Once again we have read many articles and want to share abstracts about some of special interest to you, our readers. We have had suggestions that we link to the areas of the web where we read these medical articles. You can certainly find medical articles on the AMA site and on the ADA and JDF sites (you'll find a link to them in our links area) as well as on medical school sites where they do research. However, for many of the sites from which we give abstracts, you will need medical credentials. For others, you can just join their organization. Since we give you the source reference on the abstracts, you can then go to the proper site to find the entire article. Our plate is full this month with articles on high blood pressure, GI tract symptoms in diabetics, diabetic mastopathy, the treatment of elderly diabetic patients, the MI, and the type 2 family.
As always, we begin with some headlines that caught our eye when we were researching the journals this month. The first article from Diabetes Care 2000;23:1556-1562 looks at the complex relationship between diabetes and depression. The researchers found that major depressive disorder is independent of the onset of type 2 diabetes, however, when it is involved, this may increase the probability of developing the disease. Also they found that major depressive disorder lasts longer in both type 1 and type 2 diabetics and that complications are more likely in those with major depression and diabetes. Our second headline comes from the ADA, which reported that Repaglinide is at least as effective as conventional drugs in improving glycemic control. This was reported in the International Journal of Obesity, but you can read about it on the ADA web site. Want another reason to stop your children from smoking? The Nov. issue of the American Journal of Medicine has an article that looked at 21,000 physicians and that indicated smoking is associated with a substantial increase in the incidence of type 2 diabetes. Finally, a good thing as Martha would say. The Richmond Times Dispatch reported that the University of Virginia is testing a device that allows insulin to be inhaled. You can contact Dr. William L. Clarke and the Division of Pediatric Endocrinology and Diabetes at the U. VA medical center. According to the report, this system reduces the number of daily injections patients need from three a day to only one.
Now to our journal articles. The Archives of Internal Medicine 2000;160: 2447-2452 has an article titled High blood pressure and diabetes mellitus by Grossman, E. MD et al. The researchers assessed the benefits of antihypertensive therapy in hypertensive patients with diabetes mellitus. They searched MEDLINE for English-language articles published until June 1999. The results indicated that the coexistence of diabetes doubled the risk of cardiovascular events, cardiovascular mortality, and total mortality in hypertensive patients ( approximate relative risk of 1.73-2.77 for cardiovascular events, 2.25-3.66 for cardiovascular mortality, and 1.73-2.18 for total mortality). Intensive blood pressure control to levels lower than 130/85 mm HG was beneficial in diabetic hypertensive patients. All 4 drug classes-diuretics, B- blockers, argiotensin-converting enzyme inhibitors, and calcium antagonists-were effective in reducing cardiovascular events in diabetic hypertensive patients. In elderly patients with isolated systolic hypertension, calcium antagonosts reduced the rate of cardiac end points by 63%, stroke by 73%, and total mortality by 55%. In more then 60% of diabetic hypertensive patients, combination therapy was required to control blood pressure regardless of the type of medication. The researchers found that combination of medications may be more beneficial than monotherapy.
Again, the Archives of Internal Medicine 2000;160:2808-2816 has an article titled Gastrointestinal tract symptoms among persons with diabetes mellitus in the community by Maleki, D. MD et al who examined whether GI tract symptoms are more prevalent in unselected patients with diabetes from the general community compared with their age and sex matched counterparts without diabetes and to assessed the association of GI tract symptoms in persons with diabetes with psychosomatic symptoms, medication use, and symptoms of autonomic neuropathy.
The results indicated that in the community, in this case Olmstead County, Minn., the prevalence of most GI tract symptoms is similar in persons with or without diabetes except for a lower prevalence of heartburn and an increased prevalence of constipation or laxative use in residents with type 1 diabetes, especially in men. This difference is associated with calcium channel blocker use rather than symptoms of autonomic neuropathy. In community-based practices, physicians should not immediately assume that GI tract symptoms in patients with diabetes represent a complication of diabetes mellitus.
This next abstract caught my eye because it shares something very new to me. The Archives of Surgery 2000; 135: 1190-1193 has an article titled Diabetic mastopathy by Camulo, P. MD et al in which they examine diabetic mastopathy which is an unusual fibroinflammatory breast lesion that characteristically presents in premenopausal women with long-standing type 1 diabetes with multiple micro vascular complications. The pathogenesis of this condition is believed to involve an autoimmune reaction to the accumulation of abnormal matrix induced by hyperglycemia. Clinical features include the development of dense keloidlike breast masses that are often recurrent or bilateral or both. Clinical distinction from malignancy can be difficult. However, the benign nature of this lesion is easily recognized on histologic examination, and it is not associated with an increased incidence of epithelial or stromal neoplasia. The researchers' hypothesis was that a constellation of histopathologic and clinical features is necessary to make the diagnosis of diabetic mastopathy. Unnecessary surgery can be avoided in the clinical follow-up of patients with multiple, bilateral, and recurrent lesions.
Between Dec. 1993 and Dec 1998, 5 premenopausal women with type 2 diabetes mellitus of 18 to 23 years' duration presented with nontender, palpable, firm-to-hard breast masses. To date, progression of the tumor-like proliferations has been bilateral and recurrent in 2 patients, bilateral in a third patient, and recurrent in a fourth. The fifth patient has developed neither bilateral nor recurrent lesions. Imaging studies did not in any patient demonstrate a focal lesion. All lesions were treated by either excisional (4 patients) or core (1 patient) biopsy. The resected specimens were examined histopathologically. They measured between 3.9 and 6.0 cm in maximal diameter. Microscopic examination showed keloidal fibrosis with ductitis, lobulitus, and vasculitis. The clinical profile in combination with these pathogenic features is characteristic of diabetic mastopathy.
The conclusions were that physicians should be aware of the association of long-standing diabetes with the development of benign fibroinflammatory breast lesions when managing these in premenopausal women. Although these breast masses may be recurrent, they are not premalignant. In the appropriate setting, the diagnosis can be made by core biopsy, avoiding unnecessary surgeries in patients with multiple, bilateral, or recurrent lesions.
Our final abstract comes from the Archives of Pediatric and Adolescent Medicine 1999;153: 1063-1067 and is titled The type 2 family by Pinhas-Harriel, O. MD et al. The researchers attempt to identify physical, behavioral, and environmental features of adolescents (aged 11-17) with type 2 diabetes and their families to define the involvement of known risk factors and to define a profile of at-risk individuals. A total of 42 subjects from 11 families with an adolescent who has been diagnosed with type 2 diabetes participated. All participants underwent anthropometric measurement and completed food frequency and eating disorder questionnaires, and were classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. In addition, laboratory tests to determine levels of hemoglobin A1c, fasting glucose, C peptide, insulin, and proinsulin were performed.
The results indicated that type 2 diabetes had been diagnosed in 5 of the 11 mothers and 4 of the 11 fathers before this study. Type 2 diabetes was diagnosed in the 3 of the remaining fathers during the study. In 3 families, both parents were affected with type 2 diabetes. As a group, participants were obese, with a body mass index higher than the 95th percentile for probands and fathers, and higher than the 85th percentile for mothers and siblings. The sum of skin fold measurements was above the 95th percentile for the probands, their siblings, and the parents. All groups had high fat intake and low fiber intake. None of the subjects participated in a structured or routine exercise program, and most reported no regular physical activity. Three of the probands met the criteria for binge-eating disorder, and 6 additional patients had a notable characteristic of the disorder. Mothers affected with type 2 diabetes had markedly abnormal hemoglobin A1c levels, indicating poor control. There were no group differences in fasting concentrations of insulin, proinsulin, or C peptide. However, a third of the mothers with type 2 diabetes, and all but 1 of the siblings, had evidence of insulin resistance.
Conclusions indicated that adolescents with type 2 diabetes as well as their first degree family members were obese. The incidence of diagnosed and undiagnosed diabetes or of insulin resistance in the families of adolescents with type 2 diabetes is striking. Families and probands have lifestyles of high fat intake, minimal exercise, and a high incidence of binge eating. The research shows that families of adolescents with type 2 diabetes share many anthropometric and lifestyle risk factors. Therefore the treatment of these teens addresses the lifestyle and health habits of the entire family.
Finally one note of caution. Ephedra, an herbal stimulant used by millions of Americans for bodybuilding and weight loss can cause heart attacks, stroke, seizures and death in otherwise healthy young people. This is according to Dr. Neal Benowitz in an article in the New England Journal of Medicine. Please pass the word on to your relatives. We don't need any more young people harming themselves unknowingly.
