Once again, we ask you to write us about any questions you may have or any specific questions you want us to look up in the journals. We will do our best to find that information and share it with all of our readers.
The headlines are next. In this part of the article, we present a sentence or two about articles that we know you will want to read and share with others. Feel free to do so.
The Southern Medical Journal 2002;95:842-845 had an article H. Pylori eradication may improve control in diabetic children looks at infections which produce hyperglycemia in patients with diabetes, and the mechanisms which cause this. Dr. Begue from Children's Hospital in New Orleans et al found that insulin requirements and HbA1c levels increased in children infected with H. pylori compared to those who were uninfected. In the study. The diabetic children were successfully eradicated for H. pylori infection. At that point the insulin needs declined as did the HbA1c levels.
Diabetes Care 25:1729-1736,2002 had an article by David Dunstan, PHD et al which restates what we have said many times on this site. High-intensity progressive resistance training, in combination with moderate weight loss, was found effective in improving glycemic control in older patients with type 2 diabetes. Additional benefits of improved muscular strength and lean body mass identify high-intensity resistance training as a feasible and effective component in the management of people 60-80 years of age with type 2 diabetes. Yesterday, I called my aunt, who is currently celebrating her 93rd birthday. She also has type 2 diabetes and was complaining about the pain of neuropathy in her legs and feet at night. There is an article in Diabetes Care 25:1699-1703, 2002 by Kevin C.J. Yuen, MRCP et al on this subject in which the researchers concluded that Ososorbide Dinitrate spray offers an alternative and effective pharmacological option in relieving overall pain and burning sensation in the management of painful diabetic neuropathy. They state that the spray may alleviate other specific sensory symptoms associated with diabetic peripheral neuropathy and that this needs further research.
Circulation Journal has an article by Robert Detrano, MD, PhD. about blood tests of coronary calcium which indicate the presence and amount of coronary atherosclerosis and CRP which is a marker for inflammation in the blood stream. The authors found that the combination can be used as a predictor of cardiovascular events.
When you read What's Hot, you'll see that we have an article on diabetic medications. To go along with that we found an article in Diabetes Care 2002;25:1529-1533 by Dr. James Foley et al about combination therapy with nateglinide and thiazolidinedione improving glycemic control in type 2 diabetes. After 16 weeks HbA1c 79% of patients in the combination group reached target HbA1c levels of less than 7%. The main adverse events were increased mild hypoglycemia. "Collectively these data demonstrate that a treatment strategy designed to target the two major defects of type 2 diabetes -- losses of early insulin secretion, and insulin resistance -- with agents that have complementary mechanisms of action produce additive HbA1c reductions and are highly effective in helping patients achieve HbA1c target."
Finally, here's one that will be of interest especially if you are an environmentalist: Diabetes Care 2002;25:1534-1538 by Dr. Lars C. Stone et al of the Norwegian Institute of Public Health in Oslo. They found that low-pH drinking water in individual households is strongly associated with the risk of type 1 diabetes. They noted this when they looked at the association of type 1 diabetes and well water. They conclude that "The mechanisms by which water acidity or mineral content may be involved in etiology of type 1 diabetes remain unknown, but the mechanisms are most likely indirect and may involve the an influence on survival of microorganisms in the water". For example, enteroviruses or rotaviruses "that may be relevant in the etiology of type 1 diabetes" survive optimally at pH levels about 6.2-6.9.
We'll keep reading and reporting. Now let's look at those abstracts we promised. They are intriguing to say the least. The American Journal Of Cardiology 2002;90:243-247 has an article titled Catheter-based brachytherapy prevents restenosis in diabetic patients by Dr. Jeffery W. Moses et al from Lenox Hill Heart and Vascular Institute and Cardiovascular Research Foundation in New York City. It has been known that diabetic patients face a higher rate of in-stent restenosis after stent placement for coronary artery disease, but it was not known whether they respond favorably to intracoronary radiation therapy. Dr. Moses et al evaluated 79 diabetic patients participating in the GAMMA 1 trial of catheter-based Ir-192 gamma brachytherapy for in-stent restenosis. According to the results, the occurrence of major adverse cardiac events (death, myocardial infarction, emergent bypass surgery, or target lesion revascularization) in the first 30 days did not differ between diabetics and nondiabetics or between diabetics receiving intracoronary radiation and those not receiving it. After 6 months, diabetic patients treated with brachytherapy had a 40% reduction. Brachytherapy had a 40% reduction in the absolute in-lesion restenosis rate compared with a 16% reduction in nondiabetic patients. After 9 months, I192 brachytherapy lead to a 2.77-fold reduction in the rate of major adverse cardiac events in diabetic patients compared to those treated with placebo. It did not have a significant improvement in nondiabetic patients. Dr. Moses and his group suggest that "that intracoronary Ir-192 is quite effective in suppressing neointimal proliferation in diabetics." He did stress that this strategy applies to the treatment of in-stent stenosis, not to primary therapy of coronary lesions.
The Journal of American Podiatry Medical Association 2002 Sept;92(8);425-8 has an article DD Melzer, et al titled Decreasing amputation rates in patients with diabetes mellitus. an outcome study from the Institute for Tissue Regeneration and Rehabilitation, Dept. of Veterans Affairs, Bay Pines, FL. We have read many research articles about team care of people with diabetes. Here is one that shows just how important this is. Amputations are a frightening topic but we all know that caring for our feet is mandatory. Do re-read the article in What's Hot about the podiatrist visit that we posted in last month's magazine. The lower-extremity amputation rate in people with diabetes is high, and the wound failure rate at the time of amputation is as high as 28%.Even with successful healing of the primary amputation site, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years. The study provides valid outcome data from before (control period) and 18 months after (test period) implementation of a multidisciplinary team approach using verified methods to improve the institutional care of wounds. The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level. No above-the-knee amputations were required in 45 patients during the test period, compared with 14 of 76 patients during the control period. These outcome data suggest that unified care is an effective approach for patients with diabetic foot problems.
When I saw the title of this article, it hit home as I had bypass surgery when I was 48 years old after having type 1 diabetes for 6 1/2 years. At the time I was running 5-6 miles per day and going to an exercise class but had denied the changes that were occurring to my health. After reading the article, I must say that the odds are still in our favor and if it means anything, I just passed my latest Stress Test with flying colors and that is more than a decade later. The Annals of Thoracic Surgery 2002 Sep;74(3):712-9 has an article titled Early postoperative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary bypass grafting by Szabo, Z et al. An increasing proportion of patients undergoing coronary artery bypass grafting (CABG) are diabetics. This article examines the early postoperative outcome and the midterm survival in diabetic patients. The results indicated that the diabetic group was younger and included a higher proportion of women, and patients with hypertension, triple-vessel disease, and unstable angina. They required a higher number of bypasses and longer cross-clamp and cardiopulmonary bypass times. Intensive care unit time and hospital stays were prolonged, and the need for inotropic agents, hemotransfusions, and dialysis was higher in the diabetic group. Renal failure, stroke, mediastinitis, and wound infections were frequently encountered. Thirty-day mortality was 2.6% verses 1.6%. Cumulative 5-year survival was 84.4% versus 91.3%. The authors concluded that short-term mortality was acceptable in diabetic patients after CABG but they had increased postoperative morbidity in comparison with nondiabetic patients, particularly with regard to renal function, cerebral complications, and infections. Midterm survival was impaired in diabetic patients mainly because of a less favorable outcome in patients treated with insulin.
Our last article is titled Higher nocturnal blood pressure predicts diabetic renal disease which appears in the New England Journal of Medicine 2002; 347(11):797-805 and is written by Daniel Battle, M.D. et al from Northwest University in Chicago. We frequently receive questions about hypertension so we though this would be of help to those of you who have shown concern. In this article the authors suggest that nocturnal blood pressure may be the best early indicator of subsequent vascular complications and renal disease. They suggest that this marker may be helpful in determining who should have early intervention and who may not need it. "In persons with type 1 diabetes, an increase in systolic blood pressure during sleep precedes the development of microalbuminuria," says Empar Lurbe, MD form the University of Valencia in Spain, and colleagues. "In those whose blood pressure during sleep decreases normally, the progression from normal albumin excretion to microalbuminuria appears to be less likely". This study involved 75 adolescents and young adults with type 1 diabetes for more than 5 years who still had normal urinary albumin excretion and blood pressure. The subjects had ambulatory blood-pressure monitoring at the initial evaluation and about 2 years later, at which time all subjects had normal urinary albumin excretion. Microalbuminuria developed subsequently in 14 subjects. Systolic pressure during sleep increased significantly in the subjects who later developed microalbuminuria but not in those who continued to have normal albumin excretion. The ratio of systolic pressure during sleep to systolic pressure during the day predicted the risk for progression to microalbuminuria. The researchers concluded that "blood pressure measured randomly at the physician's office cannot fully reflect blood pressure levels around the clock.
BSP
