The demographic, psychosocial and clinical characteristics associated with cardiac risk factor control: an analysis of secondary prevention in adults with established coronary heart disease

Funding Acknowledgements

Type of funding sources: None.

Background and Purpose

Achieving risk factor (RF) control in patients with established coronary heart disease (CHD) reduces the risk of CHD events.(1) Cross-sectional studies have shown that the implementation of current prevention guidelines is poor, with most patients failing to meet recommended targets.(2,3) This study aims to identify demographic, psychosocial and clinical characteristics associated with the non-achievement of RF targets in a population with CHD.

Methods

In this post-hoc cross-sectional analysis, multivariable logistic regression identified characteristics significantly associated with poor RF control in participants of the iASPIRE study which recently assessed secondary CHD prevention in Ireland.

Results

An unhealthy diet (Odds Ratio [OR] 1.6, 95% CI 1.1-2.4, p=0.015), male sex (OR 1.8, 95% CI 1.2-2.8, p=0.007) and type of acute coronary syndrome event (OR 0.6, 95% CI 0.4-0.9, p=0.012) were associated with failure to achieve blood pressure recommendations. Female sex (OR 2.3, 95% CI 1.4-3.8, p=0.002), lack of high-intensity statin (OR 2.4, 95% CI 1.5-3.8, p<0.001) and recurrent hospitalisation for CHD (OR 1.9, 95% CI 1.3-2.8, p=0.001) were associated with poor LDL-C control. Decreasing age (OR 0.9, 95% CI 0.9-1.0, p=0.018), marriage (OR 4.3, 95% CI 1.5-12.1, p=0.007) and insulin use (OR 9.7, 95% CI 1.9-50.4, p=0.007) were associated with a HbA1c of ≥53mmol/mol. The absence of a longstanding illness or disability and decreasing resting heart rate were associated with composite RF control.

Conclusion

Several demographic, psychosocial and clinical characteristics are associated with achieving guideline-recommended RF targets. These findings will support the development of targeted solutions that will improve guideline implementation and the practice of CHD prevention in a high-risk population.

A prospective study of risk factors for foot ulceration: the West of Ireland Diabetes Foot Study

BACKGROUND

This is the first study to examine risk factors for diabetic foot ulceration in Irish general practice.

AIM

To determine the prevalence of established risk factors for foot ulceration in a community-based cohort, and to explore the potential for estimated glomerular filtration rate (eGFR) to act as a novel risk factor.

DESIGN

A prospective observational study.

METHODS

Patients with diabetes attending 12 (of 17) invited general practices were invited for foot screening. Validated clinical tests were carried out at baseline to assess for vascular and sensory impairment and foot deformity. Ulcer incidence was ascertained by patient self-report and medical record. Patients were re-assessed 18 months later.

RESULTS

Of 828 invitees, 563 (68%) attended screening. On examination 23-25% had sensory dysfunction and 18-39% had evidence of vascular impairment. Using the Scottish Intercollegiate Guidelines Network risk stratification system we found the proportion at moderate and high risk of future ulceration to be 25% and 11%, respectively. At follow-up 16/383 patients (4.2%) developed a new foot ulcer (annual incidence rate of 2.6%). We observed an increasing probability of abnormal vascular and sensory test results (pedal pulse palpation, doppler waveform assessment, 10 g monofilament, vibration perception and neuropathy disability score) with declining eGFR levels. We were unable to show an independent association between new ulceration and reduced eGFR [Odds ratio 1.01; P = 0.64].

CONCLUSION

Our data show the extent of foot complications in a representative sample of diabetes patients in Ireland. Use of eGFR did not improve identification of patients at risk of foot ulceration.

The prevalence of diabetes, pre-diabetes and the metabolic syndrome in an Irish regional homeless population

BACKGROUND

Diabetes is a major chronic health condition. Prevalence is rising, superseding public health estimates. Chronic diseases are more common among lower socioeconomic groups, for example, the homeless population. There is paucity of data on the health status of the homeless population in Ireland, and the prevalence of diabetes and associated cardiovascular risk factors is unknown.

AIM

We aimed to assess the prevalence of diabetes, pre-diabetes and the metabolic syndrome (MetS) in an Irish regional homeless population.

DESIGN

This study is a cross-sectional study of the homeless population living in a regional university city of Ireland.

METHODS

After informed consent and following an overnight fast, blood was drawn for fasting plasma glucose, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein and glycosylated haemoglobin (HbA1c). A 75 g glucose load was given orally and an oral glucose tolerance test completed. Anthropometric measurements and blood pressure were recorded. Smoking, alcohol and drug status were noted.

RESULTS

Of the 252 participants, 8% (n = 20), 10% (n = 24) and 21% (n = 54) were diagnosed with type 2 diabetes, pre-diabetes and MetS, respectively. Obesity (body mass index >30) was present in 22%, while 90% displayed abdominal obesity. Participants who screened positive for diabetes, pre-diabetes and MetS demonstrated an inferior cardiovascular risk profile.

CONCLUSION

The prevalence of diabetes, pre-diabetes and MetS in this homeless population is in keeping with national estimates. As this cohort is less likely to seek health care, this may result in later diagnosis and a greater risk of diabetic complications at presentation.

New estimates of the costs of universal screening for gestational diabetes mellitus in Ireland

The new International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria have been predicted to increase the prevalence of gestational diabetes mellitus 2-to-3 fold and will have important resource implications for healthcare systems. A bottom-up, prevalence-based analysis was undertaken to estimate the costs of universal screening for gestational diabetes mellitus in Ireland using the new criteria. Healthcare activity was identified from the Atlantic Diabetes in Pregnancy database and grouped into five categories: (i) screening and testing, (ii) GDM treatment, (iii) prenatal care, (iv) delivery care, and (v) neonatal care. When individual resource components were valued using unit cost data and aggregated, the total healthcare cost was estimated at Euro 46,311,301 (95% CI: Euro 36,381,038, Euro 68,007,432). The average cost per case detected was Euro 351 (95% CI: (Euro 126, Euro 558) and the average total cost per case detected and treated was Euro 9,325 (95% CI: Euro 5,982, Euro 13,996). Further research is required to determine the cost effectiveness of screening in the region with a view to improving resource allocation in this area in the future.

Moderate and extreme maternal obesity

The aim of this study was to investigate the prevalence of moderate and extreme obesity among an Irish obstetric population over a 10-year period, and to evaluate the obstetric features of such pregnancies. Of 31,869 women delivered during the years 2000-2009, there were 306 women in the study group, including 173 in the moderate or Class 2 obese category (BMI 35-39.9) and 133 in the extreme or Class 3 obese category (BMI > or = 40).The prevalence of obese women with BMI > or = 35 was 9.6 per 1000 (0.96%), with an upward trend observed from 2.1 per 1000 in the year 2000, to 11.8 per 1000 in the year 2009 (P = 0.001). There was an increase in emergency caesarean section (EMCS) risk for primigravida versus multigravid women, within both obese categories (P < 0.001). However, there was no significant difference in EMCS rates observed between Class 2 and Class 3 obese women, when matched for parity. The prevalence of moderate and extreme obesity reported in this population is high, and appears to be increasing. The increased rates of abdominal delivery, and the levels of associated morbidity observed, have serious implications for such women embarking on pregnancy.

ATLANTIC DIP: pregnancy outcomes for women with type 1 and type 2 diabetes

ATLANTIC DIP prospectively evaluated the perinatal and maternal outcomes of pregnancies complicated by Type 1 and Type 2 diabetes during 2006/2007 in 5 antenatal centres. All women with established diabetes for at least 6 months prior to the index pregnancy and booking for antenatal care between 1/1/2006 and 31/12/2007 were included in the study. Results were collected electronically via the DIAMOND Diabetes Information System. Pregnancy outcome was compared with that of the background population receiving antenatal care in the region during the same time. There were 104 singleton pregnancies during the period of study. The stillbirth rate (SBR) of 25/1000 was 5 times greater than that reported in the background population at 5/1000 and the perinatal mortality rate (PMR) of 25/1000 was 3.5 times greater than background 7/1000. The congenital malformation rate (CMR) of 24/1000 was twice that observed in the background population. Women were not well prepared for pregnancy with 28% receiving pre pregnancy care (PPC), 43% receiving pre pregnancy folic acid and 51% achieving a HbA1C < = 7% at first antenatal visit. Pregnancy induced hypertension (PIH) and/or pre eclampsia toxaemia (PET) were three times more common than in women in the background population. In conclusion women are not well prepared for pregnancy. Maternal and infant morbidity and infant mortality are greater in women with diabetes. A regional pre pregnancy care (PPC) programme and centralised glucose management are urgently needed.

Is there a socioeconomic gradient in the prevalence of gestational diabetes mellitus?

Previous studies have shown an association between Type 2 diabetes and lower socioeconomic status. This link is less clear in those with gestational diabetes mellitus (GDM). We test for a socioeconomic gradient in the prevalence of GDM by analysing data on 9,842 pregnant women who were offered testing for GDM in the Atlantic Diabetes in Pregnancy universal screening programme. A bivariate probit model relating GDM prevalence to socioeconomic status was estimated, controlling for variation in screening uptake rates across socioeconomic groups. The estimated increased prevalence of GDM is 8.6% [95% CI 2.7%-12.0%] for women in the lowest socioeconomic group when compared to the highest, suggesting a strong socioeconomic gradient in the prevalence of GDM. This gradient is found to be driven by differences in personal, clinical and lifestyle factors across socioeconomic groups.

Atlantic DIP: subject recruitment, data collection, missing data management and analysis procedures

This paper describes the experiences related to the universal screening study for gestational diabetes mellitus (GDM) with reference to the subject recruitment process, data collection processes, (data entry, editing, quality assurance) and statistical analysis including the importance of missing data.

Trimester-specific reference intervals for IFCC standardised haemoglobin A(1c): new criterion to diagnose gestational diabetes mellitus (GDM)?

We established trimester-specific reference intervals for IFCC standardised HbA(1c) in 311 non-diabetic Caucasian pregnant women (n = 246) and non-pregnant women (n = 65). A selective screening strategy based on risk factors for gestational diabetes was employed. Pregnancy trimester was defined as trimester 1 (T1, n = 40) up to 12 weeks + 6 days, trimester 2 (T2, n = 106) 13 to 27 weeks + 6 days, trimester 3 (T3, n = 100) > 28 weeks to delivery. The normal HbA(1c) reference interval for Caucasian non-pregnant women was 29-37 mmol/mol (DCCT: 4.8-5.5%), T1: 24-36 mmol/mol (DCCT: 4.3-5.4%), T2: 25-35 mmol/mol (DCCT: 4.4-5.4%), and T3: 28-39 mmol/mol (DCCT: 4.7-5.7%). HbA(1c) was significantly decreased in trimesters 1 (P < 0.01) and 2 (P < 0.001) compared to non-pregnant women. Retrospective application of selective screening to Caucasian women of the Atlantic DIP cohort determined that 5,208 met the criteria. 945 of those women (18.1%) were diagnosed with Gestational Diabetes Mellitus (GDM) using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) glucose concentration thresholds. HbA(1c) measurement within 2 weeks of the diagnostic Oral Glucose Tolerance Test (OGTT) was available in 622 of 945 (66%). Applying the decision threshold for T2: HbA(1c) > 35 mmol/mol (DCCT > 5.4%) identified 287 of 622 (46%) of those with GDM. HbA(1c) measurement in T2 (13 to 27 weeks) should be included in the diagnostic armamentarium for GDM. This would reduce the need for diagnostic OGTT in a significant number of women.

Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes

Gestational diabetes mellitus (GDM) is associated with adverse foetal and maternal outcomes, and identifies women at risk of future Type 2 Diabetes Mellitus (T2DM). Breast-feeding may improve postpartum maternal glucose tolerance. We prospectively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance. We compared postpartum 75g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT). Breast-feeding data was collected at time of OGTT. Postpartum OGTT results were classified as normal [fasting plasma glucose (FPG) < 5.6mmol/l, 2-h < 7.8 mmol/l] and abnormal [impaired fasting glucose (IFG), FPG 5.6-6.9 mmol/l; impaired glucose tolerance (IGT), 2-h glucose 7.8-11 mmol/l; IFG+IGT; T2DM, FPG > or = 7 mmol/l +/- 2h glucose > or = 11.1 mmol/l]. 6 (2.7%) with NGT in pregnancy had postpartum dysglycaemia compared to 57 (19%) with GDM in index pregnancy (p < 0.001). Non-European ethnicity (OR 3.40, 95% CI 1.45-8.02, p = 0.005), family history of T2DM (OR 2.14, 95% CI 1.06-4.32, p = 0.034) and gestational insulin use (OR 2.62, 95% CI 1.17-5.87 p = 0.019) were associated with persistent dysglycaemia. The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum (8.2% v 18.4%, p < 0.001). Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

The impact of maternal obesity on gestational outcomes

To investigate the effects of raised maternal BMI on pregnancy outcome in glucose tolerant women, using the IADPSG criteria. Prospective observational study of fetal and maternal outcome in a cohort of pregnant women recruited to a universal screening programme for gestational diabetes under the ATLANTIC-DIP partnership. Maternal outcomes included glucose, delivery mode, pregnancy induced hypertension (PIH), preeclampsia (PET), antepartum hemorrhage (APH) and postpartum hemorrhage (PPH). Fetal outcomes included birthweight, congenital malformation, fetal death, neonatal jaundice, hypoglycemia and respiratory distress. Increasing maternal BMI was associated with adverse pregnancy outcomes: higher cesarean section rates, pre-eclamptic toxemia, pregnancy induced hypertension, increased birth weight and congenital malformation. There was also an association between normal range glucose and emergency cesarean section, hypertension of pregnancy and birthweight. In spite of tightening criteria for hyperglycemia during pregnancy, raised BMI is associated with adverse pregnancy outcome.

Psychological stress associated with diabetes during pregnancy: a pilot study

Gestational Diabetes Mellitus (GDM) affects approximately 12% of women. The impact of a diagnosis of GDM may lead to increased stress in pregnancy due to the demands of adherence to a treatment regimen and maternal concern about adverse outcomes for the mother and baby. We examined the psychosocial profile of 25 women with gestational diabetes mellitus (GDM) and compared them to 25 non-diabetic pregnant women. Measures administered included the Pregnancy Experiences Scale (PES), the Depression, Anxiety Stress Scale (DASS), the Problem Areas in Diabetes Scale (PAID-5) and the Perceived Social Support Scale (PSSS). The GDM group reported a significantly greater ratio of pregnancy 'hassles' to pregnancy 'uplifts'. The GDM group also had a significantly higher Depression score and were twice as likely to score above the cut-off for possible depression. Elevated levels of diabetes-related distress were found in 40% of women with GDM. In addition, the GDM group reported less social support from outside the family. Our preliminary study indicates that the experience of GDM appears to be associated with increased psychological distress in comparison to the experience of non-diabetic pregnant women. This may indicate the need for psychological screening in GDM and the provision of psychological support in some cases.

Changing clinical practice can improve clinical outcomes for women with pre-gestational diabetes mellitus

Prospective evaluation of pregnancy outcomes in women with pre-gestational diabetes over 6 years. The ATLANTIC Diabetes in Pregnancy group represents 5 antenatal centres along the Irish Atlantic seaboard, providing care for women with diabetes throughout pregnancy. In 2007 the group published a report that recognised that women were poorly prepared for pregnancy and that outcomes were sub-optimal. A change in practice occurred, offering women specialist-led, evidence-based care, both pre-pregnancy and combined antenatal/diabetes clinics during pregnancy. We now compare outcomes from 2005-2007 with 2008-2010. There was an increase in the numbers attending pre-conception care. Glycemic control before and throughout pregnancy improved. There was an overall increase in live births and decrease in perinata mortality rate. There was a decrease in large-for-gestational-age babies in mothers with Type 1 Diabetes. Elective Caesarean section rates increased while emergency section rates decreased. More women had Type 2 diabetes over time and these women were more likely to be obese. Changing the process of clinical care delivery can improve outcomes in for women with pre-gestational diabetes.

Atlantic DIP: the prevalence and consequences of gestational diabetes in Ireland

ATLANTIC DIP carried out a universal screening programme for gestational diabetes mellitus (GDM) along the Irish Atlantic seaboard. Using a 75g OGTT and new International Association of Diabetes in Pregnancy Study Groups (IADPSG) cut off points for diagnosis we found the prevalence of GDM to be 12.4%. Pregnancies complicated by GDM displayed increased morbidities for mother and infant when compared to women who had normal glucose tolerance. With rising obesity levels and older age of mothers, both risk factors for GDM, these results would support a national universal screening programme.

The cost of universal screening for gestational diabetes mellitus in Ireland

AIMS

To estimate the costs associated with universal screening for gestational diabetes mellitus in Ireland.

METHODS

Bottom-up, prevalence-based cost analysis. Healthcare activity identified using the Atlantic Diabetes in Pregnancy (ATLANTIC DIP) database was grouped into five categories: screening and testing, gestational diabetes treatment, prenatal care, delivery care and neonatal care. A vector of unit cost data (euros in 2008 prices) was applied to specified resource use and the total healthcare cost calculated. A series of one-way and probabilistic sensitivity analyses were undertaken to explore the uncertainty in the analysis.

RESULTS

When individual resource components were valued and aggregated, the total healthcare cost of gestational diabetes in Ireland was estimated at €12 433 320 (95% CI €9 298 228-16 778 193). The average cost per case detected was €1621 (95% CI €524-2603) and the average total cost per case detected and treated was €11 903 (95% CI €7645-16 121).

CONCLUSIONS

This research provides the first estimates of the healthcare costs associated with gestational diabetes mellitus in Ireland. Further research is required to determine the cost-effectiveness of gestational diabetes screening in the region with a view to improving resource allocation in this area in the future.

Atlantic Diabetes in Pregnancy (DIP): the prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria

AIMS/HYPOTHESIS

New diagnostic criteria for gestational diabetes mellitus (GDM) have recently been published. We wished to evaluate what impact these new criteria would have on GDM prevalence and outcomes in a predominantly European population.

METHODS

The Atlantic Diabetes In Pregnancy (DIP) programme performed screening for GDM in 5,500 women with an oral glucose tolerance test at 24-28 weeks. GDM was defined according to the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria and compared with previous WHO criteria; maternal and neonatal adverse outcomes were prospectively recorded.

RESULTS

Of the participants, 12.4% and 9.4% were diagnosed with GDM using IADPSG and WHO criteria, respectively. IADPSG GDM pregnancies were associated with a statistically significant increased incidence of adverse maternal outcomes (gestational hypertension, polyhydramnios and Caesarean section) and neonatal outcomes (prematurity, large for gestational age, neonatal unit admission, neonatal hypoglycaemia and respiratory distress). The odds ratio for the development of these adverse outcomes remained significant after adjustment for maternal age, body mass index and non-European ethnicity. Those women who were classified as having normal glucose tolerance by WHO criteria but as having GDM by IADPSG criteria also had significant adverse pregnancy outcomes.

CONCLUSIONS/INTERPRETATION

GDM prevalence is higher when using newer IADPSG, compared with WHO, criteria, and these women and their offspring experience significant adverse pregnancy outcomes. Higher rates of GDM pose a challenge to healthcare systems, but improved screening provides an opportunity to attempt to reduce the associated morbidity for mother and child.

Distinct Effects of High-Glucose Conditions on Endothelial Cells of Macrovascular and Microvascular Origins

Recent studies implicate hyperglycemia as an important cause of macrovascular and ocular complications in diabetes mellitus. In this study, the authors examined the effect of high glucose on macrovascular and microvascular endothelial cell viability and apoptosis in culture. Human aortic endothelial cells (HAECs) and human retinal endothelial cells (HRECs) were exposed to normal-glucose conditions (NG) and high-glucose conditions (NG supplemented with 25 mM D-glucose) for 72 h in vitro. D-Mannitol was used as an osmotic control. Cell viability was assessed by methlythiazolydiphenyltetrazolium bromide (MTT) assay, and induction of apoptosis was assessed by Hoechst staining. Statistics were analyzed by paired t tests. In HAECs, cell viability was decreased by 12.9% in high-glucose conditions, and apoptotic cells were significantly increased by 77%. However, in HRECs, cell viability was increased by 14.9% in high-glucose conditions, and apoptotic cells were significantly decreased by 33.3%. Mannitol did not show any effect on cell survival or apoptosis ruling out an osmotic effect. High-glucose conditions reduce cell viability and induce apoptosis in HAECs, which may contribute to macrovascular complications associated with diabetes. In contrast, high-glucose increases viability in HRECs and inhibits apoptosis, which may contribute to the development of diabetic retinopathy.

Traveller health: prevalence of diabetes, pre diabetes and the metabolic syndrome

Irish Travellers are an ethnic minority group exposed to a myriad of social and health inequalities. Their current life expectancy equals that of the background population in the 1940s and one of the main causes of death is cardiovascular disease (CVD). There is a paucity of information on CVD risk factor assessment in the research literature in this population. This study assesses the prevalence of Diabetes, Pre-Diabetes and the Metabolic Syndrome (MetS) in a sample population from this community. Working with the Galway Traveller Movement, and following an overnight fast we measured fasting plasma glucose, HDL-cholesterol and Triglycerides. In addition weight, height, waist circumference (WC) and blood pressure (BP) were recorded. Of the 47 subjects, there were 4 (8.5%) participants identified as having diabetes, 5 (10.6%) pre-diabetes and 25 (53.2%) with the metabolic syndrome. The point prevalence of diabetes was calculated as 8.5%, pre-diabetes 10.6% and the metabolic syndrome 53.2%. In addition abdominal obesity was present in 70% and hypertension in 43%. Targeted screening for glucose abnormalities and traditional CVD risk factors is needed. Based on current literature, appropriate interventions might reasonably be expected to lower mortality and increase life expectancy.

The Lifeways Cross-Generation Study: design, recruitment and data management considerations

The Lifeways Cross-Generation Cohort Study was first established in 2001 and is a unique longitudinal database in Ireland, with currently over three and a half thousand family participants derived from 1124 mothers recruited initially during pregnancy, mainly during 2002. The database comprises a) baseline self-reported health data for all mothers, a third of fathers and at least one grandparent b) clinical hospital data at recruitment, c) three year follow-up data from the families' General Practitioners, and d) linkage to hospital and vaccination databases. Data collection for the five-year follow-up with parents is underway, continuing through 2007. Because there is at present no single national/regional health information system in Ireland, original data instruments were designed to capture data directly from family members and through their hospitals and healthcare providers. A system of relational databases was designed to coordinate data capture for a complex array of study instruments and to facilitate tracking of family members at different time points.

Determining the quality of the medical educational environment at an Irish medical school using the DREEM inventory

A Cross-Sectional study using the already validated Dundee Ready Educational Environment (DREEM) questionnaire was used to assess the Undergraduate Medical Educational Environment in an Irish Medical School during the first semester 2004/2005. 389 of 476 students (82%) completed the questionnaire. The mean total score was 130 out of a maximum of 200 (65%) indicating relative satisfaction with the environment but with room for improvement. There were no individual areas of excellence identified. The following two areas were identified as being problematic (a) lack of a support system for stressed students (b) over emphasis on memorization of facts. These areas were perceived by clinical students to be greater when compared to pre-clinical students. Female students appeared happier in their environment but male students were more confident about passing exams. Non-Irish students had a lower overall score when compared to Irish students. The DREEM is a useful tool to assess the overall teaching environment and highlight areas of weakness. Use of DREEM as a monitoring tool would be useful to re-evaluate the environment following appropriate intervention.

The prevalence of Down syndrome in County Galway

This is a retrospective survey of all cases of Down syndrome recorded between 1981 and 2000 to mothers resident in Co. Galway. The study compares the incidence of Down syndrome in both decades and examines the effects of changing demographics on incidence rates. The overall prevalence rate was 26.8/10,000 live births for the full period. Although there were 5119 fewer births in the 1991-2000 period, the prevalence was 29.8/10,000 compared to 24.1/10,000 in the previous decade. Despite the falling birth rates and fertility rates observed in our study between the two decades we found that the higher prevalence of Down syndrome in the second decade was directly related to the significant increase in the proportion of women in the 30 plus age group. Our study also found the place of the child with Down syndrome in the family changed, with 25.3% being the 5th or more child in the first decade compared with 9.5% in the second decade.

The RAMBLER study: the role of ambulatory blood pressure measurement in routine clinical practice: a cross-sectional study

Ambulatory blood pressure measurement (ABPM) is a useful and important way of guiding clinical decisions in the diagnosis and treatment of hypertension. There has been little research on how ABPM is actually used in the community where hypertension is mainly diagnosed and managed. We aimed to review the use of ABPM in daily community practice in terms of patient demographics, changes in pharmaceutical treatment and the proportion of patients achieving recommended levels. Six practices using the dabI device for ABPM participated in this cross-sectional study. Patients who had the ABPM performed over the preceding 12 months were included. We recorded demographic details, pre- and post-ABPM clinic blood pressure measurements, the ABPM result and treatment before and after the test. 381 patients were included in the study, of whom 38.6% were male. The mean age was 58 years (SD= 14) and 46.7% were GMS eligible. 33.8%/ had a normal BP result on ABPM. There was a statistically significant reduction in both the mean systolic pressure(10.4 mmHg, CI 7.2-12.9, P<0.001) and diastolic pressure (5.1 mmHg, CI 3.2-6.6, P< 0.05) between the pre and the post-ABPM clinic measurements. It was found that 38.1% had a change in their medication after the test, with 31.7% having a new medication started. This pragmatic study provides information about the use of ABPM in routine general practice in Ireland. ABPM readings appear to have an impact on General Practitioners' decision- making and on the medical management of hypertensive patients in the community.

Haemoglobin A1c (HbA1C) in Non-diabetic and Diabetic Vascular Patients. Is HbA1C an Independent Risk Factor and Predictor of Adverse Outcome?

BACKGROUND

Plasma Haemoglobin A1c (HbA1c) reflects ambient mean glycaemia over a 2-3 months period. Reports indicate that patients, with and without diabetes, with an elevated HbA1c have an increased risk of adverse outcome following surgical intervention. Our aim was to determine whether elevated plasma HbA1c level was associated with increased postoperative morbidity and mortality in patients undergoing vascular surgical procedures.

METHODS

Plasma HbA1c was measured prospectively in 165 consecutive patients undergoing emergency and elective vascular surgical procedures over a 6-month period. Patients were categorized into four groups depending on whether their plasma HbA1c was < or =6%, 6.1-7%, 7.1-8% or >8% and clinical data was entered into a prospectively maintained database. Patients were also classified by diabetic status with suboptimal HbA1c in a patient without diabetes being >6 to < or =7% and suboptimal HbA1c in a patient with diabetes being >7%. Patients with plasma HbA1c >7% were reclassified as having undiagnosed diabetes mellitus. Composite primary endpoints were all cause 30-day morbidity and mortality and all cause 6-month mortality. Composite secondary endpoints were procedure specific complications, adverse cardiac events, stroke, infection and mean length of hospital stay.

RESULTS

Of the 165 patients studied, 43 (26.1%) had diabetes and the remaining 122 (73.9%) did not. The mean age was 72 years and 59% were male. Suboptimal HbA1c levels were found in 58% patients without diabetes and in 51% patients with diabetes. In patients without diabetes those with suboptimal HbA1c levels (6-7%) had a significantly higher incidence of overall 30-day morbidity compared to patients with HbA1c levels < or =6% (56.5 vs 15.7%, p<0.001). Similarly, for patients with diabetes those with suboptimal HbA1c levels (HbA1c >7%) had a significantly higher incidence of 30-day morbidity compared to those with HbA1c levels < or =7% (59.1% vs 19%, p=0.018). Multivariate analysis revealed that a plasma HbA1c level of >6 to < or =7% was a significant independent predictor of overall 30-day morbidity in patients without diabetes undergoing vascular surgical procedures. No difference in mortality, composite secondary endpoints, procedure specific complications, stroke or mean length of hospital stay was observed between any of the groups in the study.

CONCLUSION

Suboptimal HbA1c levels may hold prognostic significance in patients without diabetes undergoing vascular surgery.

The Impact of Differential Expression of Extracellular Matrix Metalloproteinase Inducer, Matrix Metalloproteinase-2, Tissue Inhibitor of Matrix Metalloproteinase-2 and PDGF-AA on the Chronicity of Venous Leg Ulcers

INTRODUCTION

Alteration in the expression of extracellular matrix metalloproteinase inducer (EMMPRIN), matrix metalloproteinase-2 (MMP-2), tissue inhibitors of matrix metalloproteinases (TIMP-2) and platelet derived growth factor (PDGF-AA) may contribute to poor healing in venous leg ulcers.

AIM

The aim of this study is to determine the expression of EMMPRIN, MMP-2, TIMP-2 and PDGF-AA in the ulcer exudates and perivascular tissue of healing and non-healing chronic venous ulcers.

PATIENTS, MATERIALS AND METHODS

Forty patients with chronic venous ulcers were included in this study, with a mean age of 60 years. Eleven patients were males and 29 were females. All patients had normal ankle brachial index and a venous ulcer of at least 8 weeks duration. Immuno-histochemistry using monoclonal antibodies to PDGF-AA, MMP-2, TIMP-2 and EMMPRIN was carried out on paraffin embedded punch biopsy skin specimens from the ulcer edge. Enzyme linked immunosorbent assay for PDGF, MMP-2 and TIMP-2 were carried out on wound fluids collected from patients. The ulcer size and character at the initial assessment and after 8 weeks were assessed to determine the status of ulcer healing.

RESULTS

No significant difference was seen in the expression of TIMP-2, MMP-2 and EMMPRIN between the two groups. However, in the non-healing group high levels of MMP-2 and low levels of TIMP-2 in the wound fluid suggest a strong correlation of these two markers in the state of healing. Analysis of wound fluid by ELISA demonstrated high PDGF-AA in the healing group (p = 0.021). Significantly increased levels of PDGF-AA (p<0001) was noted in the perivascular area on immuno-histochemistry of healing ulcers. These data suggest that PDGF-AA plays an important role in healing of venous ulcers.

CONCLUSION

Non-healing venous ulcers are associated with greater activity MMP-2 activity. The ratio of MMPs to their inhibitors TIMPs, dictate the rate of healing of the ulcers. PDGF-AA activity is associated with ulcer healing, though the mechanism is unclear. EMMPRIN expression in chronic venous ulcers probably parallels the chronicity of the condition rather than propagate it. However, further studies with larger samples are needed.

Interactions between Triatoma infestans and Triatoma sordida (Hemiptera: Reduviidae) in artificial ecotopes: population growth and age structure

Interaction characteristics between Triatoma infestans Klug, 1834 and Triatoma sordida Stal, 1859 populations were studied in artificial ecotopes for 16 mo. The experimental design involved simultaneous treatments with T. infestans and T. sordida together in the same experimental unit (EU) and each separately in two control units (CU) made of adobe bricks. Chickens were used as host animals. Each unit was dismantled monthly to estimate triatomine population size and age structure, rebuilt, and repopulated with the same insects. In both units, T. infestans population growth followed a logistic model, whereas T. sordida did not show this pattern. T. infestans completed a generation in 24 wk (EU) and 32 wk (CU1), whereas T. sordida did not complete one generation during this period. We concluded that T infestans showed a better colonizing success than T. sordida. After living together for 1 yr, an interference process took place that resulted in the extinction of T. sordida.

[Domestic infestation by Triatoma infestans and prevalence of Trypanosoma cruzi seropositives in a rural area of the Argentinian northeast]

An epidemiological study was carried out from April 1991 to December 1993 to obtain a general view of T. cruzi domestic transmission in rural areas of San Miguei Department, Corrientes. From 100 analyzed households, 50.0% was infested by T infestans (Klug, 1834) and 1.0% by T. sordida (Stal, 1859). Domiciliary colonization by T. sordida is reported for first time in Corrientes province. T. cruzi infection of T. infestans was 23.1%. Indirect hemagglutination and indirect immunofluorescence antibody tests were used for detection of anti T. cruzi antibodies in 388 human sera, 23.4% showed serological reactivity. An important high rate (12.9%) was observed in the age group of higher transmission risk. Seropositives percentages increased with age and reached 50.0% in 31-40 years old group. Domestic infestation by T. infestans, seropositive human prevalence to T. cruzi and householders precarious life conditions prove that this endemic disease is still a problem in the studied area.