Smoking and the risk of diabetes in elderly Finnish men. Retrospective analysis of data from a 30-year follow-up study

OBJECTIVE

To assess the association of smoking with the risk of glucose intolerance (diabetes plus impaired glucose tolerance).

RESEARCH DESIGN AND METHODS

A cohort consisting of 1,711 Finnish men born in 1900-1919 were followed up from 1959 to 1994. Smoking status was assessed in a similar way at each of the six surveys from 1959 to 1989, and subjects were classified as never, former, or current smokers. Diagnosis of diabetes and impaired glucose tolerance was made according to the oral glucose tolerance tests made in 1984 and 1989, and the 1985 World Health Organization criteria was applied.

RESULTS

Association between smoking and glucose intolerance was estimated separately for 420 participants and 243 nonparticipants in 1989. Multiple logistic regression analyses show that odds ratios of glucose intolerance in 1984 for current smokers in 1984 were 0.36 (0.19-0.70) and 1.20 (0.52-2.78), respectively, in the participants and the nonparticipants in 1989. Among the nonparticipants in 1989, the odds ratio for current smokers in 1969 was 2.23 (1.00-4.96). A reduced risk of glucose intolerance in 1989 associated with smoking in the participants in 1989 was found to be significant from the beginning of the follow-up. The participants in 1989 were generally healthier and had a longer life expectancy than the nonparticipants in 1989.

CONCLUSIONS

In a retrospective study of men, an increased risk of diabetes and impaired glucose tolerance in smokers was found among the nonparticipants, but a reduced risk was found among the participants in 1989. The difference observed might be attributed to the fact that the participants were constitutionally different from the nonparticipants.

109 cases of blepharoptosis treated by forked frontalis muscle aponeurosis procedure with long term follow-up

109 cases of severe or recurrent blepharoptosis have been treated with the forked frontalis muscle aponeurosis (FFMA) technique since 1989. In comparison with other frontalis muscle flap (FMF) protocols, this technique has three advantages: (i) no skin incision in the lower rim of the eyebrow; (ii) no incision in the frontalis muscle; and (iii) no dissection under the frontalis muscle. The FFMA is formed at the junction of the frontalis and orbicularis muscles. The 9-year follow-up shows that this is a highly effective procedure. The postoperative function of the frontalis muscle is good and the lack of damage has been confirmed by EMG. There are a few complications such as the sluggishness of the upper eyelid on downward gaze and the possibility of asymmetrical brow height in unilateral blepharoptosis. However, this technique may serve as the best choice in the treatment of severe or recurrent blepharoptosis.

Patterns of flap loss related to arterial and venous insufficiency in the rat pedicled TRAM flap

Vascular supply to the contralateral portion of the conventional transverse rectus abdominis musculocutaneous (TRAM) flap (zone IV) may become compromised, resulting in partial flap loss and requiring segmental excision. The etiology of this necrosis is not clear. This study determines skin necrosis patterns on a superiorly pedicled caudal TRAM flap during conditions of venous and arterial insufficiency, and determines whether cutaneous venous outflow can sustain a flap with venous insufficiency. Twenty-eight adult male Sprague-Dawley rats underwent superior pedicled TRAM flap elevation, and the zones were marked on the skin paddle. The animals were divided into four groups: control (group A, N = 6), arterial ligation (group B, N = 6), venous ligation (group C, N = 8), and venous ligation with cutaneous venous outflow (group D, N = 8). After 10 days, the skin paddle was photographed and the areas of necrotic skin were measured. Results showed that group B (selective arterial ligation) had 51.7 +/- 2.8% and 40.0 +/- 2.0% skin necrosis in zones I and II respectively. Zone I necrosis was significantly greater in group B compared with the control (p < 0.05). Group C (selective venous ligation) resulted in 73.8 +/- 16.4% and 93.8 +/- 33.4% skin necrosis in zones III and IV respectively. This necrosis was significantly greater compared with the control (p < 0.001). Group D rats' lateral skin necrosis compared significantly less with group C (p < 0.001). These results demonstrate that the patterns of flap necrosis in rat TRAM flaps with poor arterial inflow differ from those with venous stasis. Necrosis of the contralateral portion (zone IV) of human TRAM flaps may be related to problems with venous stasis; thus, a cutaneous venous outflow may prevent this problem.

Prevalence of retinopathy in people with diabetes, impaired glucose tolerance, and normal glucose tolerance

OBJECTIVE

Recently, an international expert committee published new revised criteria for diagnosing diabetes. According to the new criteria, the 2-h glucose level for diabetes in the oral glucose tolerance test (OGTT) is the same as in the previous World Health Organization criteria, but the cut point for the fasting blood glucose level has been lowered to be equivalent to the 2-h OGTT level. Measurement of the fasting blood glucose level is preferred to the 2-h OGTT glucose level. The ability of the new cut point for fasting blood glucose to discriminate between those at a high and a low risk for retinopathy was tested in a population-based study

RESEARCH DESIGN AND METHODS

The population consisted of all the 1,008 subjects (456 men) born in 1935 and living in a Finnish city A screening for type 2 diabetes was carried out in the first phase. All participants who were not on antidiabetic medication were invited for an OGTT in the second phase. A fasting blood glucose value was measured from the diabetic subjects on antidiabetic medication. In addition, measurements of serum cholesterol, HDL cholesterol, and triglycerides were made, and fundus photographs were taken. Altogether, 831 subjects (368 men) (82%) participated and constitute the eligible study population for the present analyses. Fundus photographs were available for 790 subjects (347 men) (95%).

RESULTS

There were 28 subjects (3.5%) who had mild retinopathic changes in the fundus photographs. Retinopathic changes were associated with higher fasting blood glucose levels, but not with any of the other background factors. The prevalence of retinopathy was 10.2% (95% CI 4.8-18.5) in subjects with a fasting blood glucose of > or =6.1 mmol/l, while it was 2.6% (1.5-4.0) in those with a lower fasting blood glucose level. In the former group, a majority (seven of nine) of the subjects with retinopathy were previously diagnosed diabetic patients. Some cases of retinopathy were found regardless the level of glycemia, and measurement of the 2-h OGTT glucose levels did not increase information.

CONCLUSIONS

The results of this population study give support to the use of fasting blood glucose levels in diagnosing type 2 diabetes. The lower limit of the highest decile of the fasting glucose level was 6.1 mmol/l, and it discriminated subjects at a high risk for retinopathy from those at a low risk. Because of the limited number of subjects with retinopathy in this study, the level of hyperglycemia associated with retinopathy cannot be estimated accurately.

Ultrasonographic manifestations of carotid atherosclerosis and glucose intolerance in elderly eastern Finnish men

OBJECTIVE

To study the association of ultrasonographic manifestations of common carotid atherosclerosis with glucose intolerance in survivors of the cohort of men born in 1900-1919 in eastern Finland.

RESEARCH DESIGN AND METHODS

Carotid ultrasonography was carried out for 182 men in 1989. Glucose tolerance status classified based on an oral glucose tolerance test in 1984 and 1989 surveys was used in both prospective and cross-sectional analyses.

RESULTS

Carotid atherosclerosis was common in men aged 70-89 years. There was no significant difference in the maximal carotid intimal-medial thickness between diabetic and nondiabetic men and over different age-groups; it was 1.28, 1.33, and 1.36 mm in subjects with diabetes, impaired glucose tolerance, and normal glucose tolerance, respectively (P = 0.69). No association between the presence of a nonmineralized or a mineralized atherosclerotic lesion with diabetes was found. Fasting plasma insulin did not relate to ultrasonographically detectable atherosclerotic lesions.

CONCLUSIONS

Hyperglycemia and hyperinsulinemia may not be main contributors to atherosclerosis in elderly men, partly because smoking is less common and total and LDL cholesterol concentrations are lower in diabetic men than in men with normal glucose tolerance.

Clinical experience with orbicularis oculi myocutaneous flaps in the temporal area

There are many methods to repair facial skin defects in clinical practice. The desired outcome for the surgeon and the patient is the restoration of facial appearance and function. The temporal region is one of the ideal donor sites for the repair of a facial skin defect, because this area is relatively inconspicuous and the skin quality is similar to that of the face. In the past, the temporal region was always used as the donor site of the local flap for repairing the facial skin defect. Because the blood supply of the skin comes from the subjacent tissue mainly rather than from the contiguous tissue, the pedicles of the local flaps are short, limiting the use of this area as a donor site. From 1993 to 1996, the anatomy of the orbicularis oculi myocutaneous flap in five cadavers was studied; what was learned allowed for the use of this flap to repair skin defects of the face in 13 patients. In this paper, the clinical experiences using the orbicularis oculi myocutaneous flaps to repair skin defects of the face and the surgical anatomy of this myocutaneous flap are discussed.

[The pathological action of surrounding connective tissues of alar cartilage in the cleft lip nose]

OBJECTIVE

This study was to explore the pathological action of the adjacent connective tissues of alar cartilage in unilateral cleft lip nose.

METHODS

Anatomic-histological and pathoanatomical study was carried on 40 normal cadavers and 30 patients with secondary deformities of unilateral cleft lip during their operations.

RESULTS

Six kinds of connective tissues with different histological features were found between the alar cartilage and adjacent skin, cartilage or bone. There was no histological difference in each connective tissue between the normal and the cleft lip nose. In the cleft lip nose, due to histological differences among the six connective tissues, there existed various changes of pathological dislocations between the alar cartilage and adjacent skin, cartilage or bone.

CONCLUSION

The authors suggest that the surrounding connective tissues of the alar cartilage play an important role and be the intrinsic basis to produce the characteristic deformities of the cleft lip nose. The result is helpful in understanding the anatomical and histological features of the connective tissues around the alar cartilage and the deformities of the unilateral cleft lip nose so as to select a reasonable operation method.

Hypertension, hyperinsulinaemia and obesity in middle-aged Finns with impaired glucose tolerance

The aim of the study was to analyse the data obtained from a 2-year follow-up study of middle-aged Finnish subjects (n = 183) with a previous history of impaired glucose tolerance (IGT) in order to elucidate the longitudinal relationships between hypertension, fasting hyperinsulinaemia and obesity. Hypertension was defined as either a systolic blood pressure (BP) of > or =160 mm Hg or a diastolic BP of > or =95 mm Hg or being on anti-hypertensive medication regardless of the BP value. Multiple logistic regression analysis adjusted for glucose tolerance status, serum lipids, exercise behaviour and alcohol consumption shows that the odds ratios of one unit (mU/l) increase in the baseline fasting insulin concentration were 1.13 (95% confidence interval 1.00-1.28) for the 2-year incidence of hypertension in subjects with IGT at baseline. Baseline body mass index (BMI) also predicted the 2-year incidence of hypertension, with an odds ratio of 1.20 (95% CI 1.02-1.42). BMI correlated positively with fasting insulin level (r = 0.54, P < 0.001). It is concluded that an elevated fasting insulin concentration as well as an increased BMI preceded the onset of hypertension in subjects with IGT. It may suggest a causal relationship between hypertension and hyperinsulinaemia.

[Clinical and experimental study of improving left ventricular diastolic function by total saponins of panax notoginseng]

OBJECTIVE

To investigate the effect of total saponins of Panax Notoginseng (TSPNS) on left ventricular diastolic function in patients with essential hypertension (EH) and possible mechanism.

METHODS

Left ventricular diastolic function (peak E, peak A, E/A, A area fraction, E area fraction), left ventricular muscle mass index (LV-MI), intraerythrocytic calcium and calcium pump activity on erythrocytes membrance of 30 patients with EH before and after the combined treatment of captopril and TSPNS were measured. Captopril was used singly on 30 patients above mentioned that were also studied as self-control. Observation of TSPNS and normal saline was used on a matched control in treating SHR rats. WKY rats of similar age were also studied as normal control.

RESULTS

Left ventricular diastolic function were improved markedly by TSPNS. The activity of calcium pump on membrance of sarcoplasmic reticulum were increased and the myocardial intracellular calcium were decreased and the left ventricular muscle mass were reduced after treatment of TSPNS. The calcium and calcium pump of erythrocyte showed marked simple correlation with myocardial cell.

CONCLUSIONS

The TSPNS could improve myocardial relaxation function due to enhancing calcium pump activity and inhibiting intracellular calcium overload and lightening left ventricular muscle mass.

[Diagnosis and treatment of congenital choledochal cysts in adults]

We report the experience with 97 adult patients with bile duct cysts in the past 30 years (1965-1995). The median age at time of initial therapy in our department was 37 years (range, 16 to 78 years). Clinical symptoms in most cases were non-specific, resulting in delayed diagnosis. 74 patients (76%) had coexistent pancreaticohepatobiliary disease. Carcinoma of the biliary duct occurred in 16 patients (17%). Abnormal pancreatobiliary duct junction (APBDJ) was found in 28 patients. 94 patients underwent a total of 169 biliarytract procedures. Cyst excision with Roux-en-y hepaticojejunostomy and internal drainage were the main procedures. The result of long-term follow-up shows that internal drainage frequently resulted in recurrent cholangitis and cyst malignancy which need reoperation. In contrast, cyst excision was associated with a significantly lower incidence of recurred cholangitis and lower occurrence of malignancy. Thus, cyst excision with Roux-en-y hepaticojejunostomy is recommended as the treatment of choice for adult patient.

Breast volume measurement in young Chinese women and clinical applications

The authors carried out research on breast volume and body surface anatomy of 125 women. As a result, an average breast volume for Chinese women was obtained (325.36 +/- 12.66 ml), and a table with several linear equations for calculating breast volume was derived. The authors applied these results to their clinical work and succeeded in making mammaplasty more precise in 178 patients.

The relationship between hemoglobin levels and diabetic retinopathy

This study evaluates the relationship between hemoglobin levels and diabetic retinopathy. Hemoglobin values measured in 1991 and 1992 were collected from 1691 subjects attending a diabetic clinic in Oulu, Finland, and the mean values for the two years were used in the analyses. A classification of retinopathy, based on non-mydriatic photographs taken in 1991 and 1992, was used as the outcome variable. Multiple logistic regression analyses, controlled for serum creatinine levels, proteinuria, and other prognostic factors associated with diabetes, showed that the odds ratio of having any retinopathy was 2.0 (95% confidence interval 1.2-3.3) among subjects with a hemoglobin level of less than 12 g/dl, as compared with those having a hemoglobin level > or = 12 g/dl. Among the retinopathic subjects with low hemoglobin levels, the relative odds of having a severe retinopathy rather than a mild one was 5.3 (2.3-12.6). We conclude that subjects with normocytic anemia tended to have an increased risk of retinopathy, especially of the severe form.

Risk for diabetes and persistent impaired glucose tolerance among middle-aged Finns

Among 183 middle-aged Finnish subjects with impaired glucose tolerance (IGT) defined according to the 1985 World Health Organization (WHO) criteria) who were retested on average 2.1 years after the first examination, diabetes developed in 14 (7.7%), persistent IGT in 54 (29.5%), and IGT was transient in 115 (62.8%). The odds ratio for diabetes was 4.4 (95% Confidence Interval (CI): 1.3-15.3) among subjects with a body mass index (BMI) of 30 kg/m2 or more, compared with those with a BMI of less than 30 kg/m2. The increase in BMI during the follow-up period was also an independent risk predictor for diabetes. The odds ratios of having persistent rather than transient IGT were 3.0 (95% CI: 1.2-7.8) and 4.3 (95% CI: 1.5-12.6), among subjects with fasting insulin levels of 8.1-12.9 mU/1 and 13.0 mU/1 or more, respectively, compared with subjects with a fasting insulin level of no more than 8.0 mU/1. the degree of glucose intolerance and the diagnosis of hypertension at the initial examination were predictive of persistent IGT. It is evident from the present data that fasting hyperinsulinaemia forms an essential basis of persistence of IGT and diabetes, and that obesity plays a precipitating role for the deterioration from IGT to diabetes. Efforts to prevented diabetes should be focused on ways to reduce insulin resistance and obesity.

Haemoglobin A(1c) measurement for diabetes among subjects with a previous history of impaired glucose tolerance

Haemoglobin A(1c) (HbA(1c)) measurement for diagnosis of diabetes and impaired glucose tolerance (IGT) was assessed during a prospective study of subjects with IGT; 183 of the 207 IGT persons underwent the second oral glucose tolerance tests (OGTT) 2.1 years, on the average, after the first tests. HbA(1c) was administered to every participant before the second OGTTs. The results of HbA(1c) were compared with those of the second OGTTs. The sensitivity of HbA(1c) test was 71% for diabetes and 41% for IGT, when the specificity was 93% at a cutoff point of 4.81%. The conclusion is that the HbA(1c) test is moderately sensitive for diabetes but insensitive for IGT, when it is specific. However, it may be useful for selecting and reducing the total number of subjects referred to 2-h OGTTs in a follow-up study of subjects with IGT, if the rate of progression to diabetes is not high.

[Mentoplasty for common congenital mandibular deformities]

Since 1987, the authors have performed mentoplasty for congenital mandibular deformities in 46 patients with the assistance of X-ray pantomoscanning. Mandibular deformities include: 1) Bilateral hyperplasia of mandibular angles and massetter hypertrophy; 2) Retrognathia or micrognathia; 3) Asymmetric mandibular deformity. In this paper, following problems are discussed: 1) The advantages of an extraoral approach in mentoplasty; 2) The importance of the X-ray pantomoscanning; 3) The specific feature of asymmetric chin; 4) The improvement of the silicon implant used in mentoplasty; 5) Evaluation of the composite operative result.

Random capillary whole blood glucose test as a screening test for diabetes mellitus in a middle-aged population

This study was aimed at assessing the adequacy of a random capillary whole blood glucose (RCBG) test as a screening test for diabetes mellitus in a middle-aged (55-year-old) Finnish population. Both the screening test (RCBG) and a standard 2-h oral glucose tolerance test (OGTT) were performed on all the participants according to the WHO criteria. The prevalence based on the 2-h OGTTs was 8.5% (11.7% for men and 6.0% for women). The sensitivity, specificity and predictive values of the screening test for diabetes and the receiver operator characteristic (ROC) curves were studied. The likelihood ratios for diabetes within the test categories were also calculated. When a cut-off point of 6.2 mmol l-1 was used, which proved to be the most appropriate in the present study, the specificity was 92% and the sensitivity 63% (79% for men and 40% for women). The men had much higher sensitivities than the women at all cut-off points, but the specificities were comparable. The present study indicated that the RCBG test could be used as a screening test in a subpopulation with a high prevalence of diabetes and severe hyperglycaemia, but it would be quite insensitive in a subpopulation with a considerable overlap of RCBG values between the diabetic group and the non-diabetic one. It would be inappropriate to use the RCBG test as a routine screening test for diabetes in a general population, particularly among subjects with a known low prevalence of diabetes.

Rheumatic pains of previously undiagnosed diabetic subjects

To identify the early diabetic musculoskeletal symptoms of previously undiagnosed diabetic subjects, a case-control study was carried out. The cases and controls were recruited from a population aged 55 years. Questions concerning the symptoms were asked before the 2-h oral glucose tolerance tests (OGTT). The results show that pain in the right hand was the most prominent symptom among the diabetic women. Pains in the left hand and the shoulders in the diabetic women and pains in the right knee and the right hip joint in the diabetic men tended to be more prevalent than the corresponding symptoms in the controls. The highest prevalence of most musculoskeletal pains occurred in the highest tertile of 2-h OGTT values among women. The conclusion is that the hand pain is closely associated with the development of diabetes and may give clues to an early diagnosis of diabetes in a middle-aged population.

[Double-circle-incision for reduction mammaplasty]

The authors have used the double-circle incision for reduction mammoplasty on 55 breasts in 28 patients. The main features of the technique are: 1. Complicated and rigid preoperative markings are substituted by a simple and flexible double-circle incision; 2. Proper dissection between the skin and glandular tissue instead of non-dissection; 3. A conic stump of residual glandular tissue is formed instead of a cylindrical stump; 4. Glandular remodelling is substituted by skin "brassiere" retailoring; 5. The nipple-areola site is determined at the end instead of being the first step of the operation. The clinical results revealed that this new method is suitable for medium or large hypertrophy, especially for young women with good, thick and elastic skin, but it is not suitable for macromastia or severe breast ptosis.

Breast volume measurement in 125 young Chinese women

The authors carried out research on breast volume and body surface anatomy of 125 unmarried young women. As a result, an average breast volume for young Chinese women was obtained (325.36 +/- 12.66 ml), and a table together with several linear equations for calculating breast volume were derived. These will provide plastic surgeons with useful tools for designing mammaplasty procedures.

[Breast volume measurement in 125 Chinese young women]

The author carried out measurement of breast volume and the body surface anatomy in 125 unmarried young women. Through the measurement and analysis, the author came to the following conclusions: 1. The characteristics of body build of Chinese young women are: a. The mean height: 159.00 cm-160.00 cm; The mean weight: 50.40 kg-60.00 kg; The standard weight: height minus 110. b. The mean chest circumference difference, 2.0 cm. c. The mean distance from nipple to the supra-sternal notch is 19.05 cm, that of between nipples 20.0 cm, forming a equilateral triangle. d. The average breast volume, 310-330 ml; The standard breast volume, 250-350 ml; if the body weight is over the standard, the breast volume increases by 20 ml every 1.0 kg in body weight. e. The standard breast forward projection: 3.0 cm-4.0 cm. 2. Variables of the breast volume are: a. The breast volume is positively correlated with weight, chest circumference, waist circumference and buttock circumference, but negatively with height. b. The breast volume is closely related to difference between the chest circumference across the nipple and that across the horizontal line just under the armpits. The correlative equation can be approximately represented as V = 250 + 50 x D + 20 x OW (D = difference OW = overweight). c. The nipple position is not dependent on the height, but varies with the breast volume, that is, the nipple position lowers 1.0 cm with every increase of 300 ml in the breast volume. 3. The breast volume calculating table is derived from the radius and forward projection of breasts.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations

The anterolateral thigh flap, first described by Song, is one of the septocutaneous flaps in the thigh. Since November 1985 we have transferred 32 anterolateral thigh flaps successfully without any loss. Six of these flaps were performed in Australia. The vascular pedicles are divided into three types: fasciocutaneous perforator (37.5%-12/32), vertical musculocutaneous perforator (56.2%-18/32) and horizontal musculocutaneous perforator (6.6%-2/32). This paper presents the surgical anatomy of the flap and clinical experience.

Experience using microvascular anastomotic rings for the transplantation of 20 free flaps

A new microvascular anastomosis technique was employed with success in 1985-1986 with the result of 18 free-flap survivals and 2 failures. The rate of success in microvascular anastomoses was 90.5 percent (38 of 42). The advantages of this technique are its simplicity, convenience, and safety, and it may shorten the duration of the operation. Our experience in using vascular anastomotic rings is presented.