Sayeeda Rahman

Diabetes-associated macrovasculopathy: pathophysiology and pathogenesis.

The complications associated with diabetic vasculopathy are commonly grouped into two categories: microvascular and macrovascular complications. In diabetes, macrovascular disease is the commonest cause of mortality and morbidity and is responsible for high incidence of vascular diseases such as stroke, myocardial infarction and peripheral vascular diseases. Macrovascular diseases are traditionally thought of as due to underlying obstructive atherosclerotic diseases affecting major arteries. Pathological changes of major blood vessels leading to functional and structural abnormalities in diabetic vessels include endothelial dysfunction, reduced vascular compliance and atherosclerosis. Besides, advanced glycation end product formation interacts with specific receptors that lead to overexpression of a range of cytokines. Haemodynamic pathways are activated in diabetes and are possibly amplified by concomitant systemic hypertension. Apart from these, hyperglycaemia, non‐enzymatic glycosylation, lipid modulation, alteration of vasculature and growth factors activation contribute to development of diabetic vasculopathy. This review focuses on pathophysiology and pathogenesis of diabetes‐associated macrovasculopathy.

Physician participation in clinical research and trials: issues and approaches

The rapid development of new drugs, therapies, and devices has created a dramatic increase in the number of clinical research studies that highlights the need for greater participation in research by physicians as well as patients. Furthermore, the potential of clinical research is unlikely to be reached without greater participation of physicians in research. Physicians face a variety of barriers with regard to participation in clinical research. These barriers are system-or organization-related as well as research-and physician-related. To encourage physician participation, appropriate organizational and operational infrastructures are needed in health care institutes to support research planning and management. All physicians should receive education and training in the fundamentals of research design and methodology, which need to be incorporated into undergraduate medical education and postgraduate training curricula and then reinforced through continuing medical education. Medical schools need to analyze current practices of teaching–learning and research, and reflect upon possible changes needed to develop a ‘student-focused teaching–learning and research culture’. This article examines the barriers to and benefits of physician participation in clinical research as well as interventions needed to increase their participation, including the specific role of undergraduate medical education. The main challenge is the unwillingness of many physicians and patients to participate in clinical trials. Barriers to participation include lack of time, lack of resources, trial-specific issues, communication difficulties, conflicts between the role of clinician and scientist, inadequate research experience and training for physicians, lack of rewards and recognition for physicians, and sometimes a scientifically uninteresting research question, among others. Strategies to encourage physician participation in clinical research include financial and nonfinancial incentives, adequate training, research questions that are in line with physician interests and have clear potential to improve patient care, and regular feedback. Finally, encouraging research culture and fostering the development of inquiry and research-based learning among medical students is now a high priority in order to develop more and better clinician-researchers.

Early manifestation of macrovasculopathy in newly diagnosed never treated type II diabetic patients with no traditional CVD risk factors

Type II diabetes patients have increased risk of macrovascular complications compared with the general population. Arterial stiffness is considered as an independent predictor of macrovascular events. This study investigated arterial stiffness in newly diagnosed never treated diabetes and impaired glucose tolerance (IGT) patients without any traditional cardiovascular diseases (CVD) risk factors. After preliminary screening of 1620 individuals, 30 diabetic and 30 IGT patients were recruited and compared with age- and sex-matched 30 normoglycaemic subjects. The subjects were newly diagnosed, never treated, normotensive, non-obese, non-hyperlipidaemic and non-smoker. Haemodynamic variables, pulse wave velocity (PWV) and augmentation index (AI) were measured. The PWV was significantly higher in diabetic patients (10.37+/-2.64m/s vs. 8.70+/-1.29m/s; p=0.035) and was of borderline significant in IGT subjects (9.54+/-1.56m/s vs.8.70+/-1.29m/s, p=0.078) compared to normoglycaemic individuals. Augmentation index was higher of borderline significant in diabetic (134.53+/-17.32% vs. 129.17+/-11.18%, p=0.055) and IGT patients (132.02+/-16.11% vs. 129.17+/-11.18%, p=0.059) compared to normoglycaemic individuals. The study demonstrated that newly diagnosed never treated diabetic patients without any CV complications had early manifestation of macrovascular diseases as evident by increased arterial stiffness. The findings also revealed early manifestations of preclinical vasculopathy and potentially increased risk for development of macrovascular diseases at an early age in diabetic patients.

Effect of rosiglitazone/ramipril on preclinical vasculopathy in newly diagnosed, untreated diabetes and IGT patients: 1-year randomised, double-blind, placebo-controlled study

ObjectiveTo investigate whether pharmacological interventions with rosiglitazone/ramipril can reverse preclinical vasculopathy in newly diagnosed untreated patients with type 2 diabetes (T2DM) and impaired glucose tolerance (IGT).MethodsIn this randomised, double-blind, placebo-controlled study, 33 T2DM and 33 IGT patients were randomised to 4 mg rosiglitazone or 5 mg ramipril or placebo for 1 year. The subjects were newly diagnosed, untreated, normotensive, nonobese, nonsmoker, and nonhyperlipidaemic. Haemodynamic variables were measured at three treatment phases and pulse wave velocity (PWV) and augmentation index (AI) were measured throughout the treatment period.ResultsRosiglitazone showed a significant reduction in PWV (p=0.039) and AI (p=0.031) and ramipril demonstrated a significant reduction of AI (p=0.025) in IGT in comparison to placebo on the 12th month of treatment. No significant difference was observed in PWV and AI in T2DM with rosiglitazone/ramipril in comparison to placebo during overall treatment period.ConclusionsRosiglitazone significantly reversed preclinical vasculopathy in IGT as evident by significant decrease in PWV and AI after 1 year of treatment. Ramipril also reduced large artery stiffness as shown by significant decrease of AI after 1 year of treatment in IGT. Further trials are needed for a longer period of time, maybe with higher doses, to show whether rosiglitazone/ramipril can reverse preclinical vasculopathy in T2DM.

Treatment of diabetic vasculopathy with rosiglitazone and ramipril: Hype or hope?

Cardiovascular diseases are responsible for increased morbidity and mortality in people with diabetes. Diabetic macrovasculopathy is associated with structural and functional changes in large arteries, which causes endothelial dysfunction, increased arterial stiffness, or decreased arterial distensability. Diabetic complications can be controlled and avoided by strict glycemic control, maintaining normal lipid profiles, regular physical exercise, adopting a healthy lifestyle and pharmacological interventions. Treatment goals for patients with type 2 diabetes specify targets for glycemia and other cardiometabolic risk factors, for example, hypertension and dyslipidemia. In recent years, special attention has been devoted to both thiazolidindiones (TZDs) and angiotensin converting enzyme (ACE) inhibitors as clinical trials revealed that these drugs may reduce the rate of progression to diabetes or delay the onset of diabetes, regression of impaired glucose tolerance (IGT) to normoglycemia and reduces the composite of all-cause mortality, nonfatal myocardial infarction and stroke in patients with diabetes. This review focuses on the potential roles of rosiglitazone, a member of TZD class of antidiabetic agents, and ramipril, an ACE inhibitor, in preventing the preclinical macrovasculopathy in diabetes and IGT population.

career choices among medical students in Bangladesh

Introduction Information regarding career choices of medical students is important to plan human resources for health, design need-based educational programs, and ensure equitable and quality health care services in a country. Aim The aim of the study is to identify career choices, nature of career, intended practice locations, and reasons for career choices of Bangladesh medical students. Method First-, third-, and fifth-year students of Bangladesh Medical College and Uttara Adhunik Medical College completed a self-report questionnaire on career choices, nature of career, intended practice locations, and reasons for career choices. The students were requested to choose three long-term choices from the given specialties. Results A total of 132 students responded (46 males and 86 females) and response rate was 75%. The popular choices (first choice) among males and females were medical specialty, surgical specialty, obstetrics and gynecology, and general practice. For first, second, and third choices altogether, male students chose surgical specialties and female students preferred medical specialties. The leading reasons for selecting a specialty were personal interest and wide job opportunity. More than 67% of respondents wanted to join private services and about 90% chose major cities as practice locations. About 43% of respondents expressed willingness to practice medicine in Bangladesh, whereas 51% of total respondents wanted to practice abroad. Discussion Majority of students intended to specialize in established clinical specialties and subsequently practice in major cities, and more than half wanted to immigrate to other countries. Basic medical subjects and service-oriented (lifestyle-related) and preventive/social medical specialties were found to be less attractive. If this pattern continues, Bangladesh will suffer a chronic shortage of health personnel in certain specialties and in rural areas. Conclusions Reorientation of health care and medical education is needed along with policy settings to attract doctors to the scarcity and high-priority disciplines so that imbalances encountered would be minimal in future.

Supporting medical students with learning disabilities in Asian medical schools

Learning disabilities (LDs) represent the largest group of disabilities in higher education (HE) institutes, including medical schools, and the numbers are continuing to rise. The worrying concern is that two-thirds to half of these students with LDs remain undiagnosed when they start their undergraduate education and may even graduate without having their disabilities diagnosed. These students struggle with their academic abilities, receive poor grades and, as a result, develop lower perceptions of their intellectual abilities than do those students without LDs. All these ultimately hamper their professional practice, employment, and career progression. Appropriate and adequate educational policies, provisions, and practices help students to progress satisfactorily. In Asian countries, public and professional awareness about LDs is low, supportive provisions are limited, legislations are inadequate, data are scarce, and equal-opportunity/widening-participation policies are not implemented effectively in the HE sector. This article discusses the issues related to LDs in medical education and draws policy, provision, and practice implications to identify, assess, and support students with LDs in medical schools, particularly in an Asian context.

Treatment of diabetic vasculopathy: an overview

Correspondence: Sayeeda Rahman Department of Clinical Sciences, School of Medical Sciences, University of Bradford, Bradford BD7 1DP, United Kingdom Tel +44 12 7423 6283 Email srahman6@bradford.ac.uk Abstract: Type 2 diabetes is a chronic, degenerative, and noncommunicable disease, and is associated with a high prevalence of cardiovascular morbidity and mortality. The complications of diabetic vasculopathy are commonly grouped into microvascular and macrovascular complications. In diabetes, macrovascular complications are the commonest cause of morbidity and mortality and are responsible for a high incidence of vascular diseases. The aim of this review to provide an overview of current treatment modalities for diabetic vasculopathy and highlight the importance of effective control of blood glucose, blood lipids, and blood pressure, as well as reduction of blood hypercoagulability, in lowering the macrovascular complications of diabetic vasculopathy. A literature review was conducted to retrieve the relevant information using the PubMed, Science Direct, and Google Scholar databases, reports, and books. People with type 2 diabetes are at markedly increased risk for cardiovascular disease and mortality. The initiators of vasculopathy that ultimately develop into long-term diabetic complications can be avoided by a healthy lifestyle and pharmacological intervention. Clinical trials have shown that effective control of blood glucose, blood lipids, blood pressure, and blood hypercoagulability can reduce macrovascular complications in patients with type 2 diabetes. Type 2 diabetes is responsible for premature mortality, predominantly through atherosclerotic vascular disease. Lifestyle modification and pharmacotherapy should be used to prevent or delay development of type 2 diabetes, including adverse cardiovascular outcomes. A multidisciplinary approach involving patients, health professionals, and diabetic educators should be used to combat the type 2 diabetes epidemic and its associated cardiovascular complications.

Increased arterial stiffness in normoglycaemic offspring of newly diagnosed, never treated type 2 diabetic and impaired glucose tolerance parents

Arterial stiffness has been used to demonstrate vasculopathy in adults with diabetes but studies on arterial stiffness in offspring of diabetic patients are scarce, and no study has been reported in the offspring of parents with impaired glucose tolerance (IGT). In this study arterial stiffness in normoglycaemic offspring (n=30) of parents with type 2 diabetes, normoglycaemic offspring (n=30) of IGT parents and 30 age and sex-matched normoglycaemic offspring of normoglycaemic parents was investigated. Arterial stiffness was assessed by pulse wave velocity (PWV) and augmentation index (AI) using SphygmoCor. Significantly higher PWV was noted in offspring of type 2 diabetes than in offspring of normoglycaemic parents (6.94±0.9 vs. 6.33±0.7 m/s, p=0.010). Offspring of type 2 diabetes parents also demonstrated significantly higher PWV than IGT offspring (6.94±0.9 vs. 6.43±1.1, p=0.021). Significantly higher AI was observed in offspring of type 2 diabetes and IGT parents than progeny of normoglycaemic parents (105.62±14.2 vs. 96.42±7.7, p=0.001; 104.98±11.1 vs. 96.42±7.7%, p=0.004, espectively). The study demonstrated that normoglycaemic offspring of newly diagnosed, never treated type 2 diabetes and IGT parents had increased arterial stiffness. Such increases in arterial stiffness revealed early manifestations of preclinical vasculopathy and potentially increased risk for development of macrovascular diseases in the normoglycaemic offspring. Br J Diabetes Vasc Dis 2009;9: 65–68.

Effect of rosiglitazone and ramipril on macrovasculopathy in patients with type 2 diabetes: needs longer treatment and/or higher doses?

Introduction The aim of the study is to investigate whether standard doses of rosiglitazone (4 mg/daily) and ramipril (5 mg/daily) can reverse pre-clinical macrovasculopathy in newly diagnosed never treated type 2 diabetes (T2DM) patients. Methods In this randomized, double-blind, placebo-controlled study, 33 T2DM patients were randomized to rosiglitazone (4 mg/daily) or ramipril (5 mg/daily) or placebo for 1 year. Hemodynamic variables were measured at 3 treatment phases and pulse wave velocity (PWV) and augmentation index (AI) were measured throughout the treatment period. Result In diabetic patients, PWV (P = 0.037) and AI (P = 0.005) with ramipril and AI (P < 0.001) with rosiglitazone were significantly reduced during overall treatment period from the baseline; however, these differences were not significant in comparison to placebo. Discussion and conclusion The present study showed that treatment with standard doses of rosiglitazone and ramipril are not adequate to reverse pre-clinical vasculopathy in T2DM. The lack of benefit in newly diagnosed T2DM may be because of the relatively short-term intervention and/or the use of lower doses of rosiglitazone/ramipril. Further trials are needed for a longer period of time, possibly with higher doses, to show whether rosiglitazone/ramipril can reverse pre-clinical vasculopathy in T2DM (ClinicalTrials.gov number, NCT00489229).