Functional Outcomes 18 Months After Total and Midarm Transplantation: A Case Report

BACKGROUND

The function reported after arm transplantation is deemed beneficial relative to the marked disability that upper arm amputation causes.

OBJECTIVE

We report a 51-year-old man with a Disabilities of the Arm, Shoulder and Hand (DASH) score of 75.83 who underwent bilateral arm transplantation in October 2015.

PROCEDURE

The right arm was transplanted at the glenohumeral joint level, including transplantation of the humeral head, joint capsule, and rotator cuff ligaments and tendons. Additionally, neurorrhaphies were performed at the origin of the terminal branches of the brachial plexus, including the axillary and musculocutaneous nerves. Therefore, this was considered a total arm transplantation. The left arm was transplanted at the transhumeral level, with complete transplantation of the biceps and triceps brachii, and terminolateral neurorrhaphy of the donor musculocutaneous nerve to the receptor radial nerve. A maintenance triple immunosuppression scheme was administered, with tacrolimus levels kept at 10 ng/mL.

RESULTS

At 18 months post-transplantation, the intrinsic musculature in the left hand showed electrical registry, DASH score was 67.5, Carroll test score was 28 in both extremities, Hand Transplant Score System was 67.5 in the right extremity and 77.5 in the left extremity, and Short Form-36 score was 96.1. The patient was healthy, with restored body integrity. He could lift medium-sized weightless objects, eat and go to the bathroom by himself, drink liquids with bimanual grasp, swim, dress almost independently, and drive.

CONCLUSION

The functional evolution of the patient was similar to previously reported transplanted arms, even though the right arm transplant involved the glenohumeral joint and axillary and musculocutaneous nerve repair.

Infundibulo-hypophysitis-like radiological image in a patient with pituitary infiltration of a diffuse large B-cell non-Hodgkin lymphoma

Non-Hodgkin lymphoma (NHL) is a hematological tumor caused by abnormal lymphoid proliferation. NHL can arise in any part of the body, including central nervous system (CNS). However, pituitary involvement is a quite rare presentation. The diffuse large B-cell lymphoma (DLBCL) is the most common subtype when pituitary is infiltrated. Here, we report a case of pituitary infiltration of NHL DLBCL type in a woman with hypopituitarism and an infundibulum-hypophysitis-like image on magnetic resonance imaging (MRI). A female aged 64 years, complained of dyspepsia, fatigue, weight loss and urine volume increment with thirst. Endoscopy and gastric biopsy confirmed diffuse large B-cell lymphoma. Treatment with chemotherapy using R-CHOP was initiated. During her hospitalization, hypotension and polyuria were confirmed. Hormonal evaluation was compatible with central diabetes insipidus and hypopituitarism. Simple T1 sequence of MRI showed thickening of the infundibular stalk with homogeneous enhancement. After lumbar puncture analysis, CNS infiltration was confirmed showing positive atypical lymphocytes. Pituitary and infundibular stalk size normalized after R-CHOP chemotherapy treatment. In conclusion, pituitary infiltration of NHL with infundibular-hypophysitis-like image on MRI is a rare finding. Clinical picture included hypopituitarism and central diabetes insipidus. Diagnosis should be suspected after biochemical analysis and MRI results. Treatment consists of chemotherapy against NHL and hormonal replacement for pituitary dysfunction.

LEARNING POINTS

Pituitary infiltration by lymphoma can present with signs and symptoms of panhypopituitarism and diabetes insipidus.MRI findings can resemble an autoimmune hypophysitis.Patients can recover pituitary function as well as normalization of MRI after chemotherapy treatment.

An ectopic adrenocorticotropic hormone syndrome caused by a sacrococcygeal chordoma: report of a case with a slow progression

OBJECTIVE

To report the first case of an ectopic adrenocorticotropic hormone (ACTH) syndrome caused by a sacrococcygeal chordoma.

METHODS

We present a case report with clinical, laboratory, and histologic details.

RESULTS

A 76-year-old man was admitted to the hospital because of urinary obstruction. Five years previously, a urethral mass had been detected, and transurethral prostatectomy had been performed. Annual computed tomographic (CT) scans showed no change in size of the mass. In 1995, skin hyperpigmentation, central obesity, and bilateral edema were noted. The patient was admitted to the hospital in July 1996. A CT scan of the abdomen revealed a large mass close to the sacrum and compressing the bladder and rectum. Cortisol measurements (AM and PM) were 309 and 271 ng/mL, respectively. The plasma ACTH concentration was extremely elevated (3,125 pg/mL). Although resection of the mass was attempted, complete resection was not possible because the tumor had infiltrated the sacrum. Plasma cortisol concentrations in samples obtained 7 and 8 days postoperatively were normal. Plasma ACTH was substantially decreased (180 pg/mL) but remained above normal. The histologic features of the tumor were compatible with a chordoma. Neoplastic cells stained positively for ACTH.

CONCLUSION

This report describes the first case of an ectopic ACTH syndrome caused by a sacrococcygeal chordoma. A slow progression of symptoms in an ectopic ACTH syndrome had been described only for carcinoid tumors. These data add a new entry to the list of neoplasms capable of causing this syndrome.

The body mass index is a less-sensitive tool for detecting cases with obesity-associated co-morbidities in short stature subjects

OBJECTIVE

To assess the ability of the body mass index (BMI) to detect obesity-associated morbidity in subjects with a normal or short stature.

METHODS

Information was obtained on 119 975 subjects from a cardiovascular risk factors detection program. Standardized questionnaires were used. Capillary glucose and cholesterol concentrations were measured. Diabetes, arterial hypertension and hypercholesterolemia were selected as end points. Sensitivity, specificity and the likelihood ratio for several BMI thresholds were calculated. ROC curves were constructed to identify the BMI cutoff points with best diagnostic performance. The area under the curve (AUC) was used to assess the proficiency of BMI.

RESULTS

Short stature (height </=150 cm for women or </=160 cm for men) was found in 24 854 subjects (20.7%). These cases had a higher prevalence of type II diabetes and arterial hypertension even after adjusting for confounding variables. In addition, the frequency of the abnormalities was higher even at the lowest BMI values; the prevalence increased in direct proportion with the BMI, but at a lower rate compared to cases with normal stature. The AUC for every co-morbidity was smaller in short stature subjects. The likelihood ratio for detecting co-morbidities increased at the same BMI value in subjects with or without short stature.

CONCLUSIONS

The prevalence of obesity-associated co-morbidities is higher in subjects with short stature compared to those without it. The proficiency of BMI as a diagnostic tool is poor in short stature subjects. This problem is not resolved by decreasing BMI thresholds used to define overweight.

Contribution of Chromosome 1q21-q23 to Familial Combined Hyperlipidemia in Mexican Families

Familial combined hyperlipidemia (FCHL) is the most common familial dyslipidemia, with a prevalence of 1-2% in the general population. A major locus for FCHL has been mapped to chromosome 1q21-q23 in Finnish, Chinese, German and US families. We studied seven extended Mexican families with 153 members, including 64 affected subjects. A total of 11 markers were genotyped, including D1S104 which has been linked to FCHL in other studies. Two point linkage analysis for the FCHL phenotype, and for the elevated triglyceride (TG) trait, allowing for heterogeneity, gave a maximum HLOD of 1.67 (alpha = 0.49) and 1.93 (alpha = 0.43) at D1S2768 (2.69 cM proximal to D1S104) respectively. Heterogeneity and non-parametric (NPL) multipoint analyses for the FCHL phenotype and the TG trait showed maximum HLODs of 1.27 (alpha = 0.46) and 1.64 (alpha = 0.38), and NPLs of 4.00 (P = 0.0001) and 3.68 (P = 0.0003) near D1S2768, respectively. In addition, analysis of four candidate genes putatively involved in the expression of FCHL showed no evidence of linkage for the LCAT gene or the APOA1/C3/A4/A5 gene cluster. However, we cannot exclude the participation of these genes, or the LIPC and LPL genes, as minor susceptibility loci in the expression of FCHL, or the TG or elevated total cholesterol (TC) traits in our families. In conclusion, our data confirm the involvement of a major susceptibility locus on chromosome 1q21-q23 in FCHL Mexican families, consistent with findings in other populations.

The combination metformin/glyburide exerts its hypoglycemic effect mainly by increasing insulin secretion: a controlled, randomized, double-blind, crossover study

The aim of the present study was to describe the mechanism by which the combination glyburide/metformin exerts its additive hypoglycemic effects. This is a double-blind, randomized and crossover clinical trial. Patients (n = 20) were included in a run-in period of 8 weeks in which an isocaloric diet was prescribed. If they did not achieve the treatment goals (n = 15), they received glyburide, metformin or combined treatment for 10 weeks each using three possible sequences. The dosage was adjusted to reach fasting plasma glucose (FPG) < 7.7 mmol/l. Treatment periods were separated by a 6-12 week washout period. At the beginning and the end of every treatment, insulin sensitivity and insulin secretion were measured by means of a minimal model and an oral glucose tolerance test. All treatment periods were completed by 12 cases. The glycemic goal was reached in 1 case during metformin, in 5 during glyburide and in 10 during the combination. The greatest reduction in HbA1c was achieved during the combination (HbA1c 11 +/- 1.6 vs 9.8 +/- 1.9 vs 9.0 +/- 2.1% for metformin, glyburide and the combination, p < 0.001). Increased insulin secretion was the explanation for the additive effects of the combination (percentual change in acute insulin response during the minimal model = 5.8 vs 51.5 vs 88.2% for metformin, glyburide and the combination, p < 0.05). No change in insulin sensitivity resulted from the treatments. In conclusion, the additive hypoglycemic effects of the combination glyburide/metformin was caused by increased insulin secretion.

Effects of omapatrilat on blood pressure and insulin sensitivity in an animal model of insulin resistance

OBJECTIVE

To assess the effects of omapatrilat, fosinopril and placebo on blood pressure, plasma insulin, glucose and triglycerides concentrations in Zucker rats, a model for insulin resistance.

DESIGN

Double blind, parallel, prospective trial.

METHODS

Forty-two male obese Zucker (falfa) rats (aged 13-18 week) initially weighing 400-600 g were used for the experiments. Omapatrilat (n = 14), placebo (n = 14) or fosinopril (n = 14) were administrated once daily at 10 micromol/kg oral for 15 days. At baseline and at the end of the study, a tail-cuff blood pressure measurement was performed; an oral glucose tolerance test was done at the end of the study.

RESULTS

Omapatrilat and fosinopril resulted in significant lower systolic blood pressure compared to the placebo group (p < 0.001). This parameter was significantly lower in the omapatrilat group compared with fosinopril-treated rats (116+/-9 vs 125+/-4 mmHg, p < 0.05). After an overnight fast, there was no difference in the fasting glucose concentrations among treatment groups. The basal and post-glucose challenge insulin concentrations were lower in the omapatrilat group compared to the placebo group. No difference was observed in the fasting triglycerides concentrations between the treatment groups.

CONCLUSIONS

Compared to placebo and fosinopril treatment, omapatrilat results in lower arterial blood pressure in an animal model of insulin resistance. The results suggest that omapatrilat may have a positive effect on insulin sensitivity.

Comparing easy and accessible parameters of glycemic control in type 2 diabetes

BACKGROUND

HbA1c is considered the gold standard of long-term glycemic control and is recommended as a routine test for every diabetic patient. However, its common use in clinical practice has some problems related to lack of standardization and its relative cost. Recent studies have suggested, that postprandial blood glucose could be better than a fasting sample, as a marker of diabetes control. The objective of the present study was to evaluate the relative value of plasma glucose samples at different times of the day, and easy and accessible programs for home blood and urinary glucose measurements compared with HbA1c in assessing the mean glycemic control of type 2 diabetic patients.

METHODS

Sixty type 2 diabetic patients were instructed to do home blood and urine glucose monitoring for two months, at the end, plasma glucose profiles were obtained.

RESULTS

The mean of all the capillary BG measurements had the best correlation with the HbA1c (r = 0.84, p < 0.001), followed by the mean of the capillary BG measurements before breakfast and supper (r = 0.82, p < 0.001), and the 2 hr. postbreakfast plasma glucose (r = 0.79 p < 0.001). The fasting PG had a low correlation (r = 0.65, p < 0.001), but a good sensitivity to predict a fair or a poor metabolic control. Diabetes duration and type of treatment explained 17% and 28% of variance in HbA1c levels.

CONCLUSIONS

A bimonthly fasting PG correlated well with the glycosylated hemoglobin and is the easiest and cheapest way of monitoring glycemic control in type 2 diabetic patients with some preserved insulin reserve (diabetes for less than 10 years and on treatment with only one hypoglycemic agent). A sample of capillary BG, fasting, once per week correlates better with the HbA1c than a fasting PG every 2-3 months. The 2 hr and 5 hr postbreakfast PG have a good correlation with the HbA1c, but are not a substitute for doing BG monitoring. Glycosuria may be a useful parameter to rule out a fair or poor metabolic control in some patients.

Efficacy and safety of atorvastatin in hyperlipidemic, type 2 diabetic patients. A 34-week, multicenter, open-label study

Hyperlipidemia is common in type 2 diabetic patients and is an independent risk factor for cardiovascular disease. The aim of this trial was to evaluate the efficacy and safety of once-daily atorvastatin 10-80 mg for the treatment of hyperlipidemia in type 2 diabetics with plasma low-density lipoprotein cholesterol (LDL-C) levels exceeding 3.4 mmol/l (130 mg/dl). One hundred and two patients met the study criteria and received 10 mg/day atorvastatin. Patients who reached the target LDL-C level of </=2.6 mmol/l (100 mg/dl) maintained the same dosage regimen until they had completed 16 weeks of treatment. Patients not reaching the target LDL-C underwent dose titration to atorvastatin 20, 40 and 80 mg/day at Weeks 4, 8 and 12, respectively. All 88 patients who completed the study attained target LDL-C levels and 52 (59%) of patients achieved the target goal at the starting dose of atorvastatin 10 mg/day. In this group the differences between baseline and post-treatment values for LDL-C were 4.3+/-0.7 mmol/l (166+/-26 mg/dl) versus 2. 2+/-0.4 mmol/l (87+/-14 mg/dl) (P<0.0001), respectively, a decrease of 47%. Similar trends were observed for total cholesterol, triglycerides, very low-density lipoprotein cholesterol and apolipoprotein B levels. The safety profile of atorvastatin in these patients was highly favorable and similar to those reported with other statins. Only one patient withdrew due to a possible drug-related adverse event. These data confirm the marked efficacy and safety of atorvastatin in type 2 diabetic patients with hyperlipidemia and the efficacy of atorvastatin 10 mg in helping patients attain their LDL-C goal.

Leukocyturia in women with diabetes and its clinical implications

BACKGROUND

Urinalysis is one of the most common studies performed on the diabetic patient at every visit. The presence of leukocyturia is relatively common but it is not clear what the attitude of the physician toward this particular finding should be. The main objective of the present study was to investigate the clinical significance of leukocyturia in diabetic women.

METHODS

Ninety-eight diabetic women (84.7% type 2) aged 57 +/- 13 years who were being seen at the diabetic out-patient clinic were randomly selected. All patients underwent a clinical and gynecologic examination and a urinalysis. A Papanicolaou smear and a urine culture were also obtained.

RESULTS

The overall prevalence of leukocyturia (>5 cells/high power field (hpf)) was 46.5%. Patients with urinary tract infections (UTI) were 7.5 times more likely to have leukocyturia, while a leukocyte count <5cells/hpf predicted the absence of UTI in 96% of the women. In the comparison of patients with and without leukocyturia, we found that proteinuria (p = 0.06) and bacteriuria (p <0.002) were more common in the women with leukocyturia. A significant association with leukorrhea was not demonstrated. The empirical use of antibiotics was 12 times more frequent in the patients with leukocyturia.

CONCLUSIONS

A urinary culture should be requested in all diabetic patients with leukocyturia. The possibility of a UTI is remote when leukocyturia is absent.

Hypopituitarism in Two Brothers Born by Breech Delivery

OBJECTIVE

To describe two brothers with hypopituitarism who had been born by breech delivery and to discuss whether this condition corresponds to a familial form or to a pituitary stalk section as a result of the breech delivery.

METHODS

We present the clinical, biochemical, and magnetic resonance imaging (MRI) characteristics of two Mexican brothers, 19 and 21 years old, with hypopituitarism and a history of breech delivery.

RESULTS

Physical examination of both patients showed short stature with normal body proportions, an obviously younger appearance than that expected for their chronologic age, high-pitched voice, irregularly positioned teeth, no axillary or pubic hair, and prepubertal genitalia. Biochemical testing showed low thyroxine and free thyroxine values with inadequate or normal thyrotropin, low basal testosterone, and mildly increased serum prolactin levels. Stimulation tests showed a normal and a delayed thyrotropin response to thyrotropin-releasing hormone, subnormal serum cortisol, considerably blunted growth hormone (GH) response to insulin-induced hypoglycemia, and absence of GH response to GH-releasing hormone in both cases. MRI showed an ectopic neuropituitary gland. In case 1, a caudal portion of a very thin pituitary stalk was observed, suggesting the preservation of a vascular component of the stalk. Because both parents of these brothers shared the major histocompatibility complex haplotype HLA-A*2301, B*3501, DRB1*0407, DQA1*03, DQB1*0201, consanguinity was suggested.

CONCLUSION

The phenotype of these patients differs from that described in families with POU1F1 (Pit-1) and PROP1 mutations. These cases are most likely related to an autosomal recessive gene mutation that warrants further research. To our knowledge, this is the first report of hypopituitarism in two brothers born by breech delivery.

The apolipoprotein E4 allele is not associated with an abnormal lipid profile in a Native American population following its traditional lifestyle

The apolipoprotein E4 allele is associated in industrialized countries with an elevated LDL cholesterol concentration and an increased cardiovascular risk. Our purpose in this study was to assess the influence of the genetic variation at the APOE gene locus on the lipid profile of a Native American rural population. We examined plasma lipid levels and the common apo E alleles in 142 healthy randomly selected adults living in their native communities in western Mexico. Their age was 38+/-17 years and the BMI 25.7+/-4.5 kg/m2. Plasma cholesterol, triglycerides, LDL C and HDL C were 165+/-29.6, 126+/-83, 98+/-26 and 42+/-12.7 mg/dl respectively. Ninety-one per cent of the subjects had Lp(a) concentrations below 20 mg/dl and 30% had levels lower than 2 mg/dl. The most common APOE genotype was E3/3 (63%), followed by E3/4 (30.1%). The prevalence of the E2 allele was very low (2.3%). No difference was observed in LDL C concentrations between the E3/E3 and E3/E4 subjects; however carriers of the E2/3 genotype had lower LDL C levels. Similar results were obtained for cholesterol and apo B levels. In summary, the increased LDL C levels associated with the E4 allele in previous studies were not observed in a population with non-westernized habits. Environmental factors, such as diet and lifestyle, could outweigh the hypercholesterolemic predisposition resulting from the presence of the apo E4 allele.

Acarbose vs. bedtime NPH insulin in the treatment of secondary failures to sulphonylurea-metformin therapy in type 2 diabetes mellitus

OBJECTIVE

To evaluate the efficacy of acarbose in the treatment of secondary failures to sulphonylurea-metformin therapy, its comparison against bedtime NPH insulin, and to measure the changes in postprandial metabolism resulting from both treatments.

METHODS

One hundred type 2 diabetic patients in a secondary failure were included. The study begun with a run-in diet period of 6 weeks, in which an isocaloric diet was prescribed. Only subjects who continued hyperglycaemic were randomly assigned to placebo and acarbose (n = 17) or bedtime NPH insulin (n = 12). Acarbose (300 mg/day) or placebo were administered using a randomized, double blind, crossover design. Treatment periods of 3 months were separated by a 3-week washout period. Insulin was administered during 3 months. At the beginning and the end of each treatment period, an i.v. glucose tolerance test and a meal test were performed. Safety tests were done every 4 weeks.

RESULTS

Acarbose resulted in a small but significant improvement in fasting plasma glucose (13.5 +/- 2.4 vs. 11.3 +/- 3.9 mmol/l, p = 0.05), HbA1c (11.1 +/- 3.4 vs. 10.3 +/- 2.5%, P = 0.3) and in a decreased plasma glucose during the meal test. Bedtime insulin significantly decreased fasting plasma glucose (13.1 +/- 2.9 vs. 8.2 +/- 2.3 mmol/l, p < 0.01), HbA1c (11.7 +/- 2.9 vs. 9.4 +/- 2.7%, p < 0.01) and plasma cholesterol. No change in insulin secretion resulted from insulin and acarbose treatment.

CONCLUSIONS

Acarbose decreases blood glucose in secondary failure to sulphonylurea-metformin therapy; however, the decrease is not enough to reach the desired metabolic control. Bedtime NPH insulin is, by far, a more effective alternative.

Lack of agreement between the World Health Organization Category of impaired glucose tolerance and the American Diabetes Association category of impaired fasting glucose

OBJECTIVE

To study the concordance between the 1997 American Diabetes Association (ADA) impaired fasting glucose (IFG) category with the World Health Organization (WHO) impaired glucose tolerance (IGT) status in a population with a high prevalence of diabetes.

RESEARCH DESIGN AND METHODS

We analyzed the oral glucose tolerance tests (OGTTs) carried out at the Instituto Nacional de la Nutrición Salvador Zubiran (INNSZ) central laboratory from June to December 1997. We included patients with fasting plasma glucose (FPG) between 60 and 160 mg/dl. The results from the glucose tolerance test were selected as the gold standard.

RESULTS

Among the 1,802 glucose tolerance test results available for analysis, 1,706 fulfilled the requirements to be included. Diabetes and IGT were remarkably more frequently diagnosed when the WHO criteria were applied. The new ADA criteria failed to diagnose 69% of WHO diabetic patients and the vast majority of WHO glucose-intolerant subjects. Using the new criteria, 82% were considered normal. Of the IFG subjects, 39% were classified as diabetic and 23% were normal according to the 2-h postchallenge glucose values. Only 37% of the IFG patients were, in fact, glucose intolerant according to the WHO criteria.

CONCLUSIONS

Our results clearly show that the 1997 ADA criteria are less sensitive for diagnosing diabetes than OGTT-based WHO criteria. Even more important, there is poor agreement between the WHO category of IGT and the ADA category of IFG.

[Laparoscopic adrenalectomy in a mexican institution]

AIM

To analyze the general characteristics and outcome of laparoscopic adrenalectomy in our institution.

METHODS

The clinical and intraoperative characteristics, complications and outcome of 29 consecutive patients undergoing lateral transperitoneal laparoscopic adrenalectomy between February 1995 and January 1998 were analyzed.

RESULTS

Their mean age was 34 +/- 11 years, 6 were males and 23 females. The most common preoperative diagnosis was recurrent Cushing's disease followed by functioning adenomas and pheochromocytomas. There were 17 unilateral and 12 bilateral adrenalectomies. The mean operative time was 2.5 +/- 1 hours for each gland. Two patients were converted to the open technique. There were two complications: a wound infection and a postsurgery hypoglycemia. The hypoglycemic patient also developed massive upper gastrointestinal bleeding 18 days after surgery and died. The mean postoperative hospital stay was 5 days. In a mean follow-up of one year, recurrence of one pheochromocytoma was seen.

CONCLUSION

Laparoscopic adrenalectomy was a safe operation that favored early recovery.

Effect of Major Improvement in Glycemic Control on Results of Cardiovascular Function Tests in Patients with Insulin-Dependent Diabetes Mellitus

OBJECTIVE

To evaluate the effect of major improvement in glycemic control on cardiovascular function tests in patients with insulin-dependent diabetes mellitus (IDDM).

METHODS

Eight men with chronic, poorly controlled IDDM (serum fructosamine >300 mmol/L and mean fasting blood glucose >200 mg/dL), who were 24 +/- 6 years of age and had a mean duration of diabetes of 8 +/- 1 years, were studied. No patient had microalbuminuria, was taking medication other than insulin, or had evidence of heart disease. Patients underwent baseline continuous ambulatory blood pressure monitoring, echocardiographic studies, and cardiovascular autonomic function tests, which were repeated after 4 weeks of an intensified insulin treatment program (IITP), during which they reached and maintained blood glucose concentrations and serum fructosamine levels in near-normal, nondiabetic ranges.

RESULTS

Substantial changes in glycemic control had no significant influence on results of ambulatory blood pressure monitoring, cardiovascular autonomic function tests, and echocardiographic studies.

CONCLUSION

Major improvement in glycemic control during a 1-month period in patients with IDDM had no significant influence on cardiovascular function tests. We cannot exclude the possibility that, after a longer duration of an IITP or in patients with clinically evident heart disease or evidence of major complications of diabetes, different responses might be observed.

Vitamin E modifies neither fructosamine nor HbA1c levels in poorly controlled diabetes

OBJECTIVE

To examine the effects of vitamin E on total serum protein glycation (fructosamine), hemoglobin glycation (HbA1c), and serum levels of glucose, total cholesterol, triglycerides, LDL-C, HDL-C, apolipoprotein A1 and apolipoprotein B.

MATERIAL AND METHODS

Sixty poorly controlled diabetic patients were randomly assigned to receive either 1200 mg/day of vitamin E or identical placebo capsules during a two month period following a double blind cross-over design with a four week wash-out period between regimens.

RESULTS

Seven patients were excluded from the study because of reasons not related to the medication. In the remaining 53 patients, the levels of serum glucose, fructosamine, HbA1c, total cholesterol, HDL-C, LDL-C, Apo A1 and Apo B did not vary significantly with vitamin E as compared with placebo.

CONCLUSIONS

No significant effects of vitamin E on any of the parameters evaluated were observed in poorly controlled diabetic patients.

[Insulin transference in 198 patients from 6 Latin American countries]

A multicentric, comparative, single-blind, randomized, prospective study was designed to evaluate the efficacy and safety of the transference from animal source insulins to rDNA human insulin in Latinamerican insulin-requiring diabetic patients. All the patients were on animal insulin for at least two months before inclusion. The patients were evaluated at the beginning, and at two and six weeks after inclusion. A total 198 patients completed the study and were considered evaluable: 94 were assigned to the animal insulin group, and 104 to the human insulin group. There were no statistically significant baseline differences between groups. The only statistically significant difference, detected at the end of the study, was a reduction in fasting blood glucose level in the human insulin group (animal insulin 212 +/- 95.3 initial vs 193 +/- 78.3 mg/dL final, p = 0.18; human insulin 198 +/- 86.8 vs 169 +/- 71.7, p = 0.025). There were no statistically significant initial-final changes in the rest of the parameters evaluated although a trend of reduction in glycohemoglobin levels was observed in both groups. There were more episodes of mild hipoglycemia in the human insulin group, and only one episode of severe unwarned hypoglycemia in the same group. We conclude that the transference of insulins in Latinamerican diabetic patients is effective and reasonably safe (with a dose adjustment when the change is made).

A controlled trial of pravastatin vs probucol in the treatment of primary hypercholesterolemia

We compared the safety, tolerability and efficacy of the HMGCoA reductase inhibitor pravastatin and probucol in the treatment of patients with primary hypercholesterolemia using an active, drug controlled, double blind, randomized, double placebo design. Patients were included if LDL-C levels after a minimum of six weeks on an AHA phase I diet were greater than 150 mg/dL and triglycerides were less than 350 mg/dL. Included patients were randomly assigned to either pravastatin 40 mg pm or probucol 500 mg bi. They also received matching placebos for each drug. The active drug period lasted 16 weeks, during which the patients were seen at 4, 8, 12 and 16 weeks after baseline. There were no significant differences in baseline values between both treatment groups. Significantly lower values of total cholesterol and LDL-C were observed with pravastatin as compared to probucol. While a non significant increase of HDL-C was observed with pravastatin, a remarkable and statistically significant decrease was observed with probucol. A large dispersion of triglycerides levels was observed with both drugs and no statistically significant changes were demonstrated. Both pravastatin and probucol were well tolerated: only minimal clinical and laboratory changes, not considered to have been drug-related, were observed. No changes, considered drug-related, were observed in the cristalline lens. This study shows an overall superiority of pravastatin over probucol with significant larger decreases of total cholesterol and LDL-C and a better effect on HDL-C.

[Efficacy and tolerance to acarbose in non-insulin-dependent diabetics]

Oral acarbose, a competitive inhibitor of alpha-glucosidase, has been shown to be effective in decreasing the postprandial rise in blood glucose and insulin. A double blind, cross-over, placebo controlled, randomized study in poorly controlled, non-insulin dependent diabetic patients under treatment with sulfonylureas was carried out. The patients continued receiving sulfonylureas throughout the study period and were randomly allocated into two sequences. In sequence A they received 100 mg tablets tid during 12 weeks; placebo tid during 2 weeks (wash-out period) and finally they were crossed over to placebo tid during 12 weeks. In sequence B, they received placebo tid 12 weeks, placebo tid during 2 weeks and finally acarbose 100 mg tid during 12 weeks. Sixteen patients were included in each sequence; three were excluded from sequence A, one because of side effects, one because of severe neuropathy and one because of change of address. One was excluded from sequence B because of failure to take the sulfonylurea. A slight but statistically significant decrease in weight was observed with acarbose as compared with placebo in both sequences. Significant reductions in postprandial glucose were observed in both sequences with acarbose. Significant reductions in fasting blood glucose were also observed in some visits. Although lower mean values of triglycerides and HbA1c were observed with acarbose, they were not statistically significant. Acarbose had side effects almost in all patients, but decreased on continued therapy. Only one patient had to be excluded for this cause. Acarbose is a useful therapeutic resource in poorly controlled non-insulin dependent diabetic patients in combination with sulfonylureas.

Combination daytime chlorpropamide-metformin/bedtime insulin in the treatment of secondary failures in non insulin dependent diabetes

OBJECTIVES

To determine the effectiveness of the combination therapy with daytime chlorpropamide-metformin and bedtime NPH insulin in the treatment of secondary failures in NIDDM and to study its effects on insulin secretion.

DESIGN

Non randomized open study with a duration of two months. The patients were followed six months after ending the study.

INSTITUTION

Department of Diabetes and Lipid Metabolism. Instituto Nacional de la Nutrición "Salvador Zubirán", Mexico City. CHARACTERISTICS OF THE PATIENTS: Nine patients (seven women and two men) were included. All had NIDDM and secondary failure to antidiabetic oral drugs. Their fasting plasma glucose was 14.5 +/- 2 mM/L and their HbA1c 13.37 +/- 2.9%. At the entry and at the end of the study a 5h-OGTT was done with assays of plasma glucose and C-peptide.

TREATMENT

Chlorpropamide (375 mg/day) plus metformin (1200 mg/day) and bedtime insulin (0.1 U/kg/day).

RESULTS

After two months on combination therapy, fasting plasma glucose and HbA1c levels were remarkably improved (decreases of 7.3 +/- 0.6 and 9.1 +/- 1.02 respectively, p less than 0.002). The insulin dose was small (6.77 +/- 2.09 U/day). Side effects were minimal and infrequent. During the 5h-OGTT, the mean glucose area under the curve also decreased. The insulin secretion did not change but the C-peptide/glucose ratio increased. At the end of the study, the insulin dose was tapered off and stopped when possible. The four patients with the best glycemic control during the study were able to suspend the bedtime insulin and maintain a good control six months after the insulin suspension.

CONCLUSIONS

The combination therapy is useful in the treatment of secondary failures in NIDDM: Its advantages are the very low mean daily insulin dose needed, the low incidence of side effects and, if a HbA1c less than 8.7% is achieved, the restoration of oral antidiabetic drugs efficacy. The very low insulin dose used in this study could be explained by complementary effects of metformin and bedtime insulin on hepatic glucose output and a putative decrease in peripheral resistance attributable both to sulfonylurea and metformin.

Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized, placebo controlled trial

Intravenous sodium bicarbonate has been used for a long time in the treatment of diabetic ketoacidosis. However, there are no clinical studies showing its effectiveness in improving arterial pH in this condition. We therefore designed this study to investigate if bicarbonate therapy improves the rate of increase of arterial pH and to find out its effects on the recovery rate of the other metabolic abnormalities. Twenty patients with severe diabetic ketoacidosis (pH less than 7.15) entered a double-blind, randomized, placebo controlled trial: nine were included in the bicarbonate group and eleven in the placebo group. All patients were studied during the first 24 hours of treatment. Their management was similar, except for the use of sodium bicarbonate in one group and 0.9% saline solution in the placebo group. Heart rate, respiratory rate, arterial pressure, mental status, blood gases, blood glucose, sodium, potassium, and urea were assessed at the beginning of treatment, and then at 2, 6, 12 and 24 hours. No clinical or metabolic differences were found between groups. Two hours after therapy was begun, the arterial pH rose in the bicarbonate group from 7.05 +/- 0.08 to 7.24 +/- 0.04, while it only rose from 7.04 +/- 0.08 to 7.11 +/- 0.09 in the placebo group (p less than 0.02). Simultaneously, arterial bicarbonate increased from 2.87 +/- 1.2 to 6.1 +/- 1.5 mEq/L in the bicarbonate group and from 2.55 +/- 0.81 to 3.6 +/- 2 mEq/L in the placebo group (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)