Differential effects of once-weekly glucagon-like peptide-1 receptor agonist dulaglutide and metformin on pancreatic ß-cell and insulin sensitivity during a standardized test meal in patients with type 2 diabetes.

This substudy of the AWARD-3 trial evaluated the effects of the once-weekly glucagon-like peptide-1 receptor agonist, dulaglutide, versus metformin on glucose control, pancreatic function and insulin sensitivity, after standardized test meals in patients with type 2 diabetes. Meals were administered at baseline, 26 and 52 weeks to patients randomized to monotherapy with dulaglutide 1.5 mg/week (n = 133), dulaglutide 0.75 mg/week (n = 136), or metformin ≥1500 mg/day (n = 140). Fasting and postprandial serum glucose, insulin, C-peptide and glucagon levels were measured up to 3 h post-meal. ß-cell function and insulin sensitivity were assessed using empirical variables and mathematical modelling. At 26 weeks, similar decreases in area under the curve for glucose [AUCglucose (0-3 h)] were observed among all groups. ß-cell function [AUCinsulin /AUCglucose (0-3 h)] increased with dulaglutide and was unchanged with metformin (p ≤ 0.005, both doses). Dulaglutide improved insulin secretion rate at 9 mmol/l glucose (p ≤ 0.04, both doses) and ß-cell glucose sensitivity (p = 0.004, dulaglutide 1.5 mg). Insulin sensitivity increased more with metformin versus dulaglutide. In conclusion, dulaglutide improves postprandial glycaemic control after a standardized test meal by enhancing ß-cell function, while metformin exerts a greater effect on insulin sensitivity.

Low incidence of anti-drug antibodies in patients with type 2 diabetes treated with once-weekly glucagon-like peptide-1 receptor agonist dulaglutide.

Therapeutic administration of peptides may result in anti-drug antibody (ADA) formation, hypersensitivity adverse events (AEs) and reduced efficacy. As a large peptide, the immunogenicity of once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist dulaglutide is of considerable interest. The present study assessed the incidence of treatment-emergent dulaglutide ADAs, hypersensitivity AEs, injection site reactions (ISRs), and glycaemic control in ADA-positive patients in nine phase II and phase III trials (dulaglutide, N = 4006; exenatide, N = 276; non-GLP-1 comparators, N = 1141). Treatment-emergent dulaglutide ADAs were detected using a solid-phase extraction acid dissociation binding assay. Neutralizing ADAs were detected using a cell-based assay derived from human endothelial kidney cells (HEK293). A total of 64 dulaglutide-treated patients (1.6% of the population) tested ADA-positive versus eight (0.7%) from the non-GLP-1 comparator group. Of these 64 patients, 34 (0.9%) had dulaglutide-neutralizing ADAs, 36 (0.9%) had native-sequence GLP-1 (nsGLP-1) cross-reactive ADAs and four (0.1%) had nsGLP-1 neutralization ADAs. The incidence of hypersensitivity AEs and ISRs was similar in the dulaglutide versus placebo groups. No dulaglutide ADA-positive patient reported hypersensitivity AEs. Because of the low incidence of ADAs, it was not possible to establish their effect on glycaemic control.

Safety and efficacy of once-weekly dulaglutide versus sitagliptin after 2 years in metformin-treated patients with type 2 diabetes (AWARD-5): a randomized, phase III study.

AIMS: To compare the once-weekly glucagon-like peptide-1 (GLP-1) receptor dulaglutide with the dipeptidyl peptidase-4 (DPP-4) inhibitor sitagliptin after 104 weeks of treatment. METHODS: This AWARD-5 study was a multicentre, double-blind trial that randomized participants to dulaglutide (1.5 or 0.75 mg) or sitagliptin 100 mg for 104 weeks or placebo (reported separately) for 26 weeks. Change in glycated haemoglobin (HbA1c) concentration from baseline was the primary efficacy measure. A total of 1098 participants with HbA1c concentrations ≥7.0% (≥53.0 mmol/mol) and ≤9.5% (≤80.3 mmol/mol) were randomized, and 657 (59.8%) completed the study. We report results for dulaglutide and sitagliptin at the final endpoint. RESULTS: Changes in HbA1c at 104 weeks were (least squares mean ± standard error) -0.99 ± 0.06% (-10.82 ± 0.66 mmol/mol), -0.71 ± 0.07% (-7.76 ± 0.77 mmol/mol) and -0.32 ± 0.06% (-3.50 ± 0.66 mmol/mol) for dulaglutide 1.5 mg, dulaglutide 0.75 mg and sitagliptin, respectively (p < 0.001, both dulaglutide doses vs sitagliptin). Weight loss was greater with dulaglutide 1.5 mg (p < 0.001) and similar with 0.75 mg versus sitagliptin (2.88 ± 0.25, 2.39 ± 0.26 and 1.75 ± 0.25 kg, respectively). Gastrointestinal adverse events were more common with dulaglutide 1.5 and 0.75 mg versus sitagliptin (nausea 17 and 15% vs 7%, diarrhoea 16 and 12% vs 6%, vomiting 14 and 8% vs 4% respectively). Pancreatic, thyroid, cardiovascular and hypersensitivity safety were similar across groups. CONCLUSIONS: Dulaglutide doses provided superior glycaemic control and dulaglutide 1.5 mg resulted in greater weight reduction versus sitagliptin at 104 weeks, with acceptable safety.

Dose-finding results in an adaptive, seamless, randomized trial of once-weekly dulaglutide combined with metformin in type 2 diabetes patients (AWARD-5).

AIMS: AWARD-5 was an adaptive, seamless, double-blind study comparing dulaglutide, a once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist, with placebo at 26 weeks and sitagliptin up to 104 weeks. The study also included a dose-finding portion whose results are presented here. METHODS: Type 2 diabetes (T2D) patients on metformin were randomized 3 : 1 : 1 to seven dulaglutide doses, sitagliptin (100 mg), or placebo. A Bayesian algorithm was used for randomization and dose selection. Patients were adaptively randomized to dulaglutide doses using available data on the basis of a clinical utility index (CUI) of glycosylated haemoglobin A1c (HbA1c) versus sitagliptin at 52 weeks and weight, pulse rate (PR) and diastolic blood pressure (DBP) versus placebo at 26 weeks. The algorithm randomly assigned patients until two doses were selected. RESULTS: Dulaglutide 1.5 mg was determined to be the optimal dose. Dulaglutide 0.75 mg met criteria for the second dose. Dulaglutide 1.5 mg showed the greatest Bayesian mean change from baseline (95% credible interval) in HbA1c versus sitagliptin at 52 weeks -0.63 (-0.98 to -0.20)%. Dulaglutide 2.0 mg showed the greatest placebo-adjusted mean change in weight [-1.99 (-2.88 to -1.20) kg] and in PR [0.78 (-2.10 to 3.80) bpm]. Dulaglutide 1.5 mg showed the greatest placebo-adjusted mean change in DBP [-0.62 (-3.40 to 2.30) mmHg]. CONCLUSIONS: The Bayesian algorithm allowed for an efficient exploration of a large number of doses and selected dulaglutide doses of 1.5 and 0.75 mg for further investigation in this trial.

Monotherapy with the once-weekly GLP-1 analogue dulaglutide for 12 weeks in patients with Type 2 diabetes: dose-dependent effects on glycaemic control in a randomized, double-blind, placebo-controlled study.

AIMS: Evaluate dose-dependent effects of once-weekly dulaglutide, a glucagon-like peptide-1 analogue, on glycaemic control in patients with Type 2 diabetes treated with lifestyle measures with or without previous metformin. METHODS: This 12-week, double-blind, placebo-controlled, dose-response trial randomized 167 patients who were anti-hyperglycaemic medication-naïve or had discontinued metformin monotherapy [mean baseline HbA(1c) 59 ± 8 to 61 ± 8 mmol/mol (7.6 ± 0.7 to 7.8 ± 0.8%)] to once-weekly injections of placebo or dulaglutide (0.1, 0.5, 1.0 or 1.5 mg). RESULTS: A significant dose-dependent reduction in HbA(1c) (least squares mean ± SE) was observed across doses (P < 0.001). HbA(1c) reductions in the 0.5, 1.0 and 1.5 mg dulaglutide groups were greater than in the placebo group [-10 ± 1, -11 ± 1 and -11 ± 1 vs. 0 ± 1 mmol/mol (-0.9 ± 0.1, -1.0 ± 0.1 and -1.0 ± 0.1 vs. 0.0 ± 0.1%), respectively, all P < 0.001]. Dose-dependent reductions in fasting plasma glucose were also observed [least squares mean difference (95% CI) ranging from -0.43 (-1.06 to 0.19) mmol/l for dulaglutide 0.1 mg to -1.87 (-2.56 to -1.19) mmol/l for dulaglutide 1.5 mg, P < 0.001]. Dose-dependent weight loss was demonstrated across doses (P = 0.009), but none of the groups were different from placebo. The most common adverse events were nausea and diarrhoea. CONCLUSIONS: The observed dulaglutide dose-dependent reduction in HbA(1c) and its acceptable safety profile support further clinical development for treatment of Type 2 diabetes.

Cytogenetic effects of 8-Cl-cAMP on human and animal chromosomes.

PURPOSE: To assess the cytogenetic effects in vitro and in vivo of a non-cytotoxic antitumor agent with biomodulator activity, 8-chloro-3',5' cyclic adenosine monophosphate (8-ClcAMP). MATERIALS AND METHODS: Cytogenetic effects of 8-Cl-cAMP where evaluated using the in vitro chromosome cytogenetic assay (CA) on human peripheral blood lymphocytes of healthy individuals and by bone marrow micronucleus assay in adult BALB/c mice. RESULTS: In the in vitro chromosome CA, 8-Cl-cAMP (in all respective doses; 1.5 and 15 microm) induced mitotic inhibition and premature centromere separation (PCS) but no chromosomal damage in cultured human peripheral blood lymphocytes. In the in vivo test, single intraperitoneal (i.p.) injection of 8-Cl-cAMP in doses of 10, 80 and 150 mg/kg showed a dose-related effect on the frequency of micronuclei, detected in murine polychromatic erythrocytes (PCE). CONCLUSION: The results of the present study show that genotoxicity of 8-Cl-cAMP has a different matrix of response when comparing results in vitro and in vivo, suggesting that high metabolic activity in vivo is responsible for the clastogenic potential of 8-Cl-cAMP. These comparative results indicate a need of having an available battery of genotoxic tests in order to evaluate possible cytogenetic effects of novel antitumor agents.

Effect of two starting insulin regimens in patients with type II diabetes not controlled on a combination of oral antihyperglycemic medications.

In an open-label, 24-week, parallel-group study, 135 patients inadequately controlled with oral antihyperglycemic medications (OAMs) were treated with maximally tolerated doses of metformin and glibenclamide for at least 8 weeks and then randomized to bedtime neutral protamine Hagedorn (NPH) insulin plus maximally tolerated dose of glibenclamide BID (glib/NPH group) or insulin lispro mix 50 (50% lispro, 50% insulin lispro protamine suspension [ILPS]) pre-breakfast and lispro mix 25 (25% lispro, 75% ILPS) pre-dinner (LM50/LM25 group) (both OAMs discontinued). The LM50/LM25 group had significantly lower 2-hour postprandial BG (both meals combined) compared with glib/NPH after 12 (11.70+/-3.40 mmol/L vs. 13.15+/-2.44 mmol/L, p=0.010) and 24 weeks (11.13+/-3.31 mmol/L vs. 14.46+/-2.93 mmol/L, p =0.0001). Both regimens significantly decreased HbA1c. The reduction was greater with LM50/LM25 (-1.31+/-2% vs. -0.5+/-1.6%; P=0.01). At endpoint, the overall hypoglycemia rate increased with LM50/LM25 and decreased with glib/NPH compared with baseline (0.22+/-0.9 vs. -0.08+/-0.72 episodes/patient/30 days; p =0.037). Treatment with LM50/LM25 compared with glib/NPH in patients with inadequate control on combined OAMs yielded better postprandial and overall glycemic control with a higher rate of hypoglycemia.

A study on the genotoxic effects of 8-Cl-cAMP on human lymphocytes in vitro.

8-chloro-cyclic adenosine 3',5'-monophosphate (8-Cl-cAMP) is the most potent cAMP analogue that selectively inhibits a variety of cancer cell lines in vitro and tumors in vivo. Its action toward a variety of tumors, especially when coupled with other antitumor agents, have lead to phase I clinical investigations and recently phase II clinical investigations. Until today very little was done to evaluate its genotoxic potential. In order to evaluate its genotoxic potential we used the cytogenetic and cytokinesis block micronucleus assay in vitro on peripheral blood lymphocytes of healthy individuals. Using three concentrations (1 microM, 5 microM and 15 microM), 8-Cl-cAMP in normal human peripheral blood lymphocytes did not induce any cytogenetic aberrations of the structural type [chromatid breakage, isochromatid breakage and gaps], but did induce premature centromere separation (PCS) in all respective doses and increased the frequency of micronuclei (p <0.05) only in the highest dose (15 microM). Antiproliferative action of 8-Cl-cAMP was estimated by using the cytokinesis block nuclear division index (NDI). The results showed a decrease in the NDI of cells exposed to all doses of 8-Cl-cAMP when compared to control. Therefore, the overall results show a genotoxic potential of 8-Cl-cAMP in peripheral blood lymphocytes in vitro.

Molecular characterization of hsp90 isoforms in colorectal cancer cells and its association with tumour progression.

A key role of hsp90 in the activity of various oncogenic proteins and pathways is currently of intense interest. To clarify the molecular basis of biological behaviour of colorectal cancers we analysed the expression characteristics of hsp90 in cytosolic, nuclear and plasma membranous fractions of cancer cells. As determined by Western blot assay all hsp90 isoforms studied, alpha (84 kDa), beta (86 kDa) and hsp90N (75 kDa), were up-regulated and differentially expressed in various stages of colorectal carcinoma. The inducible hsp90alpha isoform is a component of invasive phenotype of cancer cells thus pointing to the importance of hsp90alpha for metastasis generation. The expression of hsp90beta is definitely higher in poorly-differentiated carcinomas than in well-differentiated cancers, suggesting an involvement of hsp90beta in the inhibition of cancer cell differentiation. Especially, the expression of cytosolic hsp90N isoform in malignant cells points to the possibility that induction or overexpression of hsp90N might be causally related to tumour formation. Hsp90N is the plasma-membrane-associated protein in poorly-differentiated colorectal cancers with metastasis. This suggests that the expression of hsp90N is elevated with progressive dedifferentiation often associated with advanced cancer stages. Hsp90 was exclusively localized in the invasive front in a majority of metastatic cancers as visualized by immunohistochemical study. Consistent with these facts, the frequent expression of hsp90alpha and hsp90N on the surface of colorectal cancer cells may enable hsp90 to act as a mediator of metastasis generation. The above results indicate more complex roles for hsp90 in colorectal tumourigenesis. In this way, the hsp90 would be at the crossroads of both signalling and cell migration events.

Deregulated sequential motion of centromeres induced by antitumor agents may lead to genome instability in human peripheral blood lymphocytes.

PURPOSE: Segregation of chromosomes in anaphase is preceded by a sequential order of centromere separation. Alteration of the sequence of centromere separation or premature centromere division (PCD) has been found to be significantly higher in populations exposed to various xenobiotics. The purpose of this study was to investigate if PCD induced by various cytostatics can alter the stability of chromosomes and lead to aneuploidy. MATERIALS AND METHODS: Peripheral blood lymphocytes of 10 healthy, non smoking subjects were exposed to 8-Cl-cAMP at a dose of 1, 5 and 15 microM, paclitaxel at a dose of 0.01, 0.05 and 0.2 microM, and cycloheximide (CX) at a dose of 5, 10 and 25 microg/ml. By using the cytohalasin B (CB)-micronucleus (MN) test in vitro, in combination with fluorescent in situ hybridization (FISH), the presence of MN was analyzed in 1000 binuclear cells for each experimental and negative control group. For analysis of MN content we used the alpha-centromeric probe for chromosome 18. RESULTS: 8-Cl-cAMP and paclitaxel induced an increase in the frequency of MN in peripheral blood lymphocytes. 8-Cl-cAMP and paclitaxel proved clastogenic, i.e. they increased the frequency of MN and induced PCD in all respective doses. CX proved not clastogenic in the respected doses when using the CB-MN test in vitro, although CX is a specific PCD inducer. No correlation of PCD and aneuploidy of chromosome 18 was found in cells exposed to 8-Cl-cAMP and paclitaxel by using FISH. In cells exposed to CX we found PCD of chromosome 18 in binuclear cells and single signals in scarce MN. These findings were not statistically significant compared to the negative control group. CONCLUSION: Our results show that the properties of the investigated antitumor agents to induce PCD in peripheral blood lymphocytes and, therefore, aneuploidy and genome instability, is highly based on the nature of the alteration of centromere function, i.e. the temporal order of centromere kinetics are more regulated through the sequence of centromere separation than by the segregation processes. We suggest that PCD induced by novel antitumor agents could be included in preclinical and clinical genetic risk assessment analysis.

A quantitative morphometric study of rectal mucosa in adult and aged healthy subjects.

Rectal mucosa is relatively susceptible to pathological processes and frequently it is affected by various diseases. However, there is a notable lack of quantitative data regarding normal rectal mucosa, which would provide a reference for histoquantitative studies of the pathologically changed tissue. Therefore, we obtained the tissue from 27 healthy patients subjected to diagnostic rectoscopy during active screening for asymptomatic cancer of the large intestine, in which no disease was found. Using computer-aided morphometric analysis, we studied all structural elements of the rectal mucosa. The patients were divided into four groups according to the age and sex: adult males, elderly males, adult females and elderly females. The patients under 60 years of age were grouped as adult and those older than 60 years as aged subjects. A decreased height of surface epithelium was registered in both elderly male and female groups. This finding, however, was significant only when adult and elderly male groups were compared. The tendency towards reduction of the mucosal height was also registered comparing male adult and elderly groups. The number of crypts per 0.1 mm2 of tissue increased with aging in both males and females, whereby the crypts were always more numerous in males than in females. The increase in number of crypts in male subjects was accompanied by a decrease in their diameter and perimeter. The changes associated with ageing were discrete and affected only the male subjects.

Expression of heat shock protein 70 (HSP70) in patients with colorectal adenocarcinoma--immunohistochemistry and Western blot analysis.

The role of heat shock protein 70 (HSP70) expression has been investigated in various types of tumors. There are only little and controversial data about its clinical relevance in colorectal carcinoma, one of the most common carcinomas observed in humans. In this study we investigated expression of HSP70 in human colonic carcinoma and possible correlation with clinicopathology. To assess patterns (cytosolic and membrane) of HSP70 expression, the 48 surgically removed colorectal adenocarcinomas and 12 normal colonic and rectal mucosal samples were examined by immunohistochemistry and Western-blot. According to results of immunohistochemistry, expression of cytoplasmic HSP72 was significantly higher in colorectal carcinoma compared with normal and adjacent mucosa (p<0.01). In addition, there was significant increase in HSP72 expression in lymph node-positive compared to node-negative group (p<0.001). Dukes C2 stage of colonic cancer showed significantly higher immunohistochemical score than Dukes B2 and B1 stage groups (p< 0.05 i.e. p< 0.02). There was no relation between expression of HSP72 and degree of tumor differentiation. Using Western blot analyses, we noticed elevated levels of cytosolic HSP70 in colorectal cancer cells compared to normal. Densitometric analysis of blots of plasma membrane HSP70 expression has shown decrease in colorectal cancer cells compared to normal mucosa. According to our results, overexpression of HSP72 in malignant tissues of patients with colorectal carcinoma is related to tumor progression, suggesting that these proteins could play an important role not only in tumorigenesis but also in the development of drug resistance. Further research is necessary to clarify the mechanisms responsible for differential HSP70 expression as well as its definitive role in colorectal cancer.

A negative adaptive response is expressed in peripheral blood lymphocytes that are exposed to mitomycin C and cycloheximide.

PURPOSE: Mitomycin C (MMC) and cycloheximide (CHX) are known for their apoptotic and antitumor activity. CHX is also known for its property to inhibit protein synthesis and to reduce cytotoxicity of various antitumor drugs, i.e. inducing an adaptive survival response (ASR). The purpose of this study was to evaluate the effect of ASR induced by CHX in cells exposed to clastogenic doses of MMC. MATERIALS AND METHODS: In all experiments we used human peripheral blood lymphocytes of 10 healthy male non-smokers, 25-35 years of age. Three groups were established. One control group of PBS-treated group. Two distinctive experimental groups were based on the induction or non-induction of ASR by CHX, i.e. one with MMC alone and a second one with CHX and MMC. The effect of ASR was induced by CHX at a dose of 10 mug/ml. MMC was used in 3 dose levels: 0.05 muM, 0.15 muM and 0.6 muM. To evaluate ASR induced by CHX in cells exposed to MMC we used the cytokinesis-blocked micronucleus test (CBMN) in vitro. RESULTS: CHX at a dose of 10 mg/ml induced an ASR in human peripheral blood lymphocytes of healthy subjects exposed to increasing doses of MMC. CHX induced statistically highly significant difference (p < 0.001) in the nuclear division index (NDI) compared to cells exposed to MMC alone. Genotoxicity of MMC measured by the percentage of micronuclei in binuclear (BN) cells was not elevated in the presence of CHX. Also, the increase in the NDI was correlated with the decrease in nuclear fragmentation (NF). CONCLUSION: The observed differences in NF and the NDI between the two groups showed that ASR to MMC induced by CHX could be a consequence of inhibition of apoptosis. We argue that adaptation (pro-life processes) can overwhelm its positive aspects (antimutagenic and anticarcinogenic) by increasing the population of cells with chromosome aberrations (chromosome instability) by apoptotic inhibition. CHX disturbs the apoptotic signal. Understanding that ASR can act as a pro-survival process leading to inhibition of apoptosis shall enhance in the future our knowledge of anticarcinogenesis, thus utilizing new paths for better treatment of cancer.

Beta-cell secretory function and CD25 + lymphocyte subsets in the early stage of type 1 diabetes mellitus.

Cellular immunologic tests have not been used for diagnostic purposes in individuals at risk for autoimmune insulitis or in patients with partial beta-cell destruction because of a lack of studies that show their predictive value. In this study we initially evaluated 43 patients with recent-onset Type 1 diabetes (disease duration

Advanced glycation endproducts in peripheral nerve in type 2 diabetes with neuropathy.

Advanced glycation endproducts (AGE) accumulate over proteins as a consequence of diabetic hyperglycemia, and thus contribute to the pathogenesis of diabetic complications. To improve the understanding of the pathology of diabetic neuropathy, AGE accumulation was analyzed in sural and/or femoral nerves obtained under spinal anesthesia from 8 type 2 diabetic patients with both distal symmetrical polyneuropathy and proximal neuropathy. Pronounced AGE immunoreactivity was detected on axons and myelin sheaths in 90% of diabetic peripheral nerves but not in the control specimen. The intensity of axonal AGE immunopositivity significantly correlated with the severity of morphological alterations (p<0.005). AGE localization, demonstrated by immunohistochemical methods, was also present in the endoneurium, perineurium and microvessels. Morphometric analysis of the diabetic peripheral nerve showed perineurial thickening (diabetic vs. control, 15.5+/-4.9 vs. 6.6+/-2.1 microm, p<0.001), narrowing of the microvessel lumina (66.6+/-50.5 vs. 579.5+/-38.4 x10(3) microm(2), p<0.001) and significant reduction in the number of preserved axons (3.6+/-3 vs. 8.9+/-2.3 per 10(5) microm(2) per area, p<0.037). The sera of diabetic patients contained epitope(s) of AGE structure and soluble immune complexes containing AGE moiety. In conclusion, to the best of our knowledge, this is the first study providing evidence for excessive AGE formation on peripheral nerve components, primarily axons, and a significantly higher level of circulating AGE-immune complexes in patients with both distal diabetic polyneuropathy and proximal neuropathy. Humoral immune mechanisms, including the production of anti-AGE autoantibody, may potentially be involved in the development of structural abnormalities described in this report.

Apoptotic versus genotoxic potential of anti-tumor agents: a concept of duality in unity.

Recent advances in anti-tumor therapy have raised a problem of secondary tumors and tumor resistance. Secondary tumors induced by chemotherapeutic agents as a consequence of primary therapy have poor prognostic outcome. Many new insights into molecular controls of cell cycle progression of normal and cancer cells can provide a useful framework in order to identify potential targets for anti-tumor therapies. One of the most promising strategies is the possibility to modulate apoptosis induced by anti-tumor agents. Cancer cell survival after chemotherapy will depend on specific checkpoints and/or repair pathways that have been lost, leading either to greater susceptibility to anti-tumor agents when the repair of damage is most important for survival or to greater resistance when the apoptotic response is more important. We have proposed a hypothesis that views survival and apoptotic processes (duality) in normal and tumor cells as genetically coupled (unity). We introduce, through a theoretical background, a new pathway of apoptotic inhibition. The proposed process of apoptotic inhibition is induced by mutation fixation in which recombination/repair processes (hRAD genes) play an important role. These coupled processes (duality in unity), to our view, underline tumor resistance by apoptotic inhibition and mutation fixation in normal cells exposed to anti-tumor agents.

A comparison of insulin lispro Mix25 and human insulin 30/70 in the treatment of type 2 diabetes during Ramadan.

OBJECTIVE: To compare insulin lispro Mix25 and human insulin 30/70 with regard to their effect on morning and evening postprandial glucose (PPG) control, and on average daily blood-glucose (BG), in patients with Type 2 diabetes who wish to fast during Ramadan. METHOD: Insulin lispro Mix25 and human insulin 30/70 were compared in an open-label, multicenter, randomised, crossover study involving 151 patients. Each treatment period had a duration of 14 days during which the patients self-monitored their BG before and 2 h after the main meals on any 3 days within the last 5 days of each treatment period. RESULTS: The 2 h PPG excursion following the main evening meal after sunset was significantly lower with insulin lispro Mix25 (3.4+/-2.9 mmol/l) compared with human insulin 30/70 (4.0+/-3.2 mmol/l, P=0.007). The evening pre-meal fasting BG values were also lower with insulin lispro Mix25 (7.1+/-2.2 mmol/l) versus human insulin 30/70 (7.5+/-2.6 mmol/l, P=0.034). The average daily BG concentration was 9.5+/-2.4 mmol/l during treatment with insulin lispro Mix25 versus 10.1+/-2.5 mmol/l with human insulin 30/70 given in identical doses (P=0.004). CONCLUSION: When compared with human insulin 30/70, treatment of insulin-requiring Type 2 patients with insulin lispro Mix25 during Ramadan resulted in better average daily glycaemia, and better BG control before and after the evening meal. Insulin lispro Mix25 should be considered as a therapeutic option during Ramadan.

Interventions in diabetic patients after myocardial infarction.

Occurrence of a first acute myocardial infarction (AMI) is associated with further increase in risk of cardiovascular events. This risk is further increase is disproportionate in diabetics, who suffer from very high mortality short and long term after AMI. Factors responsible for the increased risk are only partially understood. Additional, properly designed, prospective epidemiological studies are needed for a better understanding of complicated diabetic macrovascular disease after the occurrence of the first event. These studies are also needed for designing interventional trials that target factors that carry the highest risk of new events. Published studies provide some insight into the issue of efficacy of blood pressure, cholesterol and blood glucose lowering strategies in the diabetic population. It remains unclear how important is the control of triglyceride concentration or other risk factors during various stages of recovery after AMI. The main reason is the lack of clinical trials. Evidence-based approach to patients with diabetes and AMI indicates the importance of tight control of cholesterol, blood pressure and blood glucose concentration. Although other risk factors have not been extensively studied, it is reasonable to assume that other major risk factors, such as hypertriglyceridemia, should be targeted as well. In the meantime, more data need to be collected from prospective epidemiological and interventional protocols, if better control over the cardiovascular risk in this high-risk population is to be achieved.

Retrospective analysis of cardiovascular outcomes in patients with type 2 diabetes mellitus after the first acute myocardial infarction.

We retrospectively analyzed survival in patients with type 2 diabetes mellitus (DM) after first acute myocardial infarction (AMI). The study was conducted in 5 sites in Poland and involved 521 patients who survived more than 30 days after AMI. In the 5-year period after the acute event, we investigated the following cardiovascular (CV) outcomes: death (overall mortality), next MI, stroke, hospitalization due to acute coronary symptoms (HACS), and composite outcomes (whichever occurred first). We also assessed: age, smoking habit, obesity, hypertension, dyslipidemia and coronary artery disease (CAD) diagnosed before AMI, and gender. 269 patients (52%) suffered one of the outcomes from the composite CV endpoint. HACS was the first event in 164 cases, MI in 59, death in 32, and stroke in 14 patients. Analyzing the prevalence of individual CV events, we found: HACS in 184 patients (35%), next MI in 79 patients (15%), death in 59 patients (11%), and stroke in 30 patients (6%). Only dyslipidemia, arterial hypertension, and CAD were independent risk factors with an impact on composite CV endpoint. Other analyzed risk factors like smoking and obesity did not have independent effects on the CV risk. In the retrospective analysis, we found that HACS was the most frequent CV event in individuals with type 2 DM after AMI. The CV risk in type 2 diabetics who suffered at least one myocardial infarction was further increased in those with coexisting dyslipidemia, arterial hypertension or CAD. These findings support the current guidelines which recommend aggressive management of CV risk factors including hypertension, dyslipidemia and CAD before a first myocardial infarction.