Semi-Automatic Generation of Medical Tele-Expert Opinion for Primary Care Physician

Objectives: A computer-based system has been developed for the generation of medical expert opinions on the insulin-resistance syndrome, based on clinical data obtained from primary care physicians.

Methods: An expert opinion for each patient was generated by using a decision tree for entering individual text modules and by adding optional free text. The expert opinions were returned by e-mail, telefax or by ordinary mail.

Results: 1389 primary care physician sent anonymous data sets and requested expert opinions for a total of 3768 patients. Through the set up of a rule-based system an automation of the generation of the expert opinions could be achieved and the generation time dropped from initially 40 minutes to less than 5 minutes at the end.

Conclusions: By using predefined text modules and a rule based system, a large number of medical expert opinions can be generated with relatively few additional resources.

Value of ICA512 antibodies for prediction and diagnosis of type 1 diabetes

ICA512 was isolated from an islet cDNA expression library and was identified as transmembrane protein closely related to the T-cell tyrosine phosphatase CD45. In order to determine the frequency of antibodies (ab) to ICA512, we tested sera of 124 newly diagnosed type 1 diabetic patients (IDDM) and 30 patients with long standing IDDM, 44 non-diabetic first degree relatives (FDR) with positive ICA or IAA, and 76 healthy control subjects using an ELISA. The mean +/- SD that we obtained in our control population was 4.1 +/- 3.9 U and a cut-off of 16 U was defined as normal range (mean + 3 SD). Of newly diagnosed diabetic patients and patients with long standing IDDM, 32% and 23% respectively had positive ICA512-ab with a mean of 22 +/- 33 U (vs controls p < 0.001) and 14 +/- 14 U (p < 0.01). Of antibody-positive first degree relatives, 36% were found to have elevated ICA512-ab with a mean of 24 +/- 41 U (p < 0.01). In relatives with multiple follow-up samples, ICA512-ab were found to be constantly positive or negative in 86% of cases, whereas fluctuation of ICA512-ab positivity occurred in five relatives in which three developed positive ICA512-ab and two lost ICA512-ab positivity during follow-up. Of ICA512-ab + relatives, 76% progressed to clinical type 1 diabetes within 5 years of follow-up, whereas only 24% developed diabetes in the ICA512-ab negative group (p < 0.01). ICA512-ab were more frequent in newly diagnosed diabetic children below age 15 years (p < 0.02) and in patients with positive ICA (p < 0.001) or positive IAA (p < 0.02). There was, in contrast, no correlation of ICA512-ab with GADA. One patient with newly diagnosed type 1 diabetes exclusively exhibited ICA512-ab. In conclusion, these results suggest that ICA512-ab are related to autoimmune type 1 diabetes and useful as an additional screening marker for the prediction of type 1 diabetes.

The problem of tissue oxygenation in diabetes mellitus

In order to study the determining factors for oxygen transport the oxyhaemoglobin dissociation curve (ODC), red cell 2,3-diphosphoglycerate (2,3-DPG), and plasma inorganic phosphate were estimated in insulin-requiring juvenile and adult diabetics in various conditions of metabolic control. 2,3-DPG has been shown to vary much more in diabetics than in normals, depending upon the state of metabolic control. These fluctuations of 2,3-DPG are mediated by variations in plasma inorganic phosphate as indicated by a close correlation. While 2,3-DPG was markedly decreased in diabetic ketoacidosis, it tended to be increased in ambulatory, non-acidotic patients. Since in the non-acidotic patients the oxygen-carrying capacity, i.e. the haemoglobin concentration was simultaneously elevated, these findings suggest the presence of relative tissue hypoxia in diabetes. Both in non-acidotic and in ketoacidotic patients there was a strong correlation between the amount of 2,3-DPG and the P50 at actual pH as an experssion of the oxygen affinity of haemoglobin. In order to guarantee an optimal erythrocyte oxygen release in diabetics the content of red cell 2,3-DPG and plasma inorganic phosphate should be higher than normal.

The importance of beta-cell management in type 2 diabetes

Despite intervention with effective oral glucose-lowering agents, most patients with type 2 diabetes will experience a gradual loss of glycaemic control. Irrespective of underlying levels of insulin resistance, the progressive failure and loss of beta-cells are ultimately responsible for the onset of frank type 2 diabetes. The mechanisms responsible for loss of beta-cell function are likely to be multifactorial, but may involve toxicity because of elevated glucose and/or lipid levels, increased secretory demand because of insulin resistance, amyloid deposition and altered levels of cytokines. Preservation of beta-cell function is now gaining recognition as a critical target in the management of type 2 diabetes. For patients with frank type 2 diabetes, preservation of beta-cell function has the potential to reduce or stabilise the progression of type 2 diabetes and to decrease the need for additional oral glucose-lowering agents and/or insulin therapy. There is a growing body of animal/preclinical evidence for improved and preserved beta-cell function with current glucose-lowering agents, such as the thiazolidinediones, metformin and the glucagon-like peptide-1 analogue, exenatide. Clinical studies incorporating indirect measures of beta-cell function also support a protective effect with some agents. A number of novel therapies that are currently under investigation may also offer beta-cell structural and functional protection, including dipeptidyl peptidase IV inhibitors and cannabinoid receptor type 1 blockers. Emerging evidence from interventional trials suggests that both intensive lifestyle changes and pharmacotherapy can delay or possibly prevent the onset of type 2 diabetes in high-risk individuals. For patients newly diagnosed with type 2 diabetes, early and aggressive intervention strategies that combine maximal glucose-lowering efficacy alongside potential beta-cell preserving properties may provide an opportunity to delay or prevent progression of the disease.

[Diabetes mellitus and heart failure]

Chronic heart failure (CHF) in patients with diabetes mellitus (DM) is a condition that is frequent and has a poor prognosis. Diabetes mellitus is an independent risk factor for CHF and vice versa. CHF is found in 10-15% of the patients with DM compared to 3% in individuals without DM. Apart from CHD and hypertension, hyperglycaemia and insulin resistance are directly linked to the development of diastolic dysfunction and to CHF. According to the stepwise diagnostic procedure recommended by the ESC in its guidelines from 2005, if heart failure is suspected, the disease should first be diagnosed by ECG, X-ray, or testing for natriuretic peptide and followed by echocardiography when test results are abnormal. Treatment of CHF in patients with diabetes mellitus is the same as that for nondiabetic patients and includes the use of ACEIs, ARBSs (as an alternative to or in combination with ACEIs), BBs, diuretics (in particular loop diuretics), aldosterone inhibitors and digitalis. Most importantly, meticulous glucose control is a must in patients with diabetes mellitus and CHF to improve prognosis. Contraindications for antidiabetic drugs such as glitazones for CHF-NYHA classes I-IV and metformin for NYHA classes III-IV need to be considered in patients with CHF and diabetes mellitus.

Acarbose and metabolic control in patients with type 2 diabetes with newly initiated insulin therapy

AIM

This study was designed to investigate the effect of acarbose in patients with type 2 diabetes with newly initiated insulin treatment who had previously been insufficiently controlled with oral antihyperglycaemic agents [haemoglobin A(1c) (HbA(1c)) >/= 8%].

METHODS

In this 20-week double-blind, placebo-controlled study, 163 patients were randomized to receive acarbose up to 100 mg three times a day or matching placebo. Both the groups were newly initiated with insulin, which was adjusted according to blood glucose values. Primary efficacy parameter was the change in HbA(1c) from baseline; changes in daily insulin doses were also assessed.

RESULTS

Mean HbA(1c) was significantly reduced by acarbose compared with placebo (2.31 vs. 1.81%, p = 0.033). Insulin doses were comparable at the end of the study. There was no difference in blood glucose and triglyceride levels between the treatment groups. Postprandial serum insulin levels increased in both treatment arms owing to insulin administration but less so under acarbose. In contrast to the placebo group, an increase in body mass index was prevented for acarbose-treated patients.

CONCLUSION

As adjunct administration to newly initiated insulin therapy, acarbose enhances the optimization of blood glucose control in patients with type 2 diabetes.

Chromium in metabolic and cardiovascular disease

Chromium is an essential mineral that appears to have a beneficial role in the regulation of insulin action, metabolic syndrome, and cardiovascular disease. There is growing evidence that chromium may facilitate insulin signaling and chromium supplementation therefore may improve systemic insulin sensitivity. Tissue chromium levels of subjects with diabetes are lower than those of normal control subjects, and a correlation exists between low circulating levels of chromium and the incidence of type 2 diabetes. Controversy still exists as to the need for chromium supplementation. However, supplementation with chromium picolinate, a stable and highly bioavailable form of chromium, has been shown to reduce insulin resistance and to help reduce the risk of cardiovascular disease and type 2 diabetes. Since chromium supplementation is a safe treatment, further research is necessary to resolve the confounding data. The existing data suggest to concentrate future studies on certain forms as chromium picolinate and doses as at least 200 mcg per day.

Two Caucasian Families with the Hepatocyte Nuclear Factor-1Alpha Mutation Tyr218Cys

We report on the first two Caucasian families with the MODY3 HNF-1alpha mutation Tyr218Cys. Clinical and laboratory examinations are shown in detail. Patients with HNF-1alpha related MODY may develop the full spectrum of diabetic complications. Therefore, early detection of family members with MODY3 is warranted.

Oral glucose tolerance test is needed for appropriate classification of glucose regulation in patients with coronary artery disease: a report from the Euro Heart Survey on Diabetes and the Heart

BACKGROUND

Patients with coronary artery disease (CAD) and abnormal glucose regulation (AGR) are at high risk for subsequent cardiovascular events, underlining the importance of accurate glucometabolic assessment in clinical practice.

OBJECTIVE

To investigate different methods to identify glucose disturbances among patients with acute and stable coronary heart disease.

METHODS

Consecutive patients referred to cardiologists were prospectively enrolled at 110 centres in 25 countries (n = 4961). Fasting plasma glucose (FPG) and glycaemia 2 h after a 75-g glucose load were requested in patients without known glucose abnormalities (n = 3362). Glucose metabolism was classified according to the World Health Organization and American Diabetes Association (ADA; 1997, 2004) criteria as normal, impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or diabetes.

RESULTS

Data on FPG and 2-h post-load glycaemia were available for 1867 patients, of whom 870 (47%) had normal glucose regulation, 87 (5%) had IFG, 591 (32%) had IGT and 319 (17%) had diabetes. If classification had been based on the ADA criterion from 1997, the proportion of misclassified (underdiagnosed) patients would have been 39%. The ADA 2004 criterion would have overdiagnosed 8% and underdiagnosed 33% of the patients, resulting in a total misclassification rate of 41%. For ethical concerns and practical reasons, oral glucose tolerance test (OGTT) was not conducted in 1495 of eligible patients. These patients were more often women, had higher age and waist circumference, and were therefore more likely to have AGR than those who were included. A model based on easily available clinical and laboratory variables, including FPG, high-density lipoprotein cholesterol, age and the logarithm of glycated haemoglobin A1c, misclassified 44% of the patients, of whom 18% were overdiagnosed and 26% were underdiagnosed.

CONCLUSION

An OGTT is still the most appropriate method for the clinical assessment of glucometabolic status in patients with coronary heart disease.

Rosiglitazone is effective and well-tolerated in a range of therapeutic regimens during daily practice in patients with type 2 diabetes

Subjects (N = 22,808) with inadequately controlled type 2 diabetes mellitus (T2DM) were included in a large 6-month observational study in Germany. Rosiglitazone (RSG) was added to existing therapy in line with daily practice, with 19,962 subjects evaluated for efficacy by treatment group: RSG monotherapy (n = 1017), RSG plus metformin (MET) (n = 7160), RSG plus sulphonylurea (n = 5033), triple oral therapy (n = 4247), and the remaining subject population (n = 2505). Overall, RSG significantly reduced median HbA(1c) and fasting blood glucose by 1.3% and 50 mg/dl over 6 months (p < 0.001 for both). The proportion of subjects achieving glycaemic goals of <or= 6.5% and <or= 7.0% increased from 5.7% to 33.8%, and from 13.9% to 55.5%, respectively (p < 0.001 for both). Mean systolic and diastolic blood pressures were reduced in the total subject population by 6 mmHg and 2 mmHg, respectively (p < 0.001 for both). RSG had a neutral or reductive effect on mean weight of most (69%) subjects. Consistent with clinical trial data, RSG mono- or combination therapy improved glycaemic control when used in daily clinical practice and is generally well-tolerated.

Once-daily insulin glargine administration in the morning compared to bedtime in combination with morning glimepiride in patients with type 2 diabetes: an assessment of treatment flexibility

AIMS

To compare the incidence of nocturnal hypoglycemia and glycemic control following bedtime or morning insulin glargine (LANTUS; glargine) plus glimepiride.

METHODS

In this 24-week, multinational, open, randomized study, 624 patients with type 2 diabetes poorly controlled on oral therapy received morning or bedtime glargine plus morning glimepiride (2, 3 or 4 mg) titrated to a target fasting blood glucose level < or = 5.5 mmol/l.

RESULTS

The incidence of nocturnal hypoglycemia was equivalent between the two groups, with morning glargine non-inferior to bedtime (13.0 VS. 14.9 % of patients; between-treatment difference -1.9 %; one-sided 95 % confidence interval -100 %; 2.84 %). At endpoint, similar improvements in glycemic control were observed with morning compared to bedtime glargine: HbA1c: -1.65 +/- 1.21 VS. -1.57 +/- 1.16 %; p = 0.42; fasting blood glucose: -4.25 +/- 2.82 VS. -4.48 +/- 2.75 mmol/l; p = 0.08. The endpoint mean daily glargine dose was comparable (34.7 +/- 17.4 VS. 32.4 +/- 17.0 IU; p = 0.15), and there was no significant between-treatment difference in the change in body weight (2.1 VS. 1.8 kg; p = 0.39).

CONCLUSIONS

Once-daily glargine can be administered in a flexible morning or bedtime regimen (plus morning glimepiride) to achieve good glycemic control without any difference in hypoglycemia.

[62 year-old patient with rapid progressive edema, low potassium and hypertension]

A 62 year-old patient was admitted to hospital with rapid progressive edema, low potassium and hypertension. This symptoms are caused by Cushing's syndrome through ectopic paraneoplastic ACTH-production. Primary neoplasm is a small cell cancer. A Sertoli-cell-tumor of the testis was diagnosed as an additional carcinoma. Palliative chemotherapy and adrenostatic agents did not improve the clinical findings and the patient died eight weeks after admission.

Coronary calcification in long-term type 1 diabetic patients -- a study with multi slice spiral computed tomography

The risk for cardiovascular disease in diabetes is excessive. Multislice spiral computed tomography (MSCT) is a new technique for the assessment of coronary calcification in coronary artery disease. The aim of the study was to evaluate the presence of coronary calcium in asymptomatic long-term type 1 diabetic patients. Seventy-one type 1 diabetic patients (age 48 +/- 9 y, HbA1c 7.7 +/- 1.2, BMI 24.4 +/- 2.8, duration of diabetes 26 +/- 9 y) without clinical evidence for coronary artery disease were assessed with MSCT. A volumetric score was used to calculate the coronary calcification (CC) score. Five cardiac reflex tests were performed to study patients for cardiac autonomic neuropathy. Coronary calcifications were detectable in 22 (31 %) type 1 diabetic patients (CC-score > 0, mean CC-score 174 +/- 228 [X+/-SD]). Fourty-nine (69 %) type 1 diabetic patients demonstrated no coronary calcifications (CC-score= 0). In patients with coronary calcifications, both cardiac autonomic neuropathy and retinopathy were detected more frequently than in those without (64 % vs. 29 %, p < 0.02; 59 % vs. 31 %; p < 0.02). Duration of diabetes was longer in patients with than without coronary calcification (32 +/- 10 y vs. 24 +/- 8 y, p < 0.01). Age, BMI, and HbA1c were not significantly different between patients with and without coronary calcification. The study demonstrates that nearly one third of asymptomatic long-term type 1 diabetic patients present with coronary calcifications. In the patients, there is evidence for an association between coronary calcification and both cardiac autonomic neuropathy and retinopathy. MSCT is a promising non-invasive approach to analyze early alterations of the coronary system in diabetic patients.

Effects of nateglinide on myocardial microvascular reactivity in Type 2 diabetes mellitus--a randomized study using positron emission tomography

AIMS

To evaluate effects of the oral antidiabetic insulinotropic agent nateglinide on myocardial blood flow (MBF) and microvascular reactivity in Type 2 diabetic patients.

METHODS

Forty-seven Type 2 diabetic patients were randomly assigned 2 : 1 to nateglinide 120 mg (t.i.d., n = 33) or placebo (n = 14). At baseline and after 16 weeks of treatment, MBF was quantified using positron emission tomography with N-13 ammonia at rest, during endothelial-dependent stimulation by cold pressor test and during adenosine-mediated vasodilation. Additional blood samples were taken to assess glycaemic control and lipid profile.

RESULTS

MBF at rest and during adenosine did not change during the study. The percentage of flow increase from rest during cold pressor test did not improve significantly in the nateglinide group vs. placebo (from 26.1 +/- 37.2% to 29.1 +/- 27.8% between week 0 to week 16 for nateglinide vs. 14.9 +/- 37.1% to 18.1 +/- 28.4% for placebo; P = 0.07 for nateglinide when adjusted for higher baseline values). Nateglinide decreased HbA1c by 0.4% (from 7.6 +/- 0.9% to 7.2 +/- 1.3%) compared to an increase of 0.5% in the placebo group (from 7.9 +/- 0.8% to 8.4 +/- 1.7%; P = 0.02 for nateglinide). No differences between the two groups were observed in insulin levels and lipid status.

CONCLUSIONS

Nateglinide neither improved, nor impaired myocardial blood flow in Type 2 diabetic patients. Potential effects on endothelial-dependent myocardial blood flow remain to be investigated further. Positron emission tomography is a sensitive approach to assess the effects of therapeutic agents on myocardial blood flow in patients with diabetes.

Gliclazide modified release: results of a 2-year study in patients with type 2 diabetes

AIM

To evaluate the efficacy and safety of gliclazide modified release (MR), alone or combined with other oral antidiabetic drug(s) over 2 years in type 2 diabetic patients.

METHODS

Two consecutive periods: (i) a 10-month, double-blind comparative study, where 800 type 2 diabetic patients were randomized either to gliclazide MR (30-120 mg) once daily or to gliclazide (80-320 mg) twice daily. All the patients were then treated with gliclazide MR for a 2-month switch period; (ii) 549 patients were subsequently enrolled in a 12-month, open-label period on gliclazide MR alone or in combination according to glycaemic control, 507 of whom completed the study.

RESULTS

Glycated haemoglobin (HbA1c) significantly decreased from baseline over 2 years by -0.46 +/- 1.08% in the whole cohort of 2-year completed patients, -0.95% in the subgroup of diet-failed patients and by -0.34% in the subgroup of patients pretreated with one oral antidiabetic drug. HbA1c was reduced by -0.43 +/- 1.02% and by -0.51 +/- 1.16%, when gliclazide MR was used in monotherapy and in combination therapy, respectively. The overall incidence of symptoms suggestive of hypoglycaemia was 4.8 episodes/100 patient-year, with no severe episode. This incidence was similarly low in elderly patients and patients with impaired renal function.

CONCLUSION

Gliclazide MR alone or in combination with another oral antidiabetic drug significantly improved glycaemic control in type 2 diabetic patients over 2 years with a very good safety profile, notably in the elderly and in patients with impaired renal function.

IRIS II study: the IRIS II score--assessment of a new clinical algorithm for the classification of insulin resistance in patients with Type 2 diabetes

AIMS

With the increasing availability of new drugs for the treatment of insulin resistance in patients with Type 2 diabetes, simple methods for their identification is an important challenge. The aim of our study was to compute a new algorithm for estimating insulin resistance in a routine clinical setting.

METHODS

Clinical data and blood samples were collected from 4265 Type 2 diabetic patients from 149 clinical sites. A clinical algorithm to estimate insulin resistance was developed by stepwise multiple regression analysis. The new generated score was compared with the HOMAIR-score, calculated from fasting insulin and glucose levels measured in a central laboratory. In a subgroup of 48 patients, the score was verified against a frequently sampled intravenous glucose tolerance test with subsequent modified minimal model analysis according to Bergman.

RESULTS

Multiple regression analysis revealed fasting blood glucose, BMI, triglycerides and HDL as the most powerful predictors of insulin resistance which were used for further computation of the IRIS II score. A significant overall correlation was found between the HOMAIR-score and the new clinical IRIS II score (r = 0.42; P < 0.0001). Compared with HOMAIR, the new score revealed a specificity of 0.95, a sensitivity of 0.34 and a positive predictive value of 0.95. This was in good agreement with the subset analysis of the intravenous glucose tolerance test, where a sensitivity of 0.37 and a specificity of 0.85 of the IRIS II score was calculated. Patients with insulin resistance according to the IRIS II score revealed an increased odds ratio for overall vascular complications (1.28; 1.11-1.46; P < 0.001).

CONCLUSIONS

The new IRIS II score can identify insulin resistance in Type 2 diabetic patients with high predictive value and high specificity.

[Cardiovascular risk in diabetes--diagnostic and therapeutic aspects]

In Germany, more than 27,000 diabetic patients suffer an acute myocardial infarction annually; in addition, the number of cardiac infarction patients with unrecognized permanent disturbances of the glucose metabolism is high. The cardiovascular mortality of diabetics in comparison with nondiabetics is four to six times higher. Through an intensification of diagnostics and therapy, it is possible to reduce the hospital mortality of diabetics with acute myocardial infarction. For each patient with myocardial infarction and for whom diabetes has not been previously diagnosed, it is recommended that the blood sugar be tested upon admission to the hospital and that an oral glucose tolerance test be conducted for the detection of a glucose metabolic disorder during the postinfarction phase. An example of a successful approach for metabolic intervention is glucose-insulin infusion to optimize the metabolic condition during the acute phase.

Hospital outcome of acute myocardial infarction in patients with and without diabetes mellitus

AIMS

To assess hospital mortality and morbidity in diabetic and non-diabetic patients with acute myocardial infarction and to compare the results between the two groups.

METHODS

All patients admitted in 1999 to the intensive care unit of the Schwabing City Hospital with diagnosis of acute myocardial infarction were assessed for hospital mortality and co-morbidity.

RESULTS

Three hundred and thirty patients with acute myocardial infarction were admitted. Of those, 126 (38%) were diabetic and 204 (62%) were non-diabetic patients. Mortality within 24 h after admission was 13.5% in diabetic patients and 5.4% in non-diabetic patients (P<0.01). Mortality during entire hospitalization was higher in diabetic than in non-diabetic patients (29.4% vs. 16.2%; P=0.004). Diabetic patients were resuscitated more frequently than non-diabetic patients (24% vs. 11%, P<0.01). In diabetic patients, heart rate at admission was increased (91 +/- 27 vs. 82 +/- 23/min; P<0.01) and presence of angina pectoris was reported less frequently (59% (n=72) vs. 82% (n=167); P<0.001). Preceding myocardial infarction, microalbuminuria, peripheral artery disease and arterial hypertension were more frequent in diabetic than in non-diabetic patients. Diabetic patients demonstrated higher C-reactive protein (CRP) levels than non-diabetic patients (91.4 +/- 78.2 mg/l vs. 45.2 +/- 62.4 mg/l; P<0.001).

CONCLUSIONS

In diabetic patients with acute myocardial infarction, early hospital mortality is increased and signs of cardiac autonomic dysfunction and microangiopathy are detected more frequently than in non-diabetic patients. The need for advanced treatment strategies early in the course of diabetic patients with myocardial infarction is emphasized.

Metformin: drug of choice for the prevention of type 2 diabetes and cardiovascular complications in high-risk subjects

The timely series of state-of-the-art reviews contained within this supplement provide a valuable overview of the current state of diabetes care, and the pharmacological interventions we have available. Our experts agree that one of the most important lessons to emerge recently concerns the magnitude of the malign influence on clinical outcomes of the cardiovascular risk factors associated with the dysmetabolic (insulin resistance) syndrome. Metformin is unique in being not only as effective as any other oral antidiabetic therapy in controlling blood glucose, but also having an unparalleled clinical database relating to improved clinical outcomes in pre-diabetic subjects, and patients with established type 2 diabetes.

Semi-automatic generation of medical tele-expert opinion for primary care physician

OBJECTIVES

A computer-based system has been developed for the generation of medical expert opinions on the insulin-resistance syndrome, based on clinical data obtained from primary care physicians.

METHODS

An expert opinion for each patient was generated by using a decision tree for entering individual text modules and by adding optional free text. The expert opinions were returned by e-mail, telefax or by ordinary mail.

RESULTS

1389 primary care physician sent anonymous data sets and requested expert opinions for a total of 3768 patients. Through the set up of a rule-based system an automation of the generation of the expert opinions could be achieved and the generation time dropped from initially 40 minutes to less than 5 minutes at the end.

CONCLUSIONS

By using predefined text modules and a rule based system, a large number of medical expert opinions can be generated with relatively few additional resources.

Lupus-like panniculitis in a patient with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED)

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disorder, characterised by a loss of self-tolerance to endocrine tissues, chronic candidiasis and ectodermal disorders. APECED is associated with mutations of a single gene, designated autoimmune regulator (AIRE). We describe a 31-year-old APECED patient with non-traumatic, cutaneous ulcers on both forearms with features of a lupus-like panniculitis. On admission to the ICU in September 2001, the patient suffered from a ketoacidotic, hyperglycemic coma and adrenal crisis due to an Enterobacter-cloacae sepsis, originating from multiple, necrotising deep cutaneous ulcers. These ulcers spontaneously developed on both forearms, some of which were just emerging, full blown or healing with scars. Histological examination showed signs of a scarring panniculitis and vasculitis. Immunohistochemistry and direct immunofluorescence with characterisation of immunoglobulin and complement-factor binding pattern revealed features of a lupus-like panniculitis. Sequence analysis of all 14 exons of the AIRE gene revealed a R257 X mutation in exon 6 resulting in a nonsense mutation at codon 257 confirming the diagnosis of APECED. Oral treatment with 60 mg/day corticosteroids for two weeks led to complete resolution of all ulcers. In conclusion, mutations in the AIRE gene may provide the genetic background against which additional factors can initiate an autoimmune process. Here, autoimmune panniculitis appears to be an associated feature of the APECED syndrome. Our findings support the use of immunosuppressive therapy for autoimmune disease components of the APECED syndrome.

Cardiac autonomic dysinnervation and myocardial blood flow in long-term Type 1 diabetic patients

AIMS

The aim of the study was to assess scintigraphically the relationship between myocardial blood flow response and sympathetic dysinnervation in long-term Type 1 diabetic patients. Effects of the iron chelator deferoxamine on myocardial blood flow were studied and they were investigated according to the presence of cardiac sympathetic dysfunction.

METHODS

Myocardial blood flow (MBF) was assessed with N-13 ammonia positron emission tomography in 13 long-term Type 1 diabetic patients and 13 control subjects at rest and in response to sympathetic stimulation (cold pressor test (CPT)). In diabetic patients, the study was repeated after preinfusion with deferoxamine. Furthermore, 123I metaiodobenzylguanidine (MIBG) scintigraphy was applied to assess regional cardiac sympathetic dysinnervation (uptake score 1 = normal, homogeneous uptake em leader 6 = no uptake).

RESULTS

In diabetic patients, MBF increased in response to CPT from 78 +/- 18 ml/100 g/min to 84 +/- 26 ml/100 g (8%, P < 0.001). Control subjects demonstrated an increase from 63 +/- 17 ml/100 g to 84 +/- 26 ml/100 g (33%, P < 0.001), respectively. Resting MBF was higher in diabetic patients than in control subjects (P < 0.001). In diabetic patients, increase in MBF in response to CPT was significant in regions with a MIBG uptake score of <or= 3. Regions with a MIBG uptake score of > 3 did not exhibit a significant increase in MBF in response to CPT. After administration of deferoxamine, the increase in MBF in response to CPT was 23% and the magnitude of increase was related to the MIBG uptake score (r = 0.40, P < 0.0001).

CONCLUSIONS

Myocardial blood flow response to sympathetic stimulation is significantly impaired in long-term Type 1 diabetes. After preinfusion with deferoxamine the impairment is partially reversed and a relationship between myocardial blood flow and the extent of cardiac sympathetic dysfunction is observed.

The role of oral antidiabetic agents: why and when to use an early-phase insulin secretion agent in Type II diabetes mellitus

Evidence obtained in the 1990's strongly supports the notion that glycaemic control is important not only in Type I (insulin-dependent), but also in Type II (non-insulin-dependent) diabetes mellitus. Although measurement of HbA(1c) is the standard for assessing the effect of glucose control in the occurrence and prevention of diabetic sequelae, more recent evidence indicates that other glucose parameters are also important. Postchallenge and postprandial hyperglycaemic peaks seem to be prospective determinants of vascular damage in early Type II diabetes. Currently, there is no overall accepted standard approach for the pharmacological management of Type II diabetes. The United Kingdom Prospective Diabetes Study has shown that reaching a near-normal glycaemic target is critically important and the pharmacotherapy of this progressive disease is difficult. Loss of endogenous insulin secretion has been substantiated to cause the progression of Type II diabetes in the United Kingdom Prospective Diabetes Study. Early insulinization, however, was not advantageous over other forms of therapy. The advent of polypharmacy in recent years has greatly strengthened the treatment of this disease. This synergy has been extended of late with the development of early-phase insulin secretion agents. Two such agents, nateglinide and repaglinide, can be used to reduce mealtime glucose excursions and HbA(1c) as monotherapy, and in combination with metformin; their antidiabetic potential is similar to the combination treatment with glibenclamide and metformin. Additional substantiation of their long-term effect on improving life expectancy and reducing diabetic complications in Type II diabetic patients is now required.

Insulin analogues - state of the art

The use of insulin analogues is rapidly expanding. At present, there are two short-acting analogues available for practical use, insulin aspart and insulin lispro, and one long-acting analogue, insulin glargine. Another long-acting analogue, insulin detemir, is still under development. The time action profile of short-acting analogues is both much more rapid and shorter than that of human insulin; the prominent feature of the long-acting analogues is their peakfree and fairly constant action. Insulin analogues offer alternative options for the whole spectrum of insulin therapy in type 1 and type 2 diabetes patients. The perception by many patients is strikingly positive, in particular regarding the overall quality of life. In objective efficacy terms, however, the potential to improve the degree of metabolic control appears to be only minor, yet demonstrable, provided the analogues are used according to their specific time action profile. This ensured, analogues are instrumental in minimizing the side effects of insulin therapy, i.e. the risk of (nocturnal) hypoglycaemia or problems with body weight control. Although there are no indications of safety concerns with insulin analogues, the availability of long-term outcome data based upon observations in human patients would be very valuable.

The atherosclerotic process and its exacerbation by diabetes

The excess of glucose appears to play an important and specific role in the genesis of macroangiopathy in diabetics. Activation of protein kinase-C, the sorbitol pathway, and AGE formation are thought to be the major pathways linking the degree of glycaemic compensation with the pathogenetic process of macrovascular disease. HSPG is likely to be a key element in this process since it is a regulator of endothelial permeability, vascular antithrombotic capacity, insulin sensitivity (with respect to lipoprotein lipase availability), and vascular extracellular matrix content and smooth-muscle-cell activation. Loss of HSPG is suggested clinically by the presence of microalbuminuria, to the development of which diabetic control also contributes significantly. However, genetic factors also seem to be involved. Much more insight into the precise mechanismus is necessary to unravel the cellular and molecular chains of events for the premature and accelerated atherosclerosis in diabetic patients.

Telecare of diabetic patients with intensified insulin therapy. A randomized clinical trial

BACKGROUND

Patients with insulin dependent diabetes require frequent advice if their metabolic control is suboptimal. A telemedical system for transmission of self monitoring blood glucose values from the patients' home to the diabetes center with a combined modem-interface is described. Data are processed by PC and advice is given by telephone. The study focuses on metabolic outcome, fiscal and administrative aspects.

METHODS

A prospective, randomized trial with 46 patients with intensified insulin therapy was conducted, 30 patients used telecare and 16 conventional care.

RESULTS

HbA1c, as a parameter of metabolic control, dropped from 8.3% to 7.3% in the telecare group and from 8.0% to 6.8% in the conventional group after 8 months of observation. There was no significant difference between the two groups. Time expenditure for telemanagement, compared to conventional advice, was moderately higher, but there was a substantial amount of time on the patients side that could be saved mainly by reduction of to travel time and work stoppage. Setting up an optimal telemanagement scenario a cost analysis was done. This yields a cost saving of about 650 EURO per year.

CONCLUSION

Telemanagement of insulin-requiring diabetic patients is a cost and time saving procedure for the patients and results in metabolic control comparable to conventional outpatient management.

Improved glycaemic control with miglitol in inadequately-controlled type 2 diabetics

OBJECTIVE

The study compared the long-term efficacy and safety of miglitol to placebo in Type 2 diabetic outpatients inadequately controlled on combination therapy of diet, glibenclamide and metformin.

METHODS

Type 2 diabetic patients (n = 154) receiving glibenclamide 7-20 mg/day and at least one 500-850 mg tablet metformin per day were randomized to receive additional miglitol or placebo for 24 weeks, titrated up stepwise from 25 to 100 mg trice daily.

RESULTS

Addition of miglitol to sulphonylureas and metformin (per protocol analysis) produced a statistically, significantly greater reduction in HbA1c (-0.55%, P = 0.04) and postprandial glucose (-2.6 mmol/l, P = 0.0009) from baseline to endpoint than placebo (-0.2% and -0.6 mol/l, respectively). Reduction in fasting blood glucose was greater with miglitol than placebo, and there was a possible difference in favor of miglitol for fasting and postprandial triglyceride levels, but these did not reach statistical significance. Flatulence and diarrhea were reported by statistically, significantly more patients receiving miglitol than placebo, but adverse events overall were reported by only 10% more patients in the miglitol group. No cases of hypoglycaemia were reported.

CONCLUSIONS

Miglitol can safely and effectively be added to long-term combination therapy in people with Type 2 diabetes inadequately controlled with glibenclamide plus metformin.

Autoantibodies against autonomic nervous tissues in type 2 diabetes mellitus: no association with cardiac autonomic dysfunction

There is evidence that autoimmune factors contribute to the pathogenesis of cardiac autonomic dysfunction in Type 1 Diabetes mellitus (DM). To evaluate the presence of autoantibodies against autonomic nervous tissues in Type 2 DM, 127 patients were studied for complement-fixing sympathetic and parasympathetic ganglia (CF-SG and CF-PSG) autoantibodies with an indirect immunofluorescence technique. Five cardiac reflex tests were performed to investigate cardiac autonomic neuropathy. QTc interval was assessed in all patients. As a control group, 60 healthy non-diabetic subjects were also tested for CF-SG and CF-PSG autoantibodies. CF-SG autoantibodies were detected in 11 (9%) and CF-PSG autoantibodies were observed in 7 (6%) Type 2 DM patients, whereas in control subjects, the frequency was 1 (2%) and 0 (0%) respectively (ns vs. Type 2 DM patients). In Type 2 DM patients with cardiac autonomic neuropathy (n=31, 24%), CF-SG autoantibodies and CF-PSG autoantibodies were detected in 3 (10%) patients, respectively, compared to 8 (8%) and 4 (4%) in Type 2 DM patients without cardiac autonomic neuropathy (n=96, 76%, ns v. Type 2 DM with cardiac autonomic neuropathy). Both CF-SG autoantibodies and CF-PSG autoantibodies were observed in 2 (7%) Type 2 DM patients with cardiac autonomic neuropathy and 3 (3%) Type 2 DM patients without cardiac autonomic neuropathy. Type 2 DM patients with cardiac autonomic neuropathy demonstrated a longer QTc-interval (446+/-42 ms) than Type 2 DM patients without cardiac autonomic neuropathy (413+/-45 ms, p=0.0001). In Type 2 DM patients with a prolonged QTc-interval (>440 ms: n=29, 23%), 2 (7%) patients presented with CF-SG and 3 (10%) had CF-PSG autoantibodies. In Type 2 DM, CF-SG and CF-PSG autoantibodies are not frequently observed. The results do not give evidence, that immunological factors--like in Type 1 DM--play a role in the pathogenesis of cardiac autonomic dysfunction in Type 2 DM.