The haemoglobin glycation index as predictor of diabetes-related complications in the AleCardio trial

The haemoglobin glycation index (HGI) quantifies the interindividual variation in the propensity for glycation and is a predictor of diabetes complications and adverse effects of intensive glucose lowering. We investigated the relevance of HGI as independent predictor of complications by using data of the AleCardio trial. The AleCardio trial randomized 7226 type 2 diabetes patients with an acute coronary syndrome to aleglitazar or placebo. From 6458 patients with baseline glycated haemoglobin (HbA_1c) and fasting plasma glucose (FPG), a linear regression equation, HbA_1c (%) = 5.45 + 0.0158 * FPG (mg/dl), was used to calculate predicted HbA_1c and derive HGI (= observed - predicted HbA_1c). With multivariate Cox regression we examined the association with major adverse cardiac events, cardiovascular mortality, total mortality and hypoglycaemia, irrespective of treatment allocation, using HGI subgroups (low, intermediate and high) and HGI as continuous variable. Patients with high HGI were younger, more often non-Caucasian, had a longer duration of diabetes, showed more retinopathy and used insulin more often. Hypoglycaemia occurred less often in the low HGI subgroup, but this difference disappeared after adjustment for duration of diabetes, insulin and sulphonylurea use. Low HGI patients were at lower risk for cardiovascular mortality (hazard ratio 0.64; 95% confidence interval 0.44-0.93, p = 0.020) and total mortality (hazard ratio 0.69; 95% confidence interval 0.50-0.95, p = 0.025), as compared with high HGI patients. Every percentage increase in HGI was associated with a 16% increase in the risk for cardiovascular mortality ( p = 0.005). The association between HGI and mortality disappeared with additional adjustment for HbA_1c. HGI predicts mortality in diabetes patients with acute coronary syndromes, but no better than HbA_1c.

Bromocriptine and insulin sensitivity in lean and obese subjects

Bromocriptine is a glucose-lowering drug, which was shown to be effective in obese subjects with insulin resistance. It is usually administered in the morning. The exact working mechanism of bromocriptine still has to be elucidated. Therefore, in this open-label randomized prospective cross-over mechanistic study, we assessed whether the timing of bromocriptine administration (morning vs evening) results in different effects and whether these effects differ between lean and obese subjects. We studied the effect of bromocriptine on insulin sensitivity in 8 lean and 8 overweight subjects using an oral glucose tolerance test. The subjects used bromocriptine in randomized cross-over order for 2 weeks in the morning and 2 weeks in the evening. We found that in lean subjects, bromocriptine administration in the evening resulted in a significantly higher post-prandial insulin sensitivity as compared with the pre-exposure visit (glucose area under the curve (AUC) 742 mmol/L * 120 min (695-818) vs 641 (504-750), P = 0.036, AUC for insulin did not change, P = 0.575). In obese subjects, both morning and evening administration of bromocriptine resulted in a significantly higher insulin sensitivity: morning administration in obese: insulin AUC (55,900 mmol/L * 120 min (43,236-96,831) vs 36,448 (25,213-57,711), P = 0.012) and glucose AUC P = 0.069; evening administration in obese: glucose AUC (735 mmol/L * 120 min (614-988) vs 644 (568-829), P = 0.017) and insulin AUC, P = 0.208. In conclusion, bromocriptine increases insulin sensitivity in both lean and obese subjects. In lean subjects, this effect only occurred when bromocriptine was administrated in the evening, whereas in the obese, insulin sensitivity increased independent of the timing of bromocriptine administration.

Diabetes patients' experiences with the implementation of insulin therapy and their perceptions of computer-assisted self-management systems for insulin therapy

Background

Computer-assisted decision support is an emerging modality to assist patients with type 2 diabetes mellitus (T2DM) in insulin self-titration (ie, self-adjusting insulin dose according to daily blood glucose levels). Computer-assisted insulin self-titration systems mainly focus on helping patients overcome barriers related to the cognitive components of insulin titration. Yet other (eg, psychological or physical) barriers could still impede effective use of such systems.

Objective

Our primary aim was to identify experiences with and barriers to self-monitoring of blood glucose, insulin injection, and insulin titration among patients with T2DM. Our research team developed a computer-assisted insulin self-titration system, called PANDIT. The secondary aim of this study was to evaluate patients’ perceptions of computer-assisted insulin self-titration. We included patients who used PANDIT in a 4-week pilot study as well as patients who had never used such a system.

Methods

In-depth, semi-structured interviews were conducted individually with patients on insulin therapy who were randomly recruited from a university hospital and surrounding general practices in the Netherlands. The interviews were transcribed verbatim and analyzed qualitatively. To classify the textual remarks, we created a codebook during the analysis, in a bottom-up and iterative fashion. To support examination of the final coded data, we used three theories from the field of health psychology and the integrated model of user satisfaction and technology acceptance by Wixom and Todd.

Results

When starting insulin therapy, some patients feared a lifelong commitment to insulin therapy and disease progression. Also, many barriers arose when implementing insulin therapy (eg, some patients were embarrassed to inject insulin in public). Furthermore, patients had difficulties increasing the insulin dose because they fear hypoglycemia, they associate higher insulin doses with disease progression, and some were ignorant of treatment targets. Patients who never used a computer-assisted insulin self-titration system felt they had enough knowledge to know when their insulin should be adjusted, but still believed that the system advice would be useful to confirm their reasoning. Furthermore, the time and effort saved with automated insulin advice was considered an advantage. Patients who had used PANDIT found the system useful if their glycemic regulation improved. Nevertheless, for some patients, the absence of personal contact with their caregiver was a drawback. While guidelines state that adjustment of basal insulin dose based on fasting plasma glucose values is sufficient, both patients who had and those who had not used PANDIT felt that such a system should take more patient data into consideration, such as lifestyle and diet factors.

Conclusions

Patients encounter multiple obstacles when implementing insulin therapy. Computer-assisted insulin self-titration can increase patient awareness of treatment targets and increase their confidence in self-adjusting the insulin dose. Nevertheless, some barriers may still exist when using computer-assisted titration systems and these systems could also introduce new barriers.

The influence of aspirin dose and glycemic control on platelet inhibition in patients with type 2 diabetes mellitus

BACKGROUND

Low-dose aspirin seems to offer no benefit in the primary prevention of cardiovascular disease in type 2 diabetes mellitus (DM2). The anti-platelet effect may be diminished by poor glycemic control or inadequate dosing of aspirin.

OBJECTIVES

To study the effects of both glycemic control and increasing aspirin dose on platelet response to aspirin in DM2 patients and matched controls.

PATIENTS/METHODS

Platelet effects of increasing doses of aspirin (30, 100 and 300 mg daily) were prospectively assessed in 94 DM2 patients and 25 matched controls by measuring thromboxane levels in urine (11-dhTxB2) and platelet aggregation using VerifyNow(®) and light transmission aggregometry (LTA). DM2 patients were stratified for glycemic control (hemoglobin-A1c [HbA1c] ≤ 53, 53-69, ≥ 69 mmol mol(-1)).

RESULTS

At baseline, median 11-dhTxB2 excretion was higher in the poorly controlled patients (77 ng mmol(-1)), and the moderately controlled (84 ng mmol(-1)) compared with the well-controlled patients (64 ng mmol(-1)) and controls (53 ng mmol(-1)), P < 0.01. Next, 30 mg of aspirin reduced 11-dhTxB2 excretion to 31, 29 and 24 ng mmol(-1) in the poorly, moderately and well-controlled patients, respectively, and to 19 ng mmol(-1) in controls, P < 0.001. VerifyNow(®) and LTA were also incompletely suppressed in DM2 patients using 30 mg of aspirin, but 100 mg resulted in similar platelet suppression in all groups, with no additional effect of 300 mg.

CONCLUSIONS

DM2 patients with inadequate glycemic control (HbA1c > 53 mmol mol(-1)) have higher baseline platelet activity and incomplete suppression of platelet activity with 30 mg of aspirin. However, 100 mg of aspirin leads to optimal inhibition irrespective of glycemic control, and 300 mg does not further improve platelet suppression.

Development of a web-based decision support system for insulin self-titration

Insulin is the most potent agent for the treatment of diabetes mellitus. However insulin treatment requires frequent evaluation of blood glucose levels and adjustment of the insulin dose. This process is called titration. To guide patients with type 2 diabetes using once-daily long-acting insulin, we have developed a web-based decision support system for insulin self-titration. The purpose of this paper is to provide an overview of the phases of development and the final design of the system. We reviewed the literature, consulted an expert panel, and conducted interviews with patients to elicit system requirements. This revealed four important aspects: the insulin titration algorithm, the handling of hypoglycemic events, telemedicine functionalities, and visiting frequency monitoring. We used these requirements to develop a fully functional system.

Continuation versus discontinuation of insulin secretagogues when initiating insulin in type 2 diabetes

We compared the combined use of basal insulin, metformin and insulin secretagogues with a combination of basal insulin and metformin in patients with type 2 diabetes starting basal insulin analogue therapy. This analysis was part of a 24-week trial, in which 964 insulin-naive patients with type 2 diabetes inadequately controlled on oral agents (including metformin) were randomized to insulin glargine or detemir. Secretagogues were stopped or maintained at the site-investigators' discretion. During the study, 57.6% of patients continued their secretagogue treatment. Compared with patients stopping secretagogues, those who continued experienced significantly more hypoglycaemia and weight gain. Insulin doses, however, were significantly lower: 0.6 ± 0.4 versus 0.8 ± 0.4 U/kg/day (p < 0.001). The difference between groups in mean HbA1c reduction was not statistically significant. In conclusion, in type 2 diabetic patients starting basal insulin analogue therapy, continuing both metformin and secretagogues results in more hypoglycaemia and weight gain and lower insulin doses than only maintaining metformin.

[Diabetes mellitus, but which type?]

In three patients with an unusual presentation of diabetes mellitus, the classification of their diabetes was troublesome. An adolescent male with slightly elevated blood-glucose levels turned out to have excellent glycaemic control on sulphonylurea derivatives only. When he was 40 years of age, his diabetes was finally diagnosed as 'maturity onset diabetes of the young' (MODY). A non-obese 41-year-old man was initially diagnosed with type-2 diabetes. Therapy with oral hypoglycaemic agents was unsuccessful and he was subsequently classified as having 'latent autoimmune diabetes of adults' (LADA) based on the presence of antibodies against glutaminic acid decarboxylase. A 29-year-old man presented with severe ketoacidosis and was initially believed to have type-1 diabetes. The patient himself discontinued insulin therapy and he was eventually diagnosed as having type-2 diabetes. A careful classification may have clinical consequences. Patients with MODY3, for example, respond to sulphonylurea derivatives. In MODY2, treatment with diet alone is often sufficient. In patients with LADA, insulin therapy is the treatment of choice. The recognition of diabetes mellitus type 2 as the underlying illness in some patients who present with ketoacidosis means that these patients can be specifically treated for their basic problem, which is insulin resistance. For them, weight reduction is essential and metformin is the drug of choice as far as pharmacotherapy is concerned, but of course attention must also be given to cardiovascular risk factors such as hypertension and dyslipidaemia.

[Routine funduscopic examination in hypertensive patients not useful]

Funduscopic examination according to the classification of Keith, Wagener and Barker has been used since 1939 to assess retinal damage in patients with hypertension. Improved treatment possibilities and the screening of patients with hypertension seem to have led to a decrease in the incidence and severity of the retinal abnormalities found. The following findings have been published during the past ten years. The assessment of retinopathy is subject to a large interobserver-variability, especially with respect to venous-crossings and arteriolar narrowing of retinal vessels. The positive and negative predictive value of retinopathy for high blood pressure is low. The association of retinopathy with other predictive indicators for organ damage is inconsistent and its association with cardiovascular complications is weak. These findings indicate that the usefulness of funduscopic examination as an instrument for assessing organ damage in patients with hypertension is limited. Therefore it should not be used as a routine diagnostic tool unless a hypertensive crisis is indicated.

Glucose counterregulation in Type 2 diabetes mellitus

Glucose counterregulatory failure and hypoglycaemia unawareness frequently complicate treatment of Type 1 diabetes mellitus, especially when aiming for intensive metabolic control. Since tight metabolic control reduces microvascular long-term complications in Type 2 diabetes mellitus, the integrity of glucose counterregulation in Type 2 diabetic patients is important. Using a Medline search, we identified 12 studies in which counterregulatory responses to insulin-induced hypoglycaemia were compared between Type 2 diabetic patients and appropriate controls. A review of these studies showed that some patients with Type 2 diabetes mellitus develop mild counterregulatory dysfunction and reduced awareness of insulin-induced hypoglycaemia. Some studies suggested an association between counterregulatory impairment and intensity of metabolic control. We speculate that the relatively low frequency of (severe) hypoglycaemic events in Type 2 diabetes may explain why glucose counterregulation remains unaffected in most patients. We hypothesize that residual beta-cell reserve and insulin resistance provide protection against severe hypoglycaemia and limit impaired counterregulation. Diabet. Med. 18, 519-527 (2001)

[Acute delirium, probably precipitated by clarithromycin]

Clarithromycin is a relatively new antibiotic with many applications. Its frequent use explains why side-effects previously reported seldom now become clear. Two patients, a man aged 74 and a woman aged 56 years, developed delirium after treatment with clarithromycin as part of eradication treatment of Helicobacter pylori, presumably as a result of an ideosyncratic reaction to the clarithromycin. Preclinical and clinical investigations did not reveal side effects on the central nervous system. By now the appearance of a delirium presumably related to the use of clarithromycin has been described in several patients. Furthermore some patients had a positive rechallenge. Finally, 17 reports on psychiatric side effects, of which 7 were delirium, after the use of clarithromycin reached the Netherlands Pharmacovigilance Foundation (Lareb). This combination of facts makes a causal relationship probable.

An Epstein-Barr virus-associated pulmonary lymphoproliferative disorder as complication of immunosuppression

Inherited or acquired immunodeficiencies as well as autoimmune diseases treated with cytotoxic drugs are associated with an increased incidence of lymphoma. Non-Hodgkin's lymphomas that occur in the context of drug-induced immunosuppression, acquired or congenital immunodeficiency, are frequently associated with Epstein-Barr virus infection. This report describes the occurrence of an Epstein-Barr virus associated pulmonary B cell lymphoma in a patient with longstanding rheumatoid arthritis treated with methotrexate.

[Metformin efficacious in poorly controlled diabetes mellitus type 2]

Three patients, 1 man and 2 women, aged 60, 55 and 72 years, had an insufficient glucose regulation with insulin therapy or with sulfonylurea derivatives. They started metformin therapy, after which HbA1c decreased by 0.8-1.8%. One patient had to discontinue metformin therapy due to excessive diarrhoea. Many studies have shown the beneficial effect of metformin on glucose control. The recent UK Prospective Diabetes Study has proven the effectiveness of metformin for any diabetes related endpoint. Frequent side effects of metformin are nausea, abdominal discomfort and diarrhoea. Most side effects disappear after decreasing the dosage, although in 5% of patients diarrhoea only disappears after discontinuation of metformin. Lactic acidosis is a rare, serious adverse effect of metformin, which can be prevented by carefully observing the contra-indications.

Asymptomatic bacteriuria may be considered a complication in women with diabetes. Diabetes Mellitus Women Asymptomatic Bacteriuria Utrecht Study Group

OBJECTIVE

To study the prevalence of and risk factors for asymptomatic bacteriuria (ASB) in women with and without diabetes.

RESEARCH DESIGN AND METHODS

A total of 636 nonpregnant women with diabetes (type 1 and type 2) who were 18-75 years of age and had no abnormalities of the urinary tract, and 153 women without diabetes who were visiting the eye and trauma outpatient clinic (control subjects) were included. We defined ASB as the presence of at least 10(5) colony-forming units/ml of 1 or 2 bacterial species in a culture of clean-voided midstream urine from an individual without symptoms of a urinary tract infection (UTI).

RESULTS

The prevalence of ASB was 26% in the diabetic women and 6% in the control subjects (P < 0.001). The prevalence of ASB in women with type 1 diabetes was 21%. Risk factors for ASB in type 1 diabetic women included a longer duration of diabetes, peripheral neuropathy, and macroalbuminuria. The prevalence of ASB was 29% in women with type 2 diabetes. Risk factors for ASB in type 2 diabetic women included age, macroalbuminuria, a lower BMI, and a UTI during the previous year. No association was evident between current HbA1c level and the presence of ASB.

CONCLUSIONS

The prevalence of ASB is increased in women with diabetes and might be added to the list of diabetic complications in these women.

Effect of metformin on glycaemic control in type 2 diabetes in daily practice: a retrospective study

INTRODUCTION

Recently the UKPDS study revealed the potency of metformin therapy in obese type 2 diabetic patients. A retrospective study was performed to assess the efficacy of metformin therapy in improving metabolic control in everyday practice.

PATIENTS AND METHODS

Type 2 diabetic patients were included if they met the following criteria: metformin had been added when the previous treatment failed to optimise glycaemic control expressed in HbA1c level; duration of metformin therapy had to be at least six months. Efficacy of metformin therapy, expressed as a decrease in HbA1c, was measured with a median follow-up of 32 (range 6-60) months. Variables were analysed using a paired t-test.

RESULTS

One hundred and sixty-three patients were treated with metformin. 98 patients were excluded, because of absence of an HbA1c value prior to treatment with metformin mainly (n = 78). The mean HbA1c of included patients had decreased 1.4% (p < 0.001) after 6 months (n = 65), 1.6% (p < 0.001) after 24 months (n = 45) and 1.5 (p < 0.001) after 36 months (n = 28). During follow-up there was no significant weight gain or loss.

CONCLUSION

Metformin can be considered an effective treatment to improve glycaemic control in obese type 2 diabetic patients.

Abnormal clotting parameters before therapeutic ERCP: do they predict major bleeding?

A total of 399 consecutive patients undergoing 598 ERCPs (endoscopic retrograde cholangiopancreatographies), including 88 pre-cut papillotomies and 206 conventional papillotomies, are described in a retrospective study. Clotting parameters, haemoglobin levels, indications for pre-cut and/or conventional papillotomy and the use of drugs assumed to interfere with blood clotting (anticoagulants, platelet-aggregation inhibitors, low-molecular-weight heparin) were evaluated in order to detect risk factors for ERCP-associated bleeding. The overall incidence of ERCP-associated bleeding was 18/598 (3.0%). The incidence of bleeding in the group without papillotomy was 7/346 (2.0%). This group consisted of patients who underwent only a diagnostic ERCP, patients who had undergone papillotomy previously, patients in whom a renewed attempt was made to extract biliary stones, and patients in whom removal or change of a stent was necessary. The incidence of papillotomy-associated bleeding was 11/252 (4.4%). Pre-cut papillotomy did and conventional papillotomy did not significantly increase the incidence of bleeding: 15.2% (P < 0.001) and 1.9% (P= 1.00) respectively. The incidence of ERCP-associated bleeding in the group not using any drugs interfering with blood clotting was 2.5%. The use of low-molecular-weight heparin (10.3%) during ERCP significantly increased the risk of bleeding (P= 0.01). However, the use of platelet aggregation inhibitors (2.4%) did not (P= 1.00). As the incidence of bleeding in patients with normal clotting parameters, including the patients with abnormal parameters which were well corrected (4.3%), was higher than in patients with abnormal haemostatic screens (2.7%), abnormal coagulation tests did not predict ERCP-associated bleeding.

No effect of long-term physical activity on the glycemic control in type 1 diabetes patients: a cross-sectional study

BACKGROUND

The main purpose of the present study was to assess the relation between long-term physical activity and glycemic control in patients with type 1 diabetes mellitus.

METHODS

Medical data and blood samples for the determination of glycosylated hemoglobin (glyHb) were collected in 221 consecutive type 1 diabetes patients between 18 and 45 years of age without late complications. A self-report questionnaire was used to determine the degree of physical activity. Correlation coefficients and analysis of variance were used for statistical analyses.

RESULTS

No correlation was observed between the different levels of physical activity and glycemic control. Females showed a significantly higher total physical activity index than males (p = 0.004), mostly due to the leisure time activity index. More active patients used a lower amount of insulin (r = -0.20, p = 0.002) than less active patients.

CONCLUSIONS

Glycemic control was not found to be associated with long-term physical activity in type 1 diabetes patients. Physical activity did not negatively affect long-term glycemic control.

Troglitazone. Is it all over?

In January 1997 a drug from a new pharmacological class, the thiazolidinediones, became available: troglitazone. Troglitazone indirectly enhances peripheral insulin sensitivity. In this way it lowers the levels of both glucose and insulin. Troglitazone also has a lowering effect on the levels of triglycerides. In clinical trials only mild side effects had been observed. Therefore, troglitazone seemed a promising drug. Recently, however, it became clear that troglitazone could cause liver dysfunction in some patients. Although this side effect is reversible in most cases, six deaths have been described due to liver damage. Troglitazone was to be introduced in Europe in 1998 but registration procedures and clinical trials have been stopped because of its side effects on the liver. In the United States and Japan troglitazone is still being used, albeit with extra precautions. Troglitazone is a valuable addition to the arsenal of antidiabetic drugs for type 2 diabetes. It can be particularly useful, both as an additive and as a replacement, in patients for whom metformin is not suitable because of contraindications or side effects. The risk of severe liver dysfunction is a reason to reserve troglitazone as a second-line drug.

Serum leptin levels are not influenced by physical training in type 2 diabetes mellitus patients

AIM

To investigate the effect of physical training on leptin levels in elderly, obese patients with type 2 diabetes mellitus.

METHODS

Twenty men and 38 women with type 2 diabetes mellitus with a body mass index (BMI) of > 25 kg/m2 participated in a prospective randomized study. Patients were either on oral glucose lowering drugs (n = 39) or insulin therapy (n = 19). Physical training consisted of a guided, standardized, 6-week training programme performed in the hospital on a cyclo ergometer followed by a 6-week period of guided training at home and ended in a 12-week period of training at home without supervision. Clinical data and laboratory samples including fasting insulin and leptin levels and maximal aerobic capacity were assessed at the start of the study and at 6 and 26 weeks thereafter.

RESULTS

Physical training resulted in significantly positive changes in maximal aerobic capacity (VO2max) and maximum work load. No effects of physical training on serum leptin levels and insulin concentrations were detected. Leptin levels were strongly correlated with body mass index (r = 0.63), body fat content (r = 0.61), and fasting insulin concentrations (r = 0.38). Women had threefold higher leptin levels than men. No differences in leptin levels between patients on insulin therapy and patients on oral glucose lowering drugs were found.

CONCLUSIONS

No effect of physical training on leptin levels was detectable in elderly, obese type 2 diabetes mellitus patients.

Fever as presenting symptom of multiple myeloma

We describe a 68-year-old patient presenting with recurrent fever, who eventually turned out to suffer from multiple myeloma. He was treated with Vincristine, Doxorubicin and Dexamethasone combination chemotherapy and intermediate dose Melphalan (70 mg/m2), respectively. Apart from periods of fever due to sepsis following chemotherapy, the recurrent fever disappeared after response, but recurred synchronously with progression of the disease. Recurrent fever in this case should be considered as a symptom of active multiple myeloma. This form of presentation of multiple myeloma has been described in literature only a few times.

Piperacillin/tazobactam therapy for diabetic foot infection

In this study, 29 patients were hospitalized with a diabetic foot infection and were treated with piperacillin/tazobactam. Of these 23 patients who were evaluated for efficacy of treatment, 22 patients improved or were clinically cured. In seven patients (30%), there was persistence of one of the baseline pathogens. Adverse events were reported in 15 patients (58%), three of which were serious. Piperacillin/tazobactam may be useful as monotherapy in diabetic foot infection giving an adequate clinical response and the level of side effects equivalent to those of other broad-spectrum antibiotics.

[The Montignac method: scientific foundation debatable]

Obesity is a major health issue in Western society. In the Netherlands every fifth person suffers from obesity and every third person is on a weight-reducing diet. The Montignac method is a very popular diet. The diet is claimed to be a nutritional science. The method is based on several hypotheses about the metabolism of carbohydrates and fatty acids: carbohydrates with a low glycaemic index are preferred, carbohydrates are not to be eaten in combination with fatty acids, fruit is propagated but must not be combined with other components. The scientific literature refutes the hypotheses of Montignac regarding the metabolic effects of carbohydrates and fatty acids. As a method to lose weight, the conventional recommendations of caloric restriction, less intake of saturated fatty acids and more physical activity should be preferred to the Montignac diet.

Tissue concentrations after a single-dose, orally administered ofloxacin in patients with diabetic foot infections

We studied the penetration of orally administered ofloxacin at the site of diabetes-related foot infections in patients with a planned debridement of the lesion. A total of nine patients received 800 mg of oral ofloxacin 120 to 150 minutes before surgery. During surgery, vital margin tissue and a serum sample were obtained. Serum and tissue concentrations of ofloxacin were measured. From seven patients sufficient amounts of tissue were obtained. Mean serum concentration was 7.0+/-3.5 mg/liter; mean tissue concentrations was 11.5+/-8.4 mg/kg. Mean serum and tissue concentrations exceed the minimal inhibitory concentration90 (MIC90) of commonly involved pathogens. This indicates that orally administered ofloxacin can be an effective treatment for infected diabetic foot lesions.

Effects of physical training on metabolic control in elderly type 2 diabetes mellitus patients

1. The specific role of physical activity in the treatment of type 2 diabetes is still subject to discussion. A randomized prospective study was performed, investigating both the influence of physical training on metabolic control and the feasibility of physical training in the elderly. 2. A total of 58 patients (mean age: 62 +/- 5 years; range: 55-75 years) with type 2 diabetes were randomized to either a physical training or a control programme. The training programme consisted of three sessions a week, aiming at 60-80% of the maximal oxygen uptake (VO2max). The 12 week supervised period was followed by a 14 week non-supervised one. The control group followed an educational programme. VO2max was assessed during exercise on a cycle ergometer. Glycosylated haemoglobin (HbA1c) was used as a measure for glucose control, and an insulin tolerance test was performed to test insulin sensitivity. Multivariate analysis of variance, with repeated measures design, was used to test differences between groups. 3. Fifty-one patients completed the study. VO2max was higher in the training group than in the control group both after 6 weeks (P < or = 0.01 between groups) and after 26 weeks [training group: 1796 +/- 419 ml/min (prestudy), 1880 +/- 458 ml/min (6 weeks), 1786 +/- 591 ml/min (26 weeks); control group: 1859 +/- 455 ml/min (prestudy), 1742 +/- 467 ml/min (6 weeks), 1629 +/- 504 ml/min (26 weeks)]. Blood glucose control and insulin sensitivity did not change during the study. Levels of total triacylglycerols, very-low-density lipoprotein-triacylglycerols and apolipoprotein B were significantly lower after 6 weeks (P < or = 0.01, P < or = 0.05, P < or = 0.05 between groups respectively), and so was the level of total cholesterol after 12 weeks of training (P < or = 0.05 between groups). 4. Physical training in obese type 2 diabetic patients over 55 years of age does not change glycaemic control or insulin sensitivity in the short-term. Regular physical activity may lower triacylglycerol and cholesterol levels in this group of patients. 5. Finally, physical training in motivated elderly type 2 diabetic patients without major cardiovascular or musculoskeletal disorders is feasible, but only under supervision.

Patients with diabetes mellitus and atherosclerosis; a role for cytomegalovirus?

Diabetic patients are known to have an impaired immune response to viral antigens and a high incidence of atherosclerosis. This study was initiated to evaluate the association between cytomegalovirus infection and atherosclerosis in patients with diabetes mellitus. Patients with diabetes mellitus type 1 and 2 (> 5 years) with (group A) and without (group B) clinical signs of atherosclerosis were included. Cytomegalovirus cultures were obtained, serum was screened for CMV-antibodies and CMV-IgG and CMV-IgM titers were determined. Cytomegalovirus antibodies were detected more often in diabetic patients with atherosclerosis compared to patients without atherosclerosis (70.7 vs. 45.2%, P = 0.018. In female patients the prevalence of CMV-antibodies was 89.5 vs. 40.0% (P = 0.0037). CMV IgG titers were twice as high in group A compared to group B. Cytomegalovirus was cultured from four urine samples and two throat swabs in group B and in one urine and one throat swab in group A. The prevalence of cytomegalovirus antibodies was higher in diabetic patients with atherosclerosis compared to diabetic patients without atherosclerosis. This difference was most striking in the female population. CMV-IgG titers were twice as high in the atherosclerosis group. These data suggest that cytomegalovirus may play a role in the development of clinical atherosclerosis in patients with diabetes mellitus.

Comparison of LysB28, ProB29-human insulin analog and regular human insulin in the correction of incidental hyperglycemia

OBJECTIVE

To obtain clinically applicable data on the effects of regular human insulin and the LysB28,ProB29-human insulin analogue (lispro) on the correction of incidental hyperglycemia.

RESEARCH DESIGN AND METHODS

The insulins were compared in a non-clamped randomized crossover study of 27 male IDDM patients. Hyperglycemia was induced by the withdrawal of the normal evening dose of insulin; the next morning patients fasted and received a single dose of study insulin according to a dosing nomogram. Blood glucose concentration and GR (a measure of glucose corrected for differences in administered insulin dose: GR = glucose concentration X BMI X insulin dose-1) were followed for 4 h.

RESULTS

The time courses of blood glucose concentration and GR were significantly different after regular insulin in comparison with lispro (multiple analysis of variance, P < 0.001). At t = 120 min, glucose concentrations had decreased 1.4 mmol/l more with lispro than with regular insulin (95% confidence interval [CI] 0.6-2.3, P = 0.002). Similarly, GR had decreased 4.4 mol.kg.IU-1.m-5 more with lispro than with regular insulin (95% CI 2.6-6.2, P < 0.001). The overall difference in glucose values was 0.87 mmol/l (lispro < regular insulin, P = 0.036), and the overall difference in GR values was 1.96 mol.kg.IU-1.m-5 (lispro < regular insulin, P = NS). Unexpectedly, the intrinsic variability of GR was higher for lispro than for regular insulin.

CONCLUSIONS

The more rapid action of lispro is an advantage in the correction of hyperglycemia, even though actual differences in glucose concentrations are smaller than suggested by previous clamped studies.

Smoking and diabetes mellitus

The goal of this review is to determine the effects of smoking on diabetes mellitus, whether it aggravates diabetic complications or influences insulin metabolism and action. Also available anti-smoking programmes applicable for diabetic patients have been studied. The prevalence of smoking among diabetic patients has been investigated by conducting a meta-analysis. Compared with normal subjects, the prevalence of smoking among diabetic patients is significantly higher (27 vs. 33%, p < 0.0001), IDDM patients largely accounting for this difference. However, care must be used in interpreting these data. Smoking presents an extra risk for development of macro- and microvascular complications in these patients, contributing to increased cardiovascular morbidity and mortality. Smoking also increases the risk of diabetes itself. Neither acute nor habitual smoking causes substantial changes in insulin sensitivity in IDDM patients, whereas it does so in NIDDM. Studies in diabetic patients concerning anti-smoking strategies are scarce and only yield disappointing results. Making these patients abstain from smoking turns out to be extremely difficult, probably due to the considerable psychosocial stress experienced.

High seroprevalence of Helicobacter pylori in diabetes mellitus patients

To assess the prevalence of Helicobacter pylori in diabetes mellitus, a serological test used to detect antibodies to H. Pylori in patients with diabetes mellitus. Within six months, 45 insulin-dependent, 98 non-insulin-dependent, and a control group of 159 outpatients were enrolled in this study. The age adjusted seroprevalence rate of Helicobacter pylori were determined using a commercial anti-Helicobacter pylori IgC and IgA ELISA (Bio-Rad). The prevalence rates increased with age in all age groups until 60-70 years. In diabetic patients, the frequency of Helicobacter pylori infection was higher than control subjects in nearly all age groups, reaching significance in three age categories of NIDDM patients and in one age category in IDDM patients. This higher seroprevalence could not be explained by differences in socioeconomic status or use of antibiotics.

Extremely elevated body temperature: case report and review of classical heat stroke

Classical heat stroke is a rare disease in moderate climates. We report a patient who demonstrated the classical triad of elevated body temperature, neurological disturbances, and anhidrosis. He developed rhabdomyolysis and acute renal failure. Eventually he died. Since manifestations of classical heat stroke appear to mimic an acute phase response, cytokines are thought to play an important role in its pathogenesis.

Postprandial reversal of the portal venous flow in a patient with liver cirrhosis

The case of a 61-year-old man with alcoholic liver cirrhosis and a hepatocellular carcinoma is presented. He was examined with duplex Doppler before and after a meal. In the fasting state a sluggish hepatopetal portal venous flow was found. After the meal a pendulating flow and then hepatofugal flow were found. The magnitude and direction of flow alternated synchronously with the action of the heart, suggesting a significant role for the hepatic artery in the postprandial reversal of portal venous flow. One year after this examination the patient died from the complications of decompensated cirrhosis and liver failure. At autopsy a large hepatocellular carcinoma was detected.

Evaluation of fine needle aspiration (FNA) cytology in the diagnosis of thyroid nodules

FNA cytology of 112 patients with thyroid nodules seen in a 5-year period in a general hospital setting, and the histology obtained from the 53 operated patients, were retrospectively analysed. The inadequacy rate of FNA cytology was 11%, sensitivity was 84% (16/19), specificity was 52% (15/29), positive predictive value was 53% (16/30) and negative predictive value was 83% (15/18). Extrapolating these figures to the whole study group a negative predictive value of 95% is put forward as a more realistic figure. The results and the clinical pitfalls of the use of FNA cytology in diagnosing thyroid nodules are discussed. The authors conclude that FNA cytology is a reliable first diagnostic step in the diagnosis of thyroid nodules, even in a general hospital setting.

Magnesium therapy in acute myocardial infarction

The trials reviewed in this study investigated the effect of intravenous magnesium on arrhythmias and mortality in acute myocardial infarction. Nine trials were carried out in the pre-thrombolytic era. They varied in set-up, number of patients, dose of magnesium, follow-up and the type of arrhythmias analyzed. Magnesium reduced mortality in most studies, but the reduction was significant in only three of them. Two meta-analyses of the smaller studies revealed a 55% reduction in mortality. In the LIMIT-2, in which 2300 patients were enrolled, magnesium reduced mortality significantly by 24%. The effect of magnesium on arrhythmias was less clear. Preliminary results of ISIS-4, in which magnesium among others was administered together with thrombolytic agents, did not provide evidence of benefit in patients with suspected myocardial infarction. At present there are no arguments for the use of magnesium in acute myocardial infarction.

Blunted postprandial reaction of portal venous flow in chronic liver disease, assessed with duplex Doppler: significance for prognosis

To establish the effects of a meal on portal venous flow and the prognostic value of this parameter, 46 patients with chronic liver disease and 28 healthy subjects were examined with duplex Doppler before and after a meal. The measurements were completed in 40 patients and 21 healthy subjects. Postprandial portal venous diameter, blood velocity and quantitative flow were measured for 60 min. Mean baseline values were: 11.4 mm versus 10.2 mm (p = 0.019), 10.8 cm.s-1 versus 13.4 cm.s-1 (p = 0.015) and 668 ml.min-1 versus 646 ml.min-1 (p = 0.7) respectively. Spleen size was 15.0 cm versus 10.6 cm (p = 0.0001) respectively. Postprandial diameter, velocity and flow increased significantly in patients and controls (p = 0.0001 for all). Mean postprandial flow could best be described by a polynomial equation with a parabolic curve. Patients' curves were more blunted than controls', with significantly different regression constants (p = 0.025 and p = 0.029). All subjects were followed up for survival and variceal haemorrhage. The mean follow-up time was 47 months. Early maximum postprandial velocity (p = 0.041) and large spleen size (p = 0.002) were significantly related to an unfavourable prognosis for survival. Early maximum velocity was also related to increased variceal haemorrhage. This study shows that postprandial portal venous flow is blunted in patients with chronic liver disease. Postprandial portal venous flow may have prognostic significance.

Hypoglycaemia unawareness

Hypoglycaemia is a severe complication of insulin-dependent diabetes mellitus, especially when it is not preceded by warning signs. A patient unaware of a low blood glucose concentration may not take any remedial action, becomes severely hypoglycaemic and may lapse into a potentially fatal coma. Hypoglycaemic unawareness is associated particularly with good glycaemic control. Hypoglycaemia unawareness was first related to diabetic autonomic neuropathy. Subsequently it emerged that well controlled diabetic patients suffered from hypoglycaemia unawareness more often than poorly controlled patients. Next to autonomic neuropathy and good glycaemic control, the transfer of more slowly resorbed beef and porcine insulin to more rapidly resorbed human insulin has been incriminated as causing an increased incidence of hypoglycaemia unawareness. Reviewing the scientific literature concerning the connection between hypoglycaemia unawareness and the use of human insulin, there is no rationale for supporting the hypothesis that human insulin leads to hypoglycaemia unawareness any longer. While the pathophysiology of hypoglycemia unawareness remains unclear in patients with insulin-dependent diabetes mellitus of long duration, it may well be related to impaired adrenaline secretion. The cause of this impaired adrenaline secretion during hypoglycaemia is unknown and it does not seem to be a result of diabetic autonomic neuropathy.

Portal venous flow and follow-up in patients with liver disease and healthy subjects. Assessment with duplex Doppler

The evolution of portal venous flow in non-end-stage chronic liver disease with portal hypertension was assessed in 59 patients and compared with that in 55 control subjects and by means of duplex Doppler measurements by a single observer. All patients were prospectively followed up, and a repeated measurement was performed in a subgroup of 23 patients. The mean (+/- SD) portal venous diameter and velocity of patients versus controls were 11.2 (+/- 2.0) mm versus 10.1 (+/- 1.4) mm (p < 0.0005) and 11.0 (+/- 4.2) cm/sec versus 13.9 (+/- 4.1) cm/sec (p < 0.0005). The portal venous flow did not differ: 671 (+/- 291) ml/min versus 652 (+/- 203) ml/min. Diagnosis, Child class, and grade of varices did not influence the portal flow. Patients were followed up during a median (+/- SD) time of 47 (+/- 17) months. Nineteen (32%) patients died, and 14 (23%) had a variceal hemorrhage. Survival and hemorrhage were not correlated with the portal venous flow. Subsequent measurements in 23 patients showed a significant decrease in portal venous flow in 5 patients who died during follow-up. This was not found in the patients who survived. It is concluded that portal venous flow in chronic liver disease with portal hypertension is stable for a long time in the evolution of chronic liver disease. The existence of a 'portostat' is postulated. Only in the terminal stage of liver disease can a reduction of the portal venous flow be detected.

Influence of blood glucose levels on peripheral lymphocytes in patients with diabetes mellitus

Abnormalities in lymphocyte subpopulations in patients with type 1 diabetes have been reported previously. To evaluate the effect of blood glucose levels on peripheral lymphocyte concentrations we studied the proportion and phenotypic composition of the T-cell population in 7 patients with type 1 and in 12 patients with type 2 diabetes at hospitalization because of metabolic dysregulation and in a period of restored control. Both the number of CD-4 and CD-8 positive cells increased significantly (p < 0.05), although no change in the CD-4:CD-8 ratio was observed. After restoring metabolic control there was a significant rise in the mean number of total lymphocytes (1760 +/- 759 x 10(6)/ml vs 2385 +/- 889 x 10(6)/ml, p < 0.05). The number of total lymphocytes increased in all patients but one. It is concluded that metabolic control can influence immunological parameters such as numbers of peripheral lymphocytes of various phenotypes.

Humoral immune response to a yeast-derived hepatitis B vaccine in patients with type 1 diabetes mellitus

The immune response following vaccination with a recombinant hepatitis B vaccine was investigated in 32 patients with Type 1 diabetes mellitus and compared with the outcome in 32 healthy age- and sex-matched volunteers. Participants were vaccinated at 0, 30, and 180 days and in vivo immune response was determined at 30, 60, 90, 180, and 210 days. The number of responders (anti-HBs greater than 1 IU l-1) was significantly lower (p less than 0.05) among patients at 30 (2 vs 11), 60 (17 vs 26), 90 (20 vs 28) and 180 (22 vs 29) days. The number of patients protected (anti-HBs greater than 10 IU l-1) was lower (p less than 0.05) than the number of protected volunteers at 60 (5 vs 14), 90 (10 vs 19), 180 (15 vs 24), and 210 days (24 vs 31). After the complete course of vaccination 8 out of 32 patients were still unprotected against hepatitis B (p less than 0.05). The anti-HBs titre of responders at 210 days was 251 (20, 3162) (geometric mean (-SD, +SD] IU l-1 in patients and 1259 (126, 12589) IU l-1 in control subjects (p less than 0.05). The HLA-antigen DQw1 frequency in the diabetic low responders (anti-HBs less than 100 IU l-1) was 0.27 compared with 0.86 in diabetic adequate responders. No relation between anti-HBs production and concentration of HbA1c could be demonstrated.

Duplex Doppler measurements of portal venous flow in normal subjects. Inter- and intra-observer variability

We investigated the variability of quantitative duplex Doppler measurements of portal flow. Measurements were validated in vitro using a flow phantom. The measured flow Q (ml/min), is related to the actual phantom output P (ml/min) according to the following formula: Q = 1.08 (P + 44) (r = 0.998). To estimate inter- and intra-observer variance, 38 subjects without portal hypertension were examined in two groups. Two observers examined the first group of subjects (n = 19), from a routine daily ultrasound schedule. Significant differences were found in mean +/- S.D. portal flow (692 +/- 182 ml/min vs. 613 +/- 185 ml/min, p = 0.04) and mean +/- S.D. velocity (15.3 +/- 3.9 cm/s vs. 13.2 +/- 2.6 cm/s, p = 0.01). The combined inter- and intra-observer coefficient of variation (S.D.) was 24% (158 ml/min), 9% (0.92 mm) and 24% (3.4 cm/s) for portal flow, diameter and velocity respectively. Non-systematic components of variance were the largest. Patient characteristics, age, sex, height, weight and body surface area did not influence measurement variations. In the second group of healthy volunteers (n = 19), where variance in measurements over 3 consecutive days was comparable to the combined variance in the first group, the non-systematic variance component was also the largest. We conclude that quantitative duplex Doppler measurements of portal venous flow are mainly subject to non-systematic variability. A coefficient of variation of 24% can be expected in diagnostic measurements in a single patient. Examination by a single observer is advisable. The value of this technique lies in the analysis of pathophysiological mechanisms in portal flow changes in large groups of subjects.