bluuebunny/crossref_metadata_2025 huggingface dataset:
Ischaemic outcomes assessment survey: A pilot study in patients with peripheral arterial disease
Authors: Howard James J , Souchek Julianne , Collins Tracie C
Published: August 2008

Background

Patients with peripheral arterial disease (PAD) are at increased risk for stroke, myocardial infarction (MI) and cardiovascular death. Prior studies have focused on the prevalence of PAD, but the rate of ischaemic outcomes among a diverse group of patients with PAD has received less attention. In addition, the assessment of ischaemic outcomes with the use of a survey in place of casenote review, to our knowledge, has not been defined. The purpose of this pilot study was to develop an ischaemic outcomes survey that could be used in place of the labour-intensive casenote review, for data collection as part of a large epidemiological study.

Methods

A data abstraction form was used as a guide in blinded casenote reviews to compare the patient's reported medical history to casenote documented ischaemic events. The proportion agreement and Cohen's kappa were used to measure the agreement and the statistical significance of this agreement between the questionnaire and casenote review items. Fifty-one patients with a history of PAD were consented and interviewed using a 23-item questionnaire that focused on the ischaemic events of unstable angina, MI, cerebral vascular accident, transient ischaemic attacks, lower extremity revascularisation, or lower extremity amputation.

Results

Of the 23 patient survey items, proportion agreement was ≥ 70% on more than half of the items with kappa statistics that were fair-to-moderate. For ischaemic outcomes such as lower extremity bypass surgery, there were no yes responses from the patient or within the medical record, which reflects the low prevalence of this outcome.

Conclusions

Overall, the ischaemic outcomes questionnaire was a valid research tool. It yielded statistically significant kappa values on several items. Although additional work is needed, the present survey provides a good framework on which to develop the final questionnaire, which will be used in a large prospective cohort study to capture ischaemic events in patients with PAD.
Audit of cardiovascular risk assessment in type 2 diabetic patients referred for insulin therapy: a cardiological perspective
Authors: Henriksen Peter A , Lockman K Ann , Robertson Sharon J , Clark Donna , Barclay Janet Ip , Chalmers John , Campbell Ian W
Published: August 2008

We present an audit of cardiovascular risk, and drug prescription of 250 type 2 diabetic patients referred from primary care to a District General Hospital for prescription of 250 type 2 diabetic patients referred from primary care to a District General Hospital for management of insulin therapy. Prescription patterns were compared to current UK guidelines for primary and secondary prevention and evidence-based practice. The audit uncovered substantial under-recognition of the high vascular risk of this type 2 diabetic population with respect to the use of antiplatelet therapy, statins and angiotensin blockers. Type 2 diabetic patients requiring insulin therapy have a particularly high cardiovascular risk and we believe they should be considered for antiplatelet, statin and angiotensin blocking therapy on initiation of insulin treatment even if they have no previous history of overt vascular events.
Diabetes and the new GMS contract — a secondary care perspective
Authors: Masding Mike , Gatling Wendy
Published: August 2008

Drs Masding and Gatling consider the potential of the new GMS contract in the standardisation of diabetes investigations and treatments in primary care in the light of a 78 practice audit in Dorset. Glycaemic control in patients treated by diet alone and hypertension control were selected as aspects of clinical care where audit could be used to influence outcome.
Review: Use of nicotinic acid in patients with elevated fasting glucose, diabetes, or metabolic syndrome
Authors: Mcgovern Mark E
Published: August 2008

This paper will focus on the use of nicotinic acid as a therapeutic option for cardiovascular risk reduction in patients with abnormal glucose metabolism and `atherogenic dyslipidaemia'. This is characterised by low levels of HDL-C, high triglycerides, and preponderance of small, dense LDL particles. Whilst nicotinic acid may increase plasma glucose in some patients, more recent studies show that the effect of nicotinic acid on glycaemic control is minimal in the majority of patients, and that nicotinic acid decreases the risk of cardiac events in patients with elevated fasting glucose, diabetes, or metabolic syndrome.
Real gains but practical limitations to glycaemic control with insulin in type 2 diabetes
Authors: Gardner Stephen , Dunachie Susanna J , Levy Jonathan C
Published: August 2008

Background

Insulin is increasingly used for type 2 diabetes when oral therapy is inadequate. We have examined the results in unselected patients in a UK hospital diabetes clinic.

Methods

Clinical database records from 1994 to 2002 were analysed for anthropomorphic data, blood pressure, HbA1C and plasma cholesterol in type 2 diabetic patients starting insulin therapy.

Results

In 335 patients, HbA 1C at four years correlated positively with HbA1C before starting insulin (r=0.31, p<0.01) and negatively correlated with age at the time of starting insulin (r=-0.19, p<0.01). In two cohorts changed to insulin therapy before and after publication of the results of the UKPDS (1998), HbA1C improved in the first year, with little subsequent change over four years, while weight continued to rise. The later cohort had a significantly greater reduction in HbA1C (p=0.001). Even in this group, only 21.6% of patients achieved HbA1C < 7.5%.

Conclusions

In a UK diabetes clinic, insulin therapy for type 2 diabetes improved glycaemic control in the first year, but not thereafter, while weight gain continued in subsequent years. Tighter targets may have promoted improved results.
Review: Diabetes and the QT interval: time for debate
Authors: Kumar Rajeev , Fisher Miles , Macfarlane Peter W
Published: August 2008

The electrocardiographic QT interval has been extensively studied in ischaemic heart disease. Recently, there has been increasing interest in the relationship between diabetes and QT abnormalities. QT prolongation and increased QTd have been shown to predict cardiac death in both type 1 and type 2 diabetes mellitus. Although there is general agreement that QT interval is affected by cardiac ischaemia, the effect of hyperglycaemia on QT measures is controversial. There are also problems surrounding QTd. First, there is controversy as to whether the measure has any physiological meaning; secondly, there is no universally accepted method of measurement and hence no consensus about the upper limit of normal. Nevertheless, several studies have shown increased QTd in diabetic patients suggesting that assessment of the QT interval could be a cost effective way of stratifying aggressive treatment could be directed appropriately to such patients according to cardiovascular risk so that improve outcome.
Review: Risk factor assessment of erectile dysfunction
Authors: Hood Stuart , Kirby Mike
Published: August 2008

Erectile dysfunction is a distressing condition that may result from organic or psychological causes. Organic ED results from neurological, hormonal or vascular pathologies, and may also have drug-related causes. Cardiovascular disease and diabetes are the most common vascular risk factors. Due to a reluctance of patients to mention ED, healthcare professionals should discuss sexual dysfunction with patients who have increased risk of ED. This article considers underlying aetiologies and outlines treatment options.
Gabapentin for the treatment of painful diabetic neuropathy: dosing to achieve optimal clinical response
Authors: Gómez-Pérez Francisco J , Perez-Monteverde Armando , Nascimento Osvaldo , Aschner Pablo , Tagle Marino , Fichtner Klaus , Subbiah Ponni , Mutisya Elizabeth M ,   For The Latin American Diabetic Neuropathy Study Group, Parsons Bruce
Published: August 2008

Objective

To determine whether gabapentin titrated to achieve clinical effect (≥ 50% reduction in pain; 900—3,600 mg/day) provides superior efficacy to a commonly prescribed fixed-dose (900 mg/day) in subjects with PDN.

Methods

In Latin America, an open-label trial randomised 339 subjects with PDN to gabapentin, 900 mg/day, for seven weeks (n=170), or to 900—3,600 mg/day titrated over four weeks to achieve clinical effect, followed by three weeks at stable dose (n=169).

Results

Gabapentin produced a significantly greater reduction in final weekly mean pain scores from baseline when titrated to clinical effect than when administered as a fixed-dose regimen (53.6% vs. 43.3%; p=0.009). Responder rate was significantly increased (64.5% vs. 47.5%; p=0.002), mean VAS scores significantly decreased, final weekly sleep interference scores significantly decreased (57% C vs. 37.2%; p=0.013), and trends favouring improvement in global functioning and QOL were seen in the titration to clinical effect group (p<0.001). Both regimens were well-tolerated.

Conclusions

Titration to clinical effect offered superior efficacy in treating PDN compared to a low fixed-dose treatment. Br J Diabetes Vasc Dis 2004;4:173—8
Socioeconomic status, cardiovascular risk factors and the incidence of microvascular and macrovascular disease in type 1 diabetes
Authors: Swaminathan Krishnan , Lewis Susan , Morris Andrew D ,   The Royal College of Physicians of Edinburgh Diabetic Registry Group
Published: August 2008

This study was undertaken to explore the associations between socioeconomic deprivation, prevalent cardiovascular risk factors and the development of microvascular and macrovascular complications in a cohort of subjects with type 1 diabetes mellitus in Scotland.

We identified 2,314 people with type 1 diabetes from clinic records in six Scottish regions from 1989 to 1996. Postcode sectors were used to determine the Carstairs Index as a proxy for socioeconomic status. Clinic records and linkage to Scottish morbidity records allowed the association of socioeconomic status with the development of microvascular and macrovascular disease and the prevalence of cardiovascular risk factors to be evaluated.

There was no overall association between prevalence of disease and socioeconomic status. There was a significant univariate relationship between smoking and deprivation (trend test p<0.0 D 0001; 47% of the most deprived were current smokers compared to 25% of the least deprived). Multivariate analysis showed that raised blood pressure, increasing age, smoking, high glycated haemoglobin and albuminuria were all independently associated with the development of macrovascular disease. Raised blood pressure, increasing duration of diabetes and high glycated haemoglobin were independently associated with microvascular disease. No associations were observed between either medical problem and socioeconomic status either before or after adjustment for other factors.

Our study concluded that social deprivation is associated with an increased risk of smoking. Our results did not confirm a tendency to poor glycaemic or blood pressure control in people who are deprived and there was no association between deprivation and incident microvascular or macrovascular disease.
Collaboration between hospital and primary care can improve the management of diabetic nephropathy
Authors: Thomas Nicola
Published: August 2008

The incidence of end-stage renal failure (ESRF) due to diabetic nephropathy is increasing. Nicola Thomas considers the role of patient empowerment as a tool to reduce the onset and progression of this condition. She outlines a study to facilitate an understanding of the scope for improving renal management of diabetes in primary and secondary care.
Review: Mechanisms contributing to the development of type 2 diabetes
Authors: Jayapaul Muthu K , Walker Mark
Published: August 2008

We are in the midst of an explosion in the prevalence of type 2 diabetes with a key concern that this will translate into a major future burden of diabetes-related complications. To develop rational and effective means of preventing type 2 diabetes and its complications, we need to understand the mechanisms that predispose to the development of diabetes in at-risk individuals. In this brief review, we provide an overview of the principal metabolic changes that have been identified in at-risk individuals and how they contribute to the progression from normal glucose tolerance (NGT) through to type 2 diabetes. Specifically, both impaired insulin action and defective insulin secretion are key predictors of type 2 diabetes, and both are evident in at-risk individuals well before the development of frank diabetes. These changes are associated with an increased prevalence of adverse cardiovascular risk factors. It is clear, therefore, that the identification of at-risk individuals provides the opportunity to introduce measures to try to prevent the development of type 2 diabetes and the associated cardiovascular disease.
Intermittent claudication in the patient with diabetes
Authors: Jude Edward B
Published: August 2008

Intermittent claudication (IC) — pain on walking that resolves at rest — is not a trivial complaint but is the first recognisable symptom of peripheral arterial disease (PAD). Diabetes is one of the most important risk factors for PAD and in people with diabetes it tends to be more distal and severe, and more likely to result in gangrene and amputation. Early diagnosis of PAD can reduce the substantial morbidity of the condition, which can culminate in limb loss for some patients. IC in the patient with diabetes can be treated with lifestyle modification, exercise programmes, medical treatment or bypass surgery.
The Diabetes Care Technician
Authors: Roland Jonathan , Hills Mimi , Hood Jo , Ellis Kerri
Published: August 2008

Dr Jonathan Roland and colleagues describe an innovative addition to the diabetes care team. A new role, the Diabetes Care Technician (DCT), has been developed, evaluated and implemented in Peterborough. This role is highly cost effective, obtainable and a quality improving contribution to the Diabetes National Service Framework (NSF) implementation.
Review: Current status of the development of inhaled insulin
Authors: Heinemann Lutz , Heise Tim
Published: August 2008

The most promising alternative route of insulin administration seems to be pulmonary delivery by inhalation. For a maximal rate of absorption insulin must be applied deep into the lung, i.e., into the alveoli. A number of inhalers designed to generate an aerosol with an appropriate particle size for pulmonary delivery are currently in clinical development. The pharmacodynamic effects of insulin formulations administered via the lung are comparable to, or are even faster than, those of subcutaneously injected regular insulin or rapid-acting insulin analogues. The relative biopotency of inhaled insulin is approximately 10%, i.e., the dose of inhaled insulin must be 10 times higher than the dose applied subcutaneously in order to induce a comparable metabolic effect. Clinical trials indicate that metabolic control with this pain free route of insulin administration is at least comparable to that of subcutaneous (sc) insulin therapy. Side effects. observed in human trials, gave rise to safety concerns that have delayed development for several years. Nevertheless, recent long-term safety studies indicate that the increased stimulation of insulin antibody formation stopped after some time and that the observed changes in lung function were minor or reversible. Consequently the first application for an approval of pulmonary insulin has been submitted to the authorities. In summary, it seems as if, after several decades of research, for the first time a feasible alternative route for insulin administration is within Reach.
Assessment of postprandial glucose: relationship between a standardised continental breakfast and the oral glucose tolerance test
Authors: Golay Alain , Guitard Christiane , Hoyer Monique , Logan John O , Brunel Patrick C
Published: August 2008

Background

To determine the relationship between postprandial glucose(PPG) and insulin values after an oral glucose tolerance test (OGTT) and a standardised continental breakfast.

Methods

An open, single-centre, randomised, crossover study in 32 fasted patients with type 2 diabetes and 10 healthy volunteers. Plasma glucose and insulin concentrations following a standardised breakfast challenge and a 75 g OGTT were measured over two hours.

Results

In both groups, the standardised breakfast induced similar plasma glucose and insulin profiles to the OGTT. Mean PPG excursions at each time-point were 1—2 mmol/L greater following the OGTT than the breakfast. Two-hour OGTT glucose levels correlated highly (r ≥ 0.80) with those following the breakfast at all time-points between 0.5—2 hours.

Conclusion

Plasma glucose levels measured 0.5—2 hours following a standardised breakfast are useful for assessing postprandial hyperglycaemia for diagnostic or post-treatment evaluations.
Fad diets in diabetes
Authors: Baldwin Eleanor J
Published: August 2008

Weight reduction is notoriously difficult to achieve and may be more difficult to attain in people with diabetes on insulin therapy and insulin secretagogues. People with diabetes may turn to fad diet books to help them lose weight. The most popular diet books are The Atkins Diet, The South Beach Diet, The pH Diet, The Blood Group Diets and The Zone. The main features of these diets are reviewed herein. The safety of some of these diets is questionable and their use is debatable.
Cardiovascular risk intervention in patients with type 2 diabetes
Authors: Masding Mike , Gatling Wendy
Published: August 2008

The risk of developing vascular disease is greatly increased in people with type 2 diabetes. The use of risk assessment tools is considered. The use of cardiovascular risk tables can underestimate risk by up to 30%. However, multiple risk factor intervention is recognised to be of benefit in reducing vascular risk and treatment strategies should include antiplatelet therapy, a statin and antihypertensive medication.
Review: Cardiovascular risk and diabetes in old people
Authors: Rodriguez-Mañas Leocadio , Castro Marta , Manzarbeitia Jorge
Published: August 2008

he transitions that took place during the second half of the 20th century produced an increase in the prevalence of cardiovascular diseases and demographic changes have brought the focus to older people. The necessity to improve the control of cardiovascular diseases and the unsatisfactory performance of available therapeutic approaches moved some of the attention to cardiovascular risk factors. Among them, one of the most outstanding is diabetes which many consider to be a cardiovascular disease equivalent. It became evident that cardiovascular risk factors act jointly, and the way to tackle them must follow a global strategy. At the end of the last century several cardiovascular risk factor tables were produced with the focus being on middle-age people, who formed the main database for studies in cardiovascular disease. However, an increasing proportion of patients are older and in this group current approaches to cardiovascular risk estimation may not be the most suitable.
Review: The laboratory evaluation of lower limb perfusion in diabetes mellitus. A clinical review
Authors: Williams Dean T , Pugh Neil D , Coleman Declan P , Harding Keith G , Price Patricia
Published: August 2008

on-invasive laboratory tests are commonly employed in the assessment of lower limb perfusion. The accuracy of non-invasive assessments in diabetes remains a concern. We evaluated the more commonly used methods with particular reference to diabetic foot disease. A literature review and clinical evaluation of tests for macrovascular disease, including hand held Doppler, blood pressure measurement and indices, Doppler waveform analysis, colour duplex imaging and plethysmography was performed. Tests reflecting tissue perfusion, including infrared detectors, transcutaneous oxygen tension, laser Doppler, capillaroscopy and skin temperature were also reviewed. Non-invasive laboratory tests reduce the requirement for invasive investigations and their inherent risks. More traditional non-invasive methods are being replaced by evolving techniques employing ultrasound technology. Arterial calcification and peripheral neuropathy associated with diabetes can potentially reduce the reliability of these methods. Distal limb and tissue perfusion assessments are more likely to reflect local vascularity. Tissue perfusion indicators are generally slow and vulnerable to environmental influences, thus limiting their clinical use. Nevertheless, non-invasive tests are an important adjunct to the clinical evaluation of diabetic foot disease. However, diabetes potentially reduces their reliability and the results require careful interpretation. Distal perfusion tests have potential advantages over macrovascular assessments. The influence of diabetes on non-invasive tests needs further evaluation.
Dyslipidaemia among Indo-Asians strategies for identification and management
Authors: Enas Enas A , Senthilkumar Annamalai , Vinod Chacko , Puthumana Neal
Published: August 2008

ndo-Asians have the highest rates of coronary artery disease (CAD) despite the fact that nearly half are lifelong vegetarians. The incidence, prevalence, and mortality from CAD among overseas Indo-Asians have been 50% to 300% higher than the Europeans, Americans, and other Asians with a higher risk at younger ages. Approximately 10% of the adults in urban India have CAD, a rate similar to overseas Indians. Traditional risk factors do not fully explain the excess burden of CAD in Indo-Asians. Therefore, conventional approaches to testing and treatment of risk factors are not sufficient in this population. Indo-Asians have a higher prevalence of glucose intolerance, metabolic syndrome, diabetes, elevated concentrations of lipoprotein(a) (LP[a]), and homocysteine, and low concentrations of high density lipoprotein (HDL). HDL particles are also smaller in Indo-Asians than Whites. A more aggressive approach to all risk factors, including HDL, LP(a), triglycerides and homocysteine is warranted. The current evidence of established safety and broad spectrum lipoprotein benefits of niacin and statins would make these invaluable agents in the armamentarium against dyslipidaemia, especially in Indo-Asians. This is particularly true for those with metabolic syndrome, diabetic dyslipidaemia and Lp(a) excess.
Has ASCOT signalled the end for beta blockers as first-line antihypertensive agents?
Authors: Kirby Mike
Published: August 2008

The blood pressure arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) compared treatment with atenolol and bendroflumethiazide against amlodipine and perindopril. This trial has been terminated early due to the emergence of significant benefits in the latter arm. Preliminary data from this trial, presented at the American College of Cardiology's 2005 meeting, are summarised and their implications for UK clinical practice are discussed.
Review: The endocannabinoid system: a new therapeutic target for cardiovascular risk factor management
Authors: Finer Nick , Pagotto Uberto
Published: August 2008

uropean guidelines on cardiovascular disease prevention in clinical practice have identified obesity and smoking as primary risk factors for cardiovascular disease, the increased prevalence of which underlines the need for new therapeutic targets. The endocannabinoid (EC) system is a physiological system, comprising the cannabinoid receptors, cannabinoid type 1 (CB1) and type 2 (CB2), and their natural ligands, such as anandamide and 2-arachidonyl-glycerol (2-AG). The system plays a key role in energy balance regulation, both centrally and peripherally impacting on food intake, lipid and glucose metabolism, and fat accumulation. The EC system is also involved in nicotine dependence. Over activity of the EC system, associated with obesity or chronic tobacco use, leads to increased levels of endogenous ligands (endocannabinoids) and disrupts the feedback mechanism related to steady state homeostasis. Rimonabant, the first selective CB1 receptor blocker, normalises the EC system, reduces food intake and body weight, improves lipid and glucose metabolism and insulin sensitivity and reduces nicotine self-administration. Clinical trials are ongoing to support the therapeutic potential of rimonabant in reducing these multiple cardiovascular risk factors.
Amylin analogue as an antidiabetic agent
Authors: Day Caroline
Published: August 2008

The amylin analogue pramlintide (SYMLIN®) is the first in a new class of injectable amylinomimetic agents to be approved for the treatment of diabetes. This adjunct to insulin treatment of type 1 and type 2 diabetes has recently been approved for use in the USA. Pramlintide, unlike native amylin is soluble. It acts mainly via central effects (area postrema) resulting in deceased glucagon secretion, slowing gastric emptying and a satiety effect. It is injected subcutaneously separately from insulin, and usually before each of the main meals. It has been shown to improve glycaemic control without causing weight gain but the dose must be titrated slowly in association with appropriate insulin adjustments to guard against insulin-induced hypoglycaemia and nausea. Thus, pramlintide is an injected amylin replacement therapy that can be used with an insulin regimen to improve glycaemic control without weight gain.
Review: Sulphonylureas and the rise and fall of beta-cell function
Authors: Matthews David R , Wallace Tara M
Published: August 2008

Sulphonylureas are an accepted and widely used treatment for hyperglycaemia in type 2 diabetes. The UK Prospective Diabetes Study (UKPDS) demonstrated that, like other oral agents used in clinical practice, there are early good results which fail over time. Conclusions drawn show that it is in fact a result of progressive loss of beta-cell function. Results from the UKPDS and several other studies reinforce the need for ongoing and tailored treatment to maintain glycaemic control and slow symptom progression. So sulphonylureas improve beta-cell function in those with type 2 diabetes over many years, but their effects are lessened by progressive beta-cell failure. In the enthusiasm for new therapies they should not be neglected as a mainstay of oral treatment early in the course of type 2 diabetes.
Review: The importance of effective early phase insulin secretion
Authors: Del Prato Stefano , Miccoli Roberto , Penno Giuseppe
Published: August 2008

Low insulin sensitivity and a selective loss of acute insulin release identify those individuals at the highest risk of developing type 2 diabetes. Normally, the rapid release of insulin after the ingestion of a meal is critical for post-prandial glucose regulation as first-phase insulin modulates suppression of endogenous glucose production and, therefore, limits meal-related plasma glucose excursions. The loss of first-phase insulin secretion contributes to the development of glucose intolerance. Indeed, postprandial hyperglycaemia represents the first and more evident perturbation of glucose homeostasis in about 60% of newly diagnosed type 2 diabetic patients. In these individuals, restoration of first-phase insulin secretion may result in more efficient inhibition of hepatic glucose production and improved glucose tolerance. In the light of these considerations, therapeutic intervention either alone or in combination with improvement of insulin resistance should be considered early in the course of the disease to prevent excessively rapid deterioration of glycaemic control.
From 4S to FIELD and PROactive: 10 years of CV trials in people with diabetes
Authors: Mccallum Roland W , Fisher Miles
Published: August 2008

he last ten years have seen a rapid expansion in the evidence-base for the reduction of cardiovascular risk in people with diabetes.in Following the landmark Scandinavian Simvastatin Survival Study (4S), several other studies have shown the benefits of statins in people with diabetes, but much less data are available for the benefit of fibrates, and the main evidence to date comes from subgroup analysis of the Veterans Affairs High Density Lipoprotein Cholesterol Intervention Trial (VA-HIT). The Hypertension in Diabetes Study (HDS), nested within the United Kingdom Prospective Diabetes Study (UKPDS), proved that tight control of hypertension reduced microvascular and macrovascular events in people with diabetes, and the Heart Outcomes Prevention Evaluation (HOPE) and MICRO-HOPE studies suggested a benefit in reducing cardiovascular events with angiotensin-converting enzyme (ACE) inhibition, additional to blood pressure lowering effects. With regards to glycaemic therapy, the UKPDS has shown the benefit of metformin in reducing myocardial infarctions. The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) studies will be presented later this year and will give information on the role of fenofibrate and pioglitazone respectively in reducing cardiovascular events in people with diabetes.
Review: Diabetes and cardiac disease in South Asians
Authors: Mukhopadhyay Babulayeb , Sattar Naveed , Fisher Miles
Published: August 2008

South Asians have a higher prevalence of diabetes, coronary heart disease and cardiovascular death. Their predisposition to insulin resistance partly explains this excess risk. After immigration, the adoption of a western diet allied to increased sedentary behaviour leads to weight gain, hypertension and hyperlipidaemia, factors which in turn combine to amplify the chances of getting heart disease. Further contributory factors are increased sub-clinical inflammation, increased thrombogenic tendency and higher serum homocysteine levels. South Asians with diabetes might do as well as White people with respect to intensive glycaemic and blood pressure control. However, there is little evidence for measures to reduce cardiovascular risk as South Asians have not been included as a subgroup in most large trials. Future prospective studies, including studies on the prevention of diabetes and cardiovascular disease in this high-risk population, are therefore urgently required.
Review: Dual blockade of the renin angiotensin system in diabetes — rationale and risks
Authors: Kumar Rajeev , Winocour Peter H
Published: August 2008

Diabetic nephropathy is the most common cause of end stage renal failure (ESRF) in the developedof world and as the incidence of diabetes increases this trend will continue, although most of these patients will die of cardiovascular diseases. The renin-angiotensin system (RAS) is believed to play a central role in the development and progression of both micro- and macrovascular complications of diabetes and blocking this system in diabetic patients is critically important. Two widely used inhibitors of RAS are angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs affect the system at different levels and thus may have an additive effect. Use of drugs from one class may not be completely effective in blocking this system for several reasons. In this article we discuss issues surrounding the use of dual blockade (i.e. the use of ARB and ACE inhibitors together in patients with diabetic nephropathy responding insufficiently to previous antihypertensive treatment including either ARB or ACE inhibitors) in patients with diabet
Early detection of coronary heart disease in diabetic patients without symptoms of coronary artery disease: implications for expanded use of myocardial perfusion imaging
Authors: Bax Jeroen J , Bonow Robert O , Tschöepe Diethelm , Inzucchi Silvio E , Barrett Eugene J
Published: August 2008

Patients with type 2 diabetes are at a markedly increased risk of a myocardial infarction than their non-diabetic peers. These patients often do not develop the classic warning signs of myocardial ischaemia, such as chest pain. Rather, they can display atypical symptoms or present with an acute myocardial infarction as the first indication of the presence of coronary artery disease. Current risk factor management techniques, largely based on risk factor scoring, have failed to identify this clinically important sub-population of patients, and the early diagnosis of silent myocardial ischaemia in this population would greatly aid risk stratification and subsequent therapy. Myocardial perfusion scintigraphy (MPS), using single-photon emission computed tomography (SPECT), has emerged as a specific and sensitive technique for detection of coronary artery disease in type 2 diabetic patients who have yet to develop signs or symptoms of coronary artery disease. Such abnormalities are common in this population, and are significantly associated with an increased risk of myocardial infarction or death from ischaemic heart disease. The current evidence supports MPS with SPECT as the methodology of choice for identifying silent myocardial ischaemia possibly improving cardiovascular risk stratification. Appropriate use of this technique allows earlier identification of coronary artery disease in diabetic patients.
Tuberculous osteomyelitis in the diabetic foot
Authors: Rajeswaran Chinnadorai , Harris Nicholas , Bodansky Haevey J , Amery Caroline M
Published: August 2008

Foot infections in patients with diabetes mellitus are associ- Fated with considerable morbidity and mortality. Tuberculosis t of the foot and ankle is an uncommon presentation of skeletal tuberculosis. We present an unusual case of tuberculous osteomyelitis involving the foot of a patient with type 2 diabetes mellitus. Skeletal tuberculosis may be difficult to diagnose as the symptoms and signs are often non-specific. In diabetic patients with a previous history of tuberculosis, it is important to include cultures of acid-fast bacillus in the work-up of deep infection of the foot. It is important to recognise peripheral tuberculosis osteomyelitis early, as prompt treatment can effectively eliminate long-term morbidity. This condition is potentially devastating and must be differentiated from other pathologies in the diabetic foot.
Review: Cardiovascular risk assessment in the metabolic syndrome, screening for subclinical disease, and implications for treatment
Authors: Wong Nathan D
Published: August 2008

he metabolic syndrome is a clustering of risk factors known to promote or increase the risk for development of cardiovascular disease. Approximately 25—35% of the adult population of developed countries are characterised with metabolic syndrome by different definitions. Metabolic syndrome, even in the absence of diabetes, is associated with an increased risk of cardiovascular disease and total mortality, and is related to an increased risk for the development of diabetes. Initial evaluation of coronary heart disease risk involves global risk estimation using Framingham or other algorithms for risk prediction. Given the absence of key metabolic syndrome risk factors (namely obesity, elevated triglycerides, and impaired fasting glucose) in these algorithms, elevations in these factors need to be considered in individual patient risk evaluation. Further, consideration of screening for novel risk factors such as C-reactive protein, as well as subclinical atherosclerosis (from carotid ultrasound, computed tomography, or ankle-brachial index), can further refine the estimation of future cardiovascular disease risk. The presence of subclinical atherosclerosis or elevated levels of C-reactive protein can potentially modify recommended treatment goals for lipid and other cardiovascular risk factors. The American Heart Association and US National Heart Lung and Blood Institute have recently released revised guidelines for the diagnosis and clinical management of metabolic syndrome. This article examines global assessment of cardiovascular risk in persons with metabolic syndrome, the role of screening for subclinical disease in risk assessment, as well as treatment strategies and their implications for reducing cardiovascular risk in those with metabolic syndrome.
The role of pharmaceutical care in diabetes management
Authors: Davis Timothy Me , Clifford Rhonda M , Davis Wendy A , Batty Kevin T
Published: August 2008

Pharmaceutical care (PC) is a process through which a pharmacist works with other healthcare professionals and the patient to optimise pharmacotherapy. Early studies, carried out before PC was established, provided limited evidence of the benefits of pharmacist involvement in diabetes management. More recent research has examined the role of PC in a range of diabetic sub-groups. Although few of these studies were randomised, prospective and included clinically important end points such as HbA1C, some beneficial effects of PC were reported. In the most recent study, a 12-month randomised controlled trial of PC in community-based diabetic patients, regular face-to-face and telephone interviews with an experienced clinical pharmacist improved glycosylated haemoglobin while glycaemic control did not change in the controls. In addition, reductions in blood pressure, and in absolute vascular risk for patients with no history of coronary artery disease, were significantly greater in the PC group. Available evidence suggests that PC can prove a valuable component of community-based multi-disciplinary diabetes care.
Review: Dual blockade of renin-angiotensin system in diabetic nephropathy: review of literature and local experience
Authors: De Parijat , Das Gautam , Harley Karen , Nair Harikrishan
Published: August 2008

Albuminuria and hypertension are predictors of poor renal and cardiovascular outcome in patients with diabetic nephropathy (DN). Intensive treatment requires blockade of the renin-angiotensin system (RAS) by either angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), which reduce blood pressure and proteinuria. Combining the two therapies has shown greater benefits than either drug alone to reduce progression of DN. Although treatment goals are more likely to be achieved with the combination, this requires close monitoring of serum creatinine and potassium which invariably rise on such therapy.
Improvements in clinical diabetes care in the first year of the new General Medical Services contract in the UK
Authors: Jaiveer Pachaiappan K , Jaiveer Saraswathy , Jujjavarapu Sagar B , Morrissey John , White Juelene , Gadsby Roger , Patel Vinod
Published: August 2008

The prevalence of diabetes and the cost of providing services will increase dramatically over the next ten years. There is a wide consensus that the way forward is for primary care to provide more care to higher clinical standards. The new General Medical Services contract (GMS2) offers incentives to achieve diabetes management targets. We compared the performances of health centres in North Warwickshire in the pre-contract year 2004 and post-contract in 2005. The audit tool comprised the GMS2 quality indicators in Alphabet Strategy format. There were statistically significant improvements in performance against almost all the quality indicators. We conclude with some reservations that GMS2 has considerably improved the quality of diabetes care in our locality.
Review: PROactive 03: Pioglitazone, type 2 diabetes and reducing macrovascular events — economic implications?
Authors: Bottomley Julia , Palmer Andrew J , Williams Rhys , Dormandy John , Massi-Benedetti Massimo
Published: August 2008

conomic value of medicines, medical devices and other technologies is an increasingly important consideration in healthcare management. Conducting high quality economic analyses alongside randomised controlled clinical trials (RCTs) is desirable since these offer timely information with high internal validity. The recent publication of the landmark PROactive study provides a relevant platform upon which to base a detailed economic evaluation of the possible additional benefit of pioglitazone over and above current best treatment in patients with type 2 diabetes with severe cardiovascular (CV) disease. Pioglitazone improved CV outcome and reduced the need to add insulin to existing therapy in individuals at high risk of further macrovascular events. The predefined economic analysis of this study using well-accepted methods will inform the cost effectiveness (CE) of pioglitazone confirming (or not) its value in the management of patients with type 2 diabetes with severe CV disease.
NAUTILUS (Safety and tolerability of Niaspan®): a subgroup analysis in patients with diabetes
Authors: Vogt Anja , Kassner Ursula , Hostalek Ulrike , Steinhagen-Thiessen Elisabeth
Published: August 2008

The multiceNtre, open, uncontrolled sAfety and tolerability stUdy of a modified-release nicoTinic acId formuLation in sUbjects with dySlipidaemia and low HDL-cholesterol (NAUTILUS) trial was designed to evaluate the safety and tolerability of prolonged-release nicotinic acid (Niaspan®) in patients treated for dyslipidaemia in a usual care setting in Germany. The dyslipidaemia was inadequately controlled by diet, including low high-density lipoprotein cholesterol (HDL-C) (< 1.0 mmol/L [< 40 mg/dL] in men and < 1.2 mmol/L [<46 mg/dL] in women). This analysis focuses on the tolerability and safety of Niaspan® in patients with diabetes. Diabetic and non-diabetic subjects reported similar incidences of all-cause adverse events (AE; 59.9% vs. 60.8%, respectively), serious AE (SAE; 4.0% vs. 3.4%, respectively) and withdrawals for AE (17.6% vs. 16.4%). Flushing was the most common side effect, as expected (42% of patients in each group), but < 10% withdrew for flushing. There was no indication of hepatotoxicity or serious muscle toxicity in diabetic or non-diabetic subjects. Changes in glycaemic parameters were small (mean changes in diabetic subjects of +0.2% HbA1C and +0.4 mmol/L [+8 mg/dL] for fasting plasma glucose), despite marked reductions in the intensity of antidiabetic therapy in about one third of patients. Niaspan® was equally effective in diabetic or non-diabetic subjects in increasing HDL-C (+24% in each group) and decreasing triglycerides (-12% and -13%, respectively). Niaspan® was well tolerated in patients with type 2 diabetes and the results of NAUTILUS support its use for correction of low HDL-C in this population.
Foot guide
Authors: Day Caroline
Published: August 2008

The National Diabetes Support Team (NDST) has recently published a guide for the care of the diabetic foot to assist in strategy development and implementation to achieve the high quality care set out in the standards of the National Service Framework (NSF) for Diabetes.
Review: Inhibition of dipeptidyl peptidase-4 with vildagliptin: a potential new treatment for type 2 diabetes
Authors: Pratley Richard E , Salsali Afshin , Matfin Glenn
Published: August 2008

Type 2 diabetes mellitus is a growing problem in most parts of the world. There is now good evidence that controlling hyperglycaemia can help prevent many of the serious complications associated with the disease. Despite this evidence and the availability of several classes of oral antidiabetic agents and insulin, many people with diabetes do not achieve adequate glycaemic control (i.e. HbA1C< 6.5 or 7.0%). Thus, there is an urgent unmet medical need to develop new and better treatments for type 2 diabetes. Among the most promising new classes of drugs for type 2 diabetes are those that leverage the incretin hormone glucagon-like peptide-1 (GLP-1). Vildagliptin, an orally available, potent and specific inhibitor of dipeptidyl peptidase-4 (DPP-4), the enzyme that rapidly inactivates GLP-1, augments endogenous active GLP-1 and gastric inhibitory polypeptide/glucose-dependent insulinotropic polypeptide (GIP) and reduces hyperglycaemia in patients with type 2 diabetes. Studies to date in patients exposed for up to one year indicate that vildagliptin produces clinically significant reductions in HbA1C when used as monotherapy and in combination with metformin, glimepiride, or insulin. In general, the drug has proved to be well tolerated with low rates of hypoglycaemia and gastrointestinal side effects (including nausea) and no weight gain or oedema.
The Alphabet Strategy and standards of care in young adults with type 1 diabetes
Authors: Gholap Nitin , Pillai Meera , Virmani Sumit , Lee James D , James Diane , Morrissey John , Datta Vipan , Patel Vinod
Published: August 2008

The Alphabet Strategy is a mnemonic-based approach to assist commitment to important aspects of diabetes care: Advice; Blood pressure lowering; Cholesterol and creatinine control; Diabetes control; Eye examination; Foot examination; and use of Guardian drugs. This strategy reported high standards of care of patients with type 2 diabetes. This study assesses the impact of the Alphabet Strategy on diabetes management in young adults with type 1 diabetes and compared data with those of a recently published multicentre study. Results were analysed using the chi-square test and Student's t-test.

Data were collected retrospectively from 68 patients with type 1 diabetes aged 16—25 years attending the George Eliot Hospital (GEH) adolescent diabetes clinic and who were being managed as per The Alphabet Strategy.

Standards of diabetes care in the GEH clinic were better than those reported in the multicentre study. GEH versus multicentre study: clinic non-attendance 12% vs. 24.6%: mean HbA1C% 8.4 vs. 9.5, p<0.001: screening rates; hypertension 100% vs. 88%, p<0.05; nephropathy 80% vs. 56%, p<0.01; retinopathy 98% in GEH clinic: prevalence of complications; nephropathy 5% vs. 21%, p<0.02; retinopathy 24% vs. 28%, not significant.

In conclusion, we found regular clinic visits and separate adolescent clinics improve glycaemic control. The Alphabet Strategy may be considered an effective approach in monitoring/screening and attaining targets in young adults with type 1 diabetes.
The MERCURY II trial: benefits of rosuvastatin
Authors: Izzat Lena
Published: August 2008

Measuring Effective Reductions in Cholesterol Using Rosuvastatin therapy (MERCURY II) was a 16-week, randomised, open-label study in high-risk subjects with primary hypercholesterolaemia, comparing efficacy and safety following a switch after eight weeks from the accepted/potential start doses of atorvastatin (10 and 20 mg) and simvastatin (20 and 40 mg) to the most widely used doses of rosuvastatin (10 and 20 mg) or remaining on initial therapy. At 16 weeks, significantly more patients switched to rosuvastatin had achieved their National Cholesterol Education Programme/Adult Treatment Panel III (NCEP/ATP III) low-density lipoprotein cholesterol (LDL-C) targets than those who remained on atorvastatin or simvastatin, also patients with hypertriglyceridaemia were more likely to achieve their LDL-C, non high-density lipoprotein cholesterol (HDL-C) and apo B goals when switched to rosuvastatin. A greater number of patients deemed very high risk achieved their optional NCEP/ATP III LDL-C target of < 1.8 mmol/L (70 mg/dL) when switched to rosuvastatin from either atorvastatin or simvastatin. All statin regimes were well tolerated with a comparable side effect profile. In high-risk patients, where new lipid targets are especially difficult to achieve, switching to rosuvastatin 10 or 20 mg was a safe and effective strategy.
NICE and hypertension — the judge's decision is final!
Authors: Kirby Michael G
Published: August 2008

On 28th June 2006 the National Institute for health and Clinical Excellence (NICE) announced their revised guidelines on the treatment of hypertension, which will have a major impact on prescribing practice.1 With the media excitement surrounding these new guidelines, there is also likely to be an influx of patients concerned about their current medication. This article explains the changes to the guidelines, the evidence behind them and discusses the implications for clinicians.