Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial

BACKGROUND

Patients with type 2 diabetes mellitus are at increased risk of cardiovascular disease, partly owing to dyslipidaemia, which can be amenable to fibrate therapy. We designed the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study to assess the effect of fenofibrate on cardiovascular disease events in these patients.

METHODS

We did a multinational, randomised controlled trial with 9795 participants aged 50-75 years, with type 2 diabetes mellitus, and not taking statin therapy at study entry. After a placebo and a fenofibrate run-in phase, we randomly assigned patients (2131 with previous cardiovascular disease and 7664 without) with a total-cholesterol concentration of 3.0-6.5 mmol/L and a total-cholesterol/HDL-cholesterol ratio of 4.0 or more or plasma triglyceride of 1.0-5.0 mmol/L to micronised fenofibrate 200 mg daily (n=4895) or matching placebo (n=4900). Our primary outcome was coronary events (coronary heart disease death or non-fatal myocardial infarction); the outcome for prespecified subgroup analyses was total cardiovascular events (the composite of cardiovascular death, myocardial infarction, stroke, and coronary and carotid revascularisation). Analysis was by intention to treat. The study was prospectively registered (number ISRCTN 64783481).

FINDINGS

Vital status was confirmed on all but 22 patients. Averaged over the 5 years' study duration, similar proportions in each group discontinued study medication (10% placebo vs 11% fenofibrate) and more patients allocated placebo (17%) than fenofibrate (8%; p<0.0001) commenced other lipid treatments, predominantly statins. 5.9% (n=288) of patients on placebo and 5.2% (n=256) of those on fenofibrate had a coronary event (relative reduction of 11%; hazard ratio [HR] 0.89, 95% CI 0.75-1.05; p=0.16). This finding corresponds to a significant 24% reduction in non-fatal myocardial infarction (0.76, 0.62-0.94; p=0.010) and a non-significant increase in coronary heart disease mortality (1.19, 0.90-1.57; p=0.22). Total cardiovascular disease events were significantly reduced from 13.9% to 12.5% (0.89, 0.80-0.99; p=0.035). This finding included a 21% reduction in coronary revascularisation (0.79, 0.68-0.93; p=0.003). Total mortality was 6.6% in the placebo group and 7.3% in the fenofibrate group (p=0.18). Fenofibrate was associated with less albuminuria progression (p=0.002), and less retinopathy needing laser treatment (5.2%vs 3.6%, p=0.0003). There was a slight increase in pancreatitis (0.5%vs 0.8%, p=0.031) and pulmonary embolism (0.7%vs 1.1%, p=0.022), but no other significant adverse effects.

INTERPRETATION

Fenofibrate did not significantly reduce the risk of the primary outcome of coronary events. It did reduce total cardiovascular events, mainly due to fewer non-fatal myocardial infarctions and revascularisations. The higher rate of starting statin therapy in patients allocated placebo might have masked a moderately larger treatment benefit.

Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial

AIMS/HYPOTHESIS

The relationship between cognitive function, cardiovascular disease and premature death is not well established in patients with type 2 diabetes. We assessed the effects of cognitive function in 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Furthermore, we tested whether level of cognitive function altered the beneficial effects of the BP-lowering and glycaemic-control regimens in the trial.

METHODS

Cognitive function was assessed using the Mini Mental State Examination at baseline, and defined by scores 28-30 ('normal', n = 8,689), 24-27 ('mild dysfunction', n = 2,231) and <24 ('severe dysfunction', n = 212). Risks of major cardiovascular events, death and hypoglycaemia and interactions with treatment were assessed using Cox proportional hazards analysis.

RESULTS

Relative to normal function, both mild and severe cognitive dysfunction significantly increased the multiple-adjusted risks of major cardiovascular events (HR 1.27, 95% CI 1.11-1.46 and 1.42, 95% CI 1.01-1.99; both p < 0.05), cardiovascular death (1.41, 95% CI 1.16-1.71 and 1.56, 95% CI 0.99-2.46; both p <or= 0.05) and all-cause death (1.33, 95% CI 1.16-1.54 and 1.50, 95% CI 1.06-2.12; both p < 0.03). Severe, but not mild, cognitive dysfunction increased the risk of severe hypoglycaemia (HR 2.10, 95% CI 1.14-3.87; p = 0.018). There was no evidence of heterogeneity of treatment effects on cardiovascular outcomes in subgroups defined by cognitive function at baseline.

CONCLUSIONS/INTERPRETATION

Cognitive dysfunction is an independent predictor of clinical outcomes in patients with type 2 diabetes, but does not modify the effects of BP lowering or glucose control on the risks of major cardiovascular events.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00145925.

Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non-liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti-HBc+) donors. Organs from anti-HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non-liver recipients but is not recommended in immune non-liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost-effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.

Probiotics for treatment of Clostridium difficile-associated colitis in adults

BACKGROUND

Probiotics are live microorganisms consisting of non-pathogenic yeast and bacteria that are believed to restore the microbial balance of the gastrointestinal tract altered by infection with Clostridium difficile (C. difficile).

OBJECTIVES

To assess the efficacy of probiotics in the treatment of antibiotic associated C. difficile colitis.

SEARCH STRATEGY

The databases MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and Cochrane IBD/FBD Specialized Trials register were searched to locate all published reports from 1966 to 2007.

SELECTION CRITERIA

Randomized, prospective studies using probiotics alone or in conjunction with conventional antibiotics for the treatment of documented C. difficile colitis were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data extraction and analysis was done independently by two authors.

MAIN RESULTS

Four studies met the inclusion criteria and were included in the review. The four studies examined the use of probiotics in conjunction with conventional antibiotics (vancomycin or metronidazole) for the treatment of recurrence or an initial episode of C. difficile colitis in adults. The studies were small in size and had methodological problems. A statistically significant benefit for probiotics combined with antibiotics was found in one study. McFarland 1994 found that patients receiving S. boulardii were significantly less likely than patients receiving placebo to experience recurrence of C. difficile diarrhea (RR 0.59; 95% CI 0.35 to 0.98). No benefit of probiotics treatment was found in the other studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend probiotic therapy as an adjunct to antibiotic therapy for C. difficile colitis. There is no evidence to support the use of probiotics alone in the treatment of C. difficile colitis.

Convection and fate of mitochondria in nerve fibers: axonal flow as vehicle

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Effects of combined exposure to lead and cadmium on the hypothalamic-pituitary axis function in proestrous rats

The effects of lead and cadmium on the hypothalamic-pituitary axis were studied in proestrous rats. Adult female rats were treated intraperitonially with either lead acetate and cadmium acetate alone or in combination at a dose of 0.05 mg/kg daily for 15 days. Serotonin (5-HT) and norepinephrine (NE) levels decreased in individually and combined metal treated groups whereas dopamine (DA) levels were decreased only in the cadmium-exposed group. The pituitary levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH) were decreased significantly in cadmium and combined treatment groups. In contrast, lead exposure failed to cause any change in serum LH and FSH levels, whereas cadmium and combined treatments showed significant decrease in serum LH and FSH levels as compared with control. The accumulation of both metals increased in the hypothalamus and pituitary after treatment. These data suggest that the metal accumulation disrupts the regulatory mechanisms of the hypothalamic-pituitary axis where the effects produced by the combined treatment of metals are not additive.

Surgical resection strategy and the influence of radicality on outcomes in oesophageal cancer

BACKGROUND

The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic (TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO.

METHODS

This was a cohort study based on two prospectively created databases. Short- and long-term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion.

RESULTS

Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In-hospital mortality (1·1 versus 3·2 per cent for THO and TTO respectively; P = 0·110) and in-hospital stay (14 versus 17 days respectively; P < 0·001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1·07, 95 per cent c.i. 0·84 to 1·36) or time to tumour recurrence (HR 0·99, 0·76 to 1·29) between the two operations. Local tumour recurrence patterns were similar (22·8 versus 24·4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage.

CONCLUSION

There was no difference in survival or tumour recurrence for TTO and THO.

The incidence of Perthes' disease in Southwest Scotland

We have investigated the annual incidence of Perthes' disease in Dumfries and Galloway (Southwest Scotland), in relation to the population density and socio-economic status. The incidence of Perthes' disease in rural Scotland is comparable with that in urban areas (15.4 per 100,000). There was a direct association between the incidence of Perthes' disease and deprivation scores, with the highest incidence in the most deprived areas. A higher incidence of Perthes' disease was noted in areas with a lower population density compared with those with a higher density. We found no correlation between population density and deprivation scores for individual electoral wards within the region.

The efficacy of lowering glycated haemoglobin with a gliclazide modified release-based intensive glucose lowering regimen in the ADVANCE trial

The aim of these analyses was to examine the efficacy of the intensive gliclazide MR-based glucose lowering regimen used in the ADVANCE trial in lowering the level of glycated haemoglobin (HbA1c). All 11,140 randomised patients were included in analyses of treatment efficacy. Treatment efficacy was also examined in subgroups defined by baseline characteristics and treatments. At the end of 5 years follow-up, the mean HbA1c was reduced from 7.5% at baseline to 6.5% in those on intensive glucose control and to 7.3% in those on standard glucose control. With intensive glucose lowering greater proportions achieved HbA1c levels of < or =7.0%, < or =6.5% and < or =6.0%. With intensive glucose lowering substantial reductions in HbA1c were observed across subgroups defined by baseline age, sex, duration of diabetes, BMI, HbA1c or treatment regimen (p<0.0001). The main independent predictors of reduction in HbA1c during follow-up were baseline HbA1c, duration of diabetes and BMI. There was no weight gain in the intensive glucose control group and severe hypoglycaemia was uncommon, though more frequent than in the standard control group. Intensive glucose control with a gliclazide MR-based regimen was well tolerated and consistently effective in lowering HbA1c across a broad range of patient with type 2 diabetes.

Hypothenar Hammer Syndrome: Rare or Underdiagnosed?

Hypothenar hammer Syndrome (HHS) is a condition characterised by digital ischaemia as a result of repetitive trauma to the hypothenar eminence of the hand. It occurs in people who repeatedly use the palm of the hand as a hammer to push, grind or twist objects. It is a curable and a preventable cause of upper digital ischemia. In this report we present a case of HHS and discuss the causes and pathogenesis of this syndrome. We review the incidence, clinical characteristics, differential diagnosis, investigation and treatment.

Interleukin 3 is a growth factor for human follicular B cell lymphoma

More than one-half of adults with non-Hodgkin's B cell lymphomas present with low-grade follicular lymphomas. These tumor cells are found in close association with follicular T lymphocytes and dendritic cells, suggesting that the surrounding cells may play a role in the support of follicular tumors. Supernatants from activated human peripheral blood lymphocytes were found to promote the in vitro proliferation of follicular tumor cells. This effect was entirely due to interleukin 3 (IL-3), a factor generally thought to cause the growth and differentiation of immature hematopoietic cells. IL-3 receptors were detected on fresh isolates of all primary follicular cell tumors examined. These findings suggest that follicular cell tumors may be dependent in vivo on IL-3 and that therapies directed against IL-3, its receptor, or the T cells that produce it may be effective treatment for follicular lymphoma.

Repeated, intermittent exposures to diisopropylfluorophosphate in rats: protracted effects on cholinergic markers, nerve growth factor-related proteins, and cognitive function

Organophosphates (OPs) pose a constant threat to human health due to their widespread use as pesticides and their potential employment in military and terrorist attacks. The acute toxicity of OPs has been extensively studied; however, the consequences of prolonged or repeated exposure to levels of OPs that produce no overt signs of acute toxicity (i.e. subthreshold levels) are poorly understood. Further, there is clinical evidence that such repeated exposures to OPs lead to prolonged deficits in cognition, although the mechanism for this effect is unknown. In this study, the behavioral and neurochemical effects of repeated, intermittent, and subthreshold exposures to the alkyl OP, diisopropylfluorophosphate (DFP) were investigated. Rats were injected with DFP s.c. (dose range, 0.25-1.0 mg/kg) every other day over the course of 30 days, and then given a 2 week, DFP-free washout period. In behavioral experiments conducted at various times during the washout period, dose dependent decrements in a water maze hidden platform task and a spontaneous novel object recognition (NOR) procedure were observed, while prepulse inhibition of the acoustic startle response was unaffected. There were modest decreases in open field locomotor activity and grip strength (particularly during the DFP exposure period); however, rotarod performance and water maze swim speeds were not affected. After washout, DFP concentrations were minimal in plasma and brain, however, cholinesterase inhibition was still detectable in the brain. Moreover, the 1.0 mg/kg dose of DFP was associated with (brain region-dependent) alterations in nerve growth factor-related proteins and cholinergic markers. The results of this prospective animal study thus provide evidence to support two novel hypotheses: (1) that intermittent, subthreshold exposures to alkyl OPs can lead to protracted deficits in specific domains of cognition and (2) that such cognitive deficits may be related to persistent functional changes in brain neurotrophin and cholinergic pathways.

Comparison of carotid Doppler ultrasound and computerised tomographic angiography in the evaluation of carotid artery stenosis

PURPOSE

To compare results of carotid Doppler ultrasound (CDUS) and spiral computerised tomographic angiography (CTA) in patients with suspected carotid artery stenosis and to evaluate their combined effect on decision making for carotid endarterectomy (CEA).

METHODS

A total of 107 patients were studied. All of the patients had CDUS followed by CTA as a standard method of investigation. Data included the indications for investigation, stenosis degree measured in both modalities, in addition to difficulties and limitations faced while doing them.

RESULTS

Out of the 214 carotid scans performed, 187 scans were included in the comparison, while 27 scans were excluded due to inadequate data or imaging difficulties. The overall concordance between both CDUS and CTA was 79.1% (148/187) (95% CI 0.72-0.83). CDUS under-estimated and over-estimated the degree of stenosis in 26/187 (14%, 95% CI 0.09-0.19) and 13/187 (7%, 95% CI 0.04-0.12), respectively. When CTA was considered in conjunction with CDUS, the decision regarding operative treatment was changed in 29/187 cases (16%) (95% CI 0.11-0.21).

CONCLUSIONS

CDUS remains the first line non-invasive imaging for carotid artery stenosis. However, in cases where it is inconclusive, CTA is an excellent, reliable, minimally invasive, and outpatient alternative for patient selection for CEA.

Apnoeic oxygenation in pregnancy: a modelling investigation

Recent studies have shown that nasal oxygen delivery can prolong the time to desaturation during apnoea in the non-pregnant population. We investigated the benefits of apnoeic oxygenation during rapid sequence induction in the obstetric population using computational modelling. We used the Nottingham Physiology Simulator, and pre-oxygenated seven models of pregnancy for 3 min using Fi O2 1.0, before inducing apnoea. We found that increasing Fi O2 at the open glottis increased the time to desaturation, extending the time taken for Sa O2 to reach 40% from 4.5 min to 58 min in the average parturient model (not in labour). Our study suggests that a small increase in time to desaturation could be achieved at Fi O2 0.4-0.6, which could be delivered by standard nasal cannulae. The greatest increases in time to desaturation were seen at Fi O2 1.0, which could be delivered by high-flow nasal cannulae under ideal conditions.

Negative effects of chronic oral chlorpromazine and olanzapine treatment on the performance of tasks designed to assess spatial learning and working memory in rats

Learning potential and memory capacity are factors that strongly predict the level of rehabilitation and the long-term functional outcome in patients with schizophrenia. Unfortunately, however, the effects of antipsychotic drugs (i.e. the primary treatments for schizophrenia) on these components of cognition are unclear, particularly when they are administered chronically (i.e. a standard clinical practice). In this rodent study we evaluated the effects of different time periods (ranging from 2 weeks to 6 months) of oral treatment with the first generation antipsychotic chlorpromazine (10.0 mg/kg/day), or the second generation antipsychotic olanzapine (10.0 mg/kg/day) on the repeated acquisition of a water maze task (i.e. a method of assessing spatial learning potential in a repeated testing format). We assessed locomotor function (in an open field) and employed a radial arm maze (RAM) task to assess antipsychotic effects (5.0 and 10.0 mg/kg/day doses) on spatial working memory during the treatment period between 15 days and 2 months. Finally, we conducted experiments using liquid chromatography/tandem mass spectrometry (LC-MS/MS) to evaluate the therapeutic relevance of our method of drug delivery (oral administration in drinking water). In the water maze experiments, both antipsychotics were associated with impairments in acquisition in the earlier test sessions that could eventually be overcome with repeated testing while olanzapine also impaired retention in probe trials. Both antipsychotics were also associated with impairments in delayed non-match-to-position trials in the RAM and some impairments of motor function (especially in the case of olanzapine) as indicated by slightly reduced swim speeds in the water maze and decreased activity in some components of the open field assessment. Finally, LC-MS/MS studies indicated that the method of antipsychotic administration generated clinically relevant plasma levels in the rat. These animal data indicate that chronic oral treatment with chlorpromazine or olanzapine can impair the performance of tasks designed to assess specific components of cognition that are affected in schizophrenia.

A case of Haemophilus parainfluenzae pneumonia

A 41 year old woman presented with community acquired pneumonia (CAP) which failed to resolve following treatment with amoxycillin and cefaclor prior to referral. Quantitative culture of sputum revealed a pure growth of Haemophilus parainfluenzae and, following antibiotic susceptibility testing of the isolate, ciprofloxacin was prescribed resulting in resolution of the infection. Immunological investigations showed that the patient had a high titre of H parainfluenzae specific IgM. The combination of a pure growth of H parainfluenzae, a response to appropriate antimicrobial therapy, and the presence of a specific antibody response indicated that this organism had a pathogenic role in the patient's pneumonia and should be considered in the differential diagnosis of CAP.

Sudomotor function assessment as a screening tool for microvascular complications in type 2 diabetes

Sudoscan, a non invasive, quick, and simple method to measure sweat function, was evaluated as a screening tool for microvascular complications in type 2 diabetes. AUC of the ROC curve for detection of microvascular complication was 0.75 for an autonomic risk score, with a sensitivity of 82% and a specificity of 61%.

Psychogenic elaboration of simple partial seizures

Seizures that cause loss of consciousness (LOC) can be classified as epileptic or nonepileptic based on evaluation of ictal semiology and analysis of changes in EEG events, recorded with continuous scalp EEG and video monitoring. We report 3 patients who had hippocampal electrographic seizures documented with intracranial EEG recording with no accompanying scalp EEG change immediately preceding psychogenic unresponsiveness. Each patient also had complex partial seizures (CPS) originating in the hippocampus. Some individuals can have complex interactions of epileptic and nonepileptic seizures.

HLA linked resistance factors and survival in acute myelogenous leukemia

The concept that HLA-linked immune response genes may influence survival of patients with malignant disease has been investigated by performing HLA typing on a series of 150 patients with acute myelogenous leukemia. Patients with A1 and B8 and/or A2 and B12 survival longer than patients without either of these pairs of antigens in association. However, after correction of the statistical probability for the number of A and B locus combinations theoretically possible, these differences are not statistically significant. Clarification of this must await independent analysis of other series and more direct approaches to the study of immune response genes in man.

Percutaneous real-time ultrasound-guided renal biopsy performed solely by nephrologists: A case series

Renal biopsy is an integral part of the nephrologists' diagnostic armamentarium. Usually it is performed by radiologists or nephrologists with radiologist's assistance. Our aim was to assess the efficacy and safety of percutaneous ultrasound-guided renal biopsy performed solely by nephrologists. We performed real-time ultrasound-guided renal biopsy on 37 patients (N group). The results were then compared with those of a similar number of biopsies done with radiologist's support (NR group) immediately prior to these. In the N group, 36 biopsies (97.3%) were successful and were histopathologically adequate, whereas in the NR group, all biopsies were successful but only 28 were adequate (75.68%). Eighteen patients required only a single attempt in the N group, whereas majority (34 patients) in the NR group required two or more attempts. The average attempt per bit of renal tissue was 1.22 in both the groups. The average number of passes per patient was 1.77 in the N group and 2.32 in the NR group. The mean size of renal tissue obtained was 1.41 ± 0.47 cm in the N group and 1.19 ± 0.42 cm in the NR group. The average number of glomeruli was 15.62 ± 5.26 and 13.7 ± 7.38 in the N and NR groups, respectively (P<0.05). In the N group, there were no complications except two cases of post procedural hematuria that was managed conservatively. There was no need for blood transfusion and both of them were discharged after 48 hours. No patient had peri-renal collection or hematoma on repeat ultrasonography of the abdomen at 24 hours. However, in the NR group, five patients developed complications and one patient required laparotomy. Our study shows that percutaneous ultrasound-guided renal biopsy can be safely and successfully performed entirely by nephrologists without outside assistance. In our series, nephrologists who performed solely took fewer attempts, had better yield and fewer complications when compared to biopsies performed with radiologist's assistance. More and more nephrologists should take up this simple yet vital procedure.

Clindamycin in the treatment of group G beta-haemolytic streptococcal infections

We report a case of severe streptococcal cellulitis in a healthy 47 year old male, where the sole microbial isolate was a beta-haemolytic group G Streptococcus. Treatment failure with high dose penicillin was observed despite in vitro sensitivity. The addition of clindamycin resulted in dramatic clinical improvement. This may indicate an Eagle-type effect (whereby antibiotics exhibit paradoxically reduced bactericidal activities at high drug concentrations), in group G beta-haemolytic infections. Although well documented with group A streptococcal infections, this phenomenon has not been fully recognised with group G beta-haemolytic streptococcal infections. This may have important implications for clinical management.

Responders to insulin therapy at 18 months in adults with newly diagnosed diabetes: which insulin regimen?

OBJECTIVES

To describe baseline characteristics of responders to insulin therapy (HbA(1c) targets < 58 mmol/mol, 7.5%) at 18 months among adults with newly diagnosed diabetes.

METHODS

A retrospective UK study derived from 479 general practices electronic dataset. We included all adults (age > 18 years) with newly diagnosed diabetes who required insulin therapy within 6 months of diagnosis. The data comprised insulin regimen (long-acting only; premixed insulin only; basal bolus insulin regimen), gender, Townsend quintile, baseline and an 18-month measurement of clinical and biochemical variables. Multiple imputations were undertaken and logistic regression used to assess the effect of covariates.

RESULTS

A total of 1492 patients (aged 19-93 years) were analysed. Means (SD) baseline HbA(1c) and BMI were 10.3% (2.6%) and 29.6 (7.0%), respectively. Following multiple imputation for missing data, logistic regression analysis indicated important covariates to achieve HbA(1c) targets were baseline HbA(1c), lipid lowering therapy, gender and age. Including all covariates, those treated with premixed insulin were 47% more likely to achieve target HbA(1c) at 18 months than those treated with a basal-bolus regimes (adjusted OR 1.47; 95% CI 1.12-1.92, P = 0.006)) and 32% more likely than those treated with long-acting insulin was (adjusted OR 1.32; 95% CI 1.01-1.74, P = 0.044). Those with a higher baseline HbA(1c) level, on lipid-lowering therapy, women and younger patients had a lower response rate. Mean weight gain (SD) was 2.4 kg (8.5 kg) and was not influenced by treatment regimen.

CONCLUSION

The use of premixed insulin regimen among newly diagnosed patients with diabetes appears to be most effective in reaching HbA(1c) target values, independent of other confounders. The appropriate choice of insulin regimen at initiation should therefore take into account various metabolic and psychosocial factors.