The Minnesota Regional Peripheral Arterial Disease Screening Program: toward a definition of community standards of care.

The Minnesota Regional Peripheral Arterial Disease Screening Program was designed to define the efficacy of community PAD detection efforts, to assess the disease-specific and health-related morbidity, to assess PAD awareness rates, and to determine the magnitude of atherosclerosis disease risk factors and the intensity of their management. The target population was recruited via mass media efforts directed at individuals over 50 years of age and those with leg pain with ambulation. Screening sessions included assessments of the ankle-brachial index, blood pressure, fasting lipid profile, and use of validated tools to detect symptomatic claudication (by the Modified WHO-Edinburgh Claudication Questionnaire), walking impairment (Walking Impairment Questionnaire - WIQ), quality of life (MOS SF-36), PAD awareness, and the intensity of PAD medical therapeutic interventions. PAD was defined as any ankle-brachial index < or =0.85 or a history of lower extremity revascularization. The program evaluated 347 individuals and identified 92 subjects with PAD and 255 subjects without PAD, yielding a detection rate of 26.5%. Individuals with PAD were older, tended to have higher blood pressures, and had a significant walking impairment and an impaired health-related quality of life compared with the non-PAD subjects. Current rates of tobacco use were low. Lipid-lowering, estrogen replacement, anti-platelet, and antihypertensive medications and exercise therapies were underutilized in the PAD cohort. Peripheral arterial disease awareness was low in these community-identified patients. This Program demonstrated that individuals with PAD can be efficiently identified within the community, but that current standards of medical care are low. These data can assist in the future development of PAD awareness, education, and treatment programs.

In vivo human brachial artery elastic mechanics: effects of smooth muscle relaxation.

BACKGROUND: The effects of smooth muscle relaxation on arterial wall mechanics are controversial. We used a new, in vivo, noninvasive technique to measure brachial artery wall mechanics under baseline conditions and following smooth muscle relaxation with nitroglycerin (NTG). METHODS AND RESULTS: Eight healthy, normal subjects (6 male, 2 female; age 30+/-3.1 years) participated in the study. The nondominant brachial artery was imaged through a water-filled blood pressure cuff using an external ultrasound wall-tracking system at baseline and following 0.4 mg sublingual NTG. Simultaneous radial artery pressure waveforms were recorded by tonometry. Transmural pressure (TP) was reduced by increasing water pressure in the cuff. Brachial artery area, unstressed area, compliance, stress, strain, incremental elastic modulus (Einc), and pulse wave velocity (PWV) were measured over a TP range from 0 to 100 mm Hg. Baseline area versus TP curves generated 30 minutes apart were not significantly different. NTG significantly shifted area versus TP (P<0.0001) and compliance versus TP (P<0.001) curves upward, whereas the Einc versus TP (P<0.05) and PWV versus TP (P<0. 01) curves were shifted downward. NTG also significantly shifted stress versus strain (P<0.01) and Einc versus strain (P<0.01) curves to the right. CONCLUSIONS: We conclude that brachial artery elastic mechanics can be reproducibly measured over a wide range of TP and smooth muscle tone using a new noninvasive ultrasound technique. Smooth muscle relaxation with NTG increases isobaric compliance and decreases isobaric Einc and PWV in the human brachial artery.

Effect of obesity on the response to insulin therapy in noninsulin-dependent diabetes mellitus.

An initial improvement in glycemic control is often followed by gradual deterioration of glycemia during insulin treatment of patients with noninsulin-dependent diabetes mellitus (NIDDM). We examined the causes of such worsening in a 12-month follow-up analysis of 100 insulin-treated NIDDM patients in the Finnish Multicenter Insulin Therapy Study who were treated with either combination therapy with insulin or insulin alone. In the entire study group, glycemic control averaged 9.7 +/- 0.2% at 0 months and 8.0 +/- 0.1%, 8.0 +/- 0.1%, 8.2 +/- 0.1%, and 8.5 +/- 0.2% at 3, 6, 9, and 12 months (P < 0.001 for each time point vs. 0 months). Glycemic control at 12 months was significantly worse than that at 3 (P < 0.001), 6 (P < 0.001), and 9 months (P < 0.02). Baseline body mass index was the most significant predictor of deterioration in glycemic control. During 1 yr, hemoglobin A1c decreased almost 3-fold more (by 1.7 +/- 0.2%; P < 0.001 vs. 0 months) in patients whose baseline weight was below the mean baseline body mass index of 28.1 kg/m2 (nonobese patients) than in those whose weight exceeded 28.1 kg/m2 (obese patients; 0.5 +/- 0.2%; P = NS vs. 0 months; P < 0.01 vs. obese patients). Glycemic control improved similarly over 1 yr in the nonobese subjects and deteriorated similarly in the obese patients regardless of their treatment regimen. Insulin doses, per body weight, were similar in the nonobese and obese patients. The nonobese patients consistently gained less weight during 12 months of combination therapy with insulin (3.5 +/- 0.6 kg at 12 months) than during insulin therapy alone (5.1 +/- 0.6 kg; P < 0.05). The treatment regimen did not influence weight gain in the obese group, who gained 4.4 +/- 1.0 kg during combination therapy with insulin and 4.5 +/- 1.1 kg during insulin therapy alone. We reached the following conclusions: 1) after an initial good response, glycemic control deteriorates more in obese than in nonobese patients with NIDDM; 2) in obese patients, weight gain per se cannot explain the poor glycemic response to combination or insulin therapy, but it may induce a disproportionately large increase in insulin requirements because of greater insulin resistance in the obese than in the nonobese; 3) in nonobese patients, glycemic control improves equally during 1 yr with combination therapy with insulin and insulin alone, but combination therapy with insulin is associated with less weight gain than treatment with insulin alone; 4) weight gain appears harmful, as it is associated with increases in blood pressure and low density lipoprotein cholesterol.

Vitamin D treatment and bone mineral density in the aged.

The purpose of this study was to investigate whether long-term vitamin D treatment increased bone mineral density in the aged. The bone mineral density in the distal forearm and femoral neck did not differ between nine residents (mean age 81.0 years) of an old peoples' home who had received an annual injection of 150,000 IU ergocalciferol during the foregoing 2-7 years (mean 5.1 years) and nine age-, weight- and height-matched control subjects who had subnormal 25 hydroxyvitamin D level. The alkaline phosphatase and parathyroid hormone levels were clearly higher when the 25 hydroxyvitamin D level was below 10 nmol/1. The authors suggest that the ability of vitamin D treatment to diminish fracture incidence may derive from improved bone quality, not measurable by the standard dual energy X-ray absorptiometry, and/or improved nervous and muscular control of movements to counter the tendency to fall.

Effect of insulin treatment on serum lipoprotein(a) in non-insulin-dependent diabetes.

In order to evaluate whether Lp(a), a lipoprotein that is potentially thrombogenic and atherogenic, is a potential risk factor for CAD in non-insulin-dependent diabetes (NIDDM), we compared the Lp(a) and its distribution in 145 NIDDM patients with that in 94 healthy control subjects. Furthermore, we studied the effect of insulin treatment on serum Lp(a) in 108 patients with NIDDM. Male and female NIDDM patients had similar Lp(a) concentrations to healthy controls (median value 167 mg L-1, range 15-1550 mg L-1 vs. 157 mg L-1, range 15-919 mg L-1, NS and 92, range 15-1190 mg L-1 vs. 103 mg L-1, range 15-842 mg L-1, NS). Also, the cumulative distribution of Lp(a) did not differ between the NIDDM patients and healthy subjects. Insulin treatment increased Lp(a) in diabetics with a Lp(a) concentration of less than 300 mg L-1, but this effect was not related to the concomitant improvement in metabolic control (mean change (+/- SEM) of HbA1c from 9.80 +/- 0.15 to 8.00 +/- 0.12; P < 0.001). In subjects with elevated Lp(a) concentrations (> 300 mg L-1) the Lp(a) concentration was unaffected by insulin, despite a similar improvement in glycaemic control. These results suggest that insulin may modulate the concentration of Lp(a).

Effects of intravoxel velocity distributions on the accuracy of the phase-mapping method in phase-contrast MR angiography.

The phase-mapping method of phase-contrast magnetic resonance angiography is shown to be based on an implicit assumption that the intravoxel velocity distribution is symmetric about its mean velocity. The effect of asymmetric distributions on the accuracy of quantitative average velocity measurements is determined analytically and verified experimentally. An explicit formulation is developed for the estimated average velocity in a voxel as a function of the true average velocity and the asymmetry of the distribution about the true average velocity. Worst-case distributions are determined for unidirectional and bidirectional flow, and the special case of laminar flow is also investigated. Computer simulations and phantom imaging experiments demonstrate the accuracy of the analysis. For voxels with unidirectional flow, the phase-mapping method produces accurate estimates of average velocity, while results for bidirectional flow indicate possible large errors unless the aliasing velocity is increased, which decreases the signal-to-noise ratio in the resultant velocity map image.

Cumulative prevalence of urinary characteristics in very old people.

We studied in 1982 six urinary characteristics in very old inhabitants of Tampere, Finland, born in 1892 or earlier (N = 167). The majority (N = 132) of the subjects had also been studied in 1977 and 1978. The abnormalities were quite transient during the 5-year period. The cumulative percentage of those who had urinary infection was high in respect of bacterial culture and pyuria. Positive bacterial culture (> or = 10(5)/ml) could be detected in over half of the cohort, and pyuria (> 5/HPF) in 76%. Although persistence of albuminuria and haematuria was individually relatively rare in all three surveys, their cumulative percentages were 36% and 34%, respectively, during the 5-year period. Use of indwelling catheter was significantly more frequently connected with bacteriuria and haematuria than with albuminuria or pyuria.

Incidence and survival rate in cases of biopsy-proven temporal arteritis.

In the population of the city of Tampere, Finland, 66 patients with histologically verified temporal arteritis were identified during the 20-year period from 1969 to 89. The cases were followed up to March 31st in 1991. The annual age- and sex-adjusted incidence of temporal arteritis per 100,000 population aged 50 or older was 4.5 in 1970-79 and 9.2 in 1980-89. The patients showed excess mortality although this was not statistically significant. After excluding hypertensive disease, angina pectoris and congestive heart disease the survival of the remaining subgroup did not differ from the control population.

Comparison of insulin regimens in patients with non-insulin-dependent diabetes mellitus.

BACKGROUND: Insulin is widely used to improve metabolic control in patients with non-insulin-dependent diabetes mellitus (NIDDM), but there is no consensus about the optimal regimen of insulin treatment. METHODS: We treated 153 patients with NIDDM for three months with five regimens: (1) oral hypoglycemic drug therapy plus NPH insulin given at 7 a.m. (the morning-NPH group), (2) oral hypoglycemic drug therapy plus NPH insulin given at 9 p.m. (the evening-NPH group), (3) NPH and regular insulin (ratio, 70 units to 30 units) given before breakfast and dinner (the two-insulin-injection group), (4) NPH insulin at 9 p.m. and regular insulin before meals (the multiple-insulin-injection group), and (5) continued oral hypoglycemic drug therapy (the control group). RESULTS: The mean (+/- SE) value for glycosylated hemoglobin decreased similarly in all four insulin-treatment groups (1.7 +/- 0.3, 1.9 +/- 0.2, 1.8 +/- 0.3, and 1.6 +/- 0.3 percent, respectively). The decrease was significantly greater in these four groups than in the control group (0.5 +/- 0.2 percent; P < 0.001 vs. all insulin-treated groups). Weight gain was significantly less (1.2 +/- 0.5 kg) in the evening-NPH group than in the other insulin-treatment groups (2.2 +/- 0.5 kg in the morning-NPH group, 1.8 +/- 0.5 kg in the two-insulin-injection group, and 2.9 +/- 0.5 kg in the multiple-injection group; P < 0.05). In addition, the increment in the mean diurnal serum free insulin concentration was 50 to 65 percent smaller in the evening-NPH group than in the other insulin-treatment groups. Subjective well-being improved significantly more in the insulin-treatment groups than in the control group (P < 0.001). CONCLUSIONS: In patients with NIDDM who are receiving oral hypoglycemic drug therapy, the addition of NPH insulin in the evening improves glycemic control in a manner similar to combination therapy with NPH insulin in the morning, a two-insulin-injection regimen, or a multiple-insulin-injection regimen, but induces less weight gain and hyperinsulinemia. The data thus suggest that patients with NIDDM do not benefit from multiple insulin injections and that nocturnal insulin administration appears preferable to daytime administration.

Annual injection of vitamin D and fractures of aged bones.

In order to investigate the effect of a supplementation of vitamin D in the prophylaxis of fractures of the bones of aged people, an annual intramuscular injection of ergocalciferol (150,000-300,000 IU) was given to two series of aged subjects: first to 199 (45 male) of 479 subjects (110 male) aged more than 85 years who were living in their own home, and second to 142 (29 male) of 320 (58 male) subjects aged 75-84 and living in a home for aged people. This prospective series was divided into treatment groups according to month of birth. These injections were given annually from September to December in the years 1985-1989, two to five times to each participant. The fracture rates, laboratory values, vitamin D levels, possible side effects, and mortality were followed until October 1990. A total of 56 fractures occurred in the 341 vitamin D recipients (16.4%) and 100 in 458 controls (21.8%) (P = 0.034). The fracture rate was about the same in both outpatient and municipal home series. Fractures of the upper limb were fewer in the vitamin D recipients, 10/341 = 2.9% (P = 0.025), than in the controls, 28/458 = 6.1%, during the follow-up. A similar result was obtained in fractures of ribs, 3/341 = 0.9% and 12/458 = 2.6%, respectively. Fractures of the lower limbs occurred almost as frequently, 31/341 = 9.1%, among the vitamin D recipients as among the controls, 49/458 = 10.7%. The fracture rate was higher in females (22.2%) than in males (9.5%). The fractures were fewer in the vitamin D recipients only in females.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum vitamin D level after an annual intramuscular injection of ergocalciferol.

An annual intramuscular injection of ergocalciferol (150,000 IU) normalized low serum (25(OH)D concentrations in elderly people for 1 year. The treatment had a slight effect on serum 24,25(OH)2D levels but no effect on 1,25(OH)2D levels.

Body weight and the three-year prognosis in very old people.

We studied prospectively the three-year prognosis of persons aged 84-88 years living in their own homes in the city of Tampere, Finland in 1981-84. Out of the target population 722 persons (64 per cent), 181 of them male (25 per cent), participated in the initial survey. A re-examination was carried out annually for the next three years. Increased mortality was observed for subjects with body mass index less than or equal to 22.0 kg/m2, statistically significantly in women but not in men. Mortality was not increased in those with body mass index greater than or equal to 30.0 kg/m2 in either sex. Low body mass index was associated with mortality due to stroke. Low body mass index was related to permanent hospitalization and also to failure to cope with living at home. On average, body weight was somewhat reduced during the follow-up period. Both a loss and a gain in weight by two kilograms or more during the first follow-up year were associated with increased mortality but not with institutionalization during the next two years.

Blood pressure in the very old.

Seven hundred and twenty-four people (541 female, 183 male), aged 84-88 years and living at home in the city of Tampere, Finland, accepted our invitation to be examined in the outpatient department of the local geriatric hospital. These subjects were re-examined annually, and their fate was followed for 3 years. The blood pressure level was a prognostic sign for mortality during the first year after its measurement. The lowest mortality rate was found among those subjects with systolic blood pressure between 140 and 169 mmHg and diastolic blood pressure between 70 and 99 mmHg. Blood pressures outside of these ranges were associated with increased mortality rates, particularly cardiac and coronary mortality. The mortality rate was especially high among those whose systolic blood pressure had decreased to low levels in the year before, but was lower in those whose systolic blood pressure had decreased from high to middle levels (140-169 mmHg) than in those with consistently high systolic blood pressure. Eventual institutionalization was more common in those with low systolic blood pressure.

Treatment of chronic constipation with lactitol sweetened yoghurt supplemented with guar gum and wheat bran in elderly hospital in-patients.

The faecal output of 33 elderly hospitalized patients was followed daily for 4 weeks. After an observation period of 1 week 18 patients received during the following 2 weeks a 150 ml portion of yoghurt containing lactitol, guar gum and wheat bran (fibre yoghurt group) twice daily. Fifteen control patients received the same volume of yoghurt without lactitol, guar gum or wheat bran (control yoghurt group). The study design was randomized double-blind. The mean faecal output increased 1.6-fold in patients receiving fibre yoghurt, while the corresponding value for control patients was 1.2 (p less than 0.05). About 50% of the fibre yoghurt group and 25% of the controls considered the treatment effective. Some in the fibre yoghurt group experienced meteorism and loose stools. No significant changes were observed in blood glucose, serum cholesterol or triglyceride values, body weights or faecal pH values in either group.

Blood pressure and five year survival in the very old.

During 1977-8 we measured blood pressure in 561 old people (83% of those aged 85 or more living in Tampere) and analysed their five year survival according to their blood pressure group. The subjects were divided into six groups on the basis of their blood pressures (from less than 120 to greater than 200 mm Hg systolic, from less than 70 to greater than 110 diastolic). The greatest mortality was observed in those in the lowest systolic and lowest diastolic groups. Mortality was least in subjects with systolic pressures of 160 mm Hg or more and diastolic pressures of 90 mm Hg or more. The most essential finding in this series of the very old was an increased mortality in the lowest blood pressure groups.