Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial

BACKGROUND

Blood pressure is an important determinant of the risks of macrovascular and microvascular complications of type 2 diabetes, and guidelines recommend intensive lowering of blood pressure for diabetic patients with hypertension. We assessed the effects of the routine administration of an angiotensin converting enzyme (ACE) inhibitor-diuretic combination on serious vascular events in patients with diabetes, irrespective of initial blood pressure levels or the use of other blood pressure lowering drugs.

METHODS

The trial was done by 215 collaborating centres in 20 countries. After a 6-week active run-in period, 11 140 patients with type 2 diabetes were randomised to treatment with a fixed combination of perindopril and indapamide or matching placebo, in addition to current therapy. The primary endpoints were composites of major macrovascular and microvascular events, defined as death from cardiovascular disease, non-fatal stroke or non-fatal myocardial infarction, and new or worsening renal or diabetic eye disease, and analysis was by intention-to-treat. The macrovascular and microvascular composites were analysed jointly and separately. This trial is registered with ClinicalTrials.gov, number NCT00145925.

FINDINGS

After a mean of 4.3 years of follow-up, 73% of those assigned active treatment and 74% of those assigned control remained on randomised treatment. Compared with patients assigned placebo, those assigned active therapy had a mean reduction in systolic blood pressure of 5.6 mm Hg and diastolic blood pressure of 2.2 mm Hg. The relative risk of a major macrovascular or microvascular event was reduced by 9% (861 [15.5%] active vs 938 [16.8%] placebo; hazard ratio 0.91, 95% CI 0.83-1.00, p=0.04). The separate reductions in macrovascular and microvascular events were similar but were not independently significant (macrovascular 0.92; 0.81-1.04, p=0.16; microvascular 0.91; 0.80-1.04, p=0.16). The relative risk of death from cardiovascular disease was reduced by 18% (211 [3.8%] active vs 257 [4.6%] placebo; 0.82, 0.68-0.98, p=0.03) and death from any cause was reduced by 14% (408 [7.3%] active vs 471 [8.5%] placebo; 0.86, 0.75-0.98, p=0.03). There was no evidence that the effects of the study treatment differed by initial blood pressure level or concomitant use of other treatments at baseline.

INTERPRETATION

Routine administration of a fixed combination of perindopril and indapamide to patients with type 2 diabetes was well tolerated and reduced the risks of major vascular events, including death. Although the confidence limits were wide, the results suggest that over 5 years, one death due to any cause would be averted among every 79 patients assigned active therapy.

Bioinformatic discovery of microRNA precursors from human ESTs and introns

Background

MicroRNAs (miRNAs) function in many physiological processes, and their discovery is beneficial for further studying their physiological functions. However, many of the miRNAs predicted from genomic sequences have not been experimentally validated to be authentic expressed RNA transcripts, thereby decreasing the reliability of miRNA discovery. To overcome this problem, we examined expressed transcripts – ESTs and intronic sequences – to identify novel miRNAs as well as their target genes.

Results

To facilitate our approach, we developed our scanning method using criteria based on the features of 207 known human pre-miRNAs to discriminate miRNAs from random sequences. We identified 208 candidate hairpins in human ESTs and human reference gene intronic sequences, 52 of which are known pre-miRNAs. The discovery pipeline performance was further assessed using 130 newly updated pre-miRNA and randomly selected sequences. We achieved sensitivity of 85% (110/130) and overall specificity of 49.7% using this method. Because miRNAs are evolutionarily conserved regulators of gene expression, it is expected that their host genes and target genes should have respective phylogenetic orthologs. Our results confirmed that, in certain mammals, the host genes carrying the same miRNAs are orthologs, as previously reported. Moreover, this observation is also the case for some of the miRNA target genes.

Conclusion

We have predicted 208 human pre-miRNA candidates and over 10,000 putative human target genes. Using sequence information from ESTs and introns ensures that the predicted pre-miRNA candidates are expressed and the combined expression transcription information from ESTs and introns makes our prediction results more decisive with regard to expressed pre-miRNAs.

A comparison of urinary albumin excretion rate and microalbuminuria in various glucose tolerance subjects

AIMS

To investigate the difference of urinary albumin excretion rate (UAER) and microalbuminuria (MAU) in various glucose tolerance subjects, especially between isolated-impaired glucose tolerance subjects and isolated-impaired fasting glycaemia subjects.

METHODS

A total of 2934 subjects were divided into five groups with various glucose tolerances, based on a 75-g oral glucose tolerance test. Microalbuminuria was defined when urinary albumin excretion rate was between 20 and 200 microg/min.

RESULTS

(i) The UAER in the newly diagnosed Type 2 diabetes mellitus group, impaired glucose tolerance/impaired fasting glycaemia group and isolated-impaired glucose tolerance group were all higher than that in the isolated-impaired fasting glycaemia group and normal glucose tolerance group, but it was comparable between isolated-impaired fasting glycemia group and normal glucose tolerance group. The prevalence of MAU and the odds ratio for MAU with adjustment for age and sex in various glucose tolerance groups showed the same trend as the UAER. (ii) After adjusting for age and sex, there is a significant association between logUAER and independent risk factors (partial correlation coefficients: r = 0.26 for 2-h post-challenge blood glucose, r = 0.26 for systolic blood pressure, r = 0.27 for diastolic blood pressure, r = 0.27 for body mass index and r = -0.13 for high density lipoprotein-cholesterol, all P < 0.001). The risks for MAU were 2-h post-challenge blood glucose, body mass index and diastolic blood pressure, while high density lipoprotein-cholesterol was protective.

CONCLUSIONS

The urinary albumin excretion rate and prevalence of microalbuminuria were higher in isolated-impaired glucose tolerance subjects than those in isolated-impaired fasting glycaemia subjects. At early abnormal glucose tolerance stage, the increasing post-challenge glycaemia might be a more important risk factor for urinary albumin excretion rate and microalbuminuria than increasing fasting glycaemia.

An alarmingly high prevalence of diabetic nephropathy in Asian type 2 diabetic patients: the MicroAlbuminuria Prevalence (MAP) Study

AIM/HYPOTHESIS

Microalbuminuria represents the earliest clinical evidence of diabetic nephropathy and is a marker of increased cardiovascular morbidity and mortality. Its early detection allows the implementation of individualised and aggressive intervention programmes to reduce cardiovascular risk factors. There is limited information on the prevalence of microalbuminuria among hypertensive type 2 diabetic patients in Asia.

METHODS

This cross-sectional epidemiological study aimed to assess the prevalence of microalbuminuria and macroalbuminuria among consecutively screened hypertensive type 2 diabetic adult patients in 103 centres in 10 Asian countries or regions. Predictive factors for microalbuminuria and macroalbuminuria were characterised using a stepwise logistic regression model.

RESULTS

A total of 6,801 patients were enrolled and 5,549 patients constituted the per-protocol population (patients with bacteriuria and haematuria were excluded). The prevalence of microalbuminuria was 39.8% (39.2-40.5; 95% CI) and the prevalence of macroalbuminuria was 18.8% (18.2-19.3; 95% CI). Only 11.6% of the patients had systolic and diastolic blood pressure below the 130/80 mm Hg target. In the multivariate analyses, the predictive factors for the presence of microalbuminuria were age, BMI, systolic blood pressure and ethnic origin. The highlighted predictive factors for the presence of macroalbuminuria were age, sex, ethnic origin, BMI, duration of diabetes, presence of diabetic complications, intake of diuretics, intake of calcium channel blockers, diastolic and systolic blood pressure.

CONCLUSIONS/INTERPRETATION

The high prevalence (58.6%) of micro or macroalbuminuria observed in these patients is alarming and indicates an impending pandemic of diabetic cardiovascular and renal diseases in Asia with its potential economic consequences.

Metabolic, immunological and clinical characteristics in newly diagnosed Asian diabetes patients aged 12-40 years

AIM

To describe the clinical, biochemical and immunological characteristics of young-onset diabetes in Asia.

METHODS

Clinical, biochemical and immunological variables were assessed in 919 newly diagnosed (duration less than 12 months) young onset Asian diabetic patients aged between 12 and 40 years. The subjects constituted 57% Chinese, 29% Indians and 14% Malays, recruited from diabetes centres in China, Hong Kong, India, Malaysia and Singapore.

RESULTS

The mean age (+/- sd) was 31.6 +/- 7.2 years, with the majority (66%) in the 31-40 years age group. Mean body mass index (BMI) (+/- sd) was 25.3 +/- 5.0 kg/m2 with 47% exceeding the suggested Asian cut-off point for obesity (BMI > or = 25). Ethnic difference in clinical characteristics included BMI, blood pressure, mode of treatment and degree of insulin resistance. Most patients had a clinical presentation of Type 2 diabetes. About 10% had a classical combination of ketotic presentation, presence of autoimmune-markers and documented insulin deficiency indicative of Type 1 diabetes. Forty-eight percent were receiving oral hypoglycaemic agents (OHAs) while 31% were on diet only, 18% were receiving insulin and 2% were on a combination of insulin and OHA.

CONCLUSION

Young onset diabetes patients in Asia represent a heterogeneous group in terms of their clinical and biochemical characteristics and classical Type 1 diabetes is relatively uncommon. The 5-year follow up study will determine the progress of these patients and help to clarify the natural history.

The Diabcare-Asia 1998 study--outcomes on control and complications in type 1 and type 2 diabetic patients

The aim of this study was to describe the glycaemic and metabolic control and diabetes-related complications in type 1 and type 2 Asian patients.

METHODS

Data of diabetes patients from 230 diabetes centres in 12 Asian regions were collected on a retrospective-prospective basis through review of medical records, interview and laboratory assessments. Analysis of glycated haemoglobin (HbA1c) was carried out in central laboratories appointed by Bio-Rad. The data collection case record forms were scanned electronically.

RESULTS

22177 patients with valid data made up the analysis population. Among patents with type 1 and type 2 diabetes, there was a higher proportion of women than men (53% vs. 47% for type 1 patients and 56% vs. 44% for type 2 diabetes). Hypertension (61%) and overweight (40% with BMI > or = 25 kg/m2 were common in type 2 patients. Dyslipidaemia was also present in at least half of both types of patients. Control of glycaemia (mean HbA,1c and fasting blood glucose [FBG]) was poor in type 1 (9.9 +/- 2.5%; 10.2 +/- 5.2 mmol/l) and type 2 patients (8.5 +/- 2.0%; 8.9 +/- 3.4 mmol/l). Glycaemia in the majority of both types of patients fell short of those stipulated by various guidelines. In type 2 patients, glycaemia deteriorated (HbA1c > 7.5%, FBG > or = 7.0 mmol/l) with duration of diabetes > 7 years. Both types of diabetes appear to share a similar high prevalence of complications of cataract, retinopathy and neuropathy, although the prevalence of cataract (27%) and neuropathy (35%) was higher in type 2 diabetes. Screening for microalbuminuria was not common.

CONCLUSIONS

The Inadequate metabolic and hypertension control, especially in type 2 patients, needs to be addressed.

Calpains play a role in insulin secretion and action

Studies of the genetic basis of type 2 diabetes suggest that variation in the calpain-10 gene affects susceptibility to this common disorder, raising the possibility that calpain-sensitive pathways may play a role in regulating insulin secretion and/or action. Calpains are ubiquitously expressed cysteine proteases that are thought to regulate a variety of normal cellular functions. Here, we report that short-term (4-h) exposure to the cell-permeable calpain inhibitors calpain inhibitor II and E-64-d increases the insulin secretory response to glucose in mouse pancreatic islets. This dose-dependent effect is observed at glucose concentrations above 8 mmol/l. This effect was also seen with other calpain inhibitors with different mechanisms of action but not with cathepsin inhibitors or other protease inhibitors. Enhancement of insulin secretion with short-term exposure to calpain inhibitors is not mediated by increased responses in intracellular Ca2+ or increased glucose metabolism in islets but by accelerated exocytosis of insulin granules. In muscle strips and adipocytes, exposure to both calpain inhibitor II and E-64-d reduced insulin-mediated glucose transport. Incorporation of glucose into glycogen in muscle also was reduced. These results are consistent with a role for calpains in the regulation of insulin secretion and insulin action.

[Study of the growth and secretion of microencapsulated pancreatic B cell line in vitro]

AIM

To study the growth and secretion of pancreatic B cell line BTC6-F7 in the alginate polylysine-alginate (APA) microcapsules and explore the possibility of utilizing it as bioartificial islets.

METHODS

Microencapsulated BTC6-F7 cells prepared with electric droplet generator were cultured in vitro, and the growth and insulin secretion of them were measured periodically.

RESULTS

Over the 90-day observation period, BTC6-F7 cells were able to grow and survive as cell clusters in the microcapsules and finally fulfill the capsules. But the microcapsules remained well after the long-time culture. The average total cell number per capsule were increasing with time, but the cell viability was decreasing. The changes of insulin secretion and average live cell number per capsule were in a same manner: for the first two weeks they increased rapidly and then maintained in a relatively constant levels for the rest time.

CONCLUSION

The microencapsulated pancreatic B cells prepared by us could survive, grow and secretion for a long time. This has made a basis for further development of bioartificial islets, and also can be used to study the mechanism and therapy of diabetes mellitus.

Rundown of secretion after depletion of intracellular calcium stores in bovine adrenal chromaffin cells

In this study, the relationship between intracellular calcium stores and depolarization-evoked stimulation was examined in bovine chromaffin cells, using changes in membrane capacitance to monitor both exocytosis and endocytosis. Cells were voltage-clamped using the perforated whole-cell patch configuration to minimize alterations in intracellular constituents. Control cells exhibited reproducible secretory responses each time the cell was stimulated. However, the same stimulation protocol elicited progressively smaller secretory responses in cells where their intracellular calcium store was emptied by thapsigargin. Transient elevation of the intracellular calcium concentration with a brief histamine treatment enhanced subsequent secretory responses in control but not in thapsigargin-treated cells. A series of depolarizations to -20 mV, which allowed small amounts of Ca(2+) influx but which by itself did not trigger catecholamine secretion, enhanced subsequent exocytosis in both control and thapsigargin-treated cells. Caffeine-pretreated cells exhibited a rundown in the secretory response that was similar to that produced by thapsigargin. These results suggest that brief elevations of [Ca(2+)](i) could enhance subsequent secretory responses. In addition, the data suggest that intracellular calcium stores are vital for the maintenance of exocytosis during repetitive stimulation.

Effect of metformin on patients with impaired glucose tolerance

AIMS

To evaluate the effect of metformin on glucose metabolism, insulin sensitivity and rate of conversion diabetes in people with impaired glucose tolerance (IGT).

METHODS

Seventy subjects with IGT were randomized under double-blind conditions to receive either placebo (n = 37) or metformin (n = 33) at a dosage of 250 mg three times daily for a duration of 12 months. Glycaemic control, plasma insulin and other biochemical indexes were assessed before and after 3, 6 and 12 months.

RESULT

At 12 months the conversion rate to diabetes was 16.2% in the placebo group compared to 3.0% for the metformin group (P = 0.011). Of subjects treated with metformin for 12 months, 84.9% became normoglycaemic compared to 51.4% of those receiving the placebo. Significant improvements in fasting glucose, glucose tolerance and insulin sensitivity were found at 12 months and at intermediate clinic assessments.

CONCLUSIONS

Metformin can improve glucose metabolism in IGT patients and may be a treatment option in their management of IGT subjects.

Molecular study of the Na+/Ca2+ exchanger in bovine adrenal chromaffin cells

To identify the Na+/Ca2+ exchanger expressed in bovine chromaffin cells, the ncx gene was cloned from a bovine chromaffin cell cDNA library. Five partial clones were obtained and their nucleotide sequences showed that there were at least three isoforms containing different intracellular loops. The 3'-untranslated region was the same in all the clones. To examine the Na+/Ca2+ exchange activity of the clones, full-length ncx1 genes were constructed by replacing the corresponding region of bovine cardiac ncx1 clone p17 with the different regions from two bovine chromaffin cell clones; these were designated p17c and p17h. p17h, but not p17c, showed Na+/Ca2+ exchange activity when expressed in Chinese hamster ovary cells and Xenopus oocytes. The expressed exchange activity of p17 was inhibited by 8-bromoadenosine 3':5'-cyclic monophosphate (8-Br-cAMP) but was not affected by PMA. However, the activity of p17h was inhibited by PMA but enhanced by 8-Br-cAMP. The agents that changed the activity of protein kinase C and cAMP-dependent protein kinase modulated the endogenous Na+/Ca2+ exchange current of chromaffin cells in a manner similar to that of p17h. Our results suggest that the p17h clone is the major isoform of the exchanger in chromaffin cells and is similar to the major ncx1 isoform in kidney. The exchange activity could be regulated by phosphorylation, and the variable region in the intracellular loop is important for the different effects of phosphorylation on the different isoforms.

[Association between ACE gene polymorphism and therapeutic responsiveness of ACEI in diabetic nephropathy]

OBJECTIVE

[corrected] To clarify the association between ACE gene polymorphism and therapeutic responsiveness of ACEI in diabetic nephropathy.

METHOD

With the polymerase chain reaction technique, the angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism was studied in 31 NIDDM patients, 58 NIDDM patients with nephropathy, and 50 normal controls.

RESULTS

There was no significant difference in the frequency of ACE genotypes among those NIDDM patients, NIDDM patients with nephropathy and nomal controls. Among 40 patients of DN group treated with ACE inhibitor(ACE-I), there was significant difference in genotype distribution between 19 efficacious cases and 21 nonefficacious cases: 8/2/9 vs 1/3/17 had DD/DI/II genotypes responsively (P < 0.01), DD genotype was best and II genotype was worst in therapeutic efficacy of ACE-I in NIDDM patients with nephropathy.

CONCLUSION

The examination of ACE gene polymorphism is helpful for the diagnosis of the therapeutic efficacy of ACE-I in NIDDM with nephropathy.

Catecholamine secretion from bovine adrenal chromaffin cells: the role of the Na+/Ca2+ exchanger and the intracellular Ca2+ pool

The role of the Na+/Ca2+ exchanger and intracellular nonmitochondrial Ca2+ pool in the regulation of cytosolic free calcium concentration ([Ca2+]i) during catecholamine secretion was investigated. Catecholamine secretion and [Ca2+]i were simultaneously monitored in a single chromaffin cell. After high-K+ stimulation, control cells and cells in which the Na+/Ca2+ exchange activity was inhibited showed similar rates of [Ca2+]i elevation. However, the recovery of [Ca2+]i to resting levels was slower in the inhibited cells. Inhibition of the exchanger increased the total catecholamine secretion by prolonging the secretion. Inhibition of the Ca2+ pump of the intracellular Ca2+ pool with thapsigargin caused a significant delay in the recovery of [Ca2+]i and greatly enhanced the secretory events. These data suggest that both the Na+/Ca2+ exchanger and the thapsigargin-sensitive Ca2+ pool are important in the regulation of [Ca2+]i and, by modulating the time course of secretion, are important in determining the extent of secretion.

Study of the prevalence of diabetes mellitus in adults in the Shougang Corporation in Beijing

The aim was to determine the burden of diabetes mellitus (DM) in an urban area of China to aid us in planning preventive measures for those at risk of DM. A survey was conducted among the 29,859 subjects aged between 30 and 64 belonging to 32 units of the Shougang Corporation (a heavy industry enterprise) within the Beijing area. WHO study protocols and diagnostic criteria were used to determine the prevalence of DM and impaired glucose tolerance (IGT). The results showed that the age-adjusted prevalence of DM and impaired glucose tolerance (IGT) was 3.63% and 4.19%, respectively, both increasing with age. Peak prevalence for both occurred in the 60-64 age group. Prevalence showed no difference between the sexes in DM but was higher for females in IGT. Obesity, being overweight, a family history of diabetes mellitus and in women, a history of delivering babies with macrosomia, all correlated closely with the prevalence of DM and IGT. High protein intake was also associated with DM, Smoking had no effect on either DM or IGT. Intellectual workers had a higher incidence of IGT than manual workers. Seventy per cent DM was undiagnosed prior to the survey. This survey, done according to the recommendation of WHO, and including appropriate adjustments, reflects the growing prevalence of DM and IGT in this population. It can be compared with other studies for epidemiological analysis.

Rab3A delayed catecholamine secretion from bovine adrenal chromaffin cells

To study the role of Rab3A in regulated secretion, recombinant Rab3A protein plus various guanine nucleotides were perfused into bovine adrenal chromaffin cells via a patch pipette, and depolarization-evoked catecholamine secretion from individual cells was measured by amperometry. Rab3A plus GTP, GDP, and GTP gamma S all delayed the occurrence of exocytosis while Rab3A, GTP, or GDP alone had no effect. The delay of evoked-secretion is specific for Rab3A plus guanine nucleotides, since treatments with GTP plus BSA or GDP beta S plus Rab3A had no effect on the appearance of secretion events. Rab3A plus GTP increased the frequency of the exocytosis of smaller packets of catecholamine. These results are consistent with the notion that an excess of Rab3A in the cytoplasm depletes the regulatory proteins responsible for regulating the interconversion between GTP- and GDP-bound forms of Rab3A and that Rab3A is involved in the final steps of regulated exocytosis.

Hearing impairment in diabetics

Bekesy audiometry, impedance audiometry with stapedius reflex test, speech discrimination and the recording of electrocochleography (ECochG) and brain stem auditory evoked potentials (BAEP) were performed in 43 diabetics and 43 strictly sex- and age-matched nondiabetic controls. The results revealed that the average pure-tone thresholds, subjective click threshold and AP reactive threshold were significantly elevated in the diabetics. The average speech discrimination maximum score was significantly decreased in the diabetics. The diabetic hearing impairment was characterized by high frequency sensorineural hearing loss. Both the cochlear and retrocochlear pathology existed in the diabetics with hearing impairment.

[Primary treatment of contaminated syringes and needles in a ward]

Body fluid transmitted viruses become the major enemies of human health. These viruses have been reported as occupational hazards for health care personnel, and they may become environmental hazards as well. We conducted this study to examine the primary treatment of used syringes and needles in a ward, and to evaluate the effects of re-education. For questions such as "The used syringes with bloody contamination should isolated from those without" and "The cover of used needles should not be put back on", we recorded error rates during the 1st one-week observation. A lecture about the standard treatment methods of discarding instruments was given to all nurses in this ward after the 1st observation. The 2nd and 3rd one-week observations were repeated one day and one month after the lecture, respectively. The misclassification rates of discarded syringes were 4.4% (33/758), 1.4% (9/661) and 3.9% (18/616). There was a significant decrease between the 1st and 2nd observations (p less than 0.05), but no significant difference between the 1st and 3rd observations (p greater than 0.05). The rates of covered discarded needles were 50.4% (287/569), 44.3% (198/447) and 38.5% (269/699), respectively. These rates showed a trend to decrease (p less than 0.05). The misclassification rates of discarded syringes were low. Although re-education achieved only temporary effects, self-protective education on not re-covering used needles was effective. However, about 40% of all discarded syringes were still being covered after use. Based on our finding, some improvements have been made in this ward.

Application of pyridostigmine in evaluation of growth hormone reserves in children and adolescents

There is evidence that the cholinergic system positively modulates growth hormone (GH) secretion. In the present study, we observed the effects of cholinergic enhancement by pyridostigmine (PD), a cholinesterases inhibitor, on GH release in both normal (n = 13) and GH deficient children and adolescents (n = 10). Responses of GH to insulin hypoglycemia (Ins) were also observed. In the normal subjects, PD-induced serum GH peak level was significantly higher than that induced by Ins (P less than 0.01), while the GH level in the patients with pituitary dwarfism showed no increase in both tests. This study indicates that PD test may be considered a sensitive dynamic test in evaluating pituitary function of GH secretion in children and adolescents.