The clinician meets the computer--uneasy bedfellows

The transformation of healthcare has been one of the great, but unfulfilled, promises of the information technology revolution. This disappointment has been due in part to the enormously complex processes involved in bedside clinical care. Selective adoption of advances in information technology has resulted in enhancement of point-of-care healthcare delivery, medical record management and professional communication. However, the introduction of these refinements has encountered resistance, as well as sparked new challenges. The exciting progress in this field is reviewed, with reference to global and local developments.

The evaluation of aluminum oxide crystal microdermabrasion for photodamage

BACKGROUND

Aluminum oxide crystal microdermabrasion has recently become popular for facial rejuvenation. Although it is a widely used technique with perceptible benefits, the clinical efficacy on photodamaged skin has yet to be established.

OBJECTIVE

To measure and quantify the effect of microdermabrasion on photodamaged skin.

METHODS

Ten subjects underwent one treatment a week for five to six treatments. Skin surface roughness, topography, elasticity, stiffness, compliance, temperature, sebum content, and histology were analyzed.

RESULTS

Subjectively, seven patients noticed a mild improvement. Physician analysis of clinical photography indicated mild improvement in the majority of patients. Objectively, immediately following treatment skin temperature increased, sebum content decreased, and a temporary increase in skin roughness and mild flattening of some wrinkles occurred. Dynamic skin analysis demonstrated a perceptible decrease in skin stiffness and an increase in skin compliance. Histology showed slight orthokeratosis and flattening of rete ridges and a perivascular mononuclear cell infiltrate, edema, and vascular ectasia in the upper reticular dermis 1 week after completion of the series of treatments.

CONCLUSION

Immediately following the procedure, changes occurring in skin characteristics can be measured that are consistent with mild abrasion and increased blood flow. Objective biomechanical analysis demonstrated a statistically significant decrease in skin stiffness and an increase in skin compliance consistent with persistent edema. Subjectively, patients and physicians report a mild improvement in the majority of subjects. Histology showed dramatic vascular changes in the reticular dermis below the level of direct abrasion. The effect of negative pressure may result in these vascular changes.

The penetration of 0.005% fluticasone propionate ointment in eyelid skin

BACKGROUND

The use of corticosteroids to treat periorbital dermatoses carries significant risk of serious side effects such as glaucoma, cataracts, and blindness. Studies to assess levels of corticosteroid penetration in the eyelid are lacking.

OBJECTIVE

We assessed corticosteroid penetration in eyelid skin in vitro to obtain information leading to the establishment of safer dosing regimens.

METHODS

Fluticasone propionate ointment, 0.005%, was applied (approximately 2-5 mg/cm(2)) to samples of human eyelid skin, and penetration was assessed by using modified Franz diffusion cells. Drug concentration was determined at 12, 24, 36, and 48 hours after application by liquid chromatography tandem mass spectrometry.

RESULTS

Only very small amounts of fluticasone propionate penetrated the skin (range, 0.618% +/- 0.339% to 1.467% +/- 0.695%).

CONCLUSION

Further studies are warranted to examine the safety and efficacy of 0.005% fluticasone propionate ointment for the treatment of eyelid dermatoses.

The Torg--Pavlov ratio in cervical spondylotic myelopathy: a comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic, nonmyelopathic population

STUDY DESIGN

A radiologic study to compare the Torg--Pavlov ratios between patients with cervical spondylotic myelopathy and a nonspondylotic, nonmyelopathic population.

OBJECTIVES

To determine and compare the Torg--Pavlov ratios between the two groups of patients.

SUMMARY OF BACKGROUND DATA

Patients with congenital cervical spinal canal stenosis are more likely to develop cervical spondylotic myelopathy. The Torg--Pavlov ratio eliminates errors related to magnification, a problem with determination of spinal canal stenosis from direct measurements of plain cervical spine radiographs. There has only been one other study that directly compares the Torg--Pavlov ratio between patients with cervical spondylotic myelopathy and a normal control population.

METHODS

The preoperative plain lateral cervical spine radiographs of 28 patients with cervical spondylotic myelopathy requiring surgical decompression were compared with radiographs of 88 nonspondylotic, nonmyelopathic patients. The Torg--Pavlov ratio was computed for each level from C3 to C7.

RESULTS

The study showed that the Torg--Pavlov ratio is significantly smaller (P < 0.001) in myelopathic patients (mean 0.72 +/- 0.08) compared with the control patients (mean 0.95 +/- 0.14). This was so when individual levels and the mean values were compared. Age was also found to be a significant factor (P = 0.002), although lesser in magnitude when compared with the Torg--Pavlov ratio (P = 0.0001).

CONCLUSIONS

The Torg--Pavlov ratio is significantly lower in patients with cervical spondylotic myelopathy compared with a nonspondylotic, nonmyelopathic population. It could possibly be used to predict the likelihood of developing cervical spondylotic myelopathy.

Improvement of Pyoderma gangrenosum and psoriasis associated with Crohn disease with anti-tumor necrosis factor alpha monoclonal antibody

BACKGROUND

Infliximab is an anti-tumor necrosis factor alpha monoclonal antibody IgG effective in the treatment and maintenance of remission of active refractory Crohn disease and associated draining enterocutaneous fistulae. Multiple infusions of infliximab show promising results in patients with rheumatoid arthritis. Currently, there is limited clinical experience with infliximab, and no published reports exist on its use in cutaneous disorders.

OBSERVATIONS

We describe 2 patients with Crohn disease and pyoderma gangrenosum and 1 patient with Crohn disease and psoriasis who were treated with infliximab for recalcitrant Crohn fistulae, with concurrent improvement in their skin diseases.

CONCLUSIONS

These cases suggest that infliximab, a promising therapeutic agent for refractory Crohn disease and fistulae, may also be effective in the treatment of pyoderma gangrenosum and psoriasis associated with Crohn disease.

Progressive ulnar neuropathy caused by delayed migration of a foreign body

Foreign bodies in the hand can cause a variable degree of acute or delayed injuries to the important structures. We report a rare case of a progressive ulnar neuropathy caused by delayed migration of a foreign body in the forearm. Ultrasonographic localisation and surgical removal of the foreign body resulted in gradual recovery of neurological function.

Limited application of fluticasone propionate ointment, 0.005% in patients with psoriasis of the face and intertriginous areas

BACKGROUND

Facial and intertriginous skin is more susceptible to corticosteroid-induced atrophy. Dosing regimens are needed for long-term management of corticosteroid-sensitive sites.

OBJECTIVE

The safety and efficacy of 0.005% fluticasone propionate ointment were assessed in the short-and long-term management of moderate to severe psoriasis of facial and intertriginous areas compared with nonfacial, nonintertriginous areas.

METHODS

Affected areas in 20 patients with psoriasis were treated twice daily for 2 weeks, then once daily for 2 consecutive days every week for 8 more weeks.

RESULTS

More than 50% improvement occurred after 2 weeks (day 15) in 100% of facial and intertriginous lesions and was maintained during long-term therapy in more than 85% of facial and intertriginous lesions. More than 50% improvement for nonfacial, nonintertriginous areas reached only 80% by day 15. Recurrence rates for facial and intertriginous areas were lower than in the nonfacial, nonintertriginous areas. Skin atrophy and telangiectasia did not occur. Facial and intertriginous sites responded more quickly to topical fluticasone propionate ointment than nonfacial, nonintertriginous skin.

CONCLUSION

Limited application of fluticasone propionate ointment over a period of 10 weeks is effective and delays lesion recurrence without causing skin atrophy in patients with moderate to severe psoriasis in areas at risk for corticosteroid application, such as facial and intertriginous areas.

Current treatment of insulin resistance in type 2 diabetes mellitus

The two major metabolic perturbations resulting in hyperglycaemia in type 2 diabetes are insulin resistance and insulin deficiency. Insulin resistance occurs in peripheral organs (muscle and fat), leading to decreased glucose uptake and utilisation, and in liver, leading to increased hepatic glucose production. Thiazolidinediones, pharmacological ligands for PPAR gamma, can modulate the expression of genes influencing carbohydrate and lipid metabolism. Pioglitazone, a recently introduced thiazolidinedione, improves glycaemic control and lipid profiles in people with type 2 diabetes. Some of the possible mechanisms of improving glycaemic control include (a) increase in GLUT-1 and GLUT-4, (b) enhancement of insulin signalling, (c) decrease in tumour necrosis factor-alpha action, (d) reduction in plasma free fatty acid and (e) decrease in PEPCK. Together these can increase glucose uptake and utilisation in the peripheral organs and decrease gluconeogenesis in the liver. Possible mechanisms resulting in more desirable lipid profiles include an increase in phosphodiesterase-3B resulting in reduced intra-cellular lipolysis in adipocytes and an increase in lipoprotein lipase resulting in enhanced clearance of triglyceride-rich lipoproteins(TRLs). Pioglitazone, used as monotherapy or in combination with sulphonylurea, biguanide or insulin, improves glycaemic control, lowers serum triglycerides and raises high density lipoprotein (HDL)-cholesterol. It enhances hepatic and peripheral insulin sensitivity. In clinical trials, there has been no evidence of hepatotoxicity or increased incidence of elevated serum ALT in subjects taking pioglitazone compared with placebo.

Relation of genetic polymorphisms of apolipoprotein E, angiotensin converting enzyme, apolipoprotein B-100, and glycoprotein IIIa and early-onset coronary heart disease

OBJECTIVE

Apolipoprotein E (APOE) E4, apolipoprotein B-100 (APOB) Q3611 allele, the angiotensin converting enzyme (ACE) deletion (D) allele and glycoprotein IIIa (GP3A) P33 mutant allele are reported to predispose to early-onset coronary heart disease (CHD). These associations were not all confirmed in more recent studies. To determine the impact of these alleles on CHD, we examined the prevalence of these mutations in patients presenting with early-onset CHD and compared them to those manifesting CHD later in life. The delayed-onset was considered a sign of longevity and would serve as a comparative group to assess prevalence of the biochemical and genetic risk factors.

METHODS

300 patients with a history of myocardial infarction or angina pectoris and angiographically documented CHD were studied. Patients were divided into two groups: group 1 (G1 = 150 patients) presenting with these findings under the age of 50 years; while group 2 (G2 = 150 patients) were patients presenting for the first time over the age of 65 years. Prevalence of the alleles of APOE, APOB, ACE and GP3A was assessed by molecular analysis. An association of any of these genotypes with early onset CHD could lead to a higher prevalence in the younger age group.

RESULTS AND CONCLUSIONS

None of the suspected alleles namely APOB Q3611 [G1: 10.7% vs. G2: 9.0%, p = 0.57], ACE D (G1: 52.0% vs. G2: 49.7%, p = 0.57), or the GP3A P33 (G1: 17.3% vs. G2: 15.7%; p = 0.58) showed any significant difference between the two groups. Subjects with APOE E4 were more frequent in the younger age group (G1: 18.3% vs. G2: 13.7%; p = 0.047), while APOE E2 was more frequent in G2 (G2: 10.0% vs. G1: 2.7%; p = 0.0002). Multivariate analysis showed an odds ratio of APOE E2 allele in G1 of 0.27 with a confidence interval of 0.10-0.73.

Elevation of high-density lipoprotein cholesterol in humans during long-term therapy with amiodarone

The distribution of plasma lipids was studied in 18 patients receiving amiodarone for 18 months, confirming that amiodarone is associated with a 17% elevation in total cholesterol and, for the first time, documenting increases in high-density lipoprotein cholesterol. The increase in high-density lipoprotein was proportionately greater than that of low-density lipoprotein cholesterol, suggesting that the impact of changes in the predicted risk of coronary heart disease are less important than if the elevation consisted of low-density lipoprotein cholesterol alone.

No relationship between carbohydrate intake and effect of acarbose on HbA1c or gastrointestinal symptoms in type 2 diabetic subjects consuming 30-60% of energy from carbohydrate

OBJECTIVE

To determine the relationship between carbohydrate intake and the effect of acarbose on HbA1c in subjects with type 2 diabetes treated with acarbose alone, acarbose plus sulfonylurea, acarbose plus metformin, or acarbose plus insulin.

RESEARCH DESIGN AND METHODS

We conducted a double-blind randomized placebo-controlled study in which subjects with diabetes in four treatment strata (77 on diet alone, 83 treated with metformin, 103 treated with sulfonylurea, and 91 treated with insulin) were randomized to treatment with placebo or acarbose for 12 months. Before randomization, and 3, 6, 9, and 12 months after randomization, fasting blood was obtained for HbA1c, and 3-day diet records were collected. Subjects who completed at least 6 months of acarbose therapy and provided at least three 3-day diet records were included.

RESULTS

In the 114 subjects included in this analysis, carbohydrate intake varied from approximately 30-60% of energy There was no significant relationship between carbohydrate intake and change in HbA1c in any of the four treatment strata (diet: n=26, r=0.35, P=0.076; metformin: n=27, r=0.26, P=0.19; sulfonylurea: n=35, r=0.24, P=0.16; insulin: n=25, r=-0.27, P=0.19). In the 80 subjects consuming <50% of energy from carbohydrate, the fall in HbA1c (7.83 +/-0.17% at baseline to 6.72+/-0.13% on acarbose, P < 0.001) was no different from that of the 34 subjects consuming >50% of energy from carbohydrate (7.55+/-0.25% at baseline to 6.66+/-0.23% on acarbose, P < 0.001). There was no difference in carbohydrate intake between those who dropped out of the study because of gastrointestinal side effects and those who did not, and there was no relationship between severity of symptoms and the composition of the diet.

CONCLUSIONS

In subjects with type 2 diabetes consuming 30-60% of energy from carbohydrate, the effect of acarbose on HbA1c and gastrointestinal symptoms was not related to carbohydrate intake. Because most people consume at least 30% of energy from carbohydrate, we conclude that no special diet is needed for acarbose to be effective in improving blood glucose control in the treatment of type 2 diabetes.

Accuracy of CT-guided needle biopsy of musculoskeletal neoplasms

OBJECTIVE

The purpose of our study was to assess the accuracy of CT-guided biopsy of musculoskeletal neoplasms with respect to technique, anatomic site, and histology.

MATERIALS AND METHODS

During a 3-year period (January 1992 to December 1994), 176 core needle biopsies and 45 fine-needle aspirations were performed under CT guidance on patients with musculoskeletal neoplasms. To assess the accuracy of these procedures, we compared the diagnosis at biopsy with the final diagnosis as determined at the time of definitive treatment of the lesion. All biopsy findings were categorized as a primary malignancy (excluding round cell lesions), round cell lesion, local recurrence, or metastatic carcinoma. In addition, each lesion was analyzed according to which biopsy technique was used, whether frozen tissue section or rapid cytologic evaluation was used, and at which anatomic site the mass was found.

RESULTS

The accuracy for needle biopsy was 93% and that for fine-needle aspiration was 80%. The complication rate for both techniques was less than 1%. Accuracy rates for the four categories of primary malignancy, round cell lesion, local recurrence, and metastatic carcinoma were 87%, 75%, 94%, and 100%, respectively. The mismatch rates were similar in soft-tissue lesions (5/52) and bone lesions (16/169). Diminished accuracy was associated with round cell lesions (20%) and lesions located in the spine or the perivertebral region (20%). Nondiagnostic and insufficient specimens were found in 18 (8%) of the 221 patients. CONCLUSION. CT-guided biopsy of musculoskeletal malignancies is a safe and effective procedure if performed by a team of clinicians, pathologists, and radiologists who possess subspecialty expertise.

Staged diabetes management: computerizing a disease state management program

Recently, the Diabetes Control and Complication Trial (DCCT) and other similar studies have demonstrated that near-normalization of blood glucose in diabetes will reduce complications up to 75% but translation of these results into practice has been difficult. In an attempt to help provide the best possible control of patients with diabetes, we have produced an attempt to help provide the best possible control of patients with diabetes, we have produced a new disease state management system for diabetes, called "Staged Diabetes Management" (SDM), implemented it in over 100 sites worldwide, and developed a computer program to simplify its use. SDM, designed to change the way we deal with patients with diabetes, is based upon five principles: (1) community involvement in setting care guidelines; (2) negotiation of goals with patients; (3) appropriate timelines for therapeutic success; (4) use of flowcharts for medical decisions; and (5) evaluation of the program. SDM is designed to be altered by a community to meet its needs and resources. It encourages primary care physicians to deliver better diabetes care using a team approach and to refer patients with diabetes to specialists when appropriate. It has a complete set of materials for communities, individual health care providers and patients. SDM has been tested for changes in structure, process and outcomes. A meta-analysis of seven clinical trials with over 500 patients has shown a time-weighted average fall in hemoglobin A1c of 1.7 points (equivalent to a drop in mean blood glucose of about 3.5 mM or 60 mg/dL). Preliminary pharmacoeconomic analysis demonstrates a lifetime cost saving of over $27,000 per patient. A computer program has been developed for the Microsoft Windows environment that contains a client-server database, based upon DiabCare, for the data file structure.

Decompression illness associated with underwater logging: 6 case reports from Kenyir Lake, Malaysia

The formation of Kenyir Lake as part of a hydroelectric project in the 1980s caused much forest area to be submerged. From 1991, underwater divers were employed to log these sunken trees at depths of up to 100 meters. At least 6 mishaps involving underwater logging personnel were recorded from March 1994 to August 1996. We retrospectively reviewed 5 cases who were managed in Hospital Kuala Terengganu. The patients presented with marked cardiorespiratory and neurological disturbances. One diver died in the Hospital while another died at the recompression chamber. Three divers were treated with recompression and improved. Average delay before the start of recompression was 14 hours. Underwater logging has definite dangers and steps must be taken to ensure that both the divers and the equipment are appropriate for the task. Availability of a nearby recompression facility would greatly enhance the management of diving accidents, not only for commercial divers but also for recreational divers who frequent the islands nearby.

Effect of methimazole, with or without L-thyroxine, on remission rates in Graves' disease

Medical treatment of Graves' disease involves antithyroid drugs with or without the addition of exogenous T4. There have been conflicting reports as to whether the addition of T4 improves remission rates or delays relapse. To evaluate this issue in a North American population, 199 patients were treated with methimazole until they were euthyroid. They were then randomized to either methimazole alone in a dose sufficient to normalize TSH (group 1), or to 30 mg methimazole daily plus sufficient T4 to maintain TSH in the upper normal range (group 2), or to 30 mg methimazole daily plus sufficient T4 to suppress TSH below 0.6 mIU/L (group 3). After 18 months, methimazole was stopped, and T4 was continued in groups 2 and 3. Because not all patients in groups 2 and 3 achieved their target TSH concentration, they were reassigned to group A (TSH > or = 1.0) or group B (TSH < 1.0), based on the mean TSH achieved during methimazole treatment. One hundred forty-nine patients have been followed for at least 6 months after stopping methimazole (mean 27 months). Fifty-eight percent of patients have relapsed. There were no significant differences in relapse rates after stopping methimazole. Among those patients who did relapse, however, there was a significant difference in the months to relapse after stopping methimazole between groups B and 1 (group 1: 3.3 +/- 0.7, group A: 5.6 +/- 0.8, group B: 7.4 +/- 1.7; P = 0.01 for the comparison between groups B and 1). We conclude that the addition of T4 to methimazole does not improve long-term remission rates in Graves' disease.

An outbreak of rabies in dogs in the state of Terengganu 1995-1996

The presence of rabies in dogs has been well recognized in areas of Malaysia close to the Thai border but it has rarely ever been reported in Terengganu which is a state on the East Coast of Malaysia. From November 1995 to June 1996 six different rabid stray dogs were found to have been involved in dog bite attacks on 9 members of the public. We report these cases to highlight that rabid dog bites may occur even in areas where the disease is thought to be rate. Medical and veterinary staff must keep the possibility of the risk of rabies in mind when faced with patients who have been bitten by dogs.

An unusual case of Wegener's granulomatosis

A 35-year-old Malay man underwent treatment for uveitis of the right eye in 1992 but developed marked visual impairment in the affected eye after he failed to attend follow-up. Two years later, he complained of difficulty swallowing and was found to have left sided X and XI cranial nerve palsies. Chest radiograph showed a cavitating lesion in the lower zone of the right lung field. Inflammation and perforation of the nasal septum was found on examination of his upper respiratory tract. Punch biopsies taken from that area showed chronic inflammatory change and necrotizing vasculities. The patient was diagnosed as having Wegener's granulomatosis and made a very good recovery with immunosuppressive therapy.

Human plasma CETP deficiency: identification of a novel mutation in exon 9 of the CETP gene in a Caucasian subject from North America

Human plasma cholesteryl ester transfer protein (CETP) is a 476-residue hydrophobic glycoprotein that catalyzes the heterotransfer of cholesteryl esters and triacylglycerols among lipoproteins: Mutations in the CETP gene have been identified, mostly in the Japanese population. These mutations result in hypercholesterolemia due to the presence of large cholesteryl ester-rich HDL particles, elevated plasma apoA-I and apoE, and reduced apoB levels. Here we report the plasma lipoprotein phenotype and molecular defect in a 57-year-old female Nova Scotian subject lacking Japanese ancestry who is homozygous for a novel mutation in the CETP gene. Her total plasma cholesterol was 7.3 mmol/l with an LDL cholesterol of 2.9 mmol/l and HDL cholesterol of 4.4 mmol/l. She was mildly hypertriglyceridemic (1.6 mmol/l) and had markedly elevated apoA-I (256 mg/dl) and apoE (14.4 mg/dl) with only slightly reduced apo/B levels (94 mg/dl). Her VLDL and LDL were cholesteryl ester-poor (1.8 and 37.2% of lipids, respectively) and triacylglycerol-rich (67.3 and 18.9% of lipids, respectively) while her HDL was cholesteryl ester-rich (40.2-45.7% of lipids) and triacylglycerol-poor (3.3-2.5% of lipids). No plasma CETP activity or mass was detected. Bi-directional DNA sequence analysis of PCR products from all 16 exons showed a single base substitution (C-->T at nucleotide 836 in exon 9 resulting in 268 Arg-->STOP) in both alleles. No other mutation was detected. A single base mismatched, 26 bp reverse PCR primer that produced a single Mae III RFLP site upon amplification of the mutated DNA sequence was designed for rapid population screening. This subject is, we believe, the first Caucasian North American patient reported to have CETP deficiency.

Relation of HFE gene mutations, high iron stores and early onset coronary artery disease

OBJECTIVE

To determine the impact of mutations in the HFE gene (human leukocyte antigen H) on predisposition to coronary artery disease (CAD) in patients not diagnosed with hereditary hemochromatosis.

BACKGROUND

Elevated iron stores can predispose to acute myocardial infarction. Two mutations (C282Y and H63D) in the novel major histocompatibility complex (MHC) class 1 gene HFE were found in most patients with hereditary hemochromatosis causing high iron stores. The effect of these mutations on predisposition to CAD has not been investigated previously.

METHODS

Three hundred patients with a history of myocardial infarction or angina pectoris and angiographically documented CAD were studied. Patients were divided into two groups: group 1 (150 patients), manifesting early onset CAD and presenting with these findings under age 50 years; and group 2 (150 patients), presenting for the first time over age 65 years. Prevalence of the C282Y and H63D mutations was assessed by molecular analysis, and plasma ferritin was measured immunochemically.

RESULTS

There was no difference in the prevalence of homozygous, heterozygous or compound heterozygous (C282Y/H63D) states between the groups. Males in group 1 had higher plasma ferritin than those in group 2 (234 +/- 174 micrograms/L versus 136 +/- 103 micrograms/L, P < 0.0001), but this was not significantly different in females (75 +/- 54 micrograms/L versus 92 +/- 73 micrograms/L, P = 0.26). Ferritin remained higher in group 1 than in group 2 males after exclusion of mutation carriers (195 +/- 121 micrograms/L versus 109 +/- 76 micrograms/L, respectively, P < 0.0001), but did not change in females.

CONCLUSIONS

Higher iron stores were found in males with early onset CAD. This association was not related to the C282Y or H63D mutation in HFE. It is suggested that association of the MHC locus with delayed onset CAD is probably unrelated to HFE in these patients, and that HFE mutations are not a major risk factor in the development of high iron stores in early onset CAD.

Fractional esterification rate of HDL particles in patients with type 2 diabetes. Relation to coronary heart disease risk factors

OBJECTIVE

To study the fractional esterification rate of cholesterol on HDL particles (FERHDL) in adults with type 2 diabetes and assess its correlation with serum lipids and other coronary heart disease (CHD) risk factors.

RESEARCH DESIGN AND METHODS

FERHDL was measured in 90 adult (57 men, 33 women) patients by an isotopic assay method involving several steps, including preparation of VLDL- and LDL-depleted plasma, labeling of the sample with a trace amount of tritiated cholesterol, separation of free and esterified cholesterol fractions by chromatography post incubation, and subsequent counting of radioactivity in the individual fractions.

RESULTS

Male patients have higher FERHDL values than their female counterparts. When HDL cholesterol was controlled for in a multivariate regression analysis, the sex factor was not significant. There was a significant positive correlation between FERHDL and plasma total cholesterol (r = 0.32), triglycerides (r = 0.82), apolipoprotein B (apo B; r = 0.48), insulin (r = 0.46), BMI (r = 0.31), and waist-to-hip ratio (WHR; r = 0.50). There was a negative correlation between FERHDL and HDL cholesterol (r = -0.76) and apolipoprotein AI (r = -0.60). When both HDL cholesterol and triglycerides were controlled for, the only significant correlation was between FERHDL and BMI.

CONCLUSIONS

Non-insulin-requiring type 2 diabetic patients have FERHDL, which correlated positively with triglycerides and negatively with HDL cholesterol. The positive correlation of FERHDL with serum insulin, WHR, total cholesterol, and apo B, but not that with BMI, loses its significance when HDL cholesterol and triglycerides are controlled. The sex difference between men and women in FERHDL also loses its significance when HDL cholesterol is controlled.

A novel mutation in Exon 4 of the low density lipoprotein receptor gene resulting in heterozygous familial hypercholesterolemia associated with decreased ligand binding

Familial hypercholesterolemia (FH) is an autosomal dominant disorder caused by mutations in the low density lipoprotein (LDL) receptor gene. Currently, diagnosis of heterozygous FH relies on clinical phenotype; however, the use of clinical criteria for the diagnosis of heterozygous FH does not always permit unequivocable diagnosis of the disease. Molecular diagnosis of FH is clinically valuable especially in regions where founder mutations exist or where polygenic hypercholesterolemia is prevalent. In this paper we report the identification of a novel mutation, a cytosine to guanine substitution, at codon 152 in exon 4 of the LDL receptor gene in a Nova Scotian family clinically diagnosed with heterozygous FH. The mutation creates a recognition sequence for the restriction endonuclease BsrI, and can be readily detected by BsrI restriction analysis of a 160 bp amplicon spanning the mutation. This analysis was used to show that the mutation segregated with the disease in this family and is the probable cause of FH in this kindred.

Psoriasis

Psoriasis is an inflammatory disorder of the skin that involves complex interactions between the dermis and epidermis. There are several forms of psoriasis, the most common being plaque type psoriasis. Other forms include guttate, pustular and erythrodermic psoriasis. Both the skin and joints are affected in this disease. Psoriasis ranges in severity from a few small plaques to involvement of the entire cutaneous surface. Therapy of psoriasis depends on the location, type and severity of the disease. Treatments include a wide array of topical medications including tars, anthralin, topical corticosteroids, vitamin D(3) analogs, retinoids and over-the-counter preparations. Phototherapy with ultraviolet B and PUVA are used for more widespread involvement. Common systemic therapies include methotrexate, retinoids and cyclosporin. This article will review the pathogenesis and clinical features of psoriasis, as well as current and future therapies.

Efficacy and safety of a new hydroxymethylglutaryl-coenzyme A reductase inhibitor, atorvastatin, in patients with combined hyperlipidemia: comparison with fenofibrate

This 24-week, randomized, open-label multicenter study evaluated the efficacy and safety of atorvastatin compared with fenofibrate in the treatment of patients with combined hyperlipidemia (CHL). Following a 6-week baseline period, 84 patients with CHL were randomly assigned to either atorvastatin treatment, 10 mg QD for 12 weeks increasing to 20 mg QD for 12 weeks, or fenofibrate treatment, 100 mg TID for 24 weeks. Changes from baseline in lipid parameters were evaluated at weeks 12 and 24. At both 10- and 20-mg doses, atorvastatin treatment resulted in significantly greater reductions in LDL cholesterol, apolipoprotein (apo) B, total cholesterol, LDL-apoB, and lipoprotein-B compared to 300-mg fenofibrate treatment (P < .05). While atorvastatin also resulted in clinically significant reductions in triglyceride, VLDL cholesterol, apoB in VLDL, triglyceride in VLDL, and apoC-III and significant increases in HDL cholesterol and apoA-I levels, fenofibrate was more effective than atorvastatin in altering all these parameters. However, by significantly affecting both the cholesterol-rich and triglyceride-rich particles, atorvastatin holds promise as a lipid-regulator able to adequately treat a broad range of patients that includes those with CHL.

Small weight loss on long-term acarbose therapy with no change in dietary pattern or nutrient intake of individuals with non-insulin-dependent diabetes

OBJECTIVES

To see if the long-term treatment of non-insulin dependent diabetes (NIDDM) with the alpha-glucosidase inhibitor acarbose affects food intake and body weight.

DESIGN

Randomized, double-blind, placebo-controlled, parallel design clinical trial of 12 months duration.

SUBJECTS

Subjects with NIDDM in four treatment strata: 77 on diet alone, 83 also treated with metformin, 103 also treated with sulfonylurea and 91 also treated with insulin.

MEASUREMENTS

Two 3 day diet records were obtained before randomization to acarbose or placebo therapy, and additional 3 day diet records were obtained at 3, 6, 9 and 12 months after randomization. Body weight was also measured at these times.

RESULTS

Of the 354 subjects randomized, 279 (79%) completed at least 9 months of therapy and, of these, 263 (94%) provided at least one diet record during the baseline period and two diet records during the treatment period. After one year, subjects on acarbose had lost 0.46 +/- 0.28 kg, which differed significantly from the 0.33 +/- 0.25 kg weight gain on placebo (P = 0.027). The difference in weight change between acarbose and placebo did not differ significantly in the different treatment strata. Being in the study had significant effects on diet, including a reduction in energy intake from 1760-1700 Kcal/d (P < 0.05), a reduction in simple sugars intake from 18.5-17.4% of energy (P < 0.001), and reductions in the number of different foods consumed (33-30, P < 0.001) and the number of meals eaten per day (4.7-4.3, P < 0.001). However, compared to placebo treatment, acarbose had no effect on energy intake, nutrient intakes, or dietary patterns.

CONCLUSIONS

In subjects with NIDDM on weight-maintaining diets, long-term acarbose therapy results in a small weight loss, but has no effect on energy or nutrient intakes. The weight loss induced by acarbose may be due partly to reduced doses of concomitant oral agents and insulin and partly to energy loss due to increased colonic fermentation.

Blood transfusion and bone allografts. Effect on infection and outcome

Intraoperative and postoperative blood replacement have been implicated in increased rates of wound infection, decreased rates of renal allograft transplant rejection, and increased rates of local recurrence and metastasis of certain kinds of tumors, all presumably on the basis of some alteration in the immune system. Because patients who have bone allograft surgery for tumors often require transfusion and because the procedure is associated with a high rate of failure (20%), infection (9%-10%), and local recurrence (10% for high grade tumors), the effect of transfusion (range, 0-4750 ml) was studied for 264 patients who had proximal humeral, proximal or distal femoral resections, and massive cadaveric allografts but who did not have adjuvant chemotherapy or radiation. An attempt was made to statistically correlate the tumor and allograft outcome and rate of infection with patient age and gender, anatomic site, diagnosis, stage, type of graft, number of subsequent procedures, surgical margins, perioperative transfusions, blood loss, duration of operative procedures, and number of pregnancies. Of the variables studied, only blood loss, transfusion, and duration of surgery had an effect on outcome and, more specifically, on infection rate and time to union. No effect was observed on metastasis, recurrence, or the ultimate outcome of the procedure.

A unique case of tetrodotoxin poisoning

A 69-year-old lady who was referred by her general practitioner with a diagnosis of food poisoning developed cardiorespiratory arrest shortly after arriving at the Casualty Department. Cardiac output was successfully restored with resuscitation but she had to be mechanically ventilated due to the absence of any spontaneous respiratory effort. Assessment 24 hours after admission, showed fixed and dilated pupils with brain stem areflexia. Her family was told that the prognosis was hopeless. Surprisingly, her condition rapidly improved a day later and she eventually had a good recovery. Her condition was actually due to severe tetrodotoxin poisoning after eating roe of the puffer fish and it was fortunate that appropriate aggressive resuscitation was instituted to revive the patient from her critical state.

Delays in thrombolytic therapy in acute myocardial infarction: an audit from the east coast of peninsular Malaysia

The objectives of this study were to evaluate the time delays between the onset of symptoms and admission to hospital and provision of thrombolytic therapy in patients with suspected acute myocardial infarction; and to examine the accuracy of the clinical diagnosis and the therapeutic decision on thrombolysis in these patients. An observational study of 96 patients with suspected myocardial infarction was undertaken over a period of 15 months in the Coronary Care Unit of Hospital Kuala Terengganu. Seventy per cent of the patients arrived in the hospital within 6 hours of the onset of symptoms. After arrival in the emergency room, it took a median time of 85 minutes before the administration of thrombolytic therapy. Of the 67 patients who were given thrombolysis, 46 were treated within 6 hours of the onset of symptoms. About a quarter of patients said that they had delayed seeking treatment at the hospital. Treatment delays occurring in the hospital were mainly due to admission procedures as well as late diagnosis. Eighty-one patients had confirmed myocardial infarction of whom 59 received thrombolytic therapy. Eight patients receiving thrombolytic therapy had no confirmation of myocardial infarctions. Improvements in diagnostic accuracy and reduction of delays in the provision of thrombolytic therapy could be achieved by better training of health care staff as well as by further streamlining of admission procedures.

Bizarre ECG in head injury mimicking ventricular tachycardia

Bizarre electrocardiographic (ECG) changes were found in an 18-year-old girl who had a subdural haematoma following head trauma. The initial diagnosis was of ventricular tachycardia (VT) and she was treated with intravenous anti-arrhythmic drugs and electrical cardioversion, but to no effect. It was later concluded that the ECG appearances were not of a ventricular arrhythmia but were the result of the intracranial pathology. ECG abnormalities related to head injuries have been reported on many occasions, and our case report illustrates how this can create difficulties for the attending clinicians.

Phaeochromocytoma: a ten-year survey

We retrospectively evaluated our experience with phaeochromocytoma from January 1986 to December 1995. There were 18 patients with surgically-proven phaeochromocytoma: three males, 15 females, aged 12-81 years (mean 42 years) at diagnosis. Sixteen were hypertensive; only 6/18 presented with two or more of the classical triad of headaches, palpitations and diaphoresis. One patient presented with hypertensive crisis. Duration of symptoms prior to diagnosis was 2 weeks to 6 years, mean 16.4 months. Sixteen patients had adrenal tumours and two had extra-adrenal tumours or paragangliomas. One had bilateral adrenal tumours and two had a combination of both adrenal and extra-adrenal tumours. There were four familial cases: two had multiple endocrine neoplasia type IIA (MEN-IIA), one had neurofibromatosis type I (NF-I) and one von Hippel-Lindau (VHL) disease. One patient had Cushing's syndrome arising from ectopic production of adrenocorticotropic hormone (ACTH) by the phaeochromocytoma. Disease was recurrent in three patients. Pre-operative diagnosis was confirmed mainly by elevated urine vanillylmandelic acid (VMA) and/or catecholamine levels. Twelve patients had plasma catecholamine determinations: noradrenaline was elevated in all, adrenaline in six and dopamine in two. Pre-operative localization was by CT scan or MR imaging in all patients. At follow-up of 1-10 years (median 4.8 years), 15 patients were cured surgically while two were asymptomatic despite recurrence of disease. One patient with recurrent paragangliomas died post-operatively.

A pilot study on the percutaneous absorption of microfine titanium dioxide from sunscreens

Many Australians are being advised to apply microfine titanium dioxide sunscreen daily from the cradle to the grave. However, there is a surprising lack of data on the percutaneous absorption of microfine titanium dioxide. A prospective pilot study was conducted to analyse the percutaneous absorption of microfine titanium dioxide from sunscreens. Selected patients scheduled to have skin surgery, applied titanium dioxide sunscreen to the skin daily for 2-6 weeks prior to their operation. After excision, the stratum corneum of the sample was stripped and the titanium concentration of the remaining epidermis and dermis was measured by inductively coupled plasma-mass spectrometry. The results from this pilot study showed that levels of titanium in the epidermis and dermis of subjects who applied microfine titanium dioxide to their skin were higher than the levels of titanium found in controls. Studies with larger cohorts are necessary to establish if this absorption is statistically significant.

Reverse cholesterol transport: its contribution to cholesterol catabolism in normal and disease states

OBJECTIVES

To review the reverse cholesterol transport (RCT) model and its contribution to cholesterol catabolism in normal and disease states.

DATA SOURCES

Pertinent articles were identified through a MEDLINE search of the English language literature from 1983 to 1995, followed by a manual search of the bibliographies of pertinent articles.

STUDY SELECTION

Review articles, laboratory and clinical studies and case reports.

DATA EXTRACTION

The physiology of the RCT pathway as well as alterations observed in individuals with diseases or lifestyle changes were reviewed.

DATA SYNTHESIS

Data were derived mainly from laboratory studies and clinical observations. The RCT model is proposed to explain the removal of excess cholesterol from extrahepatic tissues and its delivery to liver for catabolism. This involves several regulated steps mediated by the plasma apolipoproteins and two key enzymes, lecithin:cholesterol acyltransferase (LCAT) and cholesteryl ester transfer protein (CETP). In essence free cholesterol in peripheral tissues is taken up by nascent high density lipoprotein (HDL) particles, converted to cholesteryl esters (by LCAT), and then transferred to apo B-containing lipoproteins (by CETP) for hepatic removal. Altered cholesterol catabolism may occur in individuals with disorders of a genetic or acquired nature as well as lifestyle changes, as a result of alterations in one of several of the putative steps or enzymes involved in RCT.

CONCLUSIONS

The proposed antiatherogenic role of RCT remains to be validated as a review of the possible alterations noted in various disorders showed conflicting results in atherogenic propensity.

Effect of methimazole with or without exogenous L-thyroxine on serum concentrations of thyrotropin (TSH) receptor antibodies in patients with Graves' disease

Medical treatment of Graves' disease involves use of antithyroid drugs with or without the addition of exogenous L-T4. There have been conflicting reports as to whether the addition of T4 reduces TSH receptor antibodies and improves remission rates more than antithyroid drugs alone. To further examine the effect of drug therapy on serum concentrations of TSH receptor antibodies. 70 patients with Graves' disease were treated with methimazole (Tapazole) alone until they were euthyroid. Then they were randomized to receive either: 1) methimazole alone in a dose sufficient to normalize TSH (0.3-5.4 mIU/L; Group 1); 2) 30 mg methimazole daily plus sufficient T4 (Synthroid) to maintain TSH in the high-normal range (2.0-5.4 mIU/L; Group 2); or 3) 30 mg methimazole daily plus sufficient T4 to suppress TSH to below 0.6 mIU/L (Group 3). The duration of treatment in all groups was 18 months. At baseline and after 6 and 18 months, TSH receptor antibodies were measured both by the ability of patients' sera to stimulate cAMP production by FRTL-5 cells (thyroid-stimulating Ig) and by the ability of patients' sera to inhibit binding of radiolabeled TSH to solubilized porcine thyroid membranes (TSH-binding, inhibiting Ig). Thyroid-stimulating Ig(TSI) and TSH-binding, inhibiting Ig(TBII) concentrations were similar among the three groups at baseline. Mean baseline TSI (expressed as the percent of normal control) for all patients combined was 306 +/- 21%. Mean baseline TBII (expressed as percent inhibition of TSH binding) was 38 +/- 2%. TSI was elevated in 85% and TBII was elevated in 75% of patients at baseline. After 18 months, TSI was elevated in 64% of patients, and TBII was elevated in 28%. Serum TSI decreased by 36 +/- 5% during the study, and there was no significant difference in the degree of reduction among the three groups (P = 0.99). Serum TBII decreased by 59 +/- 3%, and there also was no significant difference among the groups (P = 0.83). At baseline, serum TBII correlated with free T4 (r = 0.33, P < 0.01), total T3 (r = 0.55, P < 0.01), and thyroid size (r = 0.35, P < 0.01). There was no correlation between TSI and any of the baseline parameters or between TSI and TBII at any timepoint. In conclusion, we found that the addition of T4 to methimazole does not result in a greater decrease in TSH receptor antibody concentrations than treatment with methimazole alone. From these results, we would predict no difference in remission rates among these patients, but confirmation of this prediction will need to await long-term follow-up of these subjects.

Regulation of muscle glucose transport and GLUT-4 by nerve-derived factors and activity-related processes

Glucose transport and GLUT-4 were examined in muscles in which activity and nerve-derived factors were eliminated (denervation) and in muscles in which only muscle activity was eliminated but in which nerve-derived factors were maintained [tetrodotoxin (TTX) treatment]. After 3 days of denervation, insulin-stimulated 3-O-methylglucose transport was markedly lowered in perfused rat hindlimb muscles (soleus, plantaris, and red and white gastrocnemius; < or = 35%). GLUT-4 was also decreased by 11-65% in denervated muscles. Blocking muscle activity with TTX superfusion of the sciatic nerve for 3 days reduced the insulin-stimulated glucose transport to the same extent as in the denervated muscles (P > 0.05). However, in soleus, plantaris, and red gastrocnemius muscles, GLUT-4 expression was reduced much less by TTX treatment than by denervation (P < 0.05). GLUT-4 mRNA abundance was decreased in denervated muscles but not in TTX-treated muscles. These results suggest that muscle activity largely regulates the insulin-signaling mechanisms of glucose transport and that nerve-derived trophic factors affect pretranslational events to regulate GLUT-4 expression.

Clinical experience with acarbose: results of a Canadian multicentre study

Current therapeutic options for the treatment of non-insulin-dependent diabetes mellitus (NIDDM) focus on regimens that primarily lower fasting blood glucose concentrations. In several short-term studies, the alpha-glucosidase inhibitor, acarbose, has been reported to significantly lower post-prandial plasma glucose levels as well as HbA1c. The primary objective of this present study was to assess the long-term efficacy of adjunctive acarbose therapy to improve metabolic control. Over a 1-y period, acarbose or placebo was administered to 4 groups of patients: those managed by diet only, diet and sulfonylurea, diet and biguanide, and diet and insulin. In all treatment groups, the addition of acarbose resulted in significant reductions in postprandial blood glucose levels. Additionally, HbA1C was significantly lower after 12 months of acarbose therapy, compared with placebo, in all groups except the diet and insulin group. The addition of acarbose consequently expands the armamentarium available to clinicians for the optimization of glycemic control in patients with NIDDM.

Epidemiology of diabetes mellitus in Canada

We present data on 5 aspects of the epidemiology of diabetes mellitus in Canada: (a) the incidence of insulin-dependent diabetes mellitus in those under 15 years of age. The 2 Canadian centres that participated in the Diabetes Epidemiology Research International study had different incidence rates in IDDM:25.5/100,000 in Prince Edward Island (PEI) and 9.2/100,000 in Montreal. The reasons for this difference are not yet established. Studies on incidence of IDDM over a decade in PEI showed an apparent epidemic of the disease; (b) the prevalence of self-reported diabetes mellitus in Canadian adults. The overall prevalence of self-reported diabetes in Canadian adults (18-74 y) was 5.1% in the Canadian Heart Health Survey. There were no significant regional differences in prevalence of diabetes across Canada. The prevalence rates increased with age; (c) mortality data in people with diabetes mellitus. In PEI, 321 persons with diabetes died between January 1, 1982 and December 31, 1984, accounting for about 2% of all deaths. Diabetes was listed as the underlying cause in 16.8% of the deaths, as a contributing cause of death in 41.7%, and not mentioned at all in 41.1% of the deaths. Irrespective of whether diabetes was mentioned or not, myocardial infarction and cerebral vascular disease were the 2 major causes of deaths in these 321 persons with diabetes; (d) the prevalence of cardiovascular risk factors in Canadian adults with diabetes mellitus. In the Canadian Heart Health Survey, the prevalence rates of obesity, hypertension, sedentary lifestyle, and hypercholesterolemia were higher in the diabetic group.(ABSTRACT TRUNCATED AT 250 WORDS)

One-year acarbose treatment raises fasting serum acetate in diabetic patients

alpha-Glucosidase inhibitors such as acarbose improve blood glucose control in diabetes by delaying or reducing carbohydrate absorption. The fermentation of malabsorbed carbohydrate in the colon is associated with the production of gas, leading to flatulence, and short chain fatty acids such as acetate, which may have systemic effects. To see if acarbose raised fasting serum acetate in diabetic patients, we studied 85 subjects selected from the 267 who had completed a 1-year, double-blind, placebo-controlled, parallel design study of the effects of acarbose in the treatment of diabetes. At baseline, there was no significant difference between the 44 subjects subsequently randomized to placebo and the 41 randomized to acarbose, respectively, in fasting serum acetate (80 +/- 5 vs 71 +/- 4 mumoll-1) or glycosylated haemoglobin (HbA1C; 7.2 +/- 0.3 vs 7.4 +/- 0.3%). Compared to placebo, acarbose treatment significantly increased fasting serum acetate by 11 +/- 4 vs 2 +/- 3 mumoll-1 (p < 0.02) and reduced HbA1C by -0.59 +/- 0.16 vs -0.13 +/- 0.20% (p < 0.02). Acarbose treatment had no significant effect on serum cholesterol or non-esterified fatty acids, but was associated with a significant increase in flatulence. There was no relationship between changes in serum acetate and changes in HbA1C, serum cholesterol or symptoms. We conclude, in subjects with diabetes who tolerate therapy for a 1-year period, that acarbose treatment increases serum acetate. The magnitude of change in acetate was unrelated to side-effects or changes in blood glucose control or serum lipids.

The efficacy of acarbose in the treatment of patients with non-insulin-dependent diabetes mellitus. A multicenter controlled clinical trial

OBJECTIVE

To evaluate the long-term efficacy of acarbose, an alpha-glucosidase inhibitor, in improving glycemic control in patients with non-insulin-dependent diabetes mellitus.

DESIGN

A 1-year, multicenter, randomized, double-blind, placebo-controlled study.

SETTING

Seven university-affiliated, community-based, tertiary care diabetes clinics.

PATIENTS

354 patients with non-insulin-dependent diabetes mellitus were recruited; 77 were being treated with diet alone, 83 with diet and metformin, 103 with diet and sulfonylurea, and 91 with diet and insulin. Patients in each treatment group were randomly assigned to either acarbose or placebo for 1 year. Eighty-seven percent of patients receiving acarbose and 92% of those receiving placebo were included in the efficacy analysis (n = 316).

MEASUREMENTS

At baseline and at 3-month intervals, levels of hemoglobin A1c (HbA1c), fasting and postprandial plasma glucose, fasting and postprandial serum C-peptide, and fasting serum lipids were measured.

RESULTS

Compared with placebo, acarbose treatment caused a significant decrease in the mean postprandial plasma glucose peak (90 minutes) in all four groups (19.0 +/- 0.4 mmol/L to 15.5 +/- 0.4 mmol/L; P < 0.001). Analysis of the postprandial plasma glucose incremental area under the curve showed that the change from baseline to the end of the treatment period differed for placebo and acarbose recipients by 4.73 mmol.h/L in the diet alone group (P < 0.001), 2.06 mmol.h/L in the metformin group (P = 0.01), 2.65 mmol.h/L in the sulfonylurea group (P < 0.001), and 3.13 mmol.h/L in the insulin group (P = 0.001). Corresponding decreases in HbA1c levels occurred; these were 0.9% in the diet alone group (P = 0.005), 0.8% in the metformin group (P = 0.011), 0.9% in the sulfonylurea group (P = 0.002), and 0.4% in the insulin group (P = 0.077). Acarbose did not significantly affect mean serum C-peptide or mean serum lipid levels.

CONCLUSIONS

Acarbose improved long-term glycemic control in patients with non-insulin-dependent diabetes mellitus regardless of concomitant antidiabetic medication.

Disease and risk factor perception among patients with coronary artery disease in Kuala Terengganu

One hundred consecutive patients with coronary heart disease attending the Physician Clinic, Kuala Terengganu General Hospital self-completed a questionnaire on their awareness of the coronary risk factors and their perception of their disease. Seventy-one subjects were males. Twenty-seven subjects had never had formal education and only 6 had completed tertiary education. Whilst 52% considered themselves as having less than 25% knowledge about their disease, many were aware of hypercholesterolaemia, emotional stress, inadequate exercise and smoking as risk factors for coronary heart disease. Diabetes and family history were less known as coronary risk factors. Despite their awareness of the risk factors, though, the subjects failed to control these. For example, smoking was prevalent and their awareness of the harmful effects of smoking did not seem to deter them from this habit. Further, formal education did not seem to influence positive health behaviour. In terms of disease perception, the subjects tended to believe that their illness could be cured. Eighty subjects expected a cure from their doctors. Sixty-three subjects wanted more explanation of their illness from their doctors. These findings suggest that efforts should be made to translate patients' awareness of their illness to appropriate health behaviour, and perhaps doctors could achieve this by spending more time explaining to the patients, and educating them.

Descriptive terms used by Malay patients for exertional angina pectoris

Description of the chest pain of angina pectoris by patients is commonly used in the diagnosis, evaluation and monitoring of ischaemic heart disease. Whilst certain descriptive terms have been identified as describing angina and not other causes of chest pain, these terms have not been systematically evaluated among local Malaysian patients. Reliance on a translation of the description used by Western patients may not be totally correct in the local context. Seventy-one Malay patients with documented ischaemic heart disease were asked, by questionnaire and by interview, to identify the descriptive terms they used for their angina pectoris. Common terms used by these patients were sempit (constrictive) [56.3%], mencuck (pricking) [54.9%], berat (heavy) [53.5%], panas (burning) [50.7%], menekan (pressing) [46.4%], and pedih (smarting) [43.7%]. Other less common descriptions used were tajam (sharp), mencengkam (strangulating), hempap (compressive), ngilu, hiris (knife-like), lengoh (aching). Two-thirds of the patients used more than three terms to describe their angina pectoris. Direct translation of the description of angina may not only be inaccurate but could also be misleading. It is suggested that the actual words used by the patients in Bahasa Malaysia be recorded in the patient's notes rather than a translation of these. More studies are required to determine whether the terms used by the patients in this study are related to local dialect (in this case Terengganu) or are actually common in Malaysia. Further, similar studies among Chinese and Indian patients are also required.

Detection of familial defective apolipoprotein B-100 among patients clinically diagnosed with heterozygous familial hypercholesterolemia in maritime Canada

Familial defective apolipoprotein B-100 (FDB) is a genetic disorder resulting from a mutation in the apolipoprotein B-100 (apo B-100) gene, most frequently at position 3500, in which arginine is substituted for glutamine in the mature protein. This mutation drastically decreases the affinity of the mutant apo B-100 particle for the low-density lipoprotein (LDL) receptor, and hence decreases the clearance of cholesterol from the circulation. Familial hypercholesterolemia (FH), also a disorder of lipid metabolism, results from mutations in the gene for the LDL receptor. Both FDB and heterozygous FH occur at approximately the same frequency (1 in 500) among Caucasians and both produce clinical symptoms and signs that can be indistinguishable. Polymerase chain reaction (PCR) amplification and subsequent restriction analysis have been used to detect the substitution at codon 3500 in the apo B-100 gene using mutagenic PCR primers. At least one proband from 10 unrelated families with a history of hypercholesterolemia was screened by mutagenic PCR for FDB. Only one of 10 patients demonstrated the mutation for FDB. The mutant apo B-100 allele was shown to segregate with other clinically affected family members. These results demonstrate that molecular analysis is essential to distinguish between FDB and heterozygous FH in hypercholesterolemic families.

Determinants of diet glycemic index calculated retrospectively from diet records of 342 individuals with non-insulin-dependent diabetes mellitus

Controlled trials have shown that a diet with a low glycemic index improves blood glucose and lipid control in patients with diabetes. To study the distribution and determinants of diet glycemic index, we obtained two 3-d diet records from 342 free-living subjects with non-insulin-dependent diabetes. Mean +/- SD 24-h intakes were as follows: energy, 7170 +/- 1890 kJ; fat, 33.6 +/- 6.5% of energy; protein, 20.1 +/- 3.2% of energy; available carbohydrate, 45.3 +/- 7.2% of energy; and dietary fiber, 17.2 +/- 6.4 g. Diet glycemic index values (85.4 +/- 4.55, range, 70-97.8) were normally distributed. Diet glycemic index was inversely associated with intake of simple sugars, whether expressed in grams (r = -0.426), percent of energy (r = -0.446), or percent of carbohydrate (r = -0.453, P < 0.001). By step-wise-multiple-linear regression, grams carbohydrate and percent protein were also independently related to diet glycemic index. Differences in diet glycemic index between men and women, and between subjects on different types of diabetes therapy were explained by differences in intake of simple sugars.

Expression of the insulin-regulatable transporter GLUT-4 in muscle is influenced by neurogenic factors

To investigate whether the expression of GLUT-4 is influenced by neurogenic factor(s) released from the nerve to the muscle, we measured GLUT-4 at different time points after sectioning the sciatic nerve at different locations in two groups of rats. Specifically, GLUT-4 was measured at 12, 24, and 48 h after severing the sciatic nerve. In one group of animals the muscles were left either with a short nerve stump attached to the muscle, or, in another group of animals, a long nerve stump remained attached to the muscle. In both groups of animals the contralateral limb served as a control. We examined GLUT-4 in the red (RG) and white gastrocnemius (WG), since the RG is highly responsive to denervation and the WG is quite resistant to denervation [L. A. Megeney, P.D. Neufer, G. L. Dohm, M. H. Tan, C. A. Blewtt, G. C. B. Elder, and A. Bonen. Am. J. Physiol. 264 (Endocrinol. Metab. 27): E583-E593, 1993]. In the long nerve stump WG no change in GLUT-4 was observed at 12, 24, or 48 h after denervation (P > 0.05). In the short nerve stump WG, changes were not evident at 12 and 24 h (P > 0.05), but by 48 h a significant decrement (-12.7 +/- 6.7%) was observed (P < 0.05). GLUT-4 changes were only evident 48 h after denervation (-19.8 +/- 4.5%; P < 0.05) in the long nerve stump RG.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin availability among International Diabetes Federation member associations. Report of the Task Force on Insulin Distribution

OBJECTIVE

To assess the availability of insulin and diabetes supplies among International Diabetes Federation (IDF) member associations.

RESEARCH DESIGN AND METHODS

A mail survey of IDF member associations asked about the following issues: 1) diabetes prevalence and insulin use, 2) availability and cost of insulin and supplies, 3) availability of glycemic monitoring supplies, 4) cost of insulin and supplies to patients, and 5) availability of oral hypoglycemic agents.

RESULTS

Of 85 member associations, 60 responded. The mean prevalence of diabetes was 3.7%. Of the 39 with a population-based survey data, the prevalence was 3.9%. Insulin use was reported for 19.2% of diabetes patients and, for the 15 with population-based data, the proportion using insulin was 16.1%. Of the respondents, 47 (78%) reported insulin was always available, 11 (18%) reported insulin was available from 25 to 99% of the time, and 2 (Uganda and Tanzania) reported insulin was available < 25% of the time. Insulin is free to patients in 39 (65%) of the countries. The average cost of the least expensive insulin was U.S. $9.62 per vial. Fifteen countries imposed a mean 13% customs charge. Disposable syringes were available in 42 (72%) of countries all of the time. Glucose meters were in use in 49 countries. The most common oral agent was glyburide, which was available in 57 countries.

CONCLUSIONS

Insulin is in reasonable supply in IDF member countries. Cost and customs charges are an impediment to universal access. IDF now can recommend programs based on this data.

Comparative efficacy and safety of pravastatin, nicotinic acid and the two combined in patients with hypercholesterolemia

In a comparative study, 158 patients with type IIa or IIb primary hypercholesterolemia received either placebo, nicotinic acid extended-release capsules (0.5 to 1.0 g twice daily), pravastatin (40 mg at bedtime), or the combination for a short-term, 8-week period. A long-term, 88-week phase followed in which the addition of other lipid-lowering agents was permitted. During the short-term phase, low-density lipoprotein cholesterol levels were lower, in relation to baseline, with nicotinic acid treatment (-21%) than with placebo (P < or = 0.05), with pravastatin (-33%) than with either placebo (p < or = 0.001) or nicotinic acid (p < or = 0.05) and with combination therapy (-49%) than with the other 3 treatments (p < or = 0.05) at all weeks measured. At week 8, high-density lipoprotein cholesterol levels were increased, in relation to placebo, by nicotinic acid treatment (12%; p < or = 0.05), pravastatin therapy (13%; p < or = 0.01) and combination therapy (16%; p < or = 0.01). Adverse events were less frequent in the pravastatin and placebo groups (p < or = 0.05). In comparison with placebo, treatment with nicotinic acid resulted in significant increases in aspartate and alanine aminotransferase. The placebo and pravastatin groups did not differ significantly regarding adverse events or laboratory parameters. Similar results were observed in the long-term phase. Therefore, pravastatin is very effective and well tolerated in the treatment of type IIa or IIb primary hypercholesterolemia, and is superior to nicotinic acid in both efficacy and adverse event profile.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of muscle activity and fiber composition on glucose transport and GLUT-4

We examined glucose uptake and GLUT-4 in rat muscles [soleus (Sol), plantaris (PL), extensor digitorum longus (EDL), tibialis anterior, and the red and white gastrocnemius (WG)]. In the normally innervated perfused rat hindlimb muscles the proportion of oxidative fibers was highly correlated with the muscle's insulin-stimulated 3-O-methyl-D-glucose (3-MG) uptake (R2 = 0.78) and GLUT-4 content (r = 0.94). Insulin-stimulated 3-MG uptake and GLUT-4 were also highly correlated (R2 = 0.996). In 3-day denervated muscles, insulin-stimulated 3-MG uptake was reduced in all six muscles (-41 to -14.6%, P < 0.05), and GLUT-4 content was also reduced (-87.5 to -34.9%), except in the WG and EDL (P > 0.05). A very high correlation was observed between the decrements in GLUT-4 (%) and the decrements in 3-MG uptake (%; r = 0.99). The relatively greater loss in muscle activity (%) due to denervation in the Sol compared with the PL coincided with the reductions (%) in GLUT-4 and 3-MG uptake. These studies demonstrate that glucose uptake and GLUT-4 are regulated by insulin-independent means, namely the oxidative capacity of the muscle and the normal activity level of the muscle.