Cross-sectional study of care, socio-economic status and complications in young French patients with type 1 diabetes mellitus.

OBJECTIVES: To describe the present status of type 1 diabetes care in France and study the relations between clinical and socio-economic variables on one hand and disease management and prevalence of complications on the other hand. METHODS: A random sample of 365 French specialists in diabetes care performed a cross-sectional study and included consecutively 562 children aged 10-16 and 1691 adults aged 16-45, with more than 2 years of type 1 diabetes. The main outcome measures were the prevalence of complications (retinal, renal, lower-limb, cardiovascular, ketoacidosis); disease management parameters (blood pressure, HbA1c, daily number of insulin injections, frequency of visits to a specialist in diabetes, membership of a patient association); socio-economic status as a score, and treatments received. RESULTS: Retinal complications were rare in children (0.7%) and common in adults (28.3%). 10.2% children and 15.2% adults had micro- or macro-albuminuria, 4.7% adults had plasma creatinine >or=150 micromol/L. Only 15% children and 26% adults had HbA1c<7%, 86.2% children and 62.7% adults had blood pressure<130/85 mmHg; 58% children and 80% adults had at least 3 daily insulin injections. In adults, the risk of experiencing at least one complication was linked significantly with diabetes duration, HbA1c, and socio-economic status. Age, sex, type of insulin therapy, tobacco consumption, and blood pressure control were not significant parameters. Ketoacidosis in the preceding year was only linked with HbA1C and socio-economic status. CONCLUSION: Although this sample of patients had overall a fair socio-economic status and were followed-up by specialists of diabetes care, metabolic and blood pressure control were not optimal. The care of French type 1 diabetics could probably be improved by a stricter control of glycaemia and blood pressure, and an earlier use of intensive insulin treatment, with a particular focus on adolescents and patients with the lowest socio-economic status.

Management of French patients with type 2 diabetes mellitus in medical general practice: report of the Mediab observatory.

OBJECTIVES: The Mediab study was conducted to estimate the medical care in French patients with type 2 diabetes mellitus managed by general practitioners on an ambulatory basis, but consIdered as requiring new treatment implementation. METHODS: Five thousand one hundred and fourty eight diabetic patients without any treatment or treated with lifestyle measures either alone or combined with an oral antIdiabetic agent given as monotherapy were included in a cross-sectional study that was conducted on a nationwIde basis by using the ORP (R) methodology. The 4088 patients in whom HbA1c was determined with a reliable method were further classified into 3 categories according to whether HbA1c was<=6.5% (group I, n=525), ranging between 6.6 and 8% (group II, n=1699) or > 8% (group III, n=1864). RESULTS: A large proportion of patients (45.6%) exhibited HbA1c > 8%. Adherence to diet and regular physical activity were progressively decreasing while prevalence of diabetic complications was steadily increasing from group I to III, i.e. when diabetic control was worsening. The complications suffered from severe "underreporting". When complications were reported, the odds-ratio analysis showed that retinopathy is influenced by both the magnitude of glucose excess and the diabetes duration, while renal diseases and macroangiopathy depend mainly on diabetes duration. 38.1% of patients visited a diabetologist, but most of these patients were referred to the speciaList after the inclusion visit. CONCLUSIONS: Despite the development of guIdelines, a large percentage of patients remains poorly-controlled. Future actions should be based on: (i) better collaboration between general practitioners and diabetologists (ii) better detection of complications that suffer from severe "underreporting", (iii) reinforcement of lifestyle recommendations and of pharmacological treatments by shifting from mono- to multi-drug therapy, at earlier stages of the disease.

Dose optimization study of arterial changes associated with angiotensin converting enzyme inhibition in hypertension.

BACKGROUND: In treating hypertension the optimal dose of angiotensin converting enzyme (ACE) inhibitor is derived from dose-response curves that relate the quantity of drug taken to the resulting fall in blood pressure; the blood pressure fall reflects a decrease in vascular resistance and hence, a degree of arteriolar vasodilation. However, ACE inhibition dilates not only the small arteries but also the larger calibre arteries, which increases compliance. Given the differences in structure and function of large and small arteries, the optimal drug dose for a given vessel may differ according to the size and structure of the vessel. DOSE-RESPONSE EFFECTS IN CLINICAL STUDIES: Clinical studies indicate that in the brachial artery territory, larger doses are required to obtain arterial dilation than to produce a decrease in vascular resistance. In the aorta, an improvement in arterial compliance and distensibility is governed both by the fall in blood pressure and the drug dose. Finally, for the femoral artery, the degree of arterial dilation is influenced markedly only by the drug dose. APPLICATION TO TREATMENT: An understanding of the drug dose required to produce a given change in the hypertensive arterial system may have important implications for the control of blood pressure. For a given mean arterial pressure, systolic blood pressure is lower and diastolic blood pressure higher when aortic compliance is increased, a haemodynamic change commonly seen following ACE inhibition. Recent double-blind studies have shown that ACE inhibitors produced a more pronounced decrease in systolic than diastolic blood pressure. CONCLUSION: These findings indicate that the optimum doses required to improve the arterial wall in large arteries must be evaluated by long-term antihypertensive therapy.

Efficacy, safety and acceptability of halofantrine in the treatment of acute Plasmodium falciparum malaria in African children (Gabon).

Halofantrine chlorhydrate 2 per cent suspension was given to 50 children (mean age 6.2 years in a dose of 8 mg/kg three times a day as a single day treatment. The children were born and lived in Gabon, where malaria transmission is continuous. They all had acute Plasmodium falciparum malaria. The children were kept in hospital for 5 days, and regularly followed over a 15-day period. The 50 children were cured and efficacy was evaluated as good in 44 cases, and excellent in six cases, as judged by improvement in their clinical signs and parasitaemia. Two criterias were considered in the evaluation of efficacy: clearance of parasitaemia (mean day 4), fever clearance (mean hour 24). There were two cases of persistences of parasites at day 15 with a very low parasitaemia rate. Tolerance to halofantrine was good from a clinical and biological point of view. Acceptability was excellent in all cases. Halofantrine 2 per cent suspension is a good alternative in the treatment of acute Plasmodium falciparum malaria in children, especially with the present situation of multidrug-resistant strains in Central Africa.

Placebo-controlled study of oral enoximone in congestive heart failure with initial and final intravenous hemodynamic evaluation.

Seventeen patients with stable congestive heart failure (class II and III New York Heart Association) received intravenous and oral enoximone in a 2-part study. Hemodynamic data were first obtained after intravenous administration of 0.75 mg/kg of enoximone; data were again obtained after 12 weeks of therapy with either oral enoximone (150 mg 3 times daily) or placebo. The efficacy and safety of oral enoximone were also studied in a 12-week, double-blind randomized format. In the intravenous study, enoximone was delivered over 5 minutes and hemodynamic data were measured for up to 12 hours after. Cardiac index increased 2.76 +/- 0.63 to 3.42 +/- 0.72 liters/min/m2), pulmonary wedge pressure decreased (19.5 +/- 8.8 to 14.6 +/- 8.0 mm Hg) as did mean arterial blood pressure (101 +/- 14.8 to 85 +/- 13.7 mm Hg) and systemic vascular resistance (1,880 +/- 573 to 1,254 +/- 383 dynes s cm-5). Heart rate increased slightly (82 +/- 17 to 86 +/- 14 beats/min). All these changes were maximal 1 to 2 hours after infusion and lasted 8 hours at least. Patients were then randomized double-blind to oral treatment. Baseline values showed that the 7 patients who received placebo had more severe CHF. Therefore, comparison might be biased. Patient overall assessment showed a continuous benefit in both groups. Ejection fraction improved from 30.1 +/- 6.8% to 33.9 +/- 9.9% in the enoximone group while it remained unchanged with placebo (23.4 +/- 6.5% to 23.4 +/- 1.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Antihypertensive effect of sustained-release isosorbide dinitrate for isolated systolic systemic hypertension in the elderly.

A double-blind, randomized trial was performed in 40 patients, mean age (+/- standard deviation) 80 +/- 4 years, with isolated systolic systemic hypertension to evaluate the antihypertensive effect of oral sustained-release isosorbide dinitrate (ISDN), 20 to 40 mg twice daily, vs placebo. After 12 weeks of treatment, supine systolic blood pressure (BP) decreased from 192 +/- 10 to 162 +/- 12 mm Hg with ISDN (p less than 0.001) and from 189 +/- 10 to 175 +/- 15 mm Hg with placebo (p less than 0.001). On the basis of variance analysis, the decrease in systolic BP was significantly lower with ISDN (27 mm Hg) than with placebo (13 mm Hg). Similar results were observed for supine and erect systolic BP measured at 8 AM and 4 PM, 8 and 12 hours after drug intake. No significant differences in diastolic BP, heart rate or side effects occurred. After the ISDN tapering off-period (2 weeks), systolic BP increased significantly but did not change with placebo. The study provided evidence that in elderly patients with systolic hypertension, sustained-release ISDN induced a selective and sustained decrease in systolic BP, antihypertensive effect was observed 8 and 12 hours after drug administration, and no tolerance phenomenon was noted.

[Transport of "high-risk" newborn infants. (Apropos of 159 emergency calls by the SAMU 94-Service d'Aide Médicale Urgente-Emergency Health Service)]. / Transport des nouveau-nes "a haut risque" (a propos de 159 interventions médicales urgentes régulée par le SAMU 94)

Analysis of our experience confirms in the domain of the newborn the fundamental notion of the Emergency medical call. The EMC has two objectives: 1--Emergency treatment before the patient is moved, and the correction of failing vital functions by a medical team skilled in problems of neonates. 2--Transportation of the neonate in a stable condition, to the Intensive Care unit. The quality of such transportation depends closely upon the quality of the medical care given and upon organisation. It can only be carried out in the context of a system coordinated by a "coordinating physician" (e.g. SAMU 94). This coordinating physician has responsibility for logistics, telephone coordination, and application of the call procedure as rapidly as possible. From a logistical point of view, only coordination between:--SAMU-SMUR;--Medical team of the Intensive care unit;--Requesting service make possible the provision and quality of continuous supplies of oxygen, warmth, sugar - all under aseptic conditions, indispensable to the quality of survival of the neonate. In addition, we feel it essential--that the delay before the call is answered be as brief as possible;--that the call should be dealt with by a mixed team, including at least one physician experienced in neonatal problems;--that the choice of vehicle used for transportation should be better adapted to the situation. This choice is the responsibility of the coordinating physician, who should base his decisions on two fundamental requirements:--rapidity of dealing with the call;--personal safety of those involved. This without losing sight of--Prevention of perinatal problems lies part with the detection of high risk pregnancies, with the aim of arranging delivery in specialised "mother and baby" centres where close collaboration between obstetrician and paediatrician is assured.--The development of transportation of the "high-risk" neonate, which is so costly in manpower and equipment, depends closely upon general concepts of health care in France, which should be aimed at:--the prevention of prematury;--the detection of high risk pregnancies;--the development of mother and baby centres.