Effects of bezafibrate on insulin secretion and peripheral insulin sensitivity in hyperlipidemic patients with and without diabetes

Although it has been reported that bezafibrate influences carbohydrate metabolism, this possibility has never been properly evaluated in a controlled clinical trial. In this study we attempted to evaluate the effects of bezafibrate on plasma lipoproteins, glucose tolerance, insulin secretion and peripheral insulin sensitivity in a group of hypertriglyceridemic patients with and without diabetes. Sixteen hyperlipidemic patients (10 males and 6 females) participated in the study. Eight had type IIB and 8 type IV hyperlipoproteinemia; 6 of them also had non-insulin dependent diabetes mellitus. The study was performed according to a double blind, crossover design: after 1 month wash-out period in which patients were on diet alone, they underwent, in a random order, a period of placebo therapy and another period in which they received a single daily dose of a long-acting bezafibrate preparation (400 mg) administered in the evening. Each treatment lasted 2 months. Total plasma and VLDL triglyceride concentrations were consistently reduced by bezafibrate (-46%, P less than 0.001; and -50%, P less than 0.001). Total and VLDL-cholesterol were also reduced by bezafibrate. The effects of bezafibrate on lipoproteins were similar in diabetic and non-diabetic subjects. Bezafibrate treatment did not influence fasting blood glucose concentration, glucose tolerance, peripheral insulin sensitivity or insulin secretion. In conclusion, the results of this controlled trial clearly indicate that bezafibrate can be successfully employed to lower plasma lipid levels in patients with non-insulin dependent diabetes mellitus and hyperlipidemia.

Relation of ocular and systemic factors to survival in diabetes

The relationship of survival to systemic and ocular factors in diabetic persons was studied using data collected as part of the Wisconsin Epidemiologic Study of Diabetic Retinopathy. Six years after the baseline examination, 9.5% of 996 insulin-taking people who were younger than age 30 years when their diabetes was diagnosed (younger onset) had died. Of 1370 people whose diabetes was diagnosed after age 30 years (older onset), 35.3% had died. After adjusting for age and sex, longer duration of diabetes, presence of proteinuria, a history of cardiovascular disease, higher blood pressure, diuretic use, a history of smoking, poorer visual acuity, and more severe retinopathy were significantly associated with decreased survival in both groups. Glaucoma was associated with decreased survival in the younger onset group and cataract in the older onset group. These findings suggest that some ocular complications are important risk indicators for death. Their presence in diabetic patients suggests the need for frequent examinations to detect systemic complications and to intervene to minimize their effect.

Carriage of Staphylococcus aureus and inflamed infusion sites with insulin-pump therapy

The most common complication of continuous subcutaneous insulin infusion (CSII) is inflammation at the infusion site. To determine possible risk factors to these infections, we studied several factors in the management of CSII and compared the pyogenic skin inflammation rate, the carriage rate of Staphylococcus aureus, and the HbA1 level among 50 CSII-treated diabetic patients, 50 diabetic patients on insulin injections, 48 diabetic patients on oral medication, and 40 healthy volunteers. There was no increased carriage rate of S. aureus among CSII-treated patients (42%) as compared with the other groups. An unexpected inverse relationship existed between HbA1 level and carriage rate in the CSII-treated group (HbA1 5-8%, n = 16, 69%; HbA1 8-10% n = 15, 40%; HbA1 greater than 10, n = 19, 21% P = .02). Pyogenic skin inflammations were reported by 24 (48%) CSII-treated patients, of which 18 had infected infusion sites, 6 (12%) insulin injecting patients, 2 (4%) patients on oral medication, and 3 (8%) healthy volunteers (P less than .01). The occurrence of inflamed infusion sites was not associated with carriage of S. aureus, the indwelling time of the needle, or the insulin dosage per day. There was an association, however, with the type of insulin preparation classified according to the added preservative: m-cresol-containing insulin (n = 24, 54%); methyl p-hydroxybenzoate-containing insulin (n = 26, 19%, P = .02). We concluded that the carriage of S. aureus is not increased among diabetic patients on CSII treatment and is not a risk factor in the occurrence of inflammation at the infusion site.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic analysis of the left ventricle in patients with type II diabetes mellitus]

Left ventricular involvement in type II diabetes mellitus is poorly understood. We performed a cross-sectional, M-mode and pulsed Doppler echocardiographic study on 27 diabetic patients and 27 controls accurately matched for age, sex, weight and height. All subjects also underwent 24-hour non-invasive ambulatory blood pressure monitoring. Left ventricular wall thicknesses and dimensions in diastole and systole, left ventricular mass index (82.7 g/m2 vs 78.4 g/m2) and the echocardiographic indices of left ventricular contractility did not show any statistical differences between diabetics and controls. Clinic and 24-hour ambulatory blood pressure did not show important differences between diabetics and controls. Doppler parameters for transmitral flow velocity (including peak A and peak E velocity and their ratio, pressure half time and pressure half slope) were the same in diabetics and controls. A stepwise multivariate regression analysis showed a significant positive independent relationship of peak A/peak E ratio with age (peak A/peak E = 0.0087 + 0.20 x age; F = 18.7; p = 0.0001), but not with diabetes or glycosylated haemoglobin (Hb 1 AC). Compared with non-diabetics, diabetics showed a slight increase in aortic peak flow velocity (0.83 m/sec vs. 0.70 m/sec; p = 0.011) and a very slight increase in peak aortic gradient. Peak aortic velocity showed a highly significant positive independent relation with the duration of diabetes (Vmax = 0.572 + 0.0028* diabetes duration (months); F = 92.6; p less than 0.0001), but not with age, systolic or diastolic blood pressure of HB 1 AC.(ABSTRACT TRUNCATED AT 250 WORDS)

Sodium restriction and blood pressure in hypertensive type II diabetics: randomised blind controlled and crossover studies of moderate sodium restriction and sodium supplementation

OBJECTIVE

To determine the effect of moderate dietary sodium restriction on the hypertension of non-insulin-dependent (type II) diabetes.

DESIGN

Randomised parallel controlled study of moderate sodium restriction for three months compared with usual diabetic diet, followed by randomised double blind crossover trial of sustained release preparation of sodium for one month versus placebo for one month in patients continuing with sodium restriction.

SETTING

Patients attending diabetic outpatient clinic of city hospital.

PATIENTS

Thirty four patients with established type II diabetes complicated by mild hypertension (systolic blood pressure greater than 160 mm Hg or diastolic pressure greater than 95 mm Hg on three consecutive occasions). Patients already taking antihypertensive agents (but not diuretics) not barred from study provided that criteria for mild hypertension still met. Conditions precluding patients from study were diabetic or hypertensive nephropathy, cardiac failure, and pregnancy.

INTERVENTIONS

After run in phase with recordings at seven weeks, three weeks, and time zero patients were allocated at random to receive moderate dietary sodium restriction for three months (n = 17) or to continue with usual diabetic diet. Subsequently nine patients in sodium restriction group continued with regimen for a further two months, during which they completed a randomised double blind crossover trial of sustained release preparation of sodium (Slow Sodium 80 mmol daily) for one month versus matching placebo for one month.

END POINT

Reduction in blood pressure in type II diabetics with mild hypertension.

MEASUREMENTS AND MAIN RESULTS

Supine and erect blood pressure, body weight, and 24 hour urinary sodium and potassium excretion measured monthly during parallel group and double blind crossover studies. After parallel group study sodium restriction group showed significant reduction in systolic blood pressure (supine 19.2 mm Hg, erect 21.4 mm Hg; p less than 0.001) and mean daily urinary sodium excretion (mean reduction 60 mmol/24 h). There were no appreciable changes in weight, diabetic control, or diastolic pressure. No significant changes occurred in controls. In double blind crossover study mean supine systolic blood pressure rose significantly (p less than 0.005) during sodium supplementation (to 171 mm Hg) compared with value after three months of sodium restriction alone (159.9 mm Hg) and after one month of placebo (161.8 mm Hg).

CONCLUSIONS

Moderate dietary restriction of sodium has a definite hypotensive effect, which may be useful in mild hypertension of type II diabetes.

Effects of prazosin on blood pressure and diabetic control in patients with type II diabetes mellitus and mild essential hypertension

The effects of prazosin treatment on blood pressure and diabetic control were assessed in 22 patients with stable non-insulin-dependent diabetes mellitus and hypertension. After an initial six-week baseline period, patients were titrated to optimal therapeutic doses of prazosin (mean daily dose, 12.9 +/- 6.5 mg). Both sitting and standing systolic and diastolic blood pressures were significantly decreased (p = 0.01) with prazosin therapy from a mean of 152/99 mm Hg sitting and 144/99 mm Hg standing to a mean of 139/84 mm Hg and 133/85 mm Hg, respectively, at the end of titration and throughout the 12-week prazosin maintenance therapy period. Seventy-seven percent of patients achieved the goal sitting diastolic blood pressure of 85 mm Hg or less. Total cholesterol, high-density lipoprotein cholesterol, and triglyceride levels were not significantly altered during prazosin therapy compared with baseline measurements. Diabetic control and renal function were maintained during prazosin treatment with no significant changes from baseline noted. No unexpected adverse experiences were reported. In summary, prazosin treatment effectively reduced blood pressure without compromising diabetic control or renal function in this group of hypertensive patients with concomitant diabetes mellitus.

Effects of exercise on cardiovascular disease risk in women with NIDDM

The effect of a 4-month exercise program on measures of cardiovascular disease (CHD) risk was observed in women (mean age = 59.2 +/- 3.9 years) of postmenopausal years with NIDDM, who demonstrated fair to normal control of blood glucose control. The women were randomly assigned to either an exercise (n = 5) or control (n = 5) group. Initially, both groups had a similar body mass index, resting heart rate and blood pressures, blood glucose and hemoglobin A1. After 4 months, the exercise group demonstrated a 32% increase (P less than 0.03) in both absolute and relative maximum oxygen uptake (VO2) while the control group remained unchanged. Significant differences were found between the exercisers and non-exercisers for absolute (F(1,8) 4.94, P = 0.057) and relative (F(1,8) 7.67, P = 0.024) maximum VO2 from pretest to posttest. Body weight (kg) and body fat (%) remained unchanged for both groups. Although total cholesterol was found to be reduced by 13% for the exercise group (P less than 0.03) and 11% for the controls (P less than 0.01), a 15% decrease (P less than 0.03) in high-density lipoprotein (HDL) was observed for the control group, only. Hence, a marked difference (P less than 0.03) in the risk ratio was observed between the exercise and control groups. These data suggest that physical exercise may play an important role in the maintenance of HDL mass and in the reduction of CHD risk factors in women of postmenopausal years with NIDDM.

Obesity is an obligatory component for development of type II diabetes in predisposed monkeys: a testable hypothesis

Monkeys have been extensively studied with respect to the development of obesity and diabetes. Segregation of the two disorders on a genetic basis has not been possible.

Morphometrical and biochemical differences of endocrine pancreata between spontaneously hypertensive and normotensive rats with or without neonatal streptozotocin-induced diabetes

We studied the morphometrical and biochemical changes of endocrine pancreata in spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY) with or without noninsulin-dependent diabetes mellitus induced by neonatal streptozotocin (STZ) treatment at 4 months of age. Female (2-day-old) neonates were intraperitoneally injected with 62.5 or 75.0 mg/kg of STZ for SHR, 87.5 or 100.0 mg/kg of STZ for WKY, and vehicle for control. In STZ-treated groups, overt hyperglycemia developed in SHR with significantly decreased serum immunoreactive insulin (IRI), whereas in WKY, hyperglycemia was very mild and serum IRI was not lowered. The number and mean size of pancreatic islets did not differ between SHR and WKY, although mean islet size was reduced by half in both compared with that in the corresponding control, respectively. Percentage distribution of insulin-positive B cells in the islet was significantly reduced more in SHR than in WKY (34% of control versus 64% of control, p less than 0.05). Furthermore, pancreatic IRI content was far more reduced in SHR than in WKY (3% of control versus 43% of control, p less than 0.001). In vehicle-treated groups, the glycemic levels and the morphometrical islets did not differ between SHR and WKY. However, serum IRI was significantly lower but pancreatic IRI content was higher in SHR than in WKY. The mechanisms of strain differences between SHR and WKY seen in the present study were discussed.

[Usefulness of thermographic examination in the diagnosis of early peripheral ischemia of the extremities in patients with diabetes mellitus]

Vascular damage is the main complication of diabetes. An early sign of this complication is damage to the arterial and capillary vessels in the lower extremities with later impairment of peripheral blood flow. The aim of the present study was evaluation of the usefulness of thermography in the detection of early circulatory disturbances in the lower extremities during diabetes, and comparison of its results with those obtained in oscillometry. The study comprised 28 patients with type I diabetes aged from 16 to 57 years and 27 patients with type II diabetes aged from 35 to 65 years. The control group included 10 clinically health subjects in similar age group. It was found that thermographic changes were much more frequent than pains in the extremities and abnormal values of oscillometric++ index in diabetes type I and II. Nearly half the patients with evident thermographic disturbances had no oscillometric changes, and 2/3 of the patients felt no pains in the extremities.

Hypertension in diabetic patients and differences between insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus

In insulin-dependent diabetes mellitus (IDDM), BP levels in subjects with normal or only mildly increased levels of albumin excretion do not differ systematically from those in non-diabetic reference populations. However, it is not known whether increased albuminuria and raised blood pressure are causally related. Several studies have observed higher average BP levels in glucose-intolerant subjects, even allowing for effects of age and adiposity. This applies to subjects with glucose intolerance below and above the World Health Organization criteria for diagnosing non-insulin-dependent diabetes mellitus (NIDDM). However, there are very few satisfactory studies comparing established patients with NIDDM with appropriate reference populations, and although it is widely believed that high BP (or hypertension) is a feature of NIDDM, the evidence for this belief is scant.

Diuretics and other antihypertensive drugs and glycemic control in non-insulin-dependent diabetics with hypertension. A survey by the Fukuoka Diabetes Clinic Group

We compared the levels of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1) in non-insulin-dependent diabetics with hypertension who were treated with monotherapy of diuretics or other antihypertensive drugs (AHD) and in those who were not given any AHD. Total 162 patients were divided into the four groups; the control group without AHD (n = 45), the diuretics group (n = 42), the beta-blocker group (n = 30) and the Ca-antagonist group (n = 45). FPG and HbA1 levels were 153 +/- 44 mg/dl and 10.0 +/- 2.3% for the control group, 145 +/- 55 mg/dl and 9.8 +/- 2.2% for the diuretics, 165 +/- 63 mg/dl and 10.2 +/- 2.1% for the beta-blocker and 158 +/- 42 mg/dl and 10.4 +/- 2.0% for the Ca-antagonist, respectively. There were no significant differences in the levels of FPG and HbA1 among the four groups. Multivariate analysis also revealed no difference in glycemic control even when anti-diabetic treatment (diet alone, oral hypoglycemic agents or insulin), body mass index, serum potassium, systolic and diastolic blood pressures and age were taken into account. Blood pressure levels did not differ among the groups except control and they were well controlled at the low doses of AHD. Our results suggest that the choice of low dose diuretics for the treatment of hypertension in non-insulin-dependent diabetics might not be necessarily excluded by the only reason of the possible deleterious influence on glycemic control.

HLA-A,B,C and DR antigens in Chinese with non-insulin-dependent diabetes: comparison with goitrous diabetics

To examine the relationship between HLA antigens and Type 2 non-insulin-dependent diabetes (NIDDM), 72 patients were studied and compared with 282 controls. Twenty of 72 patients had an associated non-toxic goiter. The clinical features of the goitrous diabetic patients were similar to those without goiter except that those with goiter were predominantly female (95%). Of the 46 antigens assayed, only A10 was increased in the 72 diabetics when compared with the controls (12.5 vs 5.7%, RR = 2.37, chi 2 = 4.07, p less than 0.05), but statistically this was not significant after p value correction. In the patients with goiter, antigens A2, A9, A10, B27, BW46, CW1, DR1, DR5, DR8, DRW9 showed 2 folds or greater differences in frequencies when compared to the non-goitrous diabetics. However, only A2 had a significant decrease in the former as compared with the latter (30.0 vs 59.6%, chi 2 = 5.07, p less than 0.05), but this was also statistically insignificant. The present study showed no significant HLA associations in Chinese NIDDM patients with or without non-toxic goiter, and the distribution of each antigen was not related to the presence or absence of goiter.

Hand abnormalities are associated with the complications of diabetes in type 2 diabetes

Limited finger joint mobility, Dupuytren's contracture, and the complications of diabetes were assessed in 233 Type 2 diabetic patients. Limited joint mobility was present in 34% and Dupytren's contracture in 26%. The prevalence of limited joint mobility and Dupuytren's contracture increased with duration of diabetes and with age. Logistic regression analysis showed that, after allowing for age and duration of diabetes, limited joint mobility was independently associated with Dupuytren's contracture (odds ratio 5.7, 95% CI 2.0-16.4) and retinopathy (odds ratio 3.1, CI 1.5-6.4). Dupuytren's contracture was independently associated with vision-threatening retinopathy (odds ratio 2.6, CI 1.1-6.4), limited joint mobility (odds ratio 2.5, CI 1.3-4.8), and foot ulceration (odds ratio 4.9, CI 1.4-16.4). Both Dupuytren's contracture and limited joint mobility were associated with peripheral neuropathy but neither hand abnormality was associated with neuropathy independently of other complications of diabetes. The association of connective tissue abnormalities in the hand with the complications of diabetes suggests that similar factors may be contributing to their pathogenesis.

Effect of nicardipine on insulin secretion, glucose and lipid metabolism in hypertensive, non-insulin dependent diabetics

Certain acute and chronic metabolic effects of nicardipine have been studied in 20 patients with non-insulin dependent diabetes (NIDD). An intravenous glucose tolerance test (i.v. GTT, glucose 0.33 g/kg as a bolus) and the corresponding insulin response were assessed at the end of a 4 week placebo period, after the first dose and on administration for 12 weeks of nicardipine 20 mg t.i.d. The glucose and insulin responses to the i.v.GTT, evaluated as incremental AUCs, did not change significantly (glucose 30.5 mg/dl.90 min on placebo, 33.1 mg/dl.90 min acutely and 31.4 mg/dl.90 min on chronic administration of nicardipine; insulin 2.08 microU/ml.90 min on placebo, 1.87 microU/ml.90 min acutely and 1.93 microU/ml.90 min after chronic nicardipine). Glucose removal rate (KG) following the i.v.GTT was 0.73%/min on placebo 0.75%/min on acute administration and 0.8%.min-1 with chronic nicardipine. Active treatment produced a significant reduction of blood pressure (from 187/96 mm Hg on placebo to 166/89 mm Hg acutely and 152/83 mm Hg after 12 weeks of nicardipine treatment). It is concluded that the calcium antagonist nicardipine was an effective antihypertensive drug, and that it did not cause deterioration of metabolic control in hypertensive patients with NIDD.

Basis for myocardial mechanical defects associated with non-insulin-dependent diabetes

Hearts isolated from 12-mo non-insulin-dependent diabetic rats exhibited reduced rates of contractility and relaxation. Associated with the abnormality in contractility was a redistribution in myosin isozyme content to the least active V3 form. Defects in myocardial relaxation also occurred concomitantly with impaired handling of calcium. Total tissue calcium content rose 35% in the diabetic hearts. At the same time, the activity of the pump responsible for maintaining normal cytoplasmic calcium levels was reduced. At a free calcium concentration of 2.0 microM, the rates of sarcoplasmic reticular calcium uptake and adenosinetriphosphatase activity of the diabetic hearts were decreased approximately 30%. Diastolic ventricular stiffness increased dramatically. The net result of these abnormalities in calcium metabolism is a significant impairment in mechanical performance of the diabetic heart.

[Non-insulin-dependent diabetes mellitus and hyperlipoproteinemia in patients with ischemic cardiopathy]

Cardiovascular disease (CVD) constitutes the main cause of death in diabetes mellitus (DM): Previous studies at the "Instituto Nacional de Cardiología de México" have investigated the metabolic alterations of survivors of a myocardial infarction (MI), but none of them had focused on the metabolic profile of the diabetic patient. We compared two groups of patients with ischemic heart disease (IHD), one with (DMG) and one without (NDMG) Diabetes Mellitus, to investigate differences in the prevalence and nature of hyperlipoproteinemias (HLP) and other risk factors of atherosclerosis. DMG consisted of 117 patients (75 male, 42 female) and NDMG consisted of 119 patients (91 male y 28 female). (Female NDMG vs female DMG p less than 0.05). The presence of risks factors of atherosclerosis was investigated in all patients, and total cholesterol (chol) triglycerides (TG) and glucose were measured in post-absorptive phase. There were no differences regarding mean age (DMG: 60 +/- 8 years, NDM: 60 +/- 11 years), Quetelet Index (Kg./mt2: DMG: 26.5 +/- 3, NDMG: 26.7 +/- 3), TG: (DMG: 246.2 +/- 125, NDMG: 223.5 +/- 129) or Chol (DMG: 216 +/- 42 mg/dl, NDMG: 225 +/- 45 mg/dl). Hypertriglyceridemia was significantly higher in patients with DM, as a whole and when both sexes were studied separately (p less than 0.05). Hypercholesterolemia was significantly higher in NDMG (p less than 0.05) and without significance, in diabetic women. (p less than 0.05). Type IV phenotype was higher in DMG (p less than 0.05) whereas phenotypes IIa and IIa + IIb were more prevalent among non-diabetics (p less than 0.001, p less than 0.0001, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin secretion and glucose tolerance in non-insulin dependent diabetic patients after chronic nifedipine treatment

The effect of nifedipine 40 mg.day-1 for 3 months on glucose tolerance, insulin and C-peptide secretion after an oral glucose tolerance test (OGTT), intra-venous glucose tolerance test (IVGTT) and glucagon stimulatory test, has been studied in 8 moderately hypertensive women suffering from non-insulin dependent diabetes mellitus (NIDDM). No significant variation in glucose metabolism was noted after nifedipine treatment, except for a slight improvement in insulin secretion after OGTT at the end of the study. There was an increase in cholesterol as a collateral effect.

Comparison of type II and type I diabetics treated for end-stage renal disease in a large prepaid health plan population

From 1978 through 1984, the incidence of treated end-stage renal disease (ESRD) secondary to diabetic nephropathy increased from 3 to 19 per million population among the membership of the Kaiser Permanente Medical Care Program in Northern California. Forty-eight percent had type II diabetes. Among 66 type II diabetics retinopathy was less severe and hypertension was more frequent than among 50 type I diabetics. Blacks were represented in a higher proportion than expected from their proportion of the health plan membership. Among type II diabetics who developed ESRD, once proteinuria occurred, nephropathy progressed at the same rate observed in type I diabetics. This observation suggests that the clinical progression of diabetic nephropathy may be similar for both types of diabetes after the development of proteinuria, but requires prospectively collected data for confirmation.

Similar risks of nephropathy in patients with type I or type II diabetes mellitus

It is commonly assumed that in patients the risks of developing nephropathy and uraemia are high in type I and low in type II diabetes mellitus. Since type II occurs mostly in elderly individuals with limited life expectancy and high cardiovascular mortality, the true risk may have been underestimated, as many patients do not survive to experience renal complications. To assess renal risk further, we evaluated all patients with type II and type I diabetes mellitus without severe secondary disease who were followed in the outpatient clinic between 1970 and 1985. The cumulative risk of proteinuria after 20 years of diabetes mellitus was 27% in type II and 28% in type I, the findings after 25 years were 57% and 46% respectively. The cumulative risk of renal failure, i.e. serum creatinine greater than 1.4 mg/dl, after 3 years of persisting proteinuria was 41% in both type II and type I, and after 5 years of proteinuria were 63% and 59% respectively. We conclude that the renal risk is similar in patients with type II and type I diabetes mellitus.

Platelet function in patients with type 2 diabetes mellitus: the effect of glycaemic control

In the present study the effects of a short term intensive glycaemic control obtained with subcutaneous insulin therapy on lipids and apoprotein levels, platelet aggregation, platelet sensitivity to prostacyclin and platelet thromboxane production were investigated in 20 patients with type 2 diabetes and vascular disease. In 11 out of the 20 patients there was a significant improvement of glycaemic control (fructosamine reduction). Only with tight improvement of glycaemic control there was significant change in the concentration of ADP and collagen required to produce 50% of the maximum aggregation wave response, in the responsiveness of platelet to PGI2 and in the TxB2 synthesis. Lower Apo B levels were also shown in the tight control group suggesting that Apo B changes may have influenced platelet aggregation and thromboxane synthesis.

Pathophysiology of obesity-associated type II diabetes (NIDDM): implications from longitudinal studies of non-human primates

Clinical observations of humans who have developed adult-onset Type II, non-insulin dependent diabetes have generally supported the idea that there is a large degree of heterogeneity in this disease. Studies of monozygotic twins, however, show such a high degree of concordance as to make doubtful the idea of multiple causes and multiple disease in most instances. Such studies suggest the importance of seeking a unified hypothesis for the basis of Type II diabetes. Prospective longitudinal studies of rhesus monkeys (Macaca mulatta) now provide that integrated picture, and suggest heterogeneity in rate of progression and timing of expression of the disease, with little or no heterogeneity in its pattern of development or in the sequence of events leading to overt diabetes.

[Dynamics of lipid peroxidation in patients with noninsulin-dependent diabetes mellitus]

The time course of erythrocytic lipid peroxidation (LP) was studied in 55 patients with insulin independent diabetes mellitus aged 40 to 60 years LP was assessed by the content of malonic dialdehyde (MDA) and peroxidative hemolysis of erythrocytes (PHE). During diabetic decompensation LP activity was increased, especially in the presence of lower limb angiopathies. The authors assumed an idea of the involvement of LP products in the pathogenesis of vascular lesions. Diabetic compensation did not cause normalization of LP activity however the use of antioxidant (alpha-tocopherol acetate) led to a significant decrease in LP activity which can be of importance for the treatment of the early stages of diabetic angiopathies.

Comparison of the prevalence and associated features of abnormal albumin excretion in insulin-dependent and non-insulin-dependent diabetes

Overnight albumin excretion rates were measured in 940 diabetic patients, 416 with insulin dependent and 524 with non-insulin dependent diabetes, and in 106 healthy volunteers. A significantly higher number of non-insulin dependent diabetic patients had abnormal albumin excretion compared with the insulin-dependent group (X2 = 15.2, p less than 0.002). Ten per cent of non-insulin-dependent and 7 per cent of insulin-dependent diabetic patients had albumin excretion rates in the range 30-150 micrograms/min and thus were at risk of the cardiovascular and renal complications of diabetes. Six per cent of non-insulin-dependent and 5 per cent of insulin-dependent diabetic patients had albumin excretion rates above 150 micrograms/min and thus were entering the phase of clinical diabetic nephropathy. Multivariate analysis revealed that male sex and retinopathy in insulin-dependent diabetes, and systolic blood pressure and retinopathy and peripheral vascular disease in non-insulin-dependent diabetes, were significantly related to albumin excretion. Only one patient with insulin-dependent diabetes of less than 5 years known duration had an albumin excretion rate in the range 30-150 micrograms/min, whereas such an excretion rate indicating patients at risk was observed at all durations of non-insulin-dependent diabetes. It is possible that during the long silent phase of non-insulin-dependent diabetes, before diagnosis, significant renal damage occurred.

Cerebral ischemia in spontaneously hypertensive rats with type 2 (noninsulin-dependent) diabetes mellitus, cerebral blood flow and tissue metabolism

The present study was designed to examine the effect of chronic type 2 (noninsulin-dependent) diabetes mellitus on cerebral blood flow and metabolism during cerebral ischemia induced by bilateral carotid artery occlusion in spontaneously hypertensive rats. Diabetes was produced by streptozotocin treatment in 2-day neonates and the experiment was performed at the age of 5 months. The level of mean arterial pressure was not different between diabetic and nondiabetic rats. At 1 h after ischemia, cerebral blood flow was decreased to 1% of the resting value and supratentorial lactate was increased by 8-fold of control, being virtually the same in both groups of rats. In contrast, reduction of cerebral ATP was much less in diabetic rats (1.64 +/- 0.15 mmol/kg) than in nondiabetic rats (0.74 +/- 0.07 mmol/kg) (p less than 0.001); ATP in nonischemic control is 2.80-2.85 mmol/kg. These results could not be explained by the difference in cerebral blood flow between the groups during ischemia. The results suggest that chronic mild hyperglycemia exerts rather a protective effect on the brain against ischemic insult. Effective utilization of metabolites, such as glucose and ketone bodies, may play an important role to minimize metabolic derangements in the ischemic brain in type 2 diabetic-hyperglycemic rats.

[Content of vasopressin and beta2-microglobulin in the blood in patients with diabetes mellitus type II accompanied by microangiopathy]

Altogether 50 patients with diabetes mellitus, type II, with the presence of microangiopathies and 10 healthy controls were investigated to study the pathogenesis of vascular complications. An increased level of vasopressin and a normal level of beta 2-microglobulin were radioassayed in the blood plasma of the examinees. An acute furosemide test made it possible to establish 3 types of responses of vasopressin secretion in such patients: normal, paradoxical and areactive. The blood level of beta 2-microglobulin was raised in 65% of cases in the paradoxical response, in 34.5% in the normal response and in 0.6% in the areactive response. The data obtained suggested heterogeneity of the mechanisms of development of vascular complications in diabetes mellitus, type II.

Cardiac hypertrophy in diabetic nephropathy: an echocardiographic study

Echocardiography was used to study the prevalence and severity of left ventricular hypertrophy in patients with established diabetic nephropathy (persistent proteinuria for at least 2 y plus severe retinopathy). Fifteen patients had mild renal impairment (serum creatinine less than 150 mumol l-1), 14 patients had moderate renal impairment (serum creatinine 150-400 mumol l-1), and 20 patients had severe renal impairment (serum creatinine greater than 400 mumol l-1). Thirty-six of the 49 (73%) were on anti-hypertensive treatment, despite which mean blood pressure was 161 +/- 25/89 +/- 9 (+/- SD) mmHg. Left ventricular hypertrophy was demonstrated in 42 of the 49 patients (85%), and increased in severity with increasing renal impairment. Interventricular septal + left ventricular posterior wall thickness was 25 +/- 3 mm in those with mild renal impairment, 28 +/- 6 mm in those with moderate renal impairment and 30 +/- 4 mm in those with severe renal impairment. The most severe left ventricular hypertrophy was seen in the Afro-Caribbean patients. Left ventricular hypertrophy was present even in those with marginally raised blood pressure and was related to age and serum creatinine but not to present blood pressure or duration of proteinuria.

A single-blind study of doxazosin in the treatment of mild-to-moderate essential hypertensive patients with concomitant noninsulin-dependent diabetes mellitus

Doxazosin, a selective alpha 1-inhibitor, was assessed for antihypertensive efficacy, effect on lipid parameters, and safety profile in 21 hypertensive patients with noninsulin-dependent diabetes mellitus. The study involved a 2- to 4-week baseline period, a 10-week period in which patients received doxazosin, 1 to 8 mg, once daily, and a 4-week maintenance period. All 16 of the efficacy evaluable patients (100%) had their blood pressure controlled (sitting diastolic blood pressure less than or equal to 90 mm Hg) at a mean dose of 3.6 mg once daily. For efficacy evaluable patients mean sitting blood pressure was significantly (p less than 0.05) reduced by 26/17 mm Hg at the final visit. Five patients each reported a single side effect and none was severe. No patients required dose reduction or discontinuation of therapy because of side effects. No clinically significant laboratory changes were apparent, and no trends were observed with regard to organ systems or correlations with dose or duration of treatment. The investigators' global assessment of efficacy of once-daily doxazosin therapy was excellent or good for 15 patients and fair for six patients. The overall assessment of patient toleration was excellent or good for 19 patients, fair for one, and not reported for one. High-density lipoprotein cholesterol was significantly increased (p = 0.03). From baseline to final visit, there was a highly significant reduction of 30% (p less than 0.005) in calculated coronary heart disease risk score on the basis of the Framingham equation.

Necrotising pancreatitis and diabetes associated with disseminated small cell carcinoma of lung

Although tumour metastases to the pancreas and peripancreatic lymph nodes are found commonly at necropsy in cases of small cell carcinoma of lung, tumour-induced acute pancreatitis is described rarely. A case of metastasis-associated necrotising pancreatitis with the unusual presentation of epigastric pain followed by diabetes is described here. Patients (particularly cigarette smokers) with none of the conventional risk factors for acute pancreatitis merit chest radiography and if indicated prompt cytotoxic treatment.

[Development of angiopathies in type 2 diabetes mellitus--results of a prospective 10 year study]

In 150 newly detected type 2 diabetics the formation of macro- and microangiopathic complications during a 10-year control period was prospectively analysed, in order to demarcate possible factors of influence for the vascular prognosis under preventive points of view. Already at the time of manifestation there was with 34.3% an above average high prevalence of the coronary heart disease, particularly in the female sex. The prevalence of the coronary heart disease further increased to 49.7% in the course of diabetes and showed a correlation to the initial age, to the existence of overweight, hypertension, hyperlipoproteinaemia and nicotine consumption. The PMA was found comparatively more infrequent in the manifestation of diabetes (9.7%), but in the course of the disease highly significantly and independently of sex increased to 61.9%. The development of PMA was correlated with the age, the existence of hypertension and overweight. The frequency of retinopathy increased from initially 3.7% to 18.7%, the prevalence of nephropathy from 4.0% to 22.2%, without having found prognostic influence factors at the date of the diagnosis of diabetes.

[The value of hypertension and metabolic factors on the development of coronary heart disease in type II diabetic patients]

In 1,126 newly manifested type II diabetics of the diabetes intervention study (628 male, 498 female) between 30 and 55 years of age by a univariate and multivariate analysis the influence of atherogenic risk factors on the development of the coronary heart disease was tested. The diagnosis coronary heart disease is based on the ECG at rest (Minnesota-code), in 796 test persons an exercise electrocardiogram was made. In a manifestation of diabetes males with coronary heart disease showed higher mean values for systolic and diastolic blood pressure, body mass index and serum triglycerides than the control group free of coronary heart disease. In females systolic and diastolic blood pressure, uric acid level and age were significantly increased. By means of multidimensional analysis of variance as to the major findings in the ECG at rest (Q/QS type) in males the diastolic blood pressure, in females the systolic blood pressure and the serum uric acid proved to be significant. Minor findings (above all disturbances of repolarisation) were in males significantly associated with the triglycerides and the diastolic blood pressure, in the females with the systolic blood pressure and the age. Test persons with a stage of coronary heart disease which is to be recognized only in the exercise ECG in the behaviour of the mean value of the atherogenic risk factors did not differ from the control group free of findings with the exception of the increased serum triglycerides in the females.

Association of hypertension with blood viscosity in diabetes

Plasma and whole blood viscosity and its determinants were measured in 86 diabetic patients (29 hypertensive and 57 normotensive) and compared with 52 non-diabetic control subjects to assess whether hypertension has an additive and adverse effect on blood viscosity. Whole blood viscosity (corrected for haematocrit), at high and low shear rates (95 and 0.95 s-1), was significantly higher in both Type 1 (5.1 +/- 0.5 (+/- SD), 19.8 +/- 2.9) and Type 2 (5.2 +/- 0.3, 21.1 +/- 2.0) diabetic patients compared with control subjects (4.9 +/- 0.6, 17.4 +/- 2.6 mPa s, p less than 0.01). Corrected whole blood viscosity at high shear rate was significantly higher in hypertensive than in normotensive Type 2 diabetic patients (5.5 +/- 0.4 vs 5.2 +/- 0.3 mPa s, p less than 0.01). Plasma viscosity was significantly higher in diabetic patients compared with control subjects (1.4 +/- 0.1 vs 1.3 +/- 0.1 mPa s, p less than 0.01), but there was no difference between hypertensive and normotensive diabetic patients (1.4 +/- 0.1 vs 1.4 +/- 0.2 mPa s). Fibrinogen levels were similar in all the groups.

CPITN assessment of periodontal disease in diabetic patients

The aim of this study was to investigate, using the CPITN system, the periodontal treatment needs in diabetic patients, and to shed additional light on the possible effects of the duration and control of diabetes on the periodontal status in these patients. A comparison was made between 222 diabetic patients (mean age, 46.9 years) and 189 control subjects (mean age, 43.9 years). Edentulous patients were not included in the study. The results indicated that diabetic patients demonstrated significantly more missing teeth (P less than 0.001). The mean number of missing sextants was also significantly higher in diabetics. Pathologic pockets of 6 mm or more were found in 1.3 and 0.3 sextants in the diabetic and control group subjects, respectively (P less than 0.001). Up to the age of 34, no differences were observed between the diabetic and control group subjects regarding pathologic pockets of 6 mm or more. Above this age, diabetics demonstrated significantly more sextants with deep pockets (P less than 0.001). Concerning the type of diabetes, no differences related to CPITN score were found between insulin dependent and non-insulin dependent diabetics. Neither were any differences found in the periodontal condition related to the duration and control of diabetes, whereas diabetics with advanced retinopathy demonstrated more sextants with deep pockets. Oral hygiene instructions and scaling were required in all patients from both study groups. On an average, 1.3 sextants in 50.9% of diabetics and 0.3 sextants in 17.9% of control subjects required complex treatment.

Beta-blockers, lipoproteins and non-insulin dependent diabetes

In a study on 138 hypertensive non-insulin dependent diabetic subjects, factors influencing lipoproteins were assessed. Multiple regression analyses were carried out in order to assess the influence of beta-blocker antihypertensive therapy while making allowances for other confounding variables. In males, but not in females, on a beta-blocker for hypertension, total high density lipoprotein- (HDL-) and HDL-subfraction cholesterol were significantly lower while the serum triglyceride was increased, though not significantly. In male non-insulin dependent diabetics, regimens containing a beta-blocker may worsen an already abnormal lipoprotein profile and antihypertensive agents other than beta-blocking agents should be used if possible.

Acute lipoprotein changes associated with atenolol therapy for hypertension in non-insulin dependent diabetes

In a study on 11 stable hypertensive non-insulin dependent diabetic subjects the influence of beta-blocker (atenolol 100mg) withdrawal and reintroduction was assessed. After a three week placebo phase significant increases in pulse rate, high density lipoprotein- and high density lipoprotein2-cholesterol and a significant decrease in triglyceride were observed. Three weeks after recommencement of atenolol therapy the pulse, lipid and lipoprotein changes were reversed and significantly so. Weight and blood pressure remained constant throughout. Results from this study indicate that in non-insulin dependent diabetes, atenolol-induced lipid and lipoprotein changes are reversible in the short term and occur in the absence of significant changes in blood pressure control. The lipoprotein changes observed involved an alteration in high density lipoprotein composition. As a reduced high density lipoprotein cholesterol is associated with macrovascular disease, future studies on the association of lipoproteins and diabetic complications should take into account these changes in lipoproteins with beta-blocker hypotensive therapy.

Residual B cell function in patients with long-standing NIDDM and its relation to metabolic control and diabetic complications

We have evaluated the residual pancreatic B cell function by glucagon load test in 28 patients with non-insulin-dependent diabetes mellitus (NIDDM) of a duration of 20 years or more. The increase in serum C-peptide at 6 minutes after glucagon administration (delta C-peptide) was used as an index of residual B cell function. There was much less delta C-peptide in patients treated with insulin than in those treated with sulfonylurea (p less than 0.05), and it was significantly correlated with the body mass index (r = 0.40, p less than 0.05). Long term metabolic control assessed by the average annual mean fasting blood glucose for the observation period (mean, 21 years) was not correlated with delta C-peptide (r = -0.13). The prevalence of retinopathy which needed photocoagulation therapy and of neuropathy in patients with poor residual B cell function (delta C-peptide less than or equal to 0.3 ng/ml) was the same as that in those with good residual B cell function (delta C-peptide greater than or equal to 1.0 ng/ml). The present study shows that the residual B cell function is not correlated with long term glycemic control and the prevalence of diabetic complications in long-standing NIDDM patients.

Nephropathy in non-insulin-dependent diabetes mellitus

End-stage renal disease develops in about 5 percent of patients with non-insulin-dependent diabetes mellitus (NIDDM). The large majority of diabetic patients have this form of the disease. Thus, end-stage renal disease is an important clinical problem in patients with NIDDM. Moreover, hypertension and its macrovascular sequelae are significant problems in patients with NIDDM and may be linked with renal disease. A review of the problem of nephropathy in NIDDM is attempted, pointing out, where data are available, the clinical and pathophysiologic differences from its presentation in insulin-dependent diabetes. The need for further studies of the impact of renal disease in this maturity onset form of diabetes is emphasized.

Diabetic microangiopathy, genetics, environment, and treatment

As the major cause of disability and death in insulin-dependent diabetes, microangiopathy is obviously of major concern to diabetologists. Unlike macroangiopathy, which can readily be prevented by means that are currently on hand, the origin and treatment of microangiopathy remain far more problematical. The complexity of this lesion is indicated by the findings in this laboratory that hyperglycemia induced by the rodenticide, vacor, can cause microangiopathy independent of genetic diabetes, yet significant microangiopathic lesions can be detected in genetic diabetic patients before the appearance of hyperglycemia. Further, there is now intriguing evidence based both on basement membrane measurements from our laboratory and on clinical studies showing that significant microangiopathy only rarely occurs prior to the onset of puberty. The evidence that control or even normalization of blood glucose levels does not influence the course of established microangiopathy is becoming increasingly convincing. Five prospective, randomized studies over the past five years have shown that strict regulation of glucose has no consistent benefit on, and in some studies may, at least transiently, accelerate, the retinopathy of diabetes. Moreover, the first controlled study of successful pancreatic transplantation to achieve normalization of blood glucose levels has again demonstrated that established retinopathy is neither prevented nor even delayed by normal glucose levels. This review, therefore, emphasizes that, though hyperglycemia is required for clinically significant microangiopathy to occur, clearly other factors, genetic, environmental, or both, must play major roles in determining the course of microangiopathy. It is toward these nonglycemic factors in the development of diabetic microangiopathy that future research should increasingly be directed.

Glycosylated hemoglobin predicts the incidence and progression of diabetic retinopathy

The relationship between hyperglycemia, measured by glycosylated hemoglobin at the initial examination, and the four-year incidence and progression of diabetic retinopathy was examined in a population-based study in Wisconsin. Younger- (n = 891) and older-onset (n = 987) persons participating in baseline and follow-up examinations were included. Glycosylated hemoglobin was measured by microcolumn. Retinopathy was determined from stereoscopic fundus photographs. In the younger-onset group, comparing the highest with the lowest quartile of glycosylated hemoglobin, the relative risk for developing any diabetic retinopathy was 1.9; for proliferative retinopathy, 21.8; and for progression, 4.0. Among older-onset persons taking insulin, the corresponding relative risks were 1.9, 4.0, and 2.1. Among older-onset persons not taking insulin, relative risks were 4.0 for any retinopathy and 6.2 for progression. A positive relationship between incidence and progression of retinopathy and glycosylated hemoglobin remained after controlling for duration of diabetes, age, sex, and baseline retinopathy. These data suggest a strong and consistent relationship between hyperglycemia and incidence and progression of retinopathy.

Treatment of dyslipidemia in non-insulin-dependent diabetes mellitus with lovastatin

Coronary artery disease (CAD) is the leading cause of death among whites with non-insulin-dependent diabetes mellitus (NIDDM). Several risk factors--dyslipidemia induced by NIDDM, obesity, hypertension and hyperglycemia--likely contribute to accelerated atherosclerosis. The dyslipidemia in NIDDM is characterized by abnormalities in composition and metabolism of very low density lipoproteins, low-density lipoproteins (LDL) and high-density lipoproteins (HDL). However, because of the lack of long-term prospective epidemiologic studies, the relative importance of lipoprotein risk factors in the causation of CAD in diabetic patients is not clear. The World Health Organization Multinational Study of vascular disease in diabetics observed increased prevalence of CAD in diabetic populations with relatively high levels of plasma cholesterol and supports the concept that lowering cholesterol levels may significantly reduce coronary risk in NIDDM. To determine the effectiveness of lovastatin, an inhibitor of HMG CoA reductase, for lowering cholesterol levels, 16 patients with NIDDM and mild to moderate increases in plasma cholesterol were given lovastatin (20 mg twice daily) in a randomized, double-blind, placebo-controlled manner for 4 weeks. Compared with the placebo, lovastatin reduced concentrations of total cholesterol (233 +/- 10 vs 172 +/- 7 mg/dl [standard error of the mean], p less than 0.001), LDL cholesterol (140 +/- 9 vs 101 +/- 6 mg/dl, p less than 0.001), and LDL apolipoprotein-B (108 +/- 16 vs 80 +/- 16 mg/dl, p less than 0.001). Plasma triglycerides and very low density lipoprotein cholesterol levels also decreased by 31 and 42%, respectively. Although HDL cholesterol levels did not increase, the total cholesterol/HDL cholesterol ratio decreased significantly with lovastatin therapy. No adverse effects were noted and glycemic control was well-maintained.(ABSTRACT TRUNCATED AT 250 WORDS)

Treating hypertension in black compared with white non-insulin dependent diabetics: a double blind trial of verapamil and metoprolol

STUDY OBJECTIVE

To compare responses of blood pressure to the calcium antagonist verapamil and the beta blocker metoprolol in black compared with white diabetics with hypertension and to monitor urinary albumin excretion in relation to fall in blood pressure.

DESIGN

Double blind, placebo controlled, random order crossover trial with four week placebo run in period and two six week active phases separated by a two week placebo washout period.

SETTING

Outpatient department of a general hospital in a multiethnic health department. Patients--Diabetic patients with hypertension. Four dropped out before randomisation; 25 black and 14 white patients completed the trial.

INTERVENTIONS

Patients given slow release verapamil 120 mg or 240 mg twice daily with placebo or metoprolol 50 mg or 100 mg twice daily with placebo. Treatment for diabetes (diet alone or with oral hypoglycaemic drugs) remained unchanged.

END POINT

Comparison of changes in blood pressure in the two groups taking both drugs.

MEASUREMENTS AND MAIN RESULTS

Metoprolol had little effect on blood pressure in black patients (mean fall 4.0 mm Hg systolic (95% confidence interval -2.5 to 10.4 mm Hg), 4.3 mm Hg diastolic (-0.8 to 9.5)) but more effect in white patients (mean falls 13.4 mm Hg (0.1 to 26.7) and 10.6 mm Hg (4.5 to 16.7) respectively). Verapamil was more effective in both groups, with mean falls of 8.8 mm Hg (2.4 to 15.0) and 8.1 mm Hg (5.0 to 11.2) in black patients and 19.1 mm Hg (5.4 to 32.9) and 11.4 mm Hg (0.9 to 22.0) in white patients. Heart fate fell significantly in black patients taking metoprolol, which suggested compliance with treatment. Metabolic variables were unaltered by either treatment. Plasma renin activity was low in both groups after metoprolol treatment, but change in blood pressure could not be predicted from baseline plasma renin activity. Urinary albumin:creatinine ratio was independently related to baseline blood pressure but not significantly changed by treatment.

CONCLUSIONS

beta Blockers alone are not effective in treating hypertension in black diabetics. Verapamil is effective but less so than in white patients. As yet no ideal monotherapy exists for hypertension in black patients.

[Hypoglycemia caused by insulinoma in diabetes mellitus]

An hyperglycaemic metabolic state disappeared and spontaneous hypoglycaemia occurred in a 58-year-old woman with non-insulin-dependent obese type II diabetes. Abnormal absence of the hunger response with provoked hypoglycaemia, increased serum insulin concentrations and reduced blood glucose/insulin ratio led to the diagnosis of pathological hyperinsulinism, which was found to be due to an insulinoma of the tail of the pancreas. After its excision the patient's carbohydrate metabolism returned to a mild type II diabetic state and there were no further hypoglycaemic attacks.

Effect of proteinuria on mortality in NIDDM

The effect of proteinuria (greater than or equal to approximately 1 g/day) on mortality in non-insulin-dependent diabetes mellitus (NIDDM) was assessed in Pima Indians aged greater than or equal to 45 yr. Among 1426 subjects, 48% with NIDDM at the beginning of followup, there were 489 deaths in 13,345 person-yr of observation. The age- and sex-adjusted mortality rate was 32.7/1000 person-yr (95% Cl = 27.6, 37.8) in diabetic subjects without proteinuria, similar to the rate of 30.1/1000 person-yr (95% Cl = 25.7, 34.4) in nondiabetic subjects without proteinuria. By contrast, in diabetic subjects with proteinuria the mortality rate was 121.4/1000 person-yr (95% Cl = 97.5, 145.3). When controlled for age, sex, and diabetes duration, diabetic subjects with proteinuria had a death rate 3.5 times as high (95% Cl = 2.8, 4.4) as those without proteinuria. Of the excess mortality associated with NIDDM in Pima Indians, 97% was found in subjects with proteinuria. The death rate in diabetic subjects without proteinuria was not appreciably greater than the rate in nondiabetic subjects. Mortality rates from uremia and cardiovascular disease were significantly higher in diabetic Pima Indians with proteinuria than in those without. These relationships are similar to observations reported in people with insulin-dependent diabetes.