Cardiovascular risk factor management is poorer in diabetic patients with undiagnosed peripheral arterial disease than in those with known coronary heart disease or cerebrovascular disease. Results of a nationwide study in tertiary diabetes centres.

AIMS: To assess whether patients with Type 2 diabetes mellitus and unrecognized peripheral arterial disease (PAD), detected by the ankle-brachial index (ABI), have poorer cardiovascular risk factor management (CVRFs) and receive fewer medications than patients previously diagnosed with coronary heart disease (CHD) or cerebrovascular disease (CVD). METHODS: In 31 diabetes centres throughout Spain, 1303 patients with Type 2 diabetes mellitus were screened for PAD using the ABI. Patient history of CHD and CVD and treatment and control of CVRFs were recorded. RESULTS: Forty-one patients had an ABI > 1.30 and were excluded, leaving 1262 patients (age 65.3 +/- 7.7 years) for the study. Of those screened, 790 patients had a normal ABI (ABI > 0.9) and no known history of CHD or CVD (no CHD/CVD/PAD group), 194 had unrecognized PAD (ABI < or = 0.9) with no known history of CHD or CVD (undiagnosed PAD group) and 278 had a known history of CHD and/or CVD (CHD/CVD group). The undiagnosed PAD group had higher low-density lipoprotein (LDL) cholesterol (2.9 +/- 0.83 vs. 2.4 +/- 0.84 mmol/l; P < 0.001) and systolic blood pressure (150 +/- 20 vs. 145 +/- 21 mmHg; P < 0.001) compared with the CHD/CVD group. They were less likely to take statins (56.9 vs. 71.6%; P < 0.001), anti-hypertensive agents (75.9 vs. 90.1%, P = 0.001), and anti-platelet agents (aspirin, 28.7 vs. 57.2%; P < 0.001; clopidogrel, 5.6 vs. 20.9%; P < 0.001) and more likely to smoke (21.0 vs. 9.2%; P < 0.001). Higher LDL in the undiagnosed PAD group was associated with the underutilization of statins. CONCLUSIONS: Measurement of ABI detected a significant number of patients with PAD, who did not have CHD or CVD, but whose CVRFs were under treated and poorly controlled compared with subjects with CHD and/or CVD.

Socio-economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain.

AIMS: To establish the relationship between socio-economic status and the prevalence of known Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications. METHODS: In 2000, a cross-sectional survey was conducted among 61 general practitioners (GPs) who studied 65 651 people older than 24 years. Of those, 2985 known Type 2 diabetic patients were registered. The main outcome measures were: diabetes prevalence, major cardiovascular risk factors, chronic diabetic complications and primary care services utilization in Type 2 diabetic patients. Socio-economic status was based on area-based socio-economic measures. RESULTS: The prevalence of known Type 2 diabetes was higher in patients of lower socio-economic status (OR: 2.17, 95% CI: 1.77-2.28), especially among women (OR: 2.28, 95% CI: 1.91-2.73). In Type 2 diabetes patients, obesity, sedentary lifestyle, and abnormal levels of low-density lipoprotein (LDL) cholesterol and HbA(1c) were more prevalent among those from lower socio-economic status. Macroangiopathy was inversely associated with socio-economic status after adjustment for clinical and demographic variables. Patients of lower socio-economic status more frequently visited primary care services than those of higher status. CONCLUSIONS: This study shows an association between deprivation and Type 2 diabetes prevalence, cardiovascular risk factors and chronic diabetic complications in Type 2 diabetes patients. Despite a greater use of health services by less wealthy patients, they showed worse glycaemic control and more chronic complications. Besides clinical variables, socio-economic status and environmental information need to be considered in the assessment of risk profile of diabetic patients by health professionals and by health service planners.

Incidence, prevalence and coronary heart disease risk level in known Type 2 diabetes: a sentinel practice network study in the Basque Country, Spain.

AIMS/HYPOTHESIS: The aim of this study was to determine the incidence, prevalence and coronary heart disease risk in patients with known Type 2 (non-insulin-dependent) diabetes mellitus in a Basque Country sentinel practice network study. METHODS: During the year 2000 we did a survey among sentinel practitioners who registered information about previously and newly diagnosed Type 2 diabetic patients older than 24 years of age. We studied 65,651 people attending a primary care service in the Basque Country Health Service-Osakidetza. We collected information about diabetic complications and cardiovascular risk factors and measured the coronary heart disease risk in these patients. RESULTS: In the year 2000, the standardized cumulative incidence and prevalence of known Type 2 diabetes were 5.0 per 1000 (CI 95%: 4.9-5.1) and 4.6% (CI 95%: 4.5-4.7) respectively. Macroangiopathy was the most frequent complication both in the newly diagnosed (21.6%) and previously known Type 2 diabetic patients (33%). Total cholesterol > or =5.17 mmol/l and LDL cholesterol > or =2.58 mmol/l were found in 75% and 90% of newly diagnosed and 65% and 85% of previously diagnosed Type 2 diabetic patients respectively. Of the Type 2 diabetic patients 42% were obese and 80% had high blood pressure. More than 55% of the men compared with 44% of the women with Type 2 diabetes had high or very high risk of coronary heart disease (p<0.05). CONCLUSION/INTERPRETATION: We report new epidemiological data on known Type 2 diabetes in the Basque Country. These patients have a high frequency of cardiovascular risk factors causing a high coronary heart disease risk.

[Effect of antihypertensive combinations on arterial pressure, albuminuria, and glycemic control in patients with type II diabetic nephropathy: a randomized study]. / Efecto de dos combinaciones antihipertensivas sobre la presión arterial, albuminuria y control glucémico en pacientes con nefropatía diabética tipo 2: un estudio aleatorizado.

Type II diabetic patients with albuminuria are at high risk for cardiovascular complications; the intense antihypertensive treatment required often involves using drug combinations. The aim of the present study was to compare the effect of two different, renin-angiotensin blocking combinations, on blood pressure (BP), albuminuria and glycemic control. Its design was prospective, randomised, controlled, of parallel branches, and performed in one Endocrinology Department, in Spain. 77 type-II diabetic patients, with stable albuminuria (30-1,000 mg/day) were included. After a pre-inclusion time of 2 weeks, patients were randomised to verapamil SR/trandolapril 180/2 (VT) or losartan/hydrochlorothiazide (LH) 20/12.5 mg/day. Duration of treatment was 1 year. The evaluated parameters were changes in blood pressure, urinary albumin excretion for 24 hours, glycated hemoglobin and plasmatic urea. Overall BP significantly decreased from 161.6 +/- 18.7/83.6 +/- 10.2 mmHg to 137.2 +/- 15.7/70.9 +/- 8.3 mmHg (p < 0.0005). Values, by treatment, were: For VT, 164.3 +/- 18.5/87.2 +/- 10.7 mmHg at baseline and 135.0 +/- 15.1/71.3 +/- 8.4 mmHg at conclusion. For LH, 158.8 +/- 17.4/80.1 +/- 8.4 mmHg at baseline and 139.3 +/- 16.1/70.5 +/- 8.2 mmHg at conclusion. Albuminuria significantly decreased from 308.2 +/- 544.7 mg/day to 198.0 +/- 285.3 mg/day. Both parameters showed no significant difference between treatments. Glycated hemoglobin decreased from 7.59 +/- 1.3% to 7.14 +/- 1.2% in the VT group, and from 7.96 +/- 1.29% to 7.84 +/- 1.62% in the LH group (ANOVA, p = 0.022). Changes adjusted from baseline values showed a trend to the difference between both treatments (p = 0.092). Plasmatic urea increased from 39.8 +/- 12.7 to 40.5 +/- 11.1 mg/dL in the TV group and from 43.4 +/- 12.0 mg/dL to 52.4 +/- 19.4 mg/dL in the LH group (ANOVA, p = 0.028). In conclusion, both treatments reduce blood pressure and albuminuria in a similar way in type II diabetic patients. The verapamil/trandolapril combination contributes to a better carbohydrate metabolism than losartan/hydroclorothiazide.

Efecto de dos combinaciones antihipertensivas sobre la presión arterial, albuminuria y control glucémico en pacientes con nefropatía diabética tipo 2: un estudio aleatorizado / Effect of two different antihypertensive drug combinations over blodd pressure, albuminuria and glycemic control in patients with diabetic nephropathy type II

Los pacientes diabéticos tipo 2 con albuminuria presentan un elevado riesgo de complicaciones cardiovasculares; el intenso tratamiento antihipertensivo que precisan implica con frecuencia el uso de combinaciones. El objetivo del presente estudio fue comparar el efecto de dos diferentes combinaciones, basadas en el bloqueo del sistema renina-angiotensina, sobre la PA, albuminuria y control glucémico. El diseño fue prospectivo, aleatorizado, de ramas paralelas, controlado y llevado a cabo en un único Servicio de Endocrinología, en España. Se incluyeron 77 diabéticos tipo 2 con albuminuria estable entre 30 y 1.000 mg/día. Tras un período de pre-inclusión de dos semanas, las pacientes fueron aleatorizados a verapamil SR/trandolapril 180/2 (VT) o losartan/hidroclorotiazida (LH) 20/12,5 mg/día. La duración del tratamiento fue un año. Los parámetros evaluados fueron los cambios en la presión arterial, excreción urinaria de albúmina (24 horas), hemoglobina glicosilada y urea plasmática. La PA global descendió significativamente de 161,6 ñ 18,7 / 83,6 ñ 10,2 mmHg a 137,2 ñ 15,7 / 70,9 ñ 8,3 mmHg (p < 0,0005). Por tratamientos, los valores fueron: Para VT, 164,3 ñ 18,5 / 87,2 ñ 10,7 mmHg inicial y 135,0 ñ 15,1 / 71,3 ñ 8,4 mmHg final. Para LH, 158,8 ñ 17,4 / 80,1ñ 8,4 mmHg inicial y 139,3 ñ 16,1 / 70,5 ñ 8,2 mm Hg final. La albuminuria se redujo significativamente de 308,2 ñ 544,7 mg/día a 198,0 ñ 285,3 mg/día; en ambos parámetros sin diferencias significativas entre tratamientos. La hemoglobina glicosilada descendió de 7,59 ñ 1,30 por ciento a 7,14 ñ 1,20 por ciento en el grupo VT y de 7,96 ñ 1,29 por ciento a 7,84 ñ 1,62 por ciento en el grupo LH (ANOVA, p = 0,022).Los cambios ajustados por los valores basales alcanzaron diferencias casi significativas entre tratamientos (p = 0,092). La urea plasmática pasó de 39,8 ñ 12,7 mg/dL a 40,5 ñ 11,1 mg/dL en el grupo TV y de 43,4 ñ 12,0 mg/dL a 52,4 ñ 19,4 mg/dL en el grupo LH (ANOVA, p = 0,028). En conclusión, en NEFROLOGÍA. Vol. XXII. Número 2. 2002 pacientes diabéticos tipo 2 con albuminuria estable, ambos tratamientos reducen la presión arterial y la albuminuria de forma similar. La combinación verapamil/trandolapril contribuye mejor al control metabólico hidrocarbonado que losartan/hidroclorotiazida (AU)

New monoclonal antibody diagnostic reagents for type I diabetes: differential lymphocyte surface antigen expression related to disease.

New cellular-based reagents are needed to diagnose type I diabetes as well as to monitor the outcomes of clinical trials at early time points. Four new monoclonal antibodies (mAbs) have been shown to demonstrate reduced binding to lymphocytes from identical twins with long-term type I diabetes relative to that observed with lymphocytes from their twin partners without diabetes or from control subjects. Biochemical analysis revealed mAb 3G12EG recognized an unidentified 45-kDa protein, whereas mAb 2E8F1 and 5B6E11 did not appear to precipitate specific proteins as detected by SDS-PAGE. Electrophoresis under reducing and nonreducing conditions and peptide mapping revealed that mAb 8F410 recognizes a novel dimeric form of HLA class I molecule. Predictions from crystallography studies suggested previously this class I dimer as the optimal activation of a single CD8 T-cell. In B-cells from both normal and diabetic individuals, the class I dimer was minimally associated with beta2-microglobulin rapidly formed in the endoplasmic reticulum. These new reagents appear to be able to identify new lymphocyte surface phenotypes associated with diabetes expression in both fresh blood samples and Epstein-Barr virus-established cell lines.

Course and prognosis of 132 patients with diabetic non ketotic hyperosmolar state.

One hundred and thirty two episodes of diabetic non ketotic hyperosmolar states were studied after a prospective schedule of treatment was designed. The admission data, the prognostic factors and their outcome were analyzed. Initial high osmolarity, urea and sodium plasma levels and low plasma pH were related to the admission level of consciousness (p < 0.01). High glucose, osmolarity, urea and sodium plasma levels at entry were related to the admission level of dehydration (p < 0.01). In multivariate regression analysis, osmolarity was the most influential variable in both the level of consciousness and the admission level of dehydration (p < 0.0001). Twenty two patients died (16.9%). Septic shock was the most frequent cause of death (31%) and mortality was higher in patients with cardiovascular disease (acute myocardial infarction or stroke) as the precipitating factor for diabetic hyperosmolar state (p < 0.002). Older age, low blood pressure, low sodium, pH and bicarbonate plasma levels, and high urea plasma levels were related to mortality (p < 0.01). In multiple regression analysis, urea was the most influential mortality risk factor (p < 0.0118). Non survivors received higher doses of insulin than survivors (p < 0.01). All these data suggest that it is not the hyperosmolarity itself, but the hemodynamical state of the patients, which is the most influential factor on the prognosis of a diabetic hyperosmolar state.

Hypothalamic-pituitary-testicular function in 70 patients with myotonic dystrophy.

Hypothalamic-pituitary-testicular function was studied in 70 patients with myotonic dystrophy (MD). The diagnosis was confirmed by electromyography. The mean age of the patients was 36.2 +/- 13.2 yr and the duration of the disease was 11.17 +/- 8.01 yr. Testicular atrophy (testes less than or equal to 12 ml on a Prader orchidometer) was present in 65.5% of patients. Fertility among married patients was 66.6%. Mean testosterone plasma levels were 438 +/- 298 ng/dl vs 520 +/- 185 ng/dl in the control group (P = NS). Basal plasma FSH and LH levels, and their response after the administration of 100 mcg of LH-RH were significantly increased although a wide dispersion was observed. Sperm count was carried out in 27 cases, showing a normal count in 7, oligospermia in 12, and azoospermia in 8 patients. Testicular biopsy was performed in 45 patients being normal in 2, showing mild testicular damage in 8, moderate in 14, and severe in 18; it was nule in 3 of them. A significant relationship between testicular atrophy and the sperm count (p less than 0.01), testicular damage and testicular atrophy (p less than 0.025), and sperm count and testicular damage (p = 0.017) was found. Basal plasma FSH and LH level were significantly related to the degree of damage in the testicular biopsy. All these findings indicate a primary testicular pathology, prevailing tubular over interstitial damage. We have not found any association between the duration of the disease and gonadal dysfunction.