Recovery of Candida dubliniensis and other Candida species from the oral cavity of subjects with periodontitis who had well-controlled and poorly controlled type 2 diabetes: a pilot study.

The goal of this study was to determine the prevalence of Candida dubliniensis and other Candida species from saliva samples and from subgingival plaque samples at periodontally healthy and periodontally diseased sites in subjects who had type 2 diabetes and periodontitis. Saliva and subgingival samples were obtained from 30 subjects with periodontitis: 15 with poorly controlled and 15 with well-controlled type 2 diabetes. Samples were analyzed for the presence of C. dubliniensis and other Candida species. Among subjects with poorly controlled diabetes, 53% were positive for C. albicans, 20% for C. glabrata, 6% for C. tropicalis, and 6% for C. parapsilosis. Among well-controlled subjects, 33% were positive for C. albicans and 13% for C. glabrata; none had C. tropicalis or C. parapsilosis. No samples were positive for C. dubliniensis in either group of subjects.

Reducing cardiovascular complications of type 2 diabetes by targeting multiple risk factors.

Insulin resistance syndrome is characterized by hyperglycemia, atherogenic dyslipidemia, hypertension, and abdominal obesity. Hyperglycemia is the major risk factor for microvascular complications in type 2 diabetes. However, 70% to 80% of patients with type 2 diabetes will die of macrovascular disease. Atherogenic dyslipidemia-characterized by elevated triglyceride levels, low high-density lipoprotein cholesterol (HDL-c) levels, and a preponderance of small, dense, low-density lipoprotein (LDL) particles-is the major cause of atherosclerosis in individuals with type 2 diabetes. Therefore, treatment of type 2 diabetes must address hyperglycemia to prevent microvascular disease (retinopathy, neuropathy, and nephropathy) and atherogenic dyslipidemia to prevent macrovascular complications. Emerging evidence indicates lipid and glucose homeostasis are interrelated via bile acid-activated nuclear hormone receptor signaling pathways. Agents that act on these pathways could simultaneously address hyperglycemia and dyslipidemia in patients with type 2 diabetes. Recent studies have shown that bile acid sequestrants, including cholestyramine, colestimide, and colesevelam HCl, significantly improve glycemic control and reduce LDL cholesterol levels in patients with type 2 diabetes. This paper will review the effects of bile acid sequestrants on both glucose and lipid metabolism in patients with type 2 diabetes.

What is the most effective strategy for managing diabetic dyslipidaemia?

The dyslipidaemic profile of diabetes greatly contributes to the increased cardiovascular risk associated with the disorder, and evidence from many intervention trials using statins, fibrates, nicotinic acid or a nicotinic acid-statin combination, indicates the substantial cardiovascular risk reduction to be gained from lipid modification. Several large statin trials have demonstrated the efficacy of cholesterol-lowering in individuals with coronary heart disease and raised low-density lipoprotein-cholesterol (LDL-C) (>or=130 mg/dL; >or=3.4 mmol/L), but for the 40% of patients whose LDL-C is within recommended limits, many of whom have low high-density lipoprotein-cholesterol (HDL-C), an alternative strategy is necessary if excess risk is to be minimized. The veterans affairs high-density lipoprotein cholesterol intervention trial (VA-HIT) proved the efficacy of the fibric acid derivative, gemfibrozil, to elevate HDL-C and reduce triglycerides, with a resulting 22% relative risk reduction for cardiovascular death or non-fatal myocardial infarction, and even greater reductions in individuals with insulin resistance and diabetes. Increased HDL-C was independently predictive of reduction in coronary heart disease. In the Coronary Drug Project, individuals with diabetes or insulin resistance derived as much as 70% cardiovascular risk reduction from the HDL-C elevations achieved with nicotinic acid therapy. The effects of lowering LDL-C and raising HDL-C are additive and predictive of total cardiovascular event reduction, and by using statin-nicotinic acid combination therapy, cardiovascular risk reductions as great as 90% are possible. Such combination strategies offer patients the greatest opportunity for improved cardiovascular health and are likely to become the treatment strategy of the future.

Therapeutic approaches in the prevention of cardiovascular disease in metabolic syndrome and in patients with type 2 diabetes.

PURPOSE OF REVIEW: The metabolic syndrome is commonly encountered in the United States. It has been estimated from a survey conducted nearly a decade ago that one in four American adults fulfill the criteria for the metabolic syndrome. As obesity has become more common, the prevalence of type 2 diabetes has increased, and these trends can be expected to translate into more cardiovascular disease in future years. The high cardiovascular risk that accompanies the metabolic syndrome and type 2 diabetes mandates comprehensive and aggressive preventive care. This article reviews evidence that treatments directed at the individual components of the metabolic syndrome will delay the progression to type 2 diabetes and will reduce the incidence of cardiovascular disease. RECENT FINDINGS: In overweight individuals with the metabolic syndrome, the onset of type 2 diabetes can be delayed by therapeutic lifestyle changes (weight loss and exercise), insulin sensitizers (metformin, troglitazone), angiotensin converting enzyme inhibitors (captopril, fosinopril, ramipril), and angiotensin receptor blockers (losartan, candesartan). Lipid altering therapies (statins, fibrates, and niacin) are especially efficacious for reducing cardiovascular events in metabolic syndrome and type 2 diabetes patients. SUMMARY: An aggressive multifactorial approach to cardiovascular risk factor modification facilitates a delay in the onset of type 2 diabetes and cardiovascular events among individuals with the metabolic syndrome.

Gastrointestinal tolerability of extended-release metformin tablets compared to immediate-release metformin tablets: results of a retrospective cohort study.

OBJECTIVE: Metformin, a biguanide antihyperglycemic medication, lowers blood glucose in patients with type 2 diabetes with minimal risk of hypoglycemia. Most common side effects include diarrhea, nausea and vomiting. Extended-release metformin (Glucophage XR)*, a once-daily tablet using the patented GelShield Diffusion System release mechanism, may be better tolerated than immediate-release metformin (Glucophage). This retrospective chart review examined the overall gastrointestinal (GI) tolerability of both formulations. RESEARCH DESIGN AND METHODS: Patient charts were reviewed and data were collected from October 2001 to May 2002. Adult patients with type 2 diabetes started on extended-release metformin (metformin-XR) or switched from immediate-release metformin to metformin-XR within the previous 2 years were eligible for inclusion in the metformin-XR cohort. Patients started on immediate-release metformin within the previous 2 years were eligible for inclusion in the immediate-release metformin cohort. Previous experience of GI side effects while taking immediate-release metformin did not prevent inclusion in either cohort, though patients with significant underlying GI disease or moderate to severe hepatic or renal impairment were excluded. GI tolerability was assessed during the first year of treatment with immediate-release metformin or metformin-XR. Primary endpoints were overall GI tolerability and frequency of diarrhea during the first year of treatment. RESULTS: A total of 471 patients' charts were reviewed and data were collected from four diabetes clinics; 310 (metformin-XR) and 158 (immediate-release metformin) eligible patients were included. Patients were, on average, 56 years old, and overweight (mean body mass index 33 kg/m2). The majority of patients were Caucasian (50%), Hispanic (24%) or Black (19%). Mean daily doses were 1258 mg (range 500-2500 mg) for metformin-XR and 1282 mg (range 500-2550 mg) for immediate-release metformin. About 25% of the metformin-XR cohort had been switched from immediate-release metformin due to a history of GI adverse events (AE). Despite this, the frequency of any GI AE was similar between metformin-XR and immediate release metformin (11.94 vs. 11.39%, p = 0.86). The incidence of individual GI AE also did not differ significantly between cohorts. In a cohort of 205 patients started on immediate-release metformin and switched to metformin-XR, the frequency of any GI AE was 26.34% (while taking immediate release metformin; n = 205) vs. 11.71% (after switching to metformin-XR; n = 205) (p = 0.0006) and the frequency of diarrhea was 18.05% (while taking immediate-release metformin) vs. 8.29% (after switching to metformin-XR) (p = 0.0084). CONCLUSIONS: In this retrospective chart review, patients switched from immediate-release metformin to metformin-XR experienced fewer GI side effects on comparable doses of the extended-release metformin.

Where thiazolidinediones will fit.

Individuals with type 2 diabetes have two defects: insulin resistance, which occurs in the first stages of disease progression, and pancreatic beta-cell failure, which occurs later in the disease. Insulin resistance is the major pathological defect. During the course of the disease, insulin levels are initially elevated to compensate for the increased insulin resistance and then decline as the disease progresses and beta-cells become less responsive. It is necessary to change antidiabetic therapies to address this progression. Current management of type 2 diabetes follows a stepwise treatment program of diet and exercise, monotherapy with oral antidiabetic agents, combination oral therapy and, ultimately, combination therapy with insulin to control blood glucose levels. While control of blood glucose will reduce the risk of microvascular complications, such as microalbuminuria and retinopathy, the incidence of macrovascular complications is not significantly reduced. The introduction of the thiazolidinediones (TZDs) or 'glitazones', a class of agents that offer effective glycemic control and work through the reduction of insulin resistance, offers a new strategy in the management of this condition. These agents have beneficial effects on the pancreatic beta-cell and, in addition, may have potential benefits on the macrovascular complications that commonly occur in these patients.

Elevated thyroxine levels in a euthyroid patient.

Preview Euthyroid hyperthyroxinemia is often misdiagnosed, resulting in inappropriate treatment with ablation or surgical removal of the thyroid gland. Therefore, it is important that primary care physicians be familiar with the causes of this disorder. This case report describes the diagnostic approach taken in one patient and discusses normal thyroid physiology.