Combination peroxisome proliferator-activated receptor gamma and alpha agonist treatment in Type 2 diabetes prevents the beneficial pioglitazone effect on liver fat content

AIMS

Peroxisome proliferator-activated receptor (PPAR)-gamma and PPAR-alpha agonists individually reduce intra-organ triglyceride content and improve insulin sensitivity. However, the precise effects of combined PPAR-gamma and PPAR-alpha therapy on intra-organ triglyceride content and insulin sensitivity in subjects with Type 2 diabetes have not yet been determined.

METHODS

Diet-controlled Type 2 subjects (n = 9) were studied before and after 16 weeks of combined PPAR-gamma [pioglitazone (PIO), 45 mg daily] and PPAR-alpha [bezafibrate (BEZA), modified release 400 mg daily] agonist therapy. Glucose metabolism and endogenous glucose production were measured following a standard liquid test meal. Liver and muscle triglyceride levels were measured by (1)H magnetic resonance spectroscopy.

RESULTS

Combined PIO and BEZA therapy reduced mean fasting (7.5 +/- 0.5 vs. 6.5 +/- 0.2 mmol/l, P = 0.04) and peak postprandial plasma glucose (15.3 +/- 1.1 vs. 11.7 +/- 0.6 mmol/l, P = 0.007). No significant change in hepatic or muscle triglyceride content was observed. Postprandial suppression of endogenous glucose production remained similar on both study days. Both subcutaneous and visceral fat content increased following therapy.

CONCLUSIONS

Combined PIO and BEZA therapy in Type 2 diabetes does not decrease intrahepatic triglyceride content or postprandial endogenous glucose production. This study demonstrates an unexpected adverse interaction of PPAR-alpha with PPAR-gamma agonist therapy.

Recurrent bacteremia and multifocal lower limb cellulitis due to Helicobacter-like organisms in a patient with X-linked hypogammaglobulinemia

We describe a 27-year-old man with X-linked (Bruton's) hypogammaglobulinemia who presented during a 10-month period with recurrent fevers and multifocal lower-limb cellulitis associated with bacteremia due to Helicobacter-like organisms ("Flexispira rappini" and Helicobacter canis). Susceptible individuals may acquire infection of this type as a result of exposure to young dogs.

Suppression of lymphocyte mitogenesis by tamoxifen: studies on protein kinase C, calmodulin and calcium

The effect of tamoxifen (TX; 1.0 microM) on the mitogenic response of rat lymphocytes was compared with the effect of drugs that are known to act on protein kinase C (PKC), calmodulin (CM), and calcium (Ca(2+)). The calcium ionophore A23187 (0.2 microM) was mitogenic on its own which was not influenced by TX. The agents modulating PKC or CM (phorbol-myristate-13-acetate; R24571, chlorpromazine) influenced mitogenesis differently than did TX. General inhibition of lymphocyte proliferation was seen with the Ca(2+) antagonist agents (EGTA, TMB-8) as with TX. The antiproliferative effect of TX was partially reversed by the increase of Ca(2+) in the culture medium when T cell mitogens were used, but not in the case of lipid A, a B lymphocyte mitogen. However, the concanavalin A-induced Ca(2+) influx was further elevated by TX which differed from the effect of the Ca(2+) channel-blocking agent verapamil. The results suggest that TX resets the threshold stimulus necessary for mitogenesis and is completely reversible.

Ascorbic acid-based inhibitors of alpha-amylases

A series of ascorbic acid and isoascorbic acid derivatives has been evaluated as inhibitors of malt, bacterial, fungal, pancreatic and salivary alpha-amylases using a simple and quick assay procedure. The results demonstrate that the enediol moiety of ascorbic acid is essential for alpha-amylase inhibition. Acylation of the primary and secondary alcohols, and the absolute configuration of the secondary alcohol, do not affect the potency of inhibition.

Fatal encephalitis and meningitis at the Gold Coast Hospital, 1980 to 1996

The recent association of a fatal human case of encephalitis with a newly identified lyssavirus apparently acquired from a native Australian bat has highlighted the possibility that previous human infections have passed urecognised. Infected bats have been identified on the Queensland Gold Coast where extensive close contact between bats and humans has occurred for many years. In an attempt to identify nervously unrecognised cases of fatal lyssavirus encephalitis, the medical records of the Gold Coast Hospital over a 16 years period from 1980 to 1996 were reviewed. Of 20 cases coded as 'encephalitis' or 'meningitis' where death occurred, none was consistent with an encephalitis due to an unidentified virus.

Variability in scoring the Hachinski Ischaemic Score

Multi-infarct dementia (MID) may be the second most common form of dementia in later life. A commonly used aid in the clinical diagnosis of MID is the Hachinski Ischaemic Score (HIS). The usefulness of this score is controversial, and we hypothesized that this is because many items of the HIS are open to a wide range of interpretations. We therefore canvassed 45 research and academic centres in the United Kingdom and Ireland with an interest in dementia to assess the variability of interpretation of the HIS. Five template cases were constructed, in which were embedded items which were felt to be potentially contentious. Fifty-five out of 94 (59%) respondents replied. There was a very wide variation in the scores assigned to each vignette. In only five of 65 items was there complete agreement among replies: in general there was a very large range for each item. Thirty of the items showed less than 90% agreement. The apparent simplicity of the HIS conceals possibilities for ambiguous interpretation of individual items. This is a property common to many 'simple' rating scales. It should not lead to outright rejection of these scales, but rather to a refinement and clarification of the scoring and assessment techniques.

A trainer's perspective of an innovative programme teaching health visitors about the detection, treatment and prevention of postnatal depression

Health visitors in North Staffordshire, Edinburgh and Lewisham were given the opportunity to participate in a training programme in the detection, treatment and prevention of postnatal depression, based on previously reported successful intervention strategies. They were trained in the use of the Edinburgh Postnatal Depression Scale (EPDS), and given information about the value and practice of non-directive counselling and about preventative strategies. Knowledge acquisition was evaluation by self-report questionnaires given before and after training. The health visitors were encouraged to screen postnatal women at three specified times using the EPDS and to offer non-directive counselling to women who obtained high scores. A baseline measure of the incidence of postnatal depression was obtained by asking health visitors to give an EPDS form to all women in their caseload with a 6-month-old baby before training commenced. A comparison of the number of women with high EPDS scores at 6 months postnatally, before and after training, showed that participation in the programme enabled health visitors to positively influence the emotional well-being of postnatal women. These results have implications for the role of health visitors which is currently being challenged, as well as for components of their training and continuing professional development.

Dementia and Driving

Many European countries test cars, but not their drivers, as they age. There is evidence to suggest that human factors are more important than vehicular factors as causes of motor crashes. The elderly also are involved in more accidents per distance travelled than middle-aged drivers. As the UK relies on selfcertification of health by drivers over the age of 70 years, we examined the driving practices of patients with dementia attending a Memory Clinic. Nearly one-fifth of 329 patients with documented dementia continued to drive after the onset of dementia, and impaired driving ability was noted in two-thirds of these. Their families experienced great difficulty in persuading patients to stop driving, and had to invoke outside help in many cases. Neuropsychological tests did not help to identify those who drove badly while activity of daily living scores were related to driving ability. These findings suggest that many patients with dementia drive in an unsafe fashion after the onset of the illness. The present system of selfcertification of health by the elderly for driverlicencing purposes needs to be reassessed.

Dietary omega 3 fatty acids and gestational hypertension in the Inuit

Blood pressure at the end of pregnancy and the incidence of pregnancy-induced hypertension were monitored in Inuit communities in the Keewatin region of the Northwest Territories. Communities with more fish and sea mammals in their diet had a lower blood pressure at the end of pregnancy and a lower incidence of gestational hypertension. The lower incidence of gestational hypertension was independent of other variables, including pregravida weight and parity. Cord blood phospholipid fatty acid analysis confirmed higher levels of eicosapentanoic acid, a fatty acid enriched in fish and sea mammals, in infants born to mothers from communities with higher fish in their diets.

In vitro response of human bone marrow progenitor cells to superoxide radicals

Human bone marrow progenitor cells, grown on solid agar, developed colonies of the white blood cell series, principally granulocytes, monocytes and macrophages. Following exposure to superoxide radicals, generated photochemically, a fraction of the progenitor cells was inactivated as evidenced by loss of colony formation. The loss in proliferative capacity depended on the illumination time and individual nature of the donated specimens. Protection of the progenitor cells by active superoxide dismutase depended on the illumination time and temperature. Inactive superoxide dismutase and active catalase did not protect the cells from the photochemical inactivation process.

Catecholamine responses to changes in posture during human pregnancy

Human pregnancy may induce changes in the sensitivity of the cardiovascular system to endogenous catecholamines. This was investigated in multigravid women with little likelihood of unsuspected vascular disease. The responses of blood pressure, pulse rate, plasma noradrenaline and adrenaline to a change in posture from semi-recumbency to standing were assessed in six normotensive women at 36 weeks gestation and in six non-pregnant control subjects. Standing for 10 min caused a surge in blood pressure, pulse rate and plasma noradrenaline in non-pregnant women. The pregnant women, whose basal levels of noradrenaline were higher than those in non-pregnant women, showed a slower noradrenergic response to postural change, and this response had less effect upon the cardiovascular indices. Blood pressure dropped immediately on standing and pulse rate remained unaffected throughout. It is suggested that some women may maintain a non-pregnant level of pressor sensitivity during pregnancy and thereby become hypertensive.

Glycosylated haemoglobin in cord blood following normal and diabetic pregnancies

Cord and maternal blood samples were obtained at delivery in 25 normal and 14 diabetic pregnancies (13 insulin-dependent, one gestational). Total glycosylated haemoglobin, measured by the colorimetric thiobarbiturate method (mmol hydroxymethylfurfural/mol haemoglobin), was lower in cord than maternal blood (mean 18.7 +/- 1.7 versus 26.5 +/- 2.1, mean +/- SD, p less than 0.001). Glycosylated haemoglobin was higher following diabetic pregnancies, both in cord (diabetic 19.9 +/- 1.6 versus normal 17.9 +/- 1.4, p less than 0.001) and maternal samples (diabetic 27.7 +/- 1.5 versus normal 25.6 +/- 2.1, p less than 0.005). Cord and maternal glycosylated haemoglobin correlated in the normal (r = 0.60, p less than 0.01) but not in the diabetic group (r = 0.02, NS). Birth weight ratio was higher in infants of diabetic than of normal mothers (1.10 +/- 0.16 versus 0.99 +/- 0.13, p less than 0.05) but failed to correlate with cord or maternal glycosylated haemoglobin or, in the diabetic group, with mean blood glucose.

A microcomputer measuring system applied to real-time ultrasound video imaging

The high-resolution graphics facility of a microcomputer has been synchronized with real-time ultrasound images on a television monitor, allowing quick and accurate measurements of linear distances, are lengths, perimeter lengths, and areas, whether regular or irregular in shape. No particular knowledge of computers is required, as the program gives step-by-step directions. However, the full facilities of a 48K microcomputer using BASIC language remain accessible, which is a considerable advantage over equivalent measuring systems currently available.

Evaluating summer camps 1979 - problems of measuring behaviour change in children

To develop experience in assessing behaviour change in children, sixteen children attending week-long summer camps run by the Department of Psychiatry, Adelaide Children's Hospital in January 1979, were assessed every two months for six months. Target complaints, symptom checklists and measures of social behaviour were chosen as being most likely to be sensitive to behaviour change. Hypotheses about the summer camp experience having an influence on severity of target behaviour problems, symptoms indicating child psychiatric disorder, peer group participation, mastery of aggression and development of conscience and social values were not convincingly supported. Agreement between camp staff and parents rating the children's social behaviour using the same instrument a week apart was poor. Simple ranked adjective scales have advantages over goal attainment scaling for rating target complaints, Implications for treatment evaluation in child psychiatry are discussed.

A prospective, controlled trial of six forms of hormone replacement therapy given to postmenopausal women

This study was undertaken to investigate the effect of various forms of hormone replacement therapy (HRT) upon postmenopausal women while controlling as many variables as possible. It was felt that the age, duration of amenorrhoea and the general health of the patients should be as comparable as possible and that each patient should provide her own pretherapy and post-therapy control data. In addition, it was felt that any placebo effect should be investigated and the patients were therefore randomly allocated to placebo tablets or one of six available forms of HRT. The age/sex registers of two large general practices were scrutinized and all women between 49 and 54 years of age were asked to cooperate; for a variety of reasons only 56 women were suitable and willing to take part in the project, yielding 8 women for each of the seven possible therapy groups. Blood samples were taken at 7-day intervals three times before therapy was given and the mean of the three values was used as the control value. The women returned on day 21 of each subsequent therapy cycle for six consecutive months and finally three months after discontinuing therapy. From the data the following broad conclusions can be drawn: (i) some women have classic symptoms of hot flushes and sweating despite high endogenous oestrogen concentrations; (ii) vaginal cytology is a relatively poor indicator of endogenous oestrogen status; (iii) while follicle stimulating hormone (FSH) and luteinizing hormone (LH) concentrations are reduced on HRT neither is decreased to anywhere near premenopausal values while prolactin is unaffected; (iv) plasma cholesterol levels are reduced on HRT, the pulse rate is slower and both systolic and diastolic blood pressure are reduced to a small but significant extent; (v) there is no adverse effect upon blood clotting; and (vi) most women experience significant or complete relief of symptoms on all forms of HRT as do some women taking a placebo. The combined preparations containing an oestrogen and progestogen produced vaginal bleeding in only 80 per cent of the women. Thus protection by regular endometrical shedding may not be afforded to all women. As vaginal bleeding is unacceptable to most women if they can achieve the same symptomatic relief without inducing menstruation, it is suggested that women have a low dose oestrogen preparation prescribed cyclically for 6 to 12 months. If therapy is to be maintained for a longer time, uterine curretage should be undertaken at regular intervals to exclude the possibility of endometrial carcinoma developing.

Effect of maternal parity and infant sex upon the haematological values of cord blood

Coulter Counter (Model S) analysis of 400 cord blood samples are presented, together with differential white cell counts for 249 of these. The mean values for haemoglobin and red cell count are somewhat higher than previous values determined by manual methods, while those for haematocrit and mean cell volume are slightly lower. An unexpected finding was that the red cell count, haemoglobin concentration, and haematocrit, are significantly higher in male than in female infants. A parity effect was also demonstrated: infants of both sexes born as second or subsequent births had lower values for total white cell count, haemoglobin concentration and haematocrit, than first-born infants.