Insulin improves well-being for selected elderly type 2 diabetic subjects

The effects of insulin therapy on patient well-being, treatment satisfaction and mood, and on carer strain were studied in 30 elderly Type 2 diabetic patients (age 73 +/- 7 (SD) yr) in poor glycaemic control on tablet therapy. A comparison group of ten poorly controlled patients who remained on oral agents was also studied. After 4 weeks of insulin treatment, there were significant improvements in mental health, role-emotional, role-physical (all P<0.05) and vitality (P<0.01) domains of the short form health survey (SF-36), and also in the diabetes treatment and satisfaction questionnaire (DTSQ) and geriatric depression scale (both P<0.01) compared to baseline. After 12 weeks, the improvements in mental health, social functioning and vitality (P<0.01 for all domains), and in the DTSQ were sustained. Carer strain was lower at 4 weeks. No changes in outcomes were seen in the comparison group. In selected elderly Type 2 diabetic patients, insulin treatment is associated with significant improvements in well-being, treatment satisfaction and mood, even without significant improvements in glycaemic control and without increase in carer strain. The SF-36 and DTSQ are sensitive to the benefits of the changes in the treatment for these patients.

The prevalence of diabetes mellitus and quality of diabetic care in residential and nursing homes. A postal survey

OBJECTIVE

to investigate the prevalence of known diabetes mellitus in care homes and the patterns of diabetes care in these institutions.

DESIGN

a postal questionnaire sent to all 98 care homes in Sheffield.

RESULTS

70 care homes (71%) returned the questionnaire, indicating that 233 (8.8%) of 2648 residents were known to have diabetes. Of these, 76 (33%) were treated with diet alone, 105 (45%) with diet plus oral medication and 52 (22%) with insulin. Only seven registered nurses (2%) in the homes had certified diabetes training. Forty-two homes (60%) did not carry out a structured, diabetes-related assessment of residents on entry and only 29 (42%) had regular review of diabetic residents by a general practitioner or practice nurse. Most homes (89%) were visited by an optician, 56 (80%) also had a regular chiropody service, although 32 (46%) of these charged their residents for this service.

CONCLUSIONS

the known prevalence of diabetes is similar to that reported previously. This study highlights the need for structured care with defined standards for care-home residents with diabetes.

Patient mood and carer strain during stroke rehabilitation in the community following early hospital discharge

PURPOSE

Patient mood and carer stress were assessed for stroke patients in the community following early hospital discharge.

METHOD

Patients had low Barthel Indices (13.0 (mean) +/- 4.9 (SD)) with high anxiety and depression scores, and carers had high stress scores, on starting rehabilitation. On starting rehabilitation, patient Barthel Indices correlated inversely with patient depression (r = -0.33, p < 0.02) and carer stress scores (r = -0.48, p < 0.001).

RESULTS

During rehabilitation improvements occurred in patient Barthel Indices, patient anxiety scores and carer stress scores, but not in patient depression scores. Incremental increases in patient Barthel Indices during rehabilitation correlated with reductions in carer stress scores (r = -0.55, R2 = 29.4%, p < 0.001). Following early hospital discharge stroke patients display mood abnormalities which do not resolve during rehabilitation.

CONCLUSION

Carer stress and patients depression scores are related to the severity of stroke-related disability. Strategies to address patient mood and carer stress should be present in community services providing early stroke rehabilitation.

A comparison of a low-dose warfarin induction regimen with the modified Fennerty regimen in elderly inpatients

OBJECTIVES

To compare a new low-dose warfarin induction regimen with the Fennerty regimen in elderly inpatients.

DESIGN

Age-stratified, randomized prospective study.

SUBJECTS

120 age-stratified elderly inpatients.

INTERVENTIONS

Each patient was randomized to either the new induction regimen or to a modified Fennerty regimen.

MAIN OUTCOMES MEASURES

Days to therapeutic International Normalized Ratio (INR >2); days in the therapeutic range (INR 2-3) during induction; number of patients with INR >4.5; ability of day 4 INR to predict day 8 warfarin dose.

RESULTS

The mean time to therapeutic INR was longer for the new induction regimen than modified Fennerty regimen in patients aged 65-75 years [4.6 (mean) +/- 1.6 (SD) days vs 3.8 +/- 0.8 days; P = 0.03] and in patients aged >75 years (4.5 +/- 1.4 days vs 3.5 +/- 0.7 days; P = 0.003). Patients spent more time in the therapeutic INR range with the new induction regimen [3.0 +/- 1.3 days vs 2.7 +/- 1.3 days (P = 0.03) for those aged 65-75 years and 2.9 +/- 1.1 days vs 2.4 +/- 1.3 days (P = 0.04 for those aged >75 years]. Fewer patients using the new regimen had INRs >4.5 in the first 8 days [1 (3%) vs 6 (20%) for 65-75 years (P < 0.05) and 1 (3%) vs 11 (37%) for >75 years (P < 0.01)]. The ability to predict the maintenance dose to within 1 mg was 55% for both regimens.

CONCLUSION

The low-dose regimen has important clinical advantages over the Fennerty regimen for anticoagulating elderly inpatients.

An unusual cause of pulmonary hypertension and right heart failure

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"Spontaneous" platelet aggregation in whole blood in diabetic and non diabetic survivors of acute myocardial infarction

There is increasing evidence that platelet thrombi play an important role in the pathogenesis of acute myocardial infarction (AMI). We compared "spontaneous" platelet aggregation in whole blood in 17 non-diabetic and 12 diabetic subjects on admission with AMI. There was no significant difference in the fall in platelet count between the two groups, expressed as platelets remaining (75.2 +/- 7.9% vs 77.3 +/- 6.9% at 10 min, 66.6 +/- 8.9% vs 68.5 +/- 6.3% at 20 min, 63.5 +/- 8.2% vs 64.9 +/- 6.7% at 30 min and 59.4 +/- 10.3% vs 61.3 +/- 7.6% at 60 min). The rate of "spontaneous" aggregation was increased in subjects with evidence of heart failure on admission compared to those without (59.9 +/- 7.9% vs 66.2 +/- 6.6% at 30 min [p = 0.05] and 55.4 +/- 9.6% vs 63.1 +/- 7.7% at 60 min [p = 0.04]). There was no correlation between the fall in platelet count and admission plasma glucose, glycated haemoglobin or peak aspartate amino-transferase. The subjects studied on admission with AMI had greater rates of "spontaneous" aggregation than 8 subjects studied between 6 and 12 months after acute myocardial infarction (75.9 +/- 7.4% vs 85.8 +/- 5.4% at 10 min; p = 0.001 and 64.3 +/- 7.5% vs 75.0 +/- 7.8% at 30 min; p = 0.006) and compared to normal controls (90.7 +/- 4.4% at 10 min; p < 0.001 and 83.4 +/- 6.5 at 30 min; p < 0.001). This study provides evidence of increased "spontaneous" platelet aggregation in subjects admitted with acute myocardial infarction but no difference between diabetic and non-diabetic subjects was observed.

An algorithm for tight glycaemic control in diabetic infarct survivors

An algorithm has been developed to provide predictable control of blood glucose for 48 h following acute myocardial infarction. In 29 diabetic patients intravenous infusion of soluble insulin was started upon admission to hospital and the rate adjusted hourly on the basis of bedside capillary glucose estimations. Insulin infusion rates related to glycaemia were higher in obese patients and those with severe cardiac failure. For all patients mean admission glucose levels were reduced from 18.3 +/- 5.9 mmol l-1 to 9.1 +/- 3.3 mmol l-1 at 4 h and to 8.8 +/- 2.5 mmol l-1 at 6 h. Mean glucose concentrations for 48 h after admission were 8.2 +/- 1.3 mmol l-1 for all patients. Admission glucose levels were slightly higher in patients with severe, compared to those without or mild, cardiac failure (P less than 0.1), but levels over the following 48 h were similar. Doubling insulin infusion rates before meals did not achieve tighter glycaemic control. Hypoglycaemia (glucose less than 3 mmol l-1) occurred on 11 occasions in six patients; only two episodes were symptomatic and only two episodes occurred when the insulin rates were doubled before meals. This algorithm produced tighter glycaemic control than previously published protocols, particularly in patients with severe cardiac failure. Hypoglycaemia is uncommon and the algorithm easy to administer by nursing staff.

'Spontaneous' platelet aggregation in whole blood in diabetic patients with and without microvascular disease

Consistent abnormalities of agonist-induced platelet aggregation, in either whole blood or platelet rich plasma, have not been demonstrated in diabetic patients without microvascular disease. In the present study platelet aggregation in the absence of exogenous agonists ('spontaneous' aggregation) was compared between 22 non-diabetic subjects and 23 Type 1 diabetic patients with (n = 12) and without (n = 11) microvascular disease. 'Spontaneous' aggregation was determined by measuring the percentage fall in single platelet number in aliquots of whole blood shaken for 60 min. Diabetic patients without microvascular disease had fewer single platelets remaining (greater aggregation) than non-diabetic subjects at all time-points (69.7 +/- 6.6 vs 82.3 +/- 7.3% at 60 min p less than 0.001), but more platelets remaining than in diabetic patients with microvascular disease at all time-points (69.7 +/- 6.6 vs 61.0 +/- 7.8% at 60 min p less than 0.02). No significant correlations were observed between platelet aggregation and plasma glucose, blood cell counts, or glycated haemoglobin levels. The study suggests that platelet abnormalities antedate the appearance of microvascular disease in diabetic patients.

Increased prescription of thrombolytic treatment to elderly patients with suspected acute myocardial infarction associated with audit

OBJECTIVES

To assess prescription of thrombolytic treatment to elderly patients with suspected acute myocardial infarction and the incidence of side effects.

DESIGN

Retrospective analysis of prescriptions during five months (first audit) followed by prospective analysis of uptake of treatment during five months after interventions in clinical management; prospective assessment of adverse events during thrombolytic treatment.

SETTING

Coronary care unit of large district general hospital.

PATIENTS

110 patients aged greater than or equal to 65 with subsequently proved acute myocardial infarction admitted in first audit and 119 admitted in the second.

MAIN OUTCOME MEASURES

Site of infarct, prescription of thrombolysis treatment, reasons for nonprescription, complications.

RESULTS

Before intervention thrombolytic treatment was prescribed to 13/110 (12%) patients with subsequently confirmed myocardial infarction and after intervention to 55/119 (46%) patients (p less than 0.01). In the first audit no patients with angina received thrombolytic treatment whereas 13/79 (16%) were treated in the second audit. Increased prescription of thrombolytic treatment in the second audit was associated with significantly fewer exclusions owing to dyspepsia (p less than 0.05) and unstated or unsatisfactory reasons (p less than 0.01) Streptokinase infusions were completed uneventfully in 75% (48/64) and 77% (10/13) of patients with infarction and angina respectively. Side effects of treatment were more common in patients with inferior than with anterior infarcts (16/42 (30%) v 3/24 (13%), p less than 0.05).

CONCLUSIONS

Low rates of prescription of thrombolytic treatment to elderly patients with suspected acute myocardial infarction were identified and corrected. Streptokinase treatment was associated with transient arrhythmias or hypotension in about a third of these patients with infarcts, particularly those with electrocardiographic changes in inferior leads.

Platelet function and conjugated diene concentrations in diabetic and non-diabetic survivors of acute myocardial infarction

STUDY OBJECTIVE

The aim was to compare platelet function in diabetic and non-diabetic survivors of acute myocardial infarction and to relate it to an index of free radical activity in these patients.

DESIGN

In vivo and in vitro indices of platelet function and diene conjugate molar ratios were measured in diabetic and non-diabetic infarct survivors on admission to hospital and sequentially for 72 h.

PATIENTS

The patients were 17 diabetics (age 61.9 years, range 32-74) and 12 non-diabetics (60.8 years, range 39-75) admitted to hospital with acute myocardial infarction confirmed according to WHO criteria.

MEASUREMENTS AND MAIN RESULTS

Agonist induced platelet aggregation, beta thromboglobulin levels, and linoleic acid 18:2(9,11)/18:2(9,12) molar ratios did not differ between diabetic and non-diabetic patients on admission. Concentrations of adrenaline producing 50% maximum platelet aggregation (EC50) in whole blood on admission were lower than non-infarct controls in both patient groups. The EC50 values in platelet rich plasma in both groups fell during the 72 h following admission (increases in platelet sensitivity). beta Thromboglobulin concentrations fell following admission in the diabetic group. Diene conjugate molar ratios were higher at 12 h and 24 h compared to admission in diabetic patients. Increases in diene conjugate ratios between admission and 24 h correlated with peak aspartate transaminase levels in both patient groups. No correlations were observed between platelet aggregation, beta thromboglobulin levels, or diene conjugate molar ratios.

CONCLUSIONS

During 72 h following myocardial infarction there is a reduction in platelet activation in vivo and an increase in platelet sensitivity to exogenous agonists in vitro. Free radical generated isomers of linoleic acid increase in relation to infarct size, but are unrelated to platelet function. There were no differences in platelet function between diabetic and non-diabetic subjects.

The relationships of concentrations of insulin, intact proinsulin and 32-33 split proinsulin with cardiovascular risk factors in type 2 (non-insulin-dependent) diabetic subjects

Standard radioimmunoassay for insulin may substantially overestimate levels of insulin because of cross-reaction with other insulin-like molecules. We have measured concentrations of insulin, intact proinsulin and 32-33 split proinsulin using two-site monoclonal antibody based immunoradiometric assays, and of insulin by a standard radioimmunoassay ("immunoreactive insulin") in 51 Type 2 (non-insulin-dependent) diabetic subjects in the fasting state. The relationships of these concentrations were sought with those of total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, triglyceride, plasminogen activator inhibitor, blood pressure, and indices of body fat distribution. Significant relationships were apparent between concentrations of "immunoreactive insulin" as measured by standard radioimmunoassay and triglyceride (rs = 0.42, p less than 0.001), total cholesterol (rs = 0.25, p = 0.038), high density lipoprotein cholesterol (rs = -0.30, p = 0.018) and body mass index (rs = 0.30, p = 0.017), but only the relationships with triglyceride (rs = 0.36, p = 0.006) and body mass index (rs = 0.26, p = 0.34) remained significant when concentrations of immunoradiometrically measured insulin were employed. Concentrations of 32-33 split proinsulin, which comprises the major insulin-like molecule in these subjects, correlated positively with triglyceride (rs = 0.33, p = 0.009), total cholesterol (rs = 0.23, p = 0.050), and plasminogen activator inhibitor (rs = 0.26, p = 0.049), and negatively with high density lipoprotein cholesterol (rs = -0.29, p = 0.021).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of fish oil supplements in NIDDM subjects. Controlled study

The aim of this study was to evaluate the effects of a fish oil preparation (MaxEPA) on hemostatic function and fasting lipid and glucose levels in non-insulin-dependent diabetic (NIDDM) subjects. Eighty NIDDM outpatients aged 55.9 yr (mean SD 11.5 yr) participated in a prospective double-blind placebo-controlled study of MaxEPA capsules (10 g/day) or olive oil (control) treatment over 6 wk. Patients received either MaxEPA or olive oil in addition to preexisting therapy. Metabolic and hemostatic variables were measured before treatment and after 3 and 6 wk. Platelet membrane eicosapentaenoic acid (EPA) content increased in the treatment group (P less than 0.001). MaxEPA supplementation was associated with a significant fall in total triglycerides (P less than 0.001) but did not affect total cholesterol (P = 0.7) compared with control treatment. Fasting plasma glucose increased after 3 wk (P = 0.01) but not after 6 wk (P = 0.17) treatment with MaxEPA. Spontaneous platelet aggregation in whole blood fell in the MaxEPA group (P less than 0.02) after 6 wk, but there were no changes in agonist-induced platelet aggregation, thromboxane generation in platelet-rich plasma, or plasma beta-thromboglobulin and platelet factor IV levels. An increase in clotting factor VII (P = 0.02), without changes in fibrinogen or factor X levels, occurred in the MaxEPA group. Similar reductions in blood pressure were observed in both groups. Dietary supplementation with MaxEPA capsules (10 g/day) in NIDDM subjects is associated with improvement in hypertriglyceridemia but with deleterious effects in factor VII and blood glucose levels. Most indices of platelet function are unaffected by this therapy.

The effects of dopexamine, a new dopamine analogue, on platelet function in stress

1. Dopexamine is a novel analogue of dopamine which is free of alpha-adrenoceptor activity and is of therapeutic value in chronic heart failure. The effects of dopexamine on the in vitro function of platelets from 10 healthy subjects at rest, after exercise and after in vitro addition of adrenaline and noradrenaline were investigated. 2. Dopexamine in a wide range of concentrations (10(-9)M-10(-3)M) did not appear to function as an agonist on platelets either in whole blood or in PRP preparations. 3. Dopexamine caused a dose-dependent inhibition of agonist-induced platelet aggregation in both whole blood and PRP. The inhibitory effect of dopexamine was significantly greater in PRP than in whole blood, and significantly greater to adrenaline than to collagen or ADP as agonists in whole blood. 4. After exercise or after in vitro addition of adrenaline and noradrenaline at concentrations commonly seen in myocardial infarction, dopexamine produced similar levels of inhibition seen with platelets from resting subjects. 5. Dopexamine did not affect plasma catecholamine levels but caused an increase in intraplatelet noradrenaline levels. 6. This study suggests that dopexamine is unlikely adversely to affect the hyperaggregable state found in patients with cardiogenic shock after myocardial infarction.

Anticardiolipin antibody levels in diabetic subjects with and without coronary artery disease

Moderate (greater than 20 units) and high (greater than 80 units) IgG anticardiolipin antibody (aCL) titres are strongly predictive for recurrent thrombosis and early myocardial infarction in non-diabetic subjects. We have tested the hypothesis that the excess risk of myocardial infarction in diabetic subjects relates to the presence of aCL by measuring the frequency and titre of aCL in two groups of diabetic subjects and in 2500 healthy controls. One non-diabetic subject (0.04%) had low (5-20 units) IgG aCL titres. Seven out of 126 diabetics without cardiovascular disease (5.6%) and 9 out of 79 diabetics who were either myocardial infarction survivors or who had angiographically-proven coronary artery disease (11.4%) had low aCL titres (P less than 0.01 for comparison of either diabetic group with controls, and P less than 0.1 for comparison between diabetic groups). One subject in each diabetic group, but no non-diabetics, had moderate IgM aCL titres. No subjects had high aCL titres. Diabetics have an increased frequency of low aCL titres which may relate to macrovascular disease. Macrovascular disease in diabetics is not associated with moderate or high aCL titres.

Exercise-induced changes in platelet aggregation; a comparison of whole blood and platelet rich plasma techniques

Studies have been performed to assess the effect of exercise on spontaneous platelet aggregation in shaken whole blood, and on agonist-induced platelet aggregation in whole blood and platelet rich plasma (PRP). Spontaneous platelet aggregation in shaken whole blood was increased following exercise compared to pre-exercise values. The increase in spontaneous aggregation after exercise correlated inversely with the increase in white cell count in whole blood. Platelet sensitivity in whole blood to adrenaline, collagen and adenosine diphosphate (ADP) was increased following exercise. Changes in platelet sensitivity to adrenaline following exercise correlated with increases in plasma noradrenaline levels but not with changes in blood cell counts. In PRP, platelet sensitivity to ADP and to collagen was increased following exercise when the pre and post-exercise PRP platelet counts were not corrected to allow for the increase in platelet count which occurred with exercise. When the PRP platelet counts were corrected, no changes in platelet sensitivity to any agonist after exercise were observed.

Ex vivo platelet studies following oral nisoldipine in normotensive insulin-dependent diabetics and non-diabetic controls

The effect of 24 hours and 7 days treatment with nisoldipine (10 mg, twice daily) on platelet function was studied in 12 normotensive volunteers of whom six were insulin-dependent diabetics without clinical evidence of vascular complications. Platelet aggregation was assessed by platelet rich plasma (PRP) and whole blood (WB) techniques. In addition, the effect of nisoldipine on platelet hyperaggregability following exercise was assessed. After taking nisoldipine for 24 hours, in vitro platelet hypersensitivity to adenosine diphosphate was observed in PRP (p less than 0.01) and WB (p less than 0.01), to adrenaline in WB (p less than 0.03), and to collagen in PRP (p less than 0.02). After seven days treatment, platelet sensitivities to all agonists at rest in both PRP and WB showed no differences from pre-treatment values. Exercise-induced platelet hypersensitivity in WB to all three agonists was unchanged after nisoldipine treatment. Plasma noradrenaline and adrenaline concentrations increased after 24 hours treatment, although changes in agonist EC50s at 24 hours were not related to changes in plasma catecholamine levels. No effects of nisoldipine were observed on platelet thromboxane B2 release in PRP, or on plasma beta-thromboglobulin levels. No differences in the effects of nisoldipine were observed between diabetic and non-diabetic subjects. Nisoldipine treatment for seven days is not associated with altered platelet function, but platelet hypersensitivity is observed after treatment for 24 hours in both insulin-dependent diabetics and controls.

Platelet function in uncomplicated insulin-dependent diabetic patients at rest and following exercise

There are conflicting reports of platelet function abnormalities in diabetic patients without vascular complications. We have studied in vitro platelet aggregation, using platelet rich plasma and whole blood techniques, in 18 patients with uncomplicated insulin-dependent diabetes and a matched group of 24 non-diabetic subjects. In addition we measured plasma beta-thromboglobulin levels in these groups, as an index of in vivo platelet activation, and compared the indices of in vitro and in vivo platelet function before and after maximal bicycle exercise. Before exercise plasma beta-thromboglobulin levels and platelet sensitivities to ADP, collagen or adrenaline, as assessed by both methods of platelet aggregation, were the same in diabetic and control subjects. Both groups showed similar increases in beta-thromboglobulin levels and in platelet sensitivity to all agonists in whole blood following exercise. Using platelet rich plasma there were no changes in platelet sensitivity in either group after exercise. In non-diabetic subjects, increases in noradrenaline levels after exercise correlated with increases in platelet sensitivity to adrenaline in whole blood. This was not observed in the diabetic group. Abnormalities of platelet function, using the techniques described here, are not present in diabetic patients who do not have clinical evidence of vascular disease.

Increased mean platelet volume after acute myocardial infarction relates to diabetes and to cardiac failure

Mean platelet volume, platelet count and an estimate of platelet volume distribution were studied following acute myocardial infarction in 59 diabetics and 88 non-diabetics and were compared with values in 100 non-diabetic and 50 diabetic non-infarct subjects. In the non-diabetics mean platelet volume and platelet distribution width were similar in the non-infarcted patients and in the infarcted patients without severe cardiac failure. All diabetics with myocardial infarction had larger mean platelet volumes and platelet distribution width than the diabetic non-infarct controls. All myocardial infarction patients with severe cardiac failure had larger platelet volumes than patients with mild or no failure. Increased mean platelet volume may reflect either increased platelet activation or increased numbers of large, hyperaggregable platelets. Abnormalities of platelet function may contribute to the relatively poor prognosis of myocardial infarction in patients with diabetes.

Deoxyribonucleic acid polymorphism of the apoprotein AI-CIII-AIV gene cluster and coronary heart disease in non-insulin-dependent diabetes

The prevalence of an uncommon allelic variant (S2) of the apoprotein AI-CIII-AIV gene cluster was determined in non-insulin-dependent diabetics with or without evidence of coronary heart disease and in controls. Frequencies of the S2 allele were 14% for diabetics with coronary heart disease compared with 2% for non-diabetics with no clinical evidence of occlusive vascular disease. No subject with the S2 allele was detected among a further group of matched diabetics without clinical features of macrovascular disease. The results suggest that a genetic component contributes to the susceptibility to coronary heart disease in non-insulin-dependent diabetics. Whether the observed deoxyribonucleic acid variant is aetiological for atherosclerosis or in linkage disequilibrium with other atherogenic loci on chromosome 11 remains to be clarified.