Effects of structured hospital-based care compared with standard care for Type 2 diabetes-The Asker and Baerum Cardiovascular Diabetes Study, a randomized trial

AIMS

Few studies have compared structured vs. standard care on the effects of modifying several cardiovascular (CV) risk factors in subjects with Type 2 diabetes. Because of the complexity of the disease, we hypothesized that structured care with a multi-interventional approach is necessary to effectively reach treatment goals and to reduce CV risk.

METHODS

An open 2-year parallel-group study in 120 patients (age 59 +/- 10 years, 31 females) with Type 2 diabetes (median duration 4 years) was conducted. The patients were randomized to standard care (follow-up by their general practitioner) or to structured care at a hospital outpatient clinic consisting of an initial 6 months' lifestyle programme followed by targeted intensified pharmacological treatment to reach prespecified goals for glycaemic, lipid and blood pressure (BP) control. The primary outcome was change in the estimated 10-year absolute risk for fatal coronary heart disease (CHD).

RESULTS

One hundred and six patients completed the study. Improvements were greater among patients receiving structured rather than standard care for systolic BP, triglycerides, glucose and glycated haemoglobin (HbA(1c)) (P < 0.05), as well as for the estimated 10-year CHD-risk (17.9% to 14.5% vs. 18.3% to 19.6%) and the prevalence of a CHD risk >or= 20% (38% to 22% vs. 39% to 45%). Most of the reduction in estimated CHD risk (77%) in the structured care group was obtained during the period (6-24 months) with intensified pharmacological treatment (P < 0.01).

CONCLUSIONS

This study shows that 2 years of structured care combining lifestyle and pharmacological interventions improved several CV risk factors and reduced the estimated 10-year absolute risk for CHD in patients with Type 2 diabetes.

Inflammation and coronary angiography in asymptomatic type 2 diabetic subjects

OBJECTIVE

Coronary artery disease (CAD) is prevalent in patients with type 2 diabetes mellitus (T2DM) and because it is often asymptomatic and extensive in comparison with CAD in subjects without diabetes, it represents a diagnostic challenge. The objective of the study was to investigate the prevalence of CAD in asymptomatic T2DM patients utilizing angiography and to investigate its association with cardiovascular (CV) risk factors, the metabolic syndrome and markers of inflammation.

MATERIAL AND METHODS

Eighty-two patients with T2DM without symptoms of CAD, and with >or=1 CV risk factor (hypertension, dyslipidaemia, premature familial CAD, smoking or microalbuminuria) underwent a diagnostic stress test and coronary angiography irrespective of stress test results. Stenosis detected in the main coronary arteries >or=50% of lumen diameter was categorized as one-, two- or three-vessel disease. Inflammatory markers were analysed in fasting samples.

RESULTS

Fifteen men and two women had significant CAD (21%) (1-vessel disease, n=10; 2- or 3-vessel disease, n=7). Patients with 2- or 3-vessel disease were significantly older and had a longer duration of diabetes, but the prevalence of other traditional CV risk factors or the metabolic syndrome was similar among those with 1-vessel and those with 2- or 3-vessel disease. Sensitivity for CAD of the stress test was low (0.35). The mean level of the pro-inflammatory marker interleukin-6 was elevated in patients with 2- to 3-vessel CAD as compared to patients with no or 1-vessel CAD (p<0.05).

CONCLUSIONS

Significant CAD was found in 21% of asymptomatic patients with T2DM with >or=1 CV risk factor. Inflammatory markers may be helpful in identifying patients that are likely to have significant CAD, but larger studies are warranted.

Undiagnosed dysglycaemia and inflammation in cardiovascular disease

BACKGROUND

Cardiovascular (CV) disease is associated with increased levels of glucose, but the prevalence of dysglycaemia in CV diseases is not fully known. The study examined the prevalence of unknown dysglycaemia and its association with inflammation in Caucasian patients with ischaemic vascular complications, i.e. coronary artery disease (CAD), cerebrovascular disease (CVD) and peripheral artery disease (PAD).

MATERIALS AND METHODS

This case-controlled study involved 149 patients (mean age 68 years) hospitalized for CAD, PAD or CVD and 59 control-subjects (CTR) free from CV-disease. The prevalence of dysglycaemia according to WHO/ADA criteria (impaired fasting glycaemia, impaired glucose tolerance or diabetes mellitus) was assessed by a 75-g oral glucose tolerance test. Inflammatory parameters were analyzed in fasting samples.

RESULTS

Dysglycaemia was found in 49%, 55% and 57% of patients with CAD, CVD and PAD, respectively; all were significantly higher than among the controls (29%). The odds ratio (95% CI) for being dysglycaemic were 1.7 (1.04-2.77), 1.9 (1.19-3.06) and 2.0 (1.25-3.19) for CAD, CVD and PAD, respectively. Inflammatory markers (the total leucocyte count, soluble tumour necrosis factor-receptor type I, C-reactive protein) were elevated in patient groups and tended to increase with increasing blood glucose levels in all groups. The levels of the anti-inflammatory cytokine transforming growth factor-beta1 and insulin-like growth factor binding protein 3 were lowered in patients with CAD and, in patients with PAD, the former was inversely related to the levels of the blood glucose.

CONCLUSIONS

Undiagnosed dysglycaemia was common in patients with ischaemic CV manifestations regardless of vascular bed involved. Inflammation was associated in a dosage-related manner to glucose levels.

Blood glucose lowering by means of lifestyle intervention has different effects on adipokines as compared with insulin treatment in subjects with type 2 diabetes

AIMS/HYPOTHESIS

Adipokines may be important in mediating signals from adipocytes to insulin-sensitive tissue and vasculature. We studied the effect of different glucose-lowering therapies on serum levels of plasminogen activator inhibitor-1 (PAI-1), high-sensitivity C-reactive protein (hs-CRP), TNF-alpha, leptin, adiponectin and ghrelin in patients with type 2 diabetes.

SUBJECTS AND METHODS

Twenty-eight patients with poorly controlled type 2 diabetes who were receiving oral hypoglycaemic agents were allocated to one of the following groups, and treated for 1 year: (1) lifestyle intervention (L); (2) insulin treatment (I); and (3) combined treatment (L+I).

RESULTS

Similar improvements in glycaemic control occurred in all three groups. There was a reduction in body weight of 3.0 kg (median) (95% CI -5.9 to -2.0) in group L, whereas in groups L+I and I body weight increased by 3.5 kg (95% CI 1.5-4.9) and 4.9 kg (95% CI -3.1 to 8.2), respectively. By trend analyses, group L had reduced levels of PAI-1 (p=0.002), hs-CRP (p<0.0001) and TNF-alpha (p=0.006), while no significant changes were observed in the levels of leptin or adiponectin. In group I, the median levels of PAI-1 (p=0.008), TNF-alpha (p=0.058) and leptin (p=0.004) increased. In the L+I group there was a reduction in PAI-1 levels (p=0.014) and an increase in levels of leptin (p<0.001). The differences in changes in the levels of PAI-1, hs-CRP, TNF-alpha and leptin between groups were also significant (all p<0.01).

CONCLUSIONS/INTERPRETATION

Improvement of glycaemic control through lifestyle intervention in type 2 diabetes had more beneficial effects on adipokine levels than when the same lowering of HbA(1c) was achieved with insulin treatment.

An intensified lifestyle intervention programme may be superior to insulin treatment in poorly controlled Type 2 diabetic patients on oral hypoglycaemic agents: results of a feasibility study

AIMS

The aims of this study were to assess whether, in Type 2 diabetic patients with inadequate glycaemic control on oral hypoglycaemic agents (OHA), a lifestyle intervention programme based on exercise and diet counselling (i) was as effective as insulin treatment in controlling blood glucose, and (ii) could prevent the weight gain usually accompanying the introduction of insulin treatment.

METHODS

Thirty-eight Type 2 diabetic subjects treated with OHA, HbA(1c) 8-10.5% and body mass index (BMI) 26-40 kg/m2, were randomized to the following treatments: (i) lifestyle intervention (L), (ii) lifestyle intervention + insulin treatment (L+I) and (iii) insulin treatment alone (I).

RESULTS

There was a reduction in HbA(1c) of -1.2 (interquartile range 1.0), -1.0 (1.7) and -1.5 (2.5)% in group L, L+I and I, respectively, and all treatment groups achieved beneficial changes in blood lipid variables. There was no significant difference between the groups in the change observed in levels of HbA(1c) between start and 12 months of treatment (P = 0.74). There was a significant difference in weight changes between groups (P < 0.01): group L reduced weight by median -3.0 (4.0) kg, groups L+I and I increased weight by 3.5 (3.4) and 4.9 (6.9) kg, respectively.

CONCLUSIONS

Lifestyle intervention was as effective as insulin treatment in improving glycaemic control in poorly controlled subjects with Type 2 diabetes, and resulted in weight loss during the intervention year. However, glycaemic control deteriorated and body weight increased in the lifestyle intervention group 1 year after the intervention stopped.

Ethnicity and sex are strong determinants of diabetes in an urban Western society: implications for prevention

AIMS/HYPOTHESIS

This study was conducted to investigate the prevalence of diabetes and its association with ethnicity and sex, to identify subgroups at special risk.

METHODS

We performed a population-based cross-sectional survey of 30- to 67-year-olds in an area of Oslo with low socio-economic status, and collected data using questionnaires, physical examinations and serum analyses for the 2,513 participants (attendance rate 49.3%).

RESULTS

In the age group 30-59 years, mean BMI was 28.5 (95% CI: 27.5-29.6) for South Asian women, 26.1 (25.9-26.4) for Western women, 26.7 (26.1-27.4) for South Asian men and 27.2 (26.9-27.5) for Western men. The diabetes prevalence rates were 27.5% (18.1-36.9) for South Asian women, 2.9% (1.9-3.4) for Western women, 14.3% (8.0-20.7) for South Asian men and 5.9% (4.2-7.5) for Western men. The age-adjusted odds ratio (OR) for diabetes for women vs men was 1.9 (0.9-4.1) for South Asians, and 0.4 (0.3-0.6) for the Western population (p<0.001). The age-adjusted OR for diabetes for South Asians vs Westerners was 11.0 (5.8-21.1) for women and 3.0 (1.6-5.4) for men, and after adjustment for WHR the ORs were 7.7 (3.9-15.3) for women and 2.6 (1.4-4.9) for men. After additional adjustments for physical activity, education, body height and fertility for women, the OR was 6.0 (2.3-15.4) for women and 1.9 (0.9-4.0) for men.

CONCLUSIONS/INTERPRETATION

The alarmingly high prevalence of diabetes among South Asian women in Norway needs further investigation, as it has considerable public health implications. Ethnic differences in OR for diabetes persisted after adjustment for age, adiposity, physical activity and education. These differences were still present for women after additional adjustment for body height and fertility.

Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity

AIMS

Patients with diabetes have an unfavourable prognosis after an acute myocardial infarction. In the first DIGAMI study, an insulin-based glucose management improved survival. In DIGAMI 2, three treatment strategies were compared: group 1, acute insulin-glucose infusion followed by insulin-based long-term glucose control; group 2, insulin-glucose infusion followed by standard glucose control; and group 3, routine metabolic management according to local practice.

METHODS AND RESULTS

DIGAMI 2 recruited 1253 patients (mean age 68 years; 67% males) with type 2 diabetes and suspected acute myocardial infarction randomly assigned to groups 1 (n=474), 2 (n=473), and 3 (n=306). The primary endpoint was all-cause mortality between groups 1 and 2, and a difference was hypothesized as the primary objective. The secondary objective was to compare total mortality between groups 2 and 3, whereas morbidity differences served as tertiary objectives. The median study duration was 2.1 (interquartile range 1.03-3.00) years. At randomization, HbA1c was 7.2, 7.3, and 7.3% in groups 1, 2, and 3, respectively, whereas blood glucose was 12.8, 12.5, and 12.9 mmol/L, respectively. Blood glucose was significantly reduced after 24 h in all groups, more in groups 1 and 2 (9.1 and 9.1 mmol/L) receiving insulin-glucose infusion than in group 3 (10.0 mmol/L). Long-term glucose-lowering treatment differed between groups with multidose insulin (> or =3 doses/day) given to 15 and 13% of patients in groups 2 and 3, respectively compared with 42% in group 1 at hospital discharge. By the end of follow-up, HbA1c did not differ significantly among groups 1-3 ( approximately 6.8%). The corresponding values for fasting blood glucose were 8.0, 8.3, and 8.6 mmol/L. Hence, the target fasting blood glucose for patients in group 1 of 5-7 mmol/L was never reached. The study mortality (groups 1-3 combined) was 18.4%. Mortality between groups 1 (23.4%) and 2 (22.6%; primary endpoint) did not differ significantly (HR 1.03; 95% CI 0.79-1.34; P=0.831), nor did mortality between groups 2 (22.6%) and 3 (19.3%; secondary endpoint) (HR 1.23; CI 0.89-1.69; P=0.203). There were no significant differences in morbidity expressed as non-fatal reinfarctions and strokes among the three groups.

CONCLUSION

DIGAMI 2 did not support the fact that an acutely introduced, long-term insulin treatment improves survival in type 2 diabetic patients following myocardial infarction when compared with a conventional management at similar levels of glucose control or that insulin-based treatment lowers the number of non-fatal myocardial reinfarctions and strokes. However, an epidemiological analysis confirms that the glucose level is a strong, independent predictor of long-term mortality in this patient category, underlining that glucose control seems to be an important part of their management.

Prevalence of hypertension in HIV-positive patients on highly active retroviral therapy (HAART) compared with HAART-naïve and HIV-negative controls: results from a Norwegian study of 721 patients

Highly active antiretroviral therapy (HAART) may induce dyslipidemia, insulin resistance and body fat distribution similar to that seen in the metabolic syndrome. Hypertension is often a part of the classic metabolic syndrome, but few studies are published about hypertension in HIV-positive patients on HAART. The aim of this study was to compare the prevalence of hypertension in HIV-positive patients on HAART with that in HIV-positive/HAART-naïve patients and HIV-negative controls. The cross-sectional study included 283 unselected HIV-positive ambulatory patients, 219 who were on HAART and 64 who were HAART-naïve. Age- and gender-matched controls (n=438) were randomly selected from a simultaneous health survey of the general population. The prevalence of hypertension was 21% in patients on HAART, 13% in HAART-naïve patients (P=0.20), and 24% in HIV-negative controls (P=0.28). Among several possible risk factors for hypertension, only body mass index (BMI) was found to be a confounder. BMI was similar in HAART-treated and HAART-naïve patients but elevated in controls compared to HAART-treated patients. After adjustment for BMI, the prevalence of hypertension in HIV-negative controls was slightly lower than that in patients on HAART (P=0.29). The results demonstrated a prevalence of hypertension in patients on HAART similar to that in HIV-negative controls. The prevalence of hypertension was somewhat higher in patients on HAART compared to HAART-naïve patients, but the difference was not statistically significant. Considering the marked drop in mortality following antiretroviral therapy, we conclude that the possible influence of HAART on the prevalence of hypertension appears to be a minor problem.

Plasma leptin in postmenopausal women with coronary artery disease: effect of transdermal 17beta-estradiol and intermittent medroxyprogesterone acetate

OBJECTIVES

In the present study, the relationship between plasma leptin and other cardiovascular risk factors in high-risk postmenopausal women was assessed, as well as the effect of transdermal 17beta-estradiol unopposed or in combination with intermittent medroxyprogesterone acetate (MPA) on plasma leptin.

METHODS

Postmenopausal women (n = 118) with coronary artery disease (CAD) were consecutively recruited from women admitted to hospital for coronary angiography. They were randomized to estradiol plus intermittent MPA or to a control group, and investigated at study inclusion, and after 3 and 12 months.

RESULTS

A strong relationship was found between leptin and body mass index (r = 0.69, p < 0.001). Leptin was related to lipid fractions (high-density lipoprotein cholesterol: r = -0.33, p < 0.001; apolipoprotein A: r = -0.28, p = 0.004; and triglycerides: r = 0.27, p = 0.003) and indices of glucose metabolism (C-peptide: r = 0.47, p < 0.001; fasting insulin: r = 0.42, p < 0.001; glucose: r = 0.25, p = 0.008; insulin resistance: r = 0.45, p < 0.001; and insulin secretion: r = 0.36, p < 0.001). In a multiple regression model, only body mass index (p < 0.001) and C-peptide (p = 0.002) remained as independent factors for leptin levels. Despite the association with sex hormone-binding globulin (r = 0.30, p = 0.001), no effect on leptin levels was observed with either unopposed transdermal estradiol or estradiol combined with MPA.

CONCLUSION

Plasma leptin is related to other cardiovascular risk factors in postmenopausal women with CAD, but seems to be unaffected by transdermal 17beta-estradiol administration.

The relationships between dehydroepiandrosterone sulphate (DHEAS), the intensity of Schistosoma mansoni infection and parasite-specific antibody responses. A cross-sectional study in residents of endemic communities in north-east Ethiopia

There are speculations that the puberty-related hormone dehydroepiandrosterone sulphate (DHEAS) might influence the intensity of infection and immune responses during Schistosoma infections. We studied the relationships between DHEAS, intensity of Schistosoma mansoni infection and humoral immune responses in 135 residents of Ethiopia. Serum levels of eight antibody isotypes against worm and egg antigens were determined by ELISA. DHEAS was measured with an immunoluminometric assay. There was a significant negative correlation between serum levels of DHEAS and intensity of S. mansoni infection. A significant increase in serum levels of DHEAS in the age group 15-19 years was accompanied by a progressive decline in the intensity of infection. Peak level of DHEAS coincided with the lowest intensity of infection in the age group 20-29 years. Multiple regression analysis showed that DHEAS alone had a significant (p<0.0001) negative effect when the effect of age was removed. Age also had a significant (p<0.0001) negative effect on the intensity of infection, after removing the effect of DHEAS. The two predictive variables accounted for 34.4% of the decline in the intensity of infection. Age accounted for 24.9%, whereas DHEAS accounted for 15.2% when the effect of each of the variables was removed. DHEAS had significant negative effects on AWA-specific IgG (p=0.02) and IgG1 (p=0.018) and SEA-specific IgG1 (p=0.009), after adjusting for the effect of age.

Increased serum levels of the specific AGE-compound methylglyoxal-derived hydroimidazolone in patients with type 2 diabetes

A time-delayed fluorescence immunoassay was developed for the determination of serum levels of methylglyoxal (MG)-derived hydroimidazolone using a monoclonal antiserum raised against Nalpha-acetyl-Ndelta-(5-hydro-5-methyl)-4-imidazolone, Europium-labeled anti-mouse IgG antiserum as indicator, and MG modified bovine serum albumin (BSA) as standard. Serum levels of hydroimidazolone were measured in 45 patients with type 2 diabetes aged 59.4 +/- 6.1 (mean +/- SD) years and with duration of diabetes of 7.3 +/- 3.1 years, and in 19 nondiabetic controls aged 56.3 +/- 4.3 years. The serum levels of hydroimidazolone were significantly higher in patients compared to controls: median, 3.0 (5-95 percentile, 1.6 to 5.4) U/mg protein versus 1.9 (1.2 to 2.8) U/mg protein (P =.0005). Significant positive correlations were observed between the serum levels of hydroimidazolone and serum levels of advanced glycation end products (AGEs), measured with a polyclonal anti-AGE antibody: r = 0.59 for patients (P <.0001), and r = 0.65 for controls (P =.002). Similarly, significant correlations were also found between serum levels of hydroimidazolone and N(epsilon)-(carboxymethyl)-lysine (CML): r = 0.36 in patients and r = 0.55 for controls (both P =.02). Serum hydroimidazolone levels did not correlate with fasting plasma glucose or hemoglobin A(1c) (HbA(1c)) levels. The observed differences between patients with diabetes and nondiabetic controls seem to be comparable to differences measured for other AGE compounds.

Smoking and relation to other risk factors in postmenopausal women with coronary artery disease, with particular reference to whole blood viscosity and beta-cell function

OBJECTIVES

To investigate possible associations between smoking habits and other coronary risk factors in postmenopausal women with known coronary heart disease (CHD).

SETTING

The study was conducted at a university clinic.

SUBJECTS

A total of 118 postmenopausal women with CHD verified with angiography, consecutively recruited.

INTERVENTIONS

Conventional treatment for CHD. The women were randomized to hormone replacement therapy (HRT) with transdermal 17-beta oestradiol and medroxyprogesterone acetate, or to a control group.

RESULTS

Smokers were younger (P = 0.005), had lower body mass index (P = 0.04) and lipoprotein Lp(a) levels (P = 0.02) compared with nonsmokers. Smokers had reduced beta-cell function (homeostasis model assessment, P = 0.006), whereas whole blood viscosity (WBV) was higher at all shear rates. WBV was not affected by HRT over a 12-month period. Oestrone levels were higher in smokers.

CONCLUSIONS

Smoking adversely affects insulin secretion (beta-cell function) and WBV in postmenopausal women with established CHD, which could be of importance as a mechanism for the increased risk of CHD in smokers. The importance of smoking as a risk factor, overrides the effect of Lp(a), which is lower in smokers compared with nonsmokers.

Heterogeneity of non-insulin-dependent diabetes expressed as variability in insulin sensitivity, beta-cell function and cardiovascular risk profile

AIMS

The present study investigated the variability in insulin sensitivity and beta-cell function and their relationship to anti-glutamic acid decarboxylase (GAD) positivity and the metabolic syndrome in a group of patients with non-insulin-dependent diabetes mellitus (NIDDM).

METHODS

Fifty-four subjects aged 59.5 +/- 6.1 (mean +/- SD) years with NIDDM for 7.9 +/- 3.9 years referred to hospital due to poor glycaemic control, were investigated. Insulin sensitivity was determined by the euglycaemic hyperinsulinaemic glucose clamp technique as the glucose disposal rate relative to the insulin level obtained (GDRI), and also estimated with the homeostasis model assessment (HOMA-S). beta-cell function was measured by assaying the fasting and glucagon-stimulated C-peptide levels and with the HOMA-B.

RESULTS

The insulin sensitivity varied 18-fold between subjects when estimated with the clamp and six-fold when estimated with HOMA-S, and was lower the more criteria for the metabolic syndrome present (P = 0.0001 by anova). The beta-cell function varied four-fold when measured as stimulated C-peptide, and eight-fold when estimated with the HOMA-B. The levels of fasting C-peptide and HOMA-B values tended to be lower in anti-GAD+ (n = 11) than in anti-GAD-subjects (P = 0.06 and P = 0.08, respectively). From previously published coronary risk charts, we estimated the 10-year risk of a coronary heart disease (CHD) event to be > 20% in 17 of 39 patients free from cardiovascular disease at the time of study, 16 of whom qualified for a diagnosis of the metabolic syndrome.

CONCLUSIONS

The wide variations in insulin sensitivity and beta-cell function found among subjects with NIDDM support the notion that the disorder is highly heterogeneous. Reduced insulin sensitivity was clearly related to the metabolic syndrome and an increased risk for CHD.

Active recovery and post-exercise white blood cell count, free fatty acids, and hormones in endurance athletes

Strenuous endurance exercise in fasted subjects is accompanied by increased plasma levels of catecholamines, leucocytosis, low insulin, and elevated plasma free fatty acids (FFA). Immediately after such exercise, plasma FFA may rise to high and potentially harmful levels, whereas the white blood cell count (WBCC) rapidly decreases towards or below baseline values. The present work investigated how active recovery (AR) for 15 min at 50% of maximal oxygen consumption (VO2max), after 60 min of uphill running at 83% of VO2max, influenced plasma FFA, lymphocyte, neutrophil, granulocyte, and monocyte count, as well as adrenaline, noradrenaline, insulin and cortisol concentrations until 120 min post-exercise. Thirteen endurance athletes participated in the study [24.2 (3.7) years, 1.82 (0.06) m, 76.7 (7.9) kg and VO2max 69.2 (6.8) ml min-1 kg-1]. In a randomized order, the subjects completed two sets of strenuous workouts, followed by either AR or complete rest in the supine position (RR). Compared with RR, AR strongly counteracted the rapid increase in plasma FFA 5 min post-exercise. The decreases in neutrophil and monocyte counts post-exercise were nullified by AR, and the cell count stayed above resting values throughout the observation period. AR also counteracted the rapid return of hormone concentration towards baseline levels. It would appear that active recovery at low intensity after strenuous exercise can maintain sufficient adrenergic activation to counteract the post-exercise drop in WBCC. However, in spite of keeping the catecholamine concentration high and insulin levels low, AR can also maintain a low plasma FFA concentration, probably because of the continued use of FFA in muscle. It remains to be elucidated whether the observed high FFA and low WBCC values after RR have a negative effect on health. If so, AR could be a preventive measure.

Relationship between occlusion and satisfaction with dental appearance in orthodontically treated and untreated groups. A longitudinal study

The aims of this study were to assess the relationship between occlusion, satisfaction with dental appearance, and self-esteem at the ages of 11 (T1) and 15 years (T2), and to study perceived treatment effects. Separate questionnaires were completed by children and their parents to determine their attitude. The dental casts of 224 children were collected at T1 and T2, and assessed by the Aesthetic Component (AC) and Dental Health Component (DHC) of the Index of Orthodontic Treatment Need (IOTN), and Peer Assessment Rating (PAR) Index. At T2, 16 children had been treated with removable and 51 with fixed appliances, while 157 were untreated. The children in the fixed appliance group had better dental aesthetics (AC) and occlusion (DHC) than those in the two other groups. Average PAR score reduction was 71.6 per cent (T1-T2) and satisfaction with own or child's dental appearance increased significantly. The untreated group showed increased malocclusions. In spite of that, the children expressed higher satisfaction with their own dental appearance at T2 than at T1, while the parents' satisfaction level was unchanged. For the total group, orthodontic concern at T1, AC at T2, and gender accounted for 18.0 per cent of the variation in the children's satisfaction with their own dental appearance. Parents' concern at T1 and AC at T2 accounted for 32.2 per cent of the variation in parents' satisfaction. Improvement in self-esteem from 11 to 15 years was not correlated with treatment changes. A gender difference was found. The answers to the questionnaire indicated that both children and parents rate pleasant aesthetics as an important factor for psychosocial well being.

[Prevention of cardiovascular disease in type 2 diabetes]

BACKGROUND

Patients with type 2 diabetes have a high risk of morbidity and premature mortality from cardiovascular disease. Epidemiological studies show that many of the risk factors are the same as in non-diabetic subjects. At present there are sufficient data in the literature to recommend prophylactic measures to be initiated in diabetic patients.

MATERIAL AND METHODS

We review major studies relevant for prophylactic measures against cardiovascular disease in patients with type 2 diabetes, and suggest Norwegian recommendations.

RESULTS

All patients should be advised to adhere to a healthy life style including an appropriate diet, physical exercise and no smoking. Treatment of hyperglycaemia is primarily indicated in order to improve quality of life and reduce the risk of microvascular complications, as it still remains to be proven if glucose lowering therapy may protect against macrovascular disease. Pharmacological prophylactic therapy with acetylsalicylic acid, anti-hypertensive agents and lipid lowering drugs are indicated in high-risk patients.

IMPLICATIONS

Several pharmacological and non-pharmacological interventions may protect type 2 diabetic patients from premature cardiovascular morbidity and mortality. Anti-hypertensive treatment may protect diabetic patients both from microvascular and macrovascular disease and premature death.

[Hypoglycemic treatment of type 2 diabetes]

BACKGROUND

Hyperglycaemia in type 2 diabetes results from reduced beta-cell function and insulin resistance. The treatment of type 2 diabetes must be targeted against both conditions to reduce symptoms of hyperglycaemia and the risk of diabetic late complications.

MATERIAL AND METHODS

In this review we cover the recent scientific documentation from long term studies on treatment effects. We also discuss the different treatments available.

RESULTS

Recent clinical trials have shown that lowering blood glucose levels over time significantly reduces development of microvascular complications in type 2 diabetes. There are several treatment options available which make adequate blood glucose control possible in patients with type 2 diabetes.

INTERPRETATION

A reduction in the development of microvascular complications in type 2 diabetes is an achievable goal.

Effect of rhEPO administration on serum levels of sTfR and cycling performance

PURPOSE

We assessed the possibility of using soluble transferrin receptor (sTfR) as an indicator of doping with recombinant erythropoietin (rhEPO).

METHODS

A double-blind, placebo-controlled study was conducted with the administration of 5,000 U of rhEPO (N = 10) or placebo (N = 10) three times weekly (181-232 U x kg(-1) x wk-1) for 4 wk to male athletes. We measured hematocrit and the concentration of hemoglobin, sTfR, ferritin, EPO, and quantified the effects on performance by measuring time to exhaustion and maximal oxygen uptake (VO2max) on a cycle ergometer.

RESULTS

Hematocrit increased from 42.7 +/- 1.6% to 50.8 +/- 2.0% in the EPO group, and peaked 1 d after treatment was stopped. In the EPO group, there was an increase in sTfR (from 3.1 +/- 0.9 to 6.3 +/- 2.3 mg x L(-1) , P < 0.001) and in the ratio between sTfR and ferritin (sTfR-ferritin(-1)) (from 3.2 +/- 1.6 to 11.8 +/- 5.1, P < 0.001). The sTfR increase was significant after 1 wk of treatment and remained so for 1 wk posttreatment. Individual values for sTfR throughout the study period showed that 8 of 10 subjects receiving rhEPO, but none receiving placebo, had sTfR levels that exceeded the 95% confidence interval for all subjects at baseline (= 4.6 mg x L(-1)). VO2max increased from 63.6 +/- 4.5 mL x kg(-1) x min(-1) before to 68.1 +/- 5.4 mL x kg(-1) x min(-1) 2 d post rhEPO administration (7% increase, P = 0.001) in the EPO group. Hematocrit, sTfR, sTfR-ferritin(-1), and VO2max did not change in the placebo group.

CONCLUSION

Serum levels of sTfR may be used as an indirect marker of supranormal erythropoiesis up to 1 wk after the administration of rhEPO, but the effects on endurance performance outlast the increase in sTfR.

[The obesity epidemics--do diet pills have a place in the treatment?]

BACKGROUND

Many experts consider obesity a chronic disease that may require long-term therapy. A loss of 5-15% of body weight is associated with improvements in cardiovascular risk factors and morbidity. However, most studies show that the majority of patients who lose weight relapse. Patients may be unable to maintain a low energy intake when confronted with an almost limitless supply of food. Moreover, a number of physiological mechanisms favour a set point for body weight, that may be altered with anti-obesity drugs.

MATERIAL AND RESULTS

In the current paper we describe actions and effects of current anti-obesity drugs. The centrally acting drug, sibutramine, is an adrenaline and serotonine re-uptake inhibitor which was recently approved in the USA for obesity. The USA, the European Union and Norway have approved orlistat, a pancreatic lipase inhibitor for weight reduction for up to two years. Patients must maintain a low fat intake in order to avoid gastrointestinal discomfort. In recent studies, orlistat and diet reduced body weight by 9% versus 6% on placebo and diet. No studies have documented long-term safety of anti-obesity drugs.

INTERPRETATION

Treatment of a lifestyle-related disease like obesity with medications is controversial, however, such treatment may not differ substantially from treatment of type II diabetes, hyperlipidaemia or hypertension.

The EWA (estrogen in women with atherosclerosis) study: a randomized study of the use of hormone replacement therapy in women with angiographically verified coronary artery disease. Characteristics of the study population. Effects on lipids and lipoproteins

OBJECTIVES

To evaluate the effects of hormone replacement therapy (HRT) on lipids and lipoproteins in postmenopausal women with coronary artery disease.

SETTING

In this single-centre, controlled and randomized study taking place in a tertiary referral clinic, patients were examined at baseline, and after 3 and 12 months. All analyses were performed examiner-blind.

SUBJECTS

Postmenopausal women (n = 118) with angiographically verified coronary artery disease were recruited consecutively from patients referred for investigational procedures due to coronary artery disease.

INTERVENTIONS

The women were randomized to HRT, i.e. transdermal application of continuous 17-beta oestradiol with cyclic medroxyprogesterone actetate tablets every 3rd month for 14 days, or to a control group.

MAIN OUTCOMES

Effects on lipids and lipoproteins.

RESULTS

After 3 months of unopposed oestradiol, triglycerides decreased significantly compared to the control group (P = 0.006). Sequential administration of medroxyprogesterone caused a decrease in HDL cholesterol (P = 0.01), concomitantly with a decrease in ApoA1 lipoproteins (P = 0.007). No other changes in lipids or lipoproteins were observed. After 12 months of therapy, no significant differences were observed between the two groups in lipid or lipoprotein levels. Concomitant statin treatment did not alter the main findings.

CONCLUSIONS

In postmenopausal women with established coronary artery disease in whom the majority is treated with statins, no additional effect of HRT on lipids or lipoproteins could be observed except for a transient decrease in triglycerides in the initial unopposed oestradiol phase. No deleterious effect could be observed during medroxyprogesterone administration except for a small transient decrease in HDL cholesterol and ApoA1 lipoproteins.

Improved postprandial glycaemic control with insulin Aspart in type 2 diabetic patients treated with insulin

The effect on postprandial blood glucose control of an immediately pre-meal injection of the rapid acting insulin analogue Aspart (IAsp) was compared with that of human insulin Actrapid injected immediately or 30 minutes before a test meal in insulin-treated type 2 diabetic patients with residual beta-cell function. In a double-blind, double dummy crossover design, patients attended three study days where the following insulin injections in combination with placebo were given in a random order: IAsp (0.15 IU/kg body weight) immediately before the meal, or insulin Actrapid (0.15 IU/kg) immediately (Act0) or 30 minutes before (Act-30) a test meal. We studied 25 insulin-requiring type 2 diabetic patients, including 14 males and 11 females, with a mean age of 59.7 years (range, 43-71), body mass index 28.3 kg/m2 (range, 21.9-35.0), HbA1c 8.5% (range, 6.8-10.0), glucagon-stimulated C-peptide 1.0 nmol/l (range, 0.3-2.5) and diabetes duration 12.5 years (range, 3.0-26.0). Twenty-two patients completed the study. A significantly improved postprandial glucose control was demonstrated with IAsp as compared to Act0, based on a significantly smaller postprandial blood glucose excursion (IAsp, 899 +/- 609 (SD) mmol/l.min versus Act0, 1102 +/- 497 mmol/l min, p < 0.01) and supported by a significantly lower maximum serum glucose concentration (Cmax) up to 360 min after dosing (IAsp, 10.8 +/- 2.2 mmol/l vs. Act0, 12.0 +/- 2.4 mmol/l, p < 0.02). No difference was demonstrated in glucose endpoints between IAsp, administered with a meal and Actrapid injected 30 minutes before the meal (AUCglucose IAsp, 899 +/- 609 mmol/l min vs. Act-30, 868 +/- 374 mmol/l min; Cmax IAsp, 10.8 +/- 2.2 mmol/l vs. Act-30, 11.1 +/- 1.8 mmol/l). No concerns about the safety of IAsp were raised. Immediate pre-meal administration of the rapid-acting insulin analogue Aspart in patients with type 2 diabetes resulted in an improved postprandial glucose control compared to Actrapid injected immediately before the meal, but showed similar control compared to Actrapid injected 30 minutes before the meal. These results indicate that the improved glucose control previously demonstrated with insulin Aspart compared to human insulin in healthy subjects and type 1 diabetic patients also applies to insulin-treated type 2 diabetic patients.

Factors influencing the decision about orthodontic treatment. A longitudinal study among 11- and 15-year-olds and their parents

The aims of the study were to evaluate the attitude towards orthodontic treatment among 11-(T1) and 15-year-old children (T2) and their parents, to present the distribution of referral rate and treatment uptake by a treatment need index assessed at T1 and to elucidate factors influencing the decision about orthodontic treatment in the period from T1 to T2. A group of 359 children and their parents answered separate questionnaires at T1, and 293 families responded to a follow-up study 4 years later. For the clinical examination, 224 children participated after exclusion of children in active treatment. The dental study casts were assessed by the Index of Orthodontic Treatment Need (IOTN). The mean referral rate was 56%, with a variation from 40% to 71% among different dental clinics. About 44% of the children had completed or were undergoing orthodontic treatment at T2. No significant sex differences among referred and treated children were discovered. Aesthetic motives were the most frequently reported subjective reason for orthodontic care. The untreated group expressed diminishing treatment desire in the follow-up period. The logistic regression analysis selected Dental Health Component (DHC) grades as a strong predictor for treatment uptake, followed by parents' concern and attitude to braces, while the 11-year-olds' own orthodontic concern was less significant. Children in the untreated group with late treatment decisions (T2) were best predicted by Aesthetic Component (AC) changes from T1 to T2. The results indicate that dentists play a key role in determining orthodontic treatment levels. High referral rates secured low risk of denying care to some patients. Treatment decision may be guided by the orthodontist. However, individual variation in attitude and desire influence treatment uptake even among children with great need.

Serum levels of advanced glycation end products are increased in patients with type 2 diabetes and coronary heart disease

OBJECTIVE

To investigate whether serum levels of advanced glycation end products (AGEs) and the glycoxidation product Nepsilon-(carboxymethyl)lysine (CML) are increased in patients with type 2 diabetes compared with nondiabetic control subjects and whether levels of AGEs and/or CML differ in patients with type 2 diabetes with or without coronary heart disease (CHD).

RESEARCH DESIGN AND METHODS

Serum levels of AGEs and CML were measured with an immunoassay in 32 men and 21 women aged 59.3+/-6.2 years (means +/- SD) with type 2 diabetes for 7.3 + 3.1 years and in 17 men and 17 women aged 56.2+/-4.2 years without diabetes. Of the patients with diabetes, 18 had CHD.

RESULTS

The serum levels of AGEs and CML were significantly increased in patients with type 2 diabetes compared with nondiabetic control subjects (median [5th-95th percentile]: AGEs 7.4 [4.4-10.9] vs. 4.2 [1.6-6.4] U/ml, P < 0.0001; CML 15.6 [5.6-29.9] vs. 8.6 [4.4-25.9] U/ml, P < 0.0001). The median level of AGEs but not CML was significantly increased in patients with type 2 diabetes and CHD compared with patients without CHD (8.1 [6.4-10.9] vs. 7.1 [3.5-9.8] U/ml, P = 0.03). There were significant positive correlations between serum levels of AGEs and CML in both patients and control subjects.

CONCLUSIONS

Levels of AGEs and CML were significantly increased in patients with type 2 diabetes compared with nondiabetic control subjects, and levels of AGEs but not CML were significantly higher in patients with type 2 diabetes and CHD than in patients without diabetes. These results may indicate a role for non-CML AGEs in the development of macrovascular disease in patients with type 2 diabetes.