowel with gastroparesis (1), cancer (1), cardiac events (3), hypoglycemia (1), renal failure (2), sepsis (1), and suicide in the context of retinopathy-related blindness (1).


Causes of death for 16 of 163 women reporting appropriate insulin use included cancer (1), cardiac events (11), diabetic ketoacidosis (1), sepsis (2), and unknown 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 significantly younger age, and had higher baseline hemoglobin A1c values, poorer diabetes self-care behaviors, increased levels of diabetes-specific distress, and higher scores on measures of bulimia and other eating disorder symptoms, the scientists reported. Compared with their living counterparts, deceased insulin restricters at baseline had higher BMI and hemoglobin A1c values and reported more symptoms of bulimia and higher levels of diabetes-specific distress. “These data suggest that mortality associated with insulin restriction occurred in the context of eating disorder symptoms, rather than other psychological distress,” the authors said. They added that these patients require careful monitoring and would benefit from in-depth evaluations by a mental health professional, ideally one with specialized training in diabetes. “Unfortunately, such specialty services are rarely available to individuals with type 1 diabetes,” they said. The researchers recommended that clinicians screen their type 1 diabetes patients by routinely asking them if they follow their insulin prescriptions. ■