Inflammatory markers and IL-6 polymorphism in peripheral arterial disease with and without diabetes mellitus

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis, recognized as an inflammatory disease of the vessel wall, probably accelerated by diabetes mellitus (DM). Elevated interleukin (IL)-6 levels have been associated with increased cardiovascular morbidity and a common polymorphism has been identified in the promoter region of the IL-6 gene. The aim of this prospective study was to investigate inflammatory mediators in PAD patients (±DM) and to investigate a possible relationship to the IL-6 gene polymorphism. Five groups of patients (DM, intermittent claudication ±DM, critical limb ischemia (CLI) ±DM) and a control group of 20 individuals each were included. Hemoglobin, high sensitive C-reactive protein (hsCRP), creatinine, blood lipids, white blood cells (WBC); CD11b/CD18; vascular cell adhesion molecule (sVCAM-1), intercellular adhesion molecule (sICAM-1), sE-selectin, sP-selectin; IL-6, IL-8, tumour necrosis factor (TNF)α, sTNFα-R1 and sTNFα-R2 were analysed. The IL-6 gene polymorphism was determined in all groups and also compared with 200 healthy controls from a larger study of blood donors. In a multiple regression analysis, adjusted for gender, smoking and age, the effect of CLI was significantly ( p < 0.05) associated with elevated levels of the WBC count, hsCRP, proinflammatory cytokines (IL-6, TNFα-R1-2) and endothelial (sICAM, sVCAM) and WBC (CD11b gran) markers. The effect of less advanced PAD (intermittent claudication) was related to an increased concentration of sVCAM-1 and the number of monocytes and granulocytes. DM or leg ulcers were not significantly related to any of the markers. No significant difference in frequency of the various IL-6 genotypes was found between the groups or when compared with the group of 200 blood donors ( p > 0.3). Activation of cytokines, endothelial cells and WBC was related to the Fontaine stage of PAD but not to the presence of DM or ulcers. No association was found between the polymorphism in the IL-6 promoter region and PAD.

Less pronounced response to exercise in healthy relatives to type 2 diabetic subjects compared with controls

Healthy first-degree relatives with heredity of type 2 diabetes (FH+) are known to have metabolic inflexibility compared with subjects without heredity for diabetes (FH-). In this study, we aimed to test the hypothesis that FH+ individuals have an impaired response to exercise compared with FH-. Sixteen FH+ and 19 FH- insulin-sensitive men similar in age, peak oxygen consumption (V̇o2 peak), and body mass index completed an exercise intervention with heart rate monitored during exercise for 7 mo. Before and after the exercise intervention, the participants underwent a physical examination and tests for glucose tolerance and exercise capacity, and muscle biopsies were taken for expression analysis. The participants attended, on average, 39 training sessions during the intervention and spent 18.8 MJ on exercise. V̇o2 peak/kg increased by 14%, and the participants lost 1.2 kg of weight and 3 cm waist circumference. Given that the FH+ group expended 61% more energy during the intervention, we used regression analysis to analyze the response in the FH+ and FH- groups separately. Exercise volume had a significant effect on V̇o2 peak, weight, and waist circumference in the FH- group, but not in the FH+ group. After exercise, expression of genes involved in metabolism, oxidative phosphorylation, and cellular respiration increased more in the FH- compared with the FH+ group. This suggests that healthy, insulin-sensitive FH+ and FH- participants with similar age, V̇o2 peak, and body mass index may respond differently to an exercise intervention. The FH+ background might limit muscle adaptation to exercise, which may contribute to the increased susceptibility to type 2 diabetes in FH+ individuals.

First-degree relatives of type 2 diabetic patients have reduced expression of genes involved in fatty acid metabolism in skeletal muscle

CONTEXT

First-degree relatives of patients with type 2 diabetes (FH+) have been shown to have decreased energy expenditure and decreased expression of mitochondrial genes in skeletal muscle. In previous studies, it has been difficult to distinguish whether mitochondrial dysfunction and differential regulation of genes are primary (genetic) or due to reduced physical activity, obesity, or other correlated factors.

OBJECTIVE

The aim of this study was to investigate whether mitochondrial dysfunction is a primary defect or results from an altered metabolic state.

DESIGN

We compared gene expression in skeletal muscle from 24 male subjects with FH and 26 without FH matched for age, glucose tolerance, VO(2peak) (peak oxygen uptake), and body mass index using microarrays. Additionally, type fiber composition, mitochondrial DNA content, and citrate synthase activity were measured. The results were followed up in an additional cohort with measurements of in vivo metabolism.

RESULTS

FH+ vs. FH- subjects showed reduced expression of mitochondrial genes (P = 2.75 × 10(-6)), particularly genes involved in fatty acid metabolism (P = 4.08 × 10(-7)), despite similar mitochondrial DNA content. Strikingly, a 70% reduced expression of the monoamine oxidase A (MAOA) gene was found in FH+ vs. FH- individuals (P = 0.0009). Down-regulation of the genes involved in fat metabolism was associated with decreased in vivo fat oxidation and increased glucose oxidation examined in an additional cohort of elderly men.

CONCLUSIONS

These results suggest that genetically altered fatty acid metabolism predisposes to type 2 diabetes and propose a role for catecholamine-metabolizing enzymes like MAOA in the regulation of energy metabolism.

Nonalcoholic steatohepatitis in obesity: a reversible condition

Nonalcoholic steatohepatitis is a rare complication of obesity with laboratory and histological features indistinguishable from alcoholic hepatitis. Three patients with 50-60% overweight and steatohepatitis are reported. All responded with normalization of the biochemical and/or histological changes after modest weight reduction.

Coupling between dietary changes, reduced body weight, muscle fibre size and improved glucose tolerance in middle-aged men with impaired glucose tolerance

Fourteen middle-aged med with impaired glucose tolerance were studied prior to and 6 months after exchange of simple carbohydrates for complex carbohydrates rich in fibers and saturated for polyunsaturated fats in their diet when exchangeable. Body weight was reduced by 6.4 kg (p less than 0.001). Physical work capacity was unchanged. Fasting blood glucose and insulin were lowered (p less than 0.001) at 6 months and so were the values during an OGTT at 120 min. Both serum triglyceride and cholesterol concentrations were reduced (p less than 0.01) by the changes diet, the most marked reduction being found in the VLDL fraction. HDL levels increased by 21% (p less than 0.01). Enzyme activities in gastrocnemius muscle specimens were subnormal and uninfluenced by changed dietary habits. The number of capillaries per fiber was normal throughout, but as muscle fiber size was reduced in relation to the decreased body weight, the number of capillaries/mm2 increased during the dieting period. It is suggested that the observed improvement in insulin sensitivity and glucose tolerance after a dietary period with weight reduction is related to and partly explained by shorter diffusing distances in weight-bearing muscles.

Vibrotactile sense in median and ulnar nerve innervated fingers of men with Type 2 diabetes, normal or impaired glucose tolerance

AIMS

To investigate vibrotactile sense (large fibre neuropathy) at different frequencies in index and little fingers (median and ulnar nerves, respectively) of subjects with diabetes, or impaired (IGT) or normal glucose tolerance (NGT).

METHODS

Vibration thresholds (tactilometry at seven frequencies (8, 16, 32, 64, 125, 250 and 500 Hz)) and median nerve function (electrophysiology) were examined in men (age 73.4 +/- 0.12 years; n = 58, mean +/- sd) with persistent NGT (n = 28) or IGT (n = 7) or with Type 2 diabetes mellitus (T2DM) (n = 23) for > 15 years.

RESULTS

HbA1c was increased and vibrotactile sense (sensibility index) was impaired in index and little fingers in men with T2DM. Vibration thresholds were particularly increased at 16, 250 and 500 Hz in the little finger (ulnar nerve). T2DM subjects showed electrophysiological (gold standard) signs of neuropathy in the median nerve. Although subjects with persistent IGT had higher HbA1c, vibrotactile sensation and electrophysiology remained normal. HbA1c did not correlate with vibrotactile sense or electrophysiology, but the latter two correlated with respect to Z-score (sign of neuropathy) in forearm (NGT) and at wrist level (NGT and DM).

CONCLUSIONS

Vibration thresholds are increased in the finger pulps in T2DM subjects, particularly at specific frequencies in ulnar nerve innervated finger pulps. Neuropathy is not present in IGT. Tactilometry, with a multi-frequency approach, is a sensitive technique to screen for large fibre neuropathy in T2DM. Frequency-related changes may mirror dysfunction of various receptors.

Parallel manifestation of insulin resistance and beta cell decompensation is compatible with a common defect in Type 2 diabetes

AIMS/HYPOTHESIS

The aim of the study was to evaluate the relationship between insulin sensitivity, beta cell function and glucose tolerance, and its dependence on variants in the newly identified Type 2 diabetes susceptibility gene, calpain-10 ( CAPN10).

METHODS

We studied 203 men of the same age but with varying degrees of glucose tolerance. These men participated in (i) an oral glucose tolerance test, (ii) a euglycaemic clamp combined with indirect calorimetry and infusion of [3-(3)H]-glucose and (iii) a stepwise assessment of acute insulin response to arginine (AIR) at three different glucose concentrations (fasting, 14 and 28 mmol/l).

RESULTS

There was a linear increase in NEFA levels ( p<0.0005) and WHR ( p<0.0005) and decrease in glucose uptake due to a reduction in glucose storage over the entire range of glucose tolerance ( r=-0.404; p<0.005). No increase in endogenous glucose production (EGP) was seen until patients had manifest diabetes. However, when EGP was expressed relative to fasting insulin concentrations, there was a linear deterioration of basal hepatic insulin sensitivity ( r=-0.514; p<0.005). The AIR followed a bell-shaped curve with an initial rise and subsequent decrease. However, AIR adjusted for insulin sensitivity (disposition index) showed a linear decrease with increasing glucose concentrations ( r=-0.563; p<0.001) starting already in subjects with normal glucose tolerance. There was an inverse correlation between increase in WHR and NEFA and peripheral as well as hepatic insulin sensitivity. Subjects with the genotype combination of CAPN10 consisting of SNP44 TT and SNP43 GG genotypes had significantly lower insulin-stimulated glucose uptake than carriers of the other genotype combinations (5.3+/-0.4 vs 7.2+/-0.4 mg.ffm kg(-1).min(-1).mU.l(-1); p<0.005).

CONCLUSIONS/INTERPRETATION

We conclude that the pre-diabetic state is characterised by a similar linear deterioration of peripheral and hepatic insulin sensitivity as beta cell function and that variants in the CAPN10 gene modify this relationship. These findings are compatible with a common defect in muscle, liver and beta cells in the pathogenesis of Type 2 diabetes.

Influence of plasma fibrinogen levels on the incidence of myocardial infarction and death is modified by other inflammation-sensitive proteins: a long-term cohort study

Inflammation may play an important role in atherosclerotic disease. Plasma fibrinogen is an established predictor of cardiovascular events. The aim of this study was to evaluate whether other inflammation-sensitive plasma proteins modify this prediction. We studied the incidence of cardiac events and death in men in relation to fibrinogen levels alone and in combination with other proteins. The study was based on 6075 men, who were, on average, 46 years old at the time of the screening examination, which included the quantitative assessment of plasma levels of fibrinogen, orosomucoid, alpha(1)-antitrypsin, haptoglobin, and ceruloplasmin. The concentration of each protein was divided into quartiles for each. This classification made it possible to identify 4 groups, ie, men in the first fibrinogen quartile and at the same time either not belonging to the fourth quartile of any of the other proteins (Q1/No group) or also belonging to the fourth quartile of >/=1 of the additional proteins (Q1/Yes group) and corresponding groups in the fourth fibrinogen quartile (Q4/No and Q4/Yes groups). During the follow-up, which occurred at an average of 16 years, 439 (7.2%) men experienced a cardiac event, and 653 (10.7%) died; 278 of these men died of cardiovascular diseases, with 206 deaths attributed to ischemic heart disease. From the lowest to the highest quartile, there was for each protein a stepwise increase in the incidence of cardiac events and mortality. All-cause mortality and cardiovascular mortality were significantly higher in the Q4/Yes group compared with the Q4/No group, but they were similar in the Q4/No and Q1/Yes groups. The incidence of cardiac events was significantly higher in the Q1/Yes and Q4/Yes groups compared with the Q1/No and Q4/No groups, respectively. The increased cardiovascular mortality and cardiac event rates remained after adjustment for several confounders when the Q4/Yes and Q4/No groups were compared. The results suggest that the incidence of cardiac events and death due to cardiovascular diseases in middle-aged men predicted by plasma levels of fibrinogen is modified by other inflammation-sensitive proteins.

Gliadin antibodies in adult insulin-dependent diabetes--autoimmune and immunogenetic correlates

Gliadin antibody (GA) tests used in screening for coeliac disease (CD) frequently yield positive GA results without accompanying CD in cases of diabetes mellitus type 1 (DM-1). To enlighten this phenomenon we screened 848 DM-1 patients for IgA- and IgG-GA. Subsequently, 16 out of 19 high titre GA patients (6 with CD) were compared with 37 low titre DM-1 patients matched for sex, age and disease duration, for autoimmune and immunogenetic markers. Chronic thyroiditis and thyroid peroxidase (TPO) antibody positivity were more frequent in the GA-positive than in the GA-negative sub-group (38 vs. 2.7%, p = 0.003, and 69 vs. 27%, p < 0.00, respectively). The tissue transglutaminase (tTg) IgA titres correlated with CD but not with GA. tTg IgG titres were lower in GA-positive individuals (p = 0.0012). GA-positivity correlated with a higher titre of factor XIII IgA antibodies (p < 0.001). GA-positive DM-I patients were characterised by a distinct immunogenetic profile; the risk of HLA DQB1*02 was lower among GA-positive patients than among GA-negatives (OR 0.4, preventive fraction 0.43). All CD patients were HLA DRB1*03-DQB1* 02-positive, but none of the five patients with normal biopsies. GA-positive patients instead had HLA DRB1*13 in 37.5% as compared to 8.6% in GA-negative (OR 6.4, etiologic fraction 0.32). Thus, the occurrence of positive GA in DM-1 is correlated to TPO antibody positivity, thyroiditis and factor XIII IgA antibodies, but inversely correlated to tTg IgG, and seems to be associated with another HLA haplotype than that previously found to be associated with CD.

Homocysteine is related to neopterin and endothelin-1 in plasma of subjects with disturbed glucose metabolism and reference subjects

Hyperhomocysteinemia is an independent risk factor for vascular disease. In order to evaluate relations between hyperhomocysteinemia and endothelial and leukocyte function, the investigators related homocysteine to indices of endothelial function (plasma endothelin-1 [p-ET-1] and intraplatelet levels of the nitric oxide [NO] and prostacyclin mediators 3'-5' guanosine monophosphate [cGMP] and cyclic 3'-5' adenosine monophosphate [cAMP]) and the monocyte-derived inflammatory mediator neopterin in 168 men (mean age 69, range 49-72 years) with disturbed glucose metabolism and a reference group of 52 male subjects (mean age 70, range 61-79 years). Among the 168 patients with disturbed glucose metabolism plasma (p)-homocysteine correlated significantly with age (r=0.20; p<0.01), glycosylated hemoglobin (HbA1c) (r=0.17; p<0.05), triglycerides (r=0.20; p<0.05), intraplatelet GMP (r=0.16; p<0.05), p-ET-1 (r=0.21; p<0.05), and p-neopterin (r=0.31; p<0.001). The correlation between p-homocysteine and p-ET-1 persisted (p<0.01) in multiple regression analysis. Among the 52 reference subjects p-homocysteine correlated significantly with p-ET-1 (r=0.32; p<0.05) and p-neopterin (r=0.37; p<0.01). The correlation between p-homocysteine and p-neopterin persisted (p<0.05) in multiple regression analysis. In conclusion, homocysteine is related to neopterin and endothelin-1 in plasma of subjects with disturbed glucose metabolism and in reference subjects, suggesting that homocysteine exerts its deleterious effects on vascular function through interference with endothelial and leukocyte function.

Sorbitol and myo-inositol levels and morphology of sural nerve in relation to peripheral nerve function and clinical neuropathy in men with diabetic, impaired, and normal glucose tolerance

AIMS

Sorbitol and myo-inositol levels and morphology of sural nerve were compared with nerve function and clinical neuropathy in men with diabetic, impaired (IGT), and normal glucose tolerance.

METHODS

After neurography of sural nerve and determinations of sensory thresholds for vibration, warm and cold on the foot, whole nerve sural nerve biopsy was performed in 10 men with Type 1 diabetes mellitus, 10 with IGT, and 10 with normal glucose tolerance. Polyol levels were assessed by gas-liquid chromatography/mass spectrometry.

RESULTS

Sural nerve amplitudes were significantly lower and sorbitol levels significantly higher in diabetic patients (median (interquartile range)) (3.7 (3.5) microV and 643 (412) pmol/mg protein, respectively) both compared with IGT (11.3 (10.6)microV; P = 0.04 and 286 (83) pmol/mg protein; P = 0.0032, respectively) and normally glucose tolerant (10.0 (11.6); P = 0.0142 and 296 (250) pmol/mg protein; P = 0.0191, respectively) subjects. There were no differences in nerve morphology between the three groups. Nerve myo-inositol levels correlated, however, positively with cluster density (rs = 0.56; P = 0.0054). In diabetic and IGT subjects, sural nerve amplitudes (2.6 (3.8) vs. 12.1 (10.6) microV; P = 0.0246) and myelinated nerve fibre density (MNFD; 4,076 (1091) vs. 5,219 (668) nerve fibres/mm2; P = 0.0021) were significantly lower in nine subjects with clinical neuropathy than in 10 without.

CONCLUSIONS

Nerve degeneration (i.e. MNFD) correlated with clinical neuropathy but not with glucose tolerance status whereas nerve myo-inositol levels positively correlated with signs of nerve regeneration (i.e. increased cluster density).

Long-term outcome of the Malmö preventive project: mortality and cardiovascular morbidity

OBJECTIVES

To analyse the effects on mortality and cardiovascular morbidity in a population-based sample, invited to an intervention programme incorporating a baseline screening examination and treatment programmes for subjects with cardiovascular risk factors, high alcohol intake and, in women, suspicion of breast cancer on mammography.

SETTING

Section of Preventive Medicine, Department of Medicine, University Hospital, Malmö, Sweden.

SUBJECTS

Birth cohorts (aged 32-51 years) invited to screening examination (men = 9. 923; women = 4.422) were compared to birth cohorts not invited (men = 6.655; women = 4.290). Mean participation rate in the invited cohorts was 71% (range 64-78%). SCREENING EXAMINATION: Between 1974 and 1992 a baseline screening including a physical examination, blood pressure, a questionnaire regarding, e.g. family history, lifestyle, and socio-economic factors, laboratory tests of serum cholesterol, triglycerides, gamma-glutamyl-transferase, blood glucose before and after an oral glucose load, as well as a mammography examination in women, was performed.

INTERVENTIONS

Subjects with hypertension; hyperlipidaemia; diabetes or glucose intolerance; high alcohol intake; or, in women, suspicion of breast cancer were referred to special outpatient clinics.

MAIN OUTCOME MEASURES

Total and cause-specific mortality, nonfatal myocardial infarction, and stroke, from the screening examination until the end of 1995, was followed in both the intervention and control groups, using national and/or local registries.

RESULTS

Total mortality did not differ significantly between the intervention group and control group. Cause-specific deaths were also similar except for 'other' deaths amongst men being significantly lower in the intervention group, mainly due to a lower mortality from 'other' causes (suicide, alcohol related deaths) in men under 40 years of age at baseline. Women under 40 years of age had a significantly lower mortality from cancer in the intervention group than in the control group. Nonfatal myocardial infarction and stroke did not differ between intervention and control group in either sex. Within the invited birth cohorts, nonparticipants had a higher total and cause-specific mortality.

CONCLUSIONS

Risk factor screening for major diseases such as cardiovascular disease, alcohol abuse, diabetes mellitus and breast cancer, and subsequent treatment of the detected risk factors/diseases - The Malmö Preventive Project - did not reduce total mortality in the intervention group as a whole. In subjects under 40 years of age at entry, total mortality was lower in the intervention group than in the control group. In men, this seemed to be due to a reduction of alcohol-related deaths, whilst in women death from cancer was reduced.

Alcohol consumption and disability pension among middle-aged men

PURPOSE

To analyze the relation between alcohol consumption and the risk of disability pension among middle-aged men.

METHODS

In the mid-seventies, complete birth-year cohorts of middle-aged male residents in Malmö, Sweden, were invited to participate in a general health survey. The 3751 men with complete data who constituted the cohort in this study were followed for 11 years. Alcohol consumption was estimated from the scores obtained from a test designed to identify subjects with alcohol related problems.

RESULTS

Of the 498 men granted disability pension during follow-up, 48 stated to be teetotalers. The cumulative incidence of disability pension among teetotalers was 19%, whereas, it was 12% and 16%, respectively, among men with low and high alcohol consumption. The adjusted relative risk (RR) for acquiring a disability pension (using the group with low alcohol consumption as reference) was 1.8 among abstainers and 1.3 among men with high alcohol consumption.

CONCLUSIONS

Alcohol overconsumption, as well as teetotalism, showed a positive relation to disability pension, and a moderate alcohol intake was found to be beneficial with respect to the risk of future disability pension.

Insulin-regulated mitochondrial gene expression is associated with glucose flux in human skeletal muscle

To identify abnormally expressed genes contributing to muscle insulin resistance in type 2 diabetes, we screened the mRNA populations from normal and diabetic human skeletal muscle using cDNA differential display and isolated abnormally expressed cDNA clones of mitochondrial-encoded NADH dehydrogenase 1 (ND1), cytochrome oxidase 1, tRNA(leu), and displacement loop. We then measured mRNA expression of these mitochondrial genes using a relative quantitative polymerase chain reaction method in biopsies taken before and after an insulin clamp in 12 monozygotic twin pairs discordant for type 2 diabetes and 12 matched control subjects and in muscle biopsies taken after an insulin clamp from 13 subjects with type 2 diabetes, 15 subjects with impaired glucose tolerance, and 14 subjects with normal glucose tolerance. Insulin infusion increased mRNA expression of ND1 from 1.02 +/- 0.04 to 2.55 +/- 0.30 relative units (P < 0.001) and of cytochrome oxidase 1 from 0.80 +/- 0.01 to 1.24 +/- 0.10 relative units (P < 0.001). The ND1 response to insulin correlated with glucose uptake (r = 0.46, P = 0.002). Although the rate of insulin-mediated glucose uptake was decreased in the diabetic versus the nondiabetic twins (5.2 +/- 0.7 vs. 8.5 +/- 0.8 mg x kg(-1) fat-free mass x min(-1), P < 0.01), insulin-stimulated ND1 expression was not significantly different between them (2.4 +/- 0.5 vs. 2.7 +/- 0.5 relative units). Neither was there any significant intrapair correlation of ND1 expression between the monozygotic twins (r = -0.15, NS). We conclude that insulin upregulates mitochondrial-encoded gene expression in skeletal muscle. Given the positive correlation between ND1 expression and glucose uptake and the lack of intrapair correlation between monozygotic twins, mitochondrial gene expression may represent an adaptation to intracellular glucose flux rather than an inherited trait.

Calf pain in middle-aged individuals as a predictor of ischemic cerebrovascular disease

In middle-aged individuals, calf pain while walking may be an early marker of generalized ischemic vascular disease. We investigated whether the symptom of calf pain while walking was a predictor of ischemic cerebrovascular disease (CVD). In a nested case control study, part of the Malmö Prevention Program Project, we evaluated 105 patients with ischemic CVD for the symptom of calf pain reported at screening more than a decade before their illness. Their baseline characteristics were compared with those of an age- and sex-matched control group drawn from the population cohort. Calf pain while walking was reported by 16.2% of the patient group but by only 7.6% of the control group; p < 0.0001. Multiple logistic regression analysis with adjustment for all other significant risk factors showed a history of calf pain while walking to be an independent predictor of ischemic CVD (odds ratio, 1.9; 95% confidence interval, 1.3-3.7; p < 0.002). Thus, in middle-aged individuals, the symptom of calf pain while walking would seem to be a significant independent predictor of ischemic CVD. Our data serve to target a high-risk group for improved preventive efforts.

Socioeconomic inequalities and disability pension in middle-aged men

BACKGROUND

The issue of inequalities in health has generated much discussion and socioeconomic status is considered an important variable in studies of health. It is frequently used in epidemiological studies, either as a possible risk factor or a confounder and the aim of this study was to analyse the relation between socioeconomic status and risk of disability pension.

METHODS

Five complete birth year cohorts of middle-aged male residents in Malmo were invited to a health survey and 5782 with complete data constituted the cohort in this prospective study. Each subject was followed for approximately 11 years and nationwide Swedish data registers were used for surveillance.

RESULTS

Among the 715 men (12%), granted disability pension during follow-up, three groups were distinguished. The cumulative incidence of disability pension among blue collar workers was 17% and among lower and higher level white collar workers, 11% and 6% respectively. With simultaneous adjustment for biological risk factors and job conditions, the relative risk for being granted a disability pension (using higher level white collar workers as reference) was 2.5 among blue collar workers and 1.6 among lower level white collar workers.

CONCLUSIONS

Socioeconomic status, as defined by occupation, is a risk factor for being granted disability pension even after adjusting for work conditions and other risk factors for disease.

No excess 12-year mortality in men with impaired glucose tolerance who participated in the Malmö Preventive Trial with diet and exercise

Impaired glucose tolerance (IGT) is associated with increased mortality due to ischaemic heart disease (IHD), but as it is not known whether this excess mortality can be reduced by preventing or delaying the development of non-insulin-dependent diabetes mellitus (NIDDM), a long-term NIDDM prevention trial of dietary counselling and physical exercise was launched at Malmö, Sweden, the 12-year follow-up of which is reported here. At 12-year follow-up of 6956 men who underwent health screening at 48 years of age, an IGT intervention group (n = 288) who participated in a long-term NIDDM prevention programme were compared with an IGT non-randomised routine treatment group (n = 135), a diabetic group (n = 144), and the remainder, the normal glucose tolerance (NGT) group (n = 6389). The variables studied included the levels of blood glucose, plasma insulin, blood pressure, blood lipids, lung function and maximum oxygen uptake. Subjects with IGT were characterised by overweight, poor vital capacity, hypertension, hypertriglyceridaemia and hyperinsulinaemia. The mortality rate in the IGT intervention group was similar to that in the NGT group (6.5 vs 6.2 per 1000 person years at risk) and lower than that in the IGT routine treatment group (6.5 vs 14.0, p = 0.009). In the two IGT groups taken together, intervention but not body mass index, systolic blood pressure, smoking, cholesterol or the 2-h glucose level predicted mortality. Systolic blood pressure was a predictor of IHD mortality among IGT subjects; and in the cohort as a whole, body mass index, systolic blood pressure, hypercholesterolaemica, diabetes and smoking were predictors of IHD mortality. The findings suggest that a long-term intervention programme, with an emphasis on lifestyle changes, including dietary counselling and physical exercise, will reduce mortality in subjects with IGT who are at an increased risk of both developing NIDDM and of premature death due to IHD and other causes.

A prospective study of orthostatic blood pressure in diabetic patients

To clarify whether orthostatic blood pressure is affected by the type of diabetes, cardiac autonomic neuropathy, and the duration of diabetes, orthostatic blood pressure (passive 90 degrees tilt) was evaluated in 102 patients with insulin dependent diabetes mellitus (IDDM), 51 patients with non-insulin dependent diabetes mellitus (NIDDM), and in 238 control subjects in a first study followed up after 8 to 17 years. The heart rate reaction during deep breathing (E/I ratio) and to tilt (acceleration and brake indices) assessed cardiac autonomic function. In the first study, the lowest systolic blood pressure (LSBP) and the lowest diastolic blood pressure (LDBP) after tilt were significantly lower in IDDM patients compared with NIDDM patients (p < 0.001 for LSBP and p < 0.05 for LDBP) and controls (p < 0.001). LDBP was, however, also significantly lower (p < 0.05) in NIDDM patients than in controls. Hence, although most severe in IDDM, LDBP was disturbed in both types of diabetes. In IDDM, a low E/I ratio was associated with disturbed orthostatic blood pressure. At follow-up examinations, orthostatic blood pressure deteriorated in NIDDM but not in IDDM patients. In conclusion, LSBP and LDBP were impaired in IDDM patients compared with NIDDM and control subjects; however, LDBP was also impaired in NIDDM patients compared with controls. When the duration of diabetes increased, orthostatic blood pressure deteriorated in NIDDM but not in IDDM patients.

[New drugs against insulin resistance]

Insulin resistance is an important mechanism in the development of the insulin resistance syndrome and type 2 diabetes. Although treatment has hitherto been confined to metformin or non-pharmacological measures, efforts are now being made to discover new drugs active against insulin resistance, so-called insulin sensitisers, for instance among the thiazolidinedione group. These are beginning to be tested in larger clinical trials where they have manifested effects not only on glucose metabolism but also on other cardiovascular risk factors such as hyperlipidaemia, defective fibrinolysis, and hypertension. However, adverse reactions to one of these drugs, troglitazone, include severe hepatic effects in certain cases. Accordingly, registration of the product has been stopped for use in Europe, but not in the USA and Japan. It is likely to take some time before thiazolidinediones will be introduced for clinical use in this country, though research and development continue.

Screening for coeliac disease in adult insulin-dependent diabetes mellitus

OBJECTIVES

To study, by sequential screening for gliadin antibodies (GA) and endomysial antibodies (EMA), the prevalence and clinical characteristics of coeliac disease (CD) in adult IDDM patients.

SUBJECTS AND MEASUREMENTS

A series comprising 1664 diabetes patients [848 with IDDM, 745 with non-insulin-dependent diabetes (NIDDM) and 71 with secondary diabetes] were screened for GA. IgA- or IgG-GA positive sera were analysed for EMA.

RESULTS

IgA-GA were more frequent in all the diabetes subgroups (13.7% in IDDM,12.3% in NIDDM and 23.9% in secondary diabetes, P < 0.001 in all three cases) than among healthy blood donors (4.7%). Two patients with NIDDM had CD. Of the IDDM group (n = 848), 8 had previously diagnosed CD and 14 more (of whom 7 could be biopsied) were EMA positive. All had villous atrophy. The minimum prevalence of CD (including probable cases) in IDDM was 2.6% (22/848). Patients with previously known CD had more symptoms (P < 0.001), more deficiency states (P < 0.001) and more autoimmune diseases (P < 0.04) than those identified by screening. IDDM patients with a diabetes duration of 31-40 years were characterised by a higher prevalence of CD than patients with a duration of less than 30 years (6.7% vs. 1.7%; P < 0.02).

CONCLUSIONS

Serial analysis of GA and EMA confirmed a high prevalence of CD in adult IDDM (2.6%). False-positive IgA-GA test results are frequent in patients with diabetes, irrespective of type. EMA analysis is the preferable screening tool for CD in diabetes.

Persistent postoperative complaints after whole sural nerve biopsies in diabetic and non-diabetic subjects

The postoperative effects of a whole sural nerve biopsy in diabetic (11) and non-diabetic (10 healthy controls, 10 patients with impaired glucose tolerance and 2 patients with polyneuropathy) subjects were investigated by a mailed questionnaire 20-44 months after the surgical procedure (10/11 vs 21/22 answers received). Pain in the biopsy area at follow-up was reported in 4/10 of the diabetic patients (p = 0.01) but in none of the non-diabetic subjects (0/21). An increased number (p = 0.01) of diabetic patients (5/10 vs 1/21) had cold intolerance in their foot or leg whereas 11/31 of all patients had dysaesthesia in the affected skin. Overall 6/31 patients described serious problems at the time of the questionnaire, and 4 of this 6 having diabetes. Loss of sensation was reported in almost all subjects irrespective of diabetes or not; however, a decrease in the area of loss of sensation was reported most often in diabetic patients (8/10 vs 8/21, p = 0.02). It is concluded that whole surval nerve biopsies give rise to persistent problems both in diabetic and non-diabetic subjects. The reason for a sural nerve biopsy has always to be carefully considered before being conducted.

Persistent postoperative complaints after whole sural nerve biopsies in diabetic and non-diabetic subjects

The postoperative effects of a whole sural nerve biopsy in diabetic (11) and non-diabetic (10 healthy controls, 10 patients with impaired glucose tolerance and 2 patients with polyneuropathy) subjects were investigated by a mailed questionnaire 20-44 months after the surgical procedure (10/11 vs 21/22 answers received). Pain in the biopsy area at follow-up was reported in 4/10 of the diabetic patients (p = 0.01) but in none of the non-diabetic subjects (0/21). An increased number (p = 0.01) of diabetic patients (5/10 vs 1/21) had cold intolerance in their foot or leg whereas 11/31 of all patients had dysaesthesia in the affected skin. Overall 6/31 patients described serious problems at the time of the questionnaire, and 4 of this 6 having diabetes. Loss of sensation was reported in almost all subjects irrespective of diabetes or not; however, a decrease in the area of loss of sensation was reported most often in diabetic patients (8/10 vs 8/21, p = 0.02). It is concluded that whole surval nerve biopsies give rise to persistent problems both in diabetic and non-diabetic subjects. The reason for a sural nerve biopsy has always to be carefully considered before being conducted.

Cardiovascular risk groups and mortality in an urban swedish male population: the Malmö Preventive Project

OBJECTIVES

To describe the size, overlap and mortality of four cardiovascular risk groups, in order to give a scientific background for the prevention of cardiovascular disease in a representative urban population.

SETTING

Section of Preventive Medicine, Department of Medicine, Malmö University Hospital, Malmö, Sweden.

SUBJECTS

Between 1974 and 1984 22444 men born between 1949 and 1921, constituting 75% of the total male population in these age groups, took part in a comprehensive screening examination aimed at detecting risk factors for cardiovascular disease.

INTERVENTIONS

Those at high-risk of developing cardiovascular disease were referred to their general practitioner or to special clinics for hypertension, hyperlipidaemia and diabetes. The follow-up, which lasted until the end of 1991, averaged 12.2 years.

MAIN OUTCOME MEASURES

Total death (n = 1450) and death from ischaemic heart disease (IHD) (n = 471).

RESULTS

Hypertension was found in 13%, hypercholesterolaemia in 19% and diabetes mellitus in 2.6% of the subjects; 49% of the subjects smoked. Multiple risk factors were found in over 17% of the total cohort. Despite the intervention, all-cause mortality during follow-up was increased three-fold in smokers and in men with hypercholesterolaemia, four-fold in hypertensive men and five-fold in men with diabetes, compared to men with no risk factors. The vast majority of deaths (81%) occurred in men who smoked, had hypertension or had high serum cholesterol. Ischaemic heart disease (IHD) was increased five-fold in smokers, seven-fold in men with hypercholesterolaemia, nine-fold in hypertensive men and 12-fold in men with diabetes. Again, the vast majority of IHD deaths (86%) occurred in the first three categories. Combinations of risk factors substantially increased total mortality as well as IHD mortality.

CONCLUSIONS

The large proportion (64%) of the population with risk factors for cardiovascular disease and the substantially (5-12-fold) increased IHD mortality in those risk groups, calls for actions aimed at preventing premature IHD deaths. Such action should include measures directed towards the whole population and comprehensive treatment programmes for high-risk individuals, including intervention to stop smoking. The substantial overlap between risk factors calls for one high-risk clinic caring for all risk groups.

Poor physical fitness, and impaired early insulin response but late hyperinsulinaemia, as predictors of NIDDM in middle-aged Swedish men

In a prospective population-based study of middle-aged Caucasian men, performed in Malmö, Sweden, specifically designed to evaluate physical fitness, early and late insulin response as predictors of non-insulin-dependent diabetes mellitus (NIDDM), 4,637 non-diabetic men underwent oral glucose tolerance tests at the ages of 48 and 54 years. At the baseline examination, physical fitness was measured in terms of lung vital capacity and oxygen uptake during ergometry; early insulin response in terms of the 40-min insulin increment during an oral glucose tolerance test (a correlate of acute insulin response to an intravenous glucose tolerance test), and late insulin response were measured in terms of the 2-h insulin value during the oral glucose tolerance test (a correlate of glucose disposal during euglycaemic clamp testing). Of the subjects studied 116 developed NIDDM (0.4% annually), and when compared with non-diabetic men at baseline, they were found to have an 11% higher mean body mass index (p < 0.001), a higher frequency of family history of diabetes (31 vs 18%, p < 0.001), 16% lower mean physical activity index (p < 0.05), 16% lower mean estimated maximal oxygen uptake (p < 0.001), 10% lower mean vital capacity (p < 0.001), 26% lower 40-min to total insulin response ratio (p < 0.001), and a 2.7 times higher mean 2-h insulin value during an oral glucose tolerance test (p < 0.001). Regression analysis (using Cox's proportional hazards model) showed both low vital capacity, and impaired early insulin response but late hyperinsulinaemia to be independent predictors of NIDDM, in addition to body mass index and fasting blood glucose level (p = 0.05-0.0001). Among subjects with impaired glucose tolerance at baseline (44 of 278 developed NIDDM), fasting glucose level alone predicted diabetes in this model. The findings suggest that in this age group in a Caucasian population, not only does insulin resistance precede glucose intolerance and NIDDM, but also loss of early insulin response indicating impaired beta-cell function to be an early feature of the process culminating in diabetes. As both physical fitness [which correlates inversely with late insulin response (r= -0.42, p < 0.0001)], and the level of physical activity were shown to correlate with diabetes development in this large series, measures to correct these adverse features should be included in future strategies for preventing NIDDM.

Body mass index and disability pension in middle-aged men--non-linear relations

BACKGROUND

Obesity has, in a number of studies, been found to correlate to disability and mortality, primarily due to diseases of the circulatory and musculoskeletal systems. In addition, an excess mortality among underweight subjects has been observed in previous studies.

METHODS

Five complete birth-year cohorts (1926-1930) of male residents in Malmö (n = 7697) were invited to the survey at the Department of Preventive Medicine, Malmö General Hospital, and 5926 (77%) attended with complete data. Each subject was followed from inclusion, defined by the date of examination, until the end of the calendar year when he turned 58, a total study period of approximately 11 years. Data on about 300 questionnaire items and laboratory tests were determined at the health survey visit. Nationwide Swedish data registers were used for surveillance.

RESULTS

Of the participants, 4.7% were underweight, 37.7% overweight, 7.3% obese and 50.3% normal weight; 849 (14.3%) had been granted disability pension at the end of follow-up, 717 after screening. After adjustment for smoking there was a J-shaped relation between body mass index (BMI) and incidence of disability pension, the relative risk ( with the normal group as reference) among underweight men being 1.9. For the overweight subjects it was 1.3 and for the obese 2.8, all differences were significant. Disease of the musculoskeletal and circulatory systems and mental disorders accounted for 67.2% of all main diagnoses resulting in disability pensions during follow-up. A total of 377 (6.4%) men died during follow-up. Diseases of the circulatory system, neoplasms, injury/poisoning and diseases of the respiratory system accounted for 91.8% of the deaths.

CONCLUSIONS

Both underweight, overweight and obesity were related to risk of disability pension, with a J-shaped risk relationship.

Human hexokinase II gene: exon-intron organization, mutation screening in NIDDM, and its relationship to muscle hexokinase activity

In muscle, hexokinase II (HK2) regulates phosphorylation of glucose to glucose 6-phosphate, which has been reported to be impaired in patients with non-insulin-dependent diabetes mellitus (NIDDM). Here we report decreased HK2 enzyme activity in skeletal muscle biopsies from patients with impaired glucose tolerance compared with healthy control subjects (2.7 +/- 0.9 vs 4.9 +/- 1.1 nmol.min-1.mg protein-1). Therefore, mutations in the HK2 gene could contribute to skeletal muscle insulin resistance in NIDDM. To address this question, we first determined the exon-intron structure of the human HK2 gene and using this information, we screened all 18 exons with single-strand conformation polymorphism technique in 80 Finnish NIDDM patients. Nine nucleotide substitutions were found, one of which was a missense mutation (Gln142-His142) in exon 4. In human muscle, a single HK2 mRNA transcript with a size of approximately 5500 nucleotides was detected with Northern blot analysis. We also describe an HK2 pseudogene (HK2P1), which was mapped to chromosome 4, band q26, by fluorescence in situ hybridization to metaphase chromosomes. The clinical characteristics and HK2 enzyme activities of the subjects with either Gln or His at residue 142 did not differ from each other. Instead, HK2 activity correlated inversely with fasting blood glucose levels, suggesting that changes in HK2 activity could be secondary to other metabolic abnormalities (r = 0.55; p < 0.0003; n = 39). In conclusion; the data suggest that impaired HK2 activity in prediabetic individuals is a consequence of impaired glucose tolerance rather than of a genetic abnormality. The data thus seem to rule out mutations in the HK2 gene as a major cause of inherited insulin resistance in NIDDM.

Increased skeletal muscle capillary density precedes diabetes development in men with impaired glucose tolerance. A 15-year follow-up

Gastrocnemius muscle morphology, metabolic potential, and capillarization were analyzed in 48-year-old men with regard to subsequent development of non-insulin-dependent diabetes mellitus (NIDDM) in 29 subjects with impaired glucose tolerance (IGT) and in 38 control subjects. Over a 15-year period, although participating in an intervention program, 13 of the IGT subjects developed diabetes, but none of the control subjects developed diabetes. In view of their poor aerobic capacity, lack of physical fitness, and reduced glycolytic and oxidative enzymes, these 13 subjects manifested an unexpectedly high number of capillaries around all types of muscle fibers, especially type IIb fibers, as predictors of their progression to diabetes. Moreover, the number of capillaries per muscle fiber and the 2-h insulin value in the oral glucose tolerance test were highly correlated (r = 0.82, P < 0.005), whereas no correlation was found among IGT subjects who remained nondiabetic and in the control group. With body mass index and the 2-h glucose concentration included in a regression model, 68% of the variation in the number of capillaries per muscle fiber was explained (P < 0.05), with the 2-h insulin value independently accounting for 33%. These findings may suggest that the increased circulating insulin concentrations in IGT subjects have a capillary proliferative effect, perhaps to compensate for reduced capillary insulin diffusion and metabolic capacity of the muscle.

Diabetes mellitus but not impaired glucose tolerance is associated with dysfunction in peripheral nerves

To clarify whether long-term impaired glucose tolerance (IGT) is associated with dysfunction of peripheral and autonomic nerves, age-matched men with IGT and diabetes mellitus were followed prospectively for 12-15 years, when peripheral and autonomic nerve function was assessed. The patients comprised four subgroups: (1) 51 IGT subjects (duration of IGT at least 12-15 years); (2) 35 diabetic patients, with IGT 12-15 years ago, who later developed diabetes; (3) 34 diabetic patients, duration of diabetes at least 12-15 years; and (4) 62 age-matched non-diabetic control subjects. Mean age of the whole study population was 61 +/- 2 years (mean +/- SD), not different in the four groups. Peripheral nerve function tests included nerve conduction velocities, amplitudes, distal latencies, F-reflexes, and sensory perception thresholds for heat, cold, and vibration. Autonomic nerve function tests included the heart rate reaction during deep breathing (expiration to inspiration ratio) and to tilt (acceleration and brake indices). Despite 12-15 years of IGT, peripheral nerve function did not differ between IGT and control subjects, whereas autonomic nerve function deviated; an abnormal expiration to inspiration ratio (a sign of vagal nerve dysfunction) was significantly more common (15/51 versus 5/62; p < 0.01) in IGT than in control subjects. Diabetic patients (groups 2 and 3) showed lower conduction velocities (in general 2-4 m s-1 lower) than IGT and control subjects in all tested nerves. In conclusion, diabetes but not IGT, is associated with peripheral nerve dysfunction.

Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmö feasibility study

From a previously reported 5-year screening programme of 6,956 47-49-year-old Malmö males, a series of 41 subjects with early-stage Type 2 (non-insulin-dependent) diabetes mellitus and 181 subjects with impaired glucose tolerance were selected for prospective study and to test the feasibility aspect of long-term intervention with an emphasis on life-style changes. A 5-year protocol, including an initial 6-months (randomised) pilot study, consisting of dietary treatment and/or increase of physical activity or training with annual check-ups, was completed by 90% of subjects. Body weight was reduced by 2.3-3.7% among participants, whereas values increased by 0.5-1.7% in non-intervened subjects with impaired glucose tolerance and in normal control subjects (p less than 0.0001); maximal oxygen uptake (ml.min-1.kg-1) was increased by 10-14% vs decreased by 5-9%, respectively (p less than 0.0001). Glucose tolerance was normalized in greater than 50% of subjects with impaired glucose tolerance, the accumulated incidence of diabetes was 10.6%, and more than 50% of the diabetic patients were in remission after a mean follow-up of 6 years. Blood pressure, lipids, and hyperinsulinaemia were reduced and early insulin responsiveness to glucose loading preserved. Improvement in glucose tolerance was correlated to weight reduction (r = 0.19, p less than 0.02) and increased fitness (r = 0.22, p less than 0.02). Treatment was safe, and mortality was low (in fact 33% lower than in the remainder of the cohort).(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired glucose tolerance in a middle-aged male urban population: a new approach for identifying high-risk cases

From an urban population (n = 9,033) of 47-49-year-old males, 6,956 participated in a multiphase screening programme, of whom 1.5% were already registered as diabetic patients, 1.7% were then found to be diabetic; of 6,325 subjects given oral glucose tolerance tests, 6.6% were found to have impaired glucose tolerance (WHO criteria, 1985). In 889 asymptomatic cases with initial capillary whole blood glucose values greater than or equal to 6.6 mmol/l fasting and/or 2 h post-load, fluctuation in oral glucose tolerance was studied at repeat tests within one month; the mean differences in glucose values between the first and second test were less than -1% (fasting) and -15% (2 h post-load); there were no differences in body weight, and 62% of those with initially impaired glucose tolerance had normalised by the repeat test. Only in 109 cases (1.7%) were 2 h post-load values in the 7.8-11.0 mmol/l range both at the first and the repeat test; these cases were comparable vis-à-vis body mass index, triceps skin fold, blood pressure and initial glucose and insulin values, but had significantly lower oxygen uptake (2.34 +/- 0.54 l/min vs 2.63 +/- 0.68 l/min; p less than 0.003), as compared with subjects with initially impaired glucose tolerance but normal repeat test outcome. However, subjects with high normal first test results (2 h value in the 7.0-7.7 mmol/l range) and second test results in the 7.0-11.0 mmol/l range, resembled those with persistent impairment of glucose tolerance in all respects (including oxygen uptake). The repeat test procedure (including ergometry), is therefore to be recommended in selecting true risk cases.

Transglutaminase-dependent lymphocyte transformation in type 2 diabetes mellitus

The transglutaminase involvement in phytohaemagglutinin (PHA) stimulated lymphocyte transformation (measured as (3H)thymidine incorporation) was studied in lymphocytes from 20 patients with type 2 diabetes mellitus and 20 healthy controls by including in the system the specific transglutaminase pseudosubstrate monodansylthiacadaverine (MDTC). In the presence of MDTC, (3H)thymidine incorporation was significantly and concentration-dependently reduced in both groups but more pronouncedly in the diabetes patients. The MDTC concentration needed to give a 50% reduction of the PHA-stimulated (3H)thymidine incorporation was significantly lower in lymphocytes from diabetic patients than in those from controls (p less than 0.02). The data suggest impaired lymphocyte transglutaminase function in type 2 diabetes mellitus.

The importance of diabetes heredity in lean subjects on insulin secretion, blood lipids and oxygen uptake in the pathogenesis of glucose intolerance

Insulin secretion, work capacity and plasma lipids were evaluated in 52 middle-aged men with impaired glucose tolerance (IGT), and the values were compared with those of 23 normoglycemic subjects with family histories of Type 2 diabetes and of 22 non-hereditary normoglycemic controls. All subjects were non-obese males of comparable age. Estimated maximal oxygen uptake was significantly lower (p less than 0.01) and triglyceride concentrations significantly higher (p less than 0.01) in IGT individuals than in subjects of the non-hereditary normoglycemic group, while no significant differences were noted in comparison with the hereditary group. IGT individuals showed an impaired insulin response to glucose with significantly lower absolute values of insulin and C-peptide during the early phase of the oral glucose tolerance test (OGTT) than in non-hereditary normoglycemic subjects, but not significantly lower than in the hereditary group. Similarly, at most time points of the OGTT the ratios of insulin and C-peptide to glucose were significantly lower in the IGT group than in the non-hereditary group, while these differences were less pronounced in comparison with the hereditary group. These findings suggest some similarities of metabolic disturbances in lean normoglycemics with positive family histories of Type 2 diabetes and in lean IGT individuals. Family history of diabetes (both first degree and second degree only) was significantly more prevalent among IGT individuals than among normals.

Plasma insulin and C-peptide in relation to glucose intolerance in middle-aged men

The relation between glucose homeostasis and insulin secretion (immunoreactive insulin and C-peptide) was studied in middle-aged males matched for age and body weight. Subjects with mild type II diabetes mellitus were compared to normals and to individuals with impaired glucose tolerance (IGT). In addition, the diabetics were subdivided according to duration, some of the subjects having recently deteriorated from IGT status. In the IGT individuals, there were no indications of a reduction in basal or glucose-induced insulin output. On the contrary, data indicate somewhat higher than normal secretion. Within the type II diabetics, those of short duration were largely similar to normals, whereas diabetes of longer duration was associated with some diminution in indices of B cell secretion. The data support the notion that a deficient insulin output is not a primary pathophysiological event in the development of type II diabetes.

Infectious mononucleosis and agranulocytosis

Infectious mononucleosis is often complicated by haematological abnormalities but agranulocytosis is so rare that a causal relationship has been questioned. We here describe 2 sisters, 3 and 5 years old, who both developed agranulocytosis or profound granulocytopenia 4-5 weeks after the acute onset of mononucleosis. No contributory cause could be found and we conclude that a constitutional disposition may be responsible for this complication.