Establishing priorities for diabetes action goals according to key opinion leaders and health professionals

Background

The ever-increasing burden of diabetes and the limited resources highlight the need for prioritization of national action goals for diabetes management. The Israeli National Diabetes Council (INDC) initiated a prioritization process aiming to set a top list of diabetes related goals, as suggested by decision makers and health professionals.

Methods

A 2-step prioritization process, including a small (n = 32) circle of key opinion leaders of the INDC and a larger (n = 195) nationwide circle of diabetes health professionals consisting of physicians, nurses, and dieticians working in diabetes care centers, hospitals and family practice clinics, was established. An online questionnaire presenting 45 different action areas in diabetes prevention and care was distributed to the INDC members who ranked the 3 top diabetes priorities based on their individual interpretation of importance and applicability. The 7 highest ranking priorities were later presented to hospital-based and community diabetes health professionals. These professionals selected the 3 top priorities, based on their perceived importance.

Results

Council members opted mostly for action areas regarding specific populations, such as clinics for adult type-1 diabetes patients, diabetic foot, and pediatric and adolescent patients, while the health professionals’ top priorities were mostly in the general field of prevention, namely high-risk prediabetes population, prevention of obesity, and promotion of healthy life-style. In addition, priorities differed between hospital and community health professionals as well as between different professional groups.

Conclusions

A national prioritization process of action areas in diabetes prevention and care is attainable. The resulting item list is affected by professional considerations. These priorities may direct efforts in the implementation of interventions to improve national-level diabetes management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00540-x.

[INCLUSION OF THE RISK FOR DIABETIC FOOT IN THE HOSPITAL DISCHARGE LETTER IN ORDER TO ENHANCE PREVENTIVE MEASURES IN THE COMMUNITY]

Severe foot ulceration in a diabetic patient, called "diabetic foot", is one of the most debilitating complications of diabetes mellitus resulting in huge costs, both personal and public. The best way to avoid this complication is by identifying the risk factors for diabetic foot, and taking early preventive actions. At any given time, more than 40% of hospitalized patients are diabetics, whether in departments of internal medicine or others. Every diabetic patient hospitalized in any department (Internal, Surgery, Geriatric, Rehabilitation or Psychiatric) undergoes an evaluation to determine the risk level for diabetic foot by the nursing staff (as required by the Israel Ministry of Health). Approximately 50% of hospitalized diabetics are classified as having high risk for complications from diabetic foot. This evaluation constitutes a window of opportunity for intervention in order to improve the patient's condition. Currently, the status of this evaluation does not appear on the patient's discharge form, neither in the nursing recommendations nor in the physician's instructions. This being the case, the evaluation has no practical value. Without this vital information, the community care doctor is not aware of the risks, and therefore does not take action to prevent the development of severe complications. During a recent project in which we assessed our own departmental quality, we successfully showed that we were able to increase the amount of hospital discharge forms containing the evaluation of the risk for diabetic foot, by a dramatic 23%. We intend to continue this implementation process, and to examine the response within the community in order to assure that the recommendations continue to appear on the discharge forms.

[A RARE CASE OF RELAPSING GUILLAIN-BARRE SYNDROME PRESENTING AS BRAIN DEATH]

Acute immune-mediated polyneuropathies classified as Guillain-Barre Syndrome (GBS) constitute a wide range of clinical manifestations characterized by ascending symmetrical limbs paralysis along with possible involvement of the respiratory muscles. Paralysis of facial and eye muscles including unresponsive pupils, which may mimic a brain death is rare, though previously described. This presentation is challenging because it masks the correct diagnosis and delays or prevents appropriate treatment. A 69-year-old female patient was hospitalized with progressive bilateral limb paralysis with involvement of the respiratory and facial muscles necessitating intubation. Plasmapheresis resulted in significant motor and respiratory improvement and the patient was sent for further rehabilitation. Six weeks later she was hospitalized again with complete muscle paralysis including involvement of the eye muscles and pupils. In the absence of ocular, corneal, and swallowing reflexes, a working diagnosis of brain death was initially made. However, a repeated and meticulous physical examination revealed that her consciousness was preserved. An EEG test showing brain activity ruled out brain death. EMG showed extensive axonal damage supporting the diagnosis of GBS. Repeated plasmapheresis failed to improve her condition but she had partially responded to treatment with immunoglobulins. Clinicians should be aware of those patients diagnosed as brain dead but who in fact suffer from another treatable disease that needs to be diagnosed.

Years of potential life lost in pre-diabetes and diabetes mellitus: data from a 40-year follow-up of the Israel study on Glucose intolerance, Obesity and Hypertension

INTRODUCTION

We examined years of potential life lost (YPLL) associated with pre-diabetes as compared with either normoglycemia or diabetes, using data of the Israel cohort of Glucose intolerance, Obesity and Hypertension 40-year follow-up.

RESEARCH DESIGN AND METHODS

Men and women (N=2844, mean age 52.0±8.2 years) who underwent oral glucose tolerance test and anthropometric measurements, during 1976-1982, were followed for mortality until May 2019. Multiple imputation procedures for missing mortality dates and multivariable regression mixed models were applied.

RESULTS

At baseline, 35.8%, 48.8% and 15.4% individuals were found with normoglycemia, pre-diabetes, and diabetes, respectively. The average difference in YPLL associated with pre-diabetes as compared with normoglycemia was 4.3 years (95% CI 3.3 to 5.2; p<0.001). YPLL were 1 year higher in women with pre-diabetes than in men with pre-diabetes. These differences persisted mainly in individuals younger than 60 years, and those with body mass index (BMI) <25 kg/m², at baseline. Adjusting for age, sex, country of origin, smoking status, BMI, and blood pressure, the average difference in YPLL associated with pre-diabetes as compared with normoglycemia was 2.0 years (95% CI 1.2 to 2.8; p<0.001). Significant reductions of 5.9 years (95% CI 4.8 to 7.0) on average were observed for diabetes as compared with pre-diabetes and 7.9 years (95% CI 6.7 to 9.1) as compared with individuals with normoglycemia.

CONCLUSIONS

This study reveals that life expectancy of middle-aged individuals with pre-diabetes is shorter than of normoglycemic ones. These findings are especially relevant in view of the rising worldwide prevalence of pre-diabetes within younger age groups and underscore the crucial importance of interventions by either lifestyle modification or drug therapy capable of delaying progression from pre-diabetes to diabetes to reduce the YPLL in this high-risk group.

Isolation of five Enterobacteriaceae species harbouring blaNDM-1 and mcr-1 plasmids from a single paediatric patient

In Argentina, NDM metallo-β-lactamase was first reported in 2013. By now, it has disseminated throughout the country in diverse Gram negative bacteria. Here, we report the case of a paediatric patient that underwent a 1-year hospitalisation due to erythrodermic psoriasis in 2014 and received multiple antimicrobial treatments. During his stay, five isolates were obtained from rectal swabs (rs) or blood culture (bc) suspicious of carbapenemase production: a K. quasipneumoniae subsp. quasipneumoniae (rs), Citrobacter freundii (rs), Escherichia coli (bc), Enterobacter cloacae (rs), and a Serratia marcescens (bc). The isolates were studied with broth microdilution, biparental conjugation and plasmid and whole genome sequencing (Illumina). All isolates harboured an 138,998-bp type 1 IncC plasmid that carried bla_NDM-1, ble_MBL, bla_CMY-6, rmtC, aac(6’)-Ib, and sul1 resistance genes. Additionally, the bla_NDM-plasmids contained ISKpn8 an insertion sequence previously described as associated only to bla_KPC. One isolate, a colistin-resistant E. coli, also carried a mcr-1-containing an IncI2 plasmid, which did not harbour additional resistance. The whole genome of K. quasipneumoniae subsp. quasipneumoniae isolate was fully sequenced. This isolate harboured, additionally to bla_NDM, three plasmid-mediated quinolone resistance genes: qnrB4, qnrB52 and aac(6’)-Ib-cr1. The E. cloacae isolate also harboured qnrA1. These findings alert to the underestimated horizontal dissemination of multidrug-resistant plasmids limiting treatment options with last resort antimicrobials.

Long-term Successful Antibiotic Therapy for Recurrent Aortic Graft Infection

Objective

To report a case of successful long-term conservative management of a patient with aortic graft infection due to multiple infectious agents.

Materials and methods

We describe the clinical case and present a review of relevant literature.

Results

An 82-year-old man presented with recurrent Escherichia coli bacteraemia. He was diagnosed with an endovascular aortic graft infection. As the patient declined surgery, conservative treatment with daily antibiotic therapy was instituted. We report good clinical results after almost 2 years of treatment and follow-up.

Conclusions

The preferred treatment of aortic graft infections is surgical. Conservative management is usually offered to poor surgical candidates and is associated with an unfavourable outcome. However, we report that selected patients may be successfully treated using prolonged antibiotic therapy.

LEARNING POINTS

Chairing the internal medicine department- analysis of current state and future trends in Israel

Background

Professional skills and academic records of the highest degree are essential requirements for the chairmanship of internal medicine departments. Whether the new generation and future successors of Israeli chairmen is endowed with these attributes is not known.

Purpose

To determine whether there is a lack of future suitable successors for the current heads of internal medicine departments in Israel and to compare the demographic, academic and professional characteristics of the older and newer generations of department heads.

Methods

An online anonymous questionnaire was nationally distributed during 2016 to all active heads of internal medicine departments in Israel (n = 101). First round was followed by two runs of personal phone calls to promote participation.

Results

Sixty-seven (67%) of chairmen responded. The vast majority of current chairs of internal medicine departments are males (N = 59, 88%) over 50 years of age (N = 58, 86%) with established academic background with lecturer degree or higher (N = 57, 85%).

Only 19 (28%) of current heads assigned a future successor. Comparison of chairmen who did and did not assigned successors demonstrated that assignment of successors was associated with higher academic status (P < 0.02) and longer chairmanship (p < 0.01) but not with mean age of current chairmen (p < 0.08). Nevertheless, most assignments (55%) were done by chairmen in the 61 to 67 years age group. As compared to current chairmen, the designated successors have lesser academic status (p < 0.01) and are characterized by a higher female prevalence (P < 0.03).

Conclusions

Significant demographic, professional and academic differences exist between the current chairs of internal medicine departments in Israeli hospitals and their future successors. This underscores the need for reassessment of the availability and requirements of this crucial position.

[TREATMENT WITH DUAL ANTIPLATELET THERAPY FOR SECONDARY PREVENTION OF STROKE - PROS AND CONS]

The role of dual antiplatelet therapy combining aspirin and clopidogrel, is controversial. There are two settings in which such treatment might be considered: (a) patients presenting with a first ischemic event at high risk for a recurrence; and (b) patients who experience a second ischemic event while being treated with aspirin or clopidogrel monotherapy. In this paper we review the literature dealing with secondary prevention of ischemic stroke, with an emphasis on dual antiplatelet therapy. We examine international guidelines and present a case study which illustrates the application of this information.

A Rare Case of Spinal Sarcoidosis Presenting as Multiple Bone Marrow Oedematous Lesions

Sarcoidosis is a systemic disorder that most commonly affects the lungs. Bone involvement is rare, and spinal involvement is even more rare. The presence of focal lesions of the vertebrae is highly suspicious of advanced malignancy. However, malignant metastatic spread to the spine involves the vertebral cortex rather than the bone marrow itself, a distinction that is often missed and therefore misleading. We describe here a middle-aged woman with multiple focal oedematous lesions of the bone marrow suspected of being advanced malignancy but finally diagnosed as a rare case of spinal sarcoidosis.

[THE DIAGNOSTIC AND THERAPEUTIC CHALLENGE OF TYPE 2 MYOCARDIAL INFRACTION]

Type 2 Myocardial Infarction (Type 2 MI) is considered to result from an imbalance between demand and supply of oxygen in the myocardium, other than coronary plaque instability. It is highly prevalent in internal departments and is strongly associated with mortality. To date, there is no consensus regarding the diagnostic criteria for type 2 MI and no available guidelines regarding the optimal management of this condition. We present a case study of a 64 years old male who was hospitalized with lower gastrointestinal bleeding. This patient was diagnosed with Type 2 myocardial infarct, due to a decrease in oxygen supply to the myocardium, but eventually turned out to be a Type 1 MI .We reviewed current literature regarding the clinical features, diagnosis, prognosis and treatment of Type 2 MI.

Vitamin B12 screening in metformin-treated diabetics in primary care: were elderly patients less likely to be tested?

Low serum B12 level is a common occurrence in patients with type 2 diabetes (T2DM) treated with metformin. There is lack of evidence concerning blood testing of vitamin B12 and current clinical guidelines make no recommendations on the detection or prevention of vitamin B-12 deficiency during metformin treatment. Our objective was to examine the current practice and clinical determinants of vitamin B12 testing in metformin treated T2DM patients. Data were collected from health maintenance organization patients, and consisted of T2DM patients who were newly prescribed metformin from 2008 to 2013. Patients were randomly divided into two subgroups: referred for a vitamin B12 blood test, and did not receive a referral. The demographic data and medical characteristics were analyzed. 5131 patients began taking metformin during the study period. Of these 2332 (44.5 %) had vitamin B12 tested. Significant differences were found between the groups in regard to glycosylated hemoglobin, low density lipoprotein, systolic blood pressure, dyslipidemia, chronic renal failure, and disease duration. A significant positive association (p < .05) was found between vitamin B12 testing and insulin treatment, retinopathy, neuropathy and hypertension. Vitamin B12 in elderly (>75 years) patients was significantly lower (p < .01). Insulin treatment, hypertension, and chronic diabetic complications in metformin treated T2DM patients are associated with higher rates of vitamin B12 testing. T2DM patients 75 years and above were less likely to be tested for B12 deficiency.

Achievement of partial combined control of major diabetes targets in primary care correlates with development of chronic complications in T2DM patients--A real life data

AIMS

Strict long term glucose, cholesterol and blood pressure control is advocated in type 2 Diabetes Mellitus (T2DM) patients. It is not known whether combined partial goals' achievement affects development of chronic complications.

METHODS

We evaluated the relative ability or failure of 5369 T2DM ambulatory patients to achieve and maintain control of blood pressure, glycaemia and cholesterol for 3 consecutive years. Correlation between the extent of combined goal achievement, and development of chronic complications was determined.

RESULTS

Only 9 patients (0.17%) fully achieved and none completely failed to achieve all strict goals. Therefore, patients were characterized as either partial achievers (PA) (n=699) or partial non achievers (PNA) (n=322). As compared to PA patients, PNA patients were significantly younger, single, and demonstrated a higher female and Arab ethnicity dominance. PNA patients had higher BMI, received more insulin treatment and consumed more hospital services. The incidence of microvascular complications during 3 years was significantly increased in PNA patients.

CONCLUSIONS

A negligible number of primary care patients completely and persistently achieve or fail to achieve combined control of major diabetes targets. Partial achievement of these targets correlates with specific patients' characteristics and incidence of chronic micro-vascular complications.

Intrapatient emergence of OXA-247: a novel carbapenemase found in a patient previously infected with OXA-163-producing Klebsiella pneumoniae

Two genetically related Klebsiella pneumoniae strains carrying OXA-type carbapenemases were isolated from a single patient 1 month apart. Kpn163 harboured OXA-163 and Kpn247 a new variant named OXA-247 that showed susceptibility to carbapenems and expanded-spectrum cephalosporins similar to OXA-48. Our epidemiological, biochemical and molecular results suggest the intrapatient emergence of blaOXA -247 from blaOXA -163.

Clonal dissemination of Klebsiella pneumoniae ST258 harbouring KPC-2 in Argentina

The present work describes the abrupt emergence of Klebsiella pneumoniae carbapenemase (KPC) and characterizes the first 79 KPC-producing enterobacteria from Argentina (isolated from 2006 to 2010). The emergence of bla(KPC-2) was characterized by two patterns of dispersion: the first was the sporadic occurrence in diverse enterobacteria from distant geographical regions, harbouring plasmids of different incompatibility groups and bla(KPC-2) in an unusual genetic environment flanked by ISKpn8-Δbla(TEM-1) and ISKpn6-like. bla(KPC-2) was associated with IncL/M transferable plasmids; the second was the abrupt clonal spread of K. pneumoniae ST258 harbouring bla(KPC-2) in Tn4401a.

A simple test for the detection of KPC and metallo-β-lactamase carbapenemase-producing Pseudomonas aeruginosa isolates with the use of meropenem disks supplemented with aminophenylboronic acid, dipicolinic acid and cloxacillin

We evaluated the ability of the combination disk test (CDT) and the Modified Hodge Test (MHT) to discriminate between various carbapenemase-producing Pseudomonas aeruginosa isolates (KPC, n = 36; metallo-β-lactamase (MBL), n = 38) and carbapenemase non-producers (n = 75). For the CDT, the optimal inhibitor concentrations and cut-off values were: 600 μg of 3-aminophenylboronic acid (APB) per disk (an increment of ≥4 mm), 1000 μg of dipicolinic acid (DPA) per disk (an increment of ≥5 mm) and 3000 μg of cloxacillin per disk (an increment of ≥3 mm). APB had excellent sensitivity (97%) and specificity (97%) for the detection of KPC enzymes. DPA detected MBL enzymes with a sensitivity and specificity of 97% and 81%, respectively. The MHT resulted in a low sensitivity (78%) and specificity (57%). The CDT could be very useful in daily practice to provide fast and reliable detection of KPC and MBL carbapenemases among P. aeruginosa isolates.

A strategy for the engineering of insulin producing cells with a broad spectrum of defense properties

Insulin-producing pancreatic beta cells are known to be extremely susceptible to the oxidative stress and hypoxia generated following islet transplantation in diabetic patients. We hereby present a novel in vivo selection strategy based on the isolation of insulin-producing cells with enhanced protection after repeated rounds of encapsulation and xenotransplantation. Rat insulinoma INS-1 cells were encapsulated in alginate macrobeads and transplanted in the peritoneal cavity of mice. After 2 days the beads were retrieved and cells were recovered from alginate and propagated in vitro until submitted to a second round of encapsulation and transplantation. Three days later, the surviving cells, named INS-1m2, were isolated from the alginate beads and their protection and functional activity examined. Compared to parental INS-1 cells, the selected INS-1m2 cells were more resistant to hydrogen peroxide, nitric oxide, alloxan and hypoxia. This enhanced protection of the selected cells correlated with the increased level of catalase and poly (ADP-ribose) polymerase expression. Although selected cells expressed more insulin than parental cells, no change in their insulin response to glucose was observed. We conclude that the in vivo selection strategy is a powerful tool for the engineering of insulin producing cells with a broad spectrum of defense properties.

Therapeutic potency of IL2-caspase 3 targeted treatment in a murine experimental model of inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) comprises primarily the two disorders - ulcerative colitis and Crohn's disease - that involve deregulated T cell responses. The ever-increasing incidence rate of Crohn's disease and ulcerative colitis during recent decades, combined with the limited efficacy and potential adverse effects of current treatments, explain the real need for seeking more specific and selective methods for treating these diseases.

AIM

To investigate the ability of interleukin 2 (IL2)-caspase 3 chimeric protein, designed to target activated T lymphocytes that express the high-affinity IL2 receptor, to ameliorate the clinical symptoms of acute murine experimental colitis, using a mouse model of dextran sodium sulfate (DSS)-induced colitis.

METHODS

Mice with DSS-induced colitis were treated with IL2-caspase 3 for 7 days and disease severity was assessed in parallel to control, non-treated mice, receiving only daily injections of phosphate-buffered saline. IL2-caspase 3 was tested both for its ability to prevent the development of colitis, and for its therapeutic potential to cure on-going, active acute disease. In addition, colon tissue samples were used for myeloperoxidase assays and RNA isolation followed by polymerase chain reaction to determine mRNA expression levels of specific genes.

RESULTS

Treatment with IL2-caspase 3 dose-dependently ameliorated the disease activity index (DAI) of mice colitis. We achieved up to 78% improvement in DAI with intravenous injections of 15 microg/mouse/day. Furthermore, IL2-caspase 3 decreased neutrophil and macrophage infiltration to the inflamed tissue by up to 57%. IL2-caspase 3 was proven as a therapeutic reagent in another model, where treatment begins only after disease onset. Here we demonstrated a 70% decrease in DAI when compared to non-treated sick mice. A reduction in mRNA expression levels of both IL1 beta and tumour necrosis factor alpha was found in lysates of total colon tissue of treated mice, as compared to sick, untreated mice. We also found that expression levels of Bcl2 were significantly decreased after treatment, while Bax was upregulated in comparison to non-treated mice. Moreover, the Bcl2/Bax ratio, which is elevated in both experimental colitis and in human Crohn's disease, decreased dramatically after treatment.

CONCLUSIONS

IL2-caspase 3 chimeric protein may provide a novel approach to the therapy of human IBD, and a possible suggested treatment for other pathological conditions that involve uncontrolled expansion of activated T cells.

[Recurrent hospitalizations due to false positive troponin in a patient presenting with chest pain]

A 58 year old male patient was hospitalized numerous times due to an elevated troponin I level in spite of the absence of specific chest pain and ischemic changes on ECG. The patient had undergone two coronary angiography procedures and numerous cardiac studies without evidence of ischemic heart disease. The elevated troponin level remained unchanged in between hospitalizations while the patient was asymptomatic. Further workup revealed that the troponin I level was normal when tested with an alternative laboratory kit. The troponin T level was also normal. This case report underscores the problematic nature of relying on an elevated troponin level as the sole component in the diagnosis of coronary disease.

Recurrent acute renal failure complicating IgG warm-type autoimmune intravascular haemolysis

A 44-year-old woman experienced recurrent episodes of massive intravascular haemolysis complicated by acute oliguric renal failure over a period of 22 years. The haemolysis was induced by IgG warm type autoantibody and complement and responded to corticosteroid therapy. The renal failure was treated effectively by dialysis. To our knowledge, such a life long occurrence of recurrent intravascular haemolysis induced by IgG warm type autoantibodies together with renal failure has not been reported before.

Apoptosis and proliferation of mesangial cells isolated from kidneys undergoing compensatory growth following contralateral nephrectomy: role of the renin-angiotensin system

BACKGROUND

Contralateral nephrectomy stimulates compensatory growth of the remaining kidney. Intensive growth is frequently associated with increased apoptosis. The proliferation and apoptosis of cultured rat mesangial cells isolated from the remaining kidney following contralateral nephrectomy were evaluated. The involvement of the renin-angiotensin system was concomitantly assessed.

MATERIAL/METHODS

Apoptosis was assessed by TUNEL assay and hematoxylin staining, proliferation by (3)H-thymidine incorporation, angiotensin-II (A-II) production by RIA, bradykinin synthesis by specific EIA, and AT-1/AT-2 receptor mRNA expression by RT-PCR.( 125)I-A-II labeling was applied for AT-1/AT-2 receptor density evaluation.

RESULTS

Apoptosis of unstimulated control cultures progressively increased from a baseline of 2.02+/-0.55% to 8.3+/-1.19% in 30-min and 12.8+/-4.11% in 24-h cultures (p<0.0001 in each comparison), accompanied by augmented cell proliferation and both could be abolished by captopril treatment. Endogenous A-II synthesis was increased in postnephrectomy cultures. Exogenous A-II enhanced apoptosis of control, but not of postnephrectomy cells. Bradykinin synthesis was elevated in cultures treated with captopril, but not with losartan or PD123319. AT-1 mRNA was increased 24 h following nephrectomy. Total A-II receptor density was decreased 30 min and 24 h following nephrectomy, while blockade of AT-1/AT-2 receptors was ineffective.

CONCLUSIONS

1. Contralateral nephrectomy stimulates apoptosis and proliferation of mesangial cells in the remaining kidney via increased endogenous A-II. 2. The mechanism by which A-II triggers apoptosis and proliferation of mesangial cells is not related to the AT-1/AT-2 receptor pathway. 3. The effects of angiotensin-II can be abolished by ACE inhibition and are, at least in part, mediated via bradykinin activity.

Apoptosis and proliferation of cultured mesangial cells isolated from kidneys of rosiglitazone-treated pregnant diabetic rats

BACKGROUND

The peroxisome proliferator activating nuclear receptors (PPAR) are activated in the context of inflammation, diabetes or normal pregnancy. Renal mesangial cells express PPAR-gamma which upon activation are capable of exerting anti-inflammatory effects. We investigated the effect of in vivo treatment by rosiglitazone on angiotensin II (A-II) stimulated manifestations of inflammation in cultured renal mesangial cells, such as proliferation, apoptosis, TGF-beta1 production and nuclear factor kappaB (NF-kappaB) activation, in the situation of pregnancies, complicated or not with diabetes.

METHODS

Mesangial cells were isolated from the following groups, receiving or not 5 mg/kg rosiglitazone for 20 days: normal controls, normal pregnant rats, those with streptozotocine induced diabetes and pregnant diabetic rats. Proliferation was assessed by 3H-thymidine incorporation. Apoptosis was evaluated by TUNEL assay. AT-1/AT-2 receptor density was assessed by 125I-AT-2 labelling, TGF-beta and NF-kappaB by specific ELISAs.

RESULTS

Rosiglitazone pretreatment resulted in significantly decreased proliferation, apoptosis and reduced responsiveness to A-II stimulation in cultures from controls, pregnant rats and non-pregnant diabetic animals. In the pregnant diabetic group which received rosiglitazone prior to sacrifice, responsiveness to A-II was completely blunted. Moderate attenuation of TGF-beta synthesis and significant decrease in the levels of NF-kappaB in mesangial cell nuclei were observed in all rosiglitazone treated groups.

CONCLUSIONS

PPAR-gamma activation by rosiglitazone resulted in decreased manifestation of inflammatory hallmarks, including inhibition of mesangial cell proliferation, downregulation of apoptosis and blunted responsiveness to A-II. These anti-inflammatory renoprotective effects were maximally expressed in cultures from pregnant diabetic animals. The therapeutic relevance of these observations is a matter of further investigations.

Right-left correlation of the sympathetically induced fluctuations of photoplethysmographic signal in diabetic and non-diabetic subjects

Photoplethysmography (PPG) records the cardiac-induced changes in tissue blood volume by light-transmission measurements. The baseline and amplitude of the PPG signal show very low-frequency (VLF) spontaneous fluctuations, which are mediated by the sympathetic nervous system, and high correlation between right and left extremities of healthy subjects. As sympathetic neuropathy is one of the diabetic complications, the right-left correlation of the PPG fluctuations was examined in diabetic patients. The PPG signal was simultaneously measured in the two index fingers and the two second toes of 35 diabetic patients and 33 non-diabetic subjects. For each PPG pulse, the baseline and amplitude were determined, and the right-left correlation coefficients of the VLF fluctuations in the baseline and amplitude were derived. The VLF fluctuations in the baseline showed high right-left correlation, both for fingers (0.93 +/- 0.05) and toes (0.93 +/- 0.06), for the non-diabetic subjects, and significantly lower correlation (0.78 +/- 0.22 and 0.84 +/- 0.17, respectively) for the diabetic patients. Similar results were obtained for the amplitude VLF fluctuations. The right-left correlation coefficients for diabetic patients decreased with the disease duration for the toe baseline and toe amplitude fluctuations and correlated with heart rate response to deep breathing for the finger baseline and toe amplitude fluctuations. The right-left correlation coefficients of the PPG fluctuations provide a simple and convenient means for assessing the adequacy of the sympathetic nervous system function.

Control of Hypertension with Captopril Affords Better Renal Protection as Compared with Irbesartan in Salt-Loaded Uremic Rats

BACKGROUND/AIM

Hypertension induced by exaggerated sodium consumption accelerates the progression of renal failure. We investigated the effects of a high-sodium (HS) diet on the progression of renal failure in rats maintained normotensive by angiotensin-converting enzyme inhibition or AT-1 blockade.

METHODS

In 70 Sprague-Dawley rats, renal failure was induced by five-sixths nephrectomy. They were fed isocaloric normal-sodium (NS), low-sodium (LS), or HS diets. HS rats prone to develop hypertension were divided into three subgroups: treated to normotension by irbesartan (HS-1) or captopril (HS-2) or left untreated (HS-0).

RESULTS

All HS animals developed significant proteinuria which strongly correlated with the 24-hour sodium excretion. HS-0 rats demonstrated severe hypertension, rapid deterioration of the renal function, and 100% mortality after 3 weeks. In irbesartan-treated HS-1 rats, mortality and decline of the glomerular filtration rate were similar to those of normal- or low-sodium-fed animals (100% mortality after week 12). In captopril-treated HS-2 rats, glomerular filtration rate decline and mortality were significantly blunted as compared with all other groups (50% mortality after week 12).

CONCLUSIONS

(1) In five-sixths-nephrectomized uremic rats maintained normotensive by either irbesartan or captopril, the rate of deterioration of the renal function was not aggravated by exaggerated sodium consumption. (2) In this experimental setting, captopril treatment yielded a better survival outcome as compared with irbesartan, despite the similar hypotensive effect.

Loss of captopril-bound Fe by end-stage renal failure patients during hemodialysis

BACKGROUND

Patients on chronic hemodialysis often suffer from severe anemia, the outcome of iron deficiency and inadequate response to erythropoietin. Antihypertensive treatment with captopril worsens anemia, erythropoietin production and iron balance in hemodialysis patients. We investigated the possibility that iron chelation by captopril in the blood may result in elimination of iron-captopril complexes during hemodialysis, thus minimizing the effect of both medications.

METHODS

Twelve hypertensive hemodialysis patients (group 1) were treated with 12.5 mg/day captopril, while their 12 counterparts received 1.25 mg/day ramipril. Following two weeks of treatment and two weeks of "washout", captopril in group 1 was substituted with ramipril and ramipril in group 2 was replaced by captopril for an additional two week period. Blood and dialysate samples were procured at the beginning and the end of the dialysis, for iron, aluminum, transferin, ferritin, hemoglobin (Hb) and hematocrit (Htc) determination.

RESULTS

Iron, ferritin, transferin, Hb and Htc were decreased in the captopril-treated group 1. They similarly decreased in group 2 following replacement of ramipril by captopril for an additional period of two weeks. Significant amounts of iron were detected in dialysates of captopril, but not ramipril-treated patients. At the end of the dialysis, iron content was further increased in dialysates of the captopril-treated groups.

CONCLUSIONS

1) Captopril-chelated iron is eliminated in dialysis fluid during the dialysis session, apparently contributing to captopril-related anemia in patients on chronic hemodialysis. 2) Antihypertensive treatment with angiotensin converting enzyme (ACE) inhibitors other than captopril might prove advantageous for this patient category.

Risperidone, but not olanzapine, decreases bone mineral density in female premenopausal schizophrenia patients

BACKGROUND

The hyperprolactinemia induced by conventional antipsychotics often leads to osteoporosis. The commonly used atypical antipsychotics risperidone and olanzapine vary in their hyperprolactinemic properties. Therefore, we compared hormone profiles and bone properties in female premenopausal schizophrenia patients treated with either risperidone or olanzapine.

METHOD

In a cross-sectional study, consecutive premenopausal, female, DSM-IV schizophrenia patients who were treated with either risperidone (N = 12) or olanzapine (N = 14) for at least 2 years were included. Dual energy X-ray absorptiometry evaluated bone mineral density, and multisite quantitative ultrasound measured bone speed of sound. In addition, profiles of urinary excretion of deoxypyridinoline and circulating levels of hormones and lipids were assessed.

RESULTS

Serum prolactin levels were higher in the risperidone-treated group as compared with the olanzapine subjects (123 +/- 144 and 25.9 +/- 25.7, p <.05). Whereas bone mineral density was similar in the treatment groups, bone speed of sound was lower in the risperidone group as compared with the olanzapine-treated group. Expressed as age-adjusted Z score, bone speed of sound at the radius was -0.31 and 0.58, respectively, p <.05, and at the phalanx, -1.41 and 0.04, respectively, p <.05. The bone speed of sound in the risperidone-treated patients inversely correlated with urinary deoxypyridinoline excretion (r = 0.73, p <.05).

CONCLUSION

Risperidone treatment, as opposed to olanzapine, for female premenopausal schizophrenia results in hyperprolactinemia and clinically relevant decrease in bone mineral density. The calculated relative risk for fragility fracture of women treated with risperidone as compared to those treated with olanzapine is 1.78 when bone speed of sound was measured at the phalanx and 1.23 when measured at the radius.

[Coronary artery ectasia: a therapeutic dilemma]

Coronary artery ectasia (CAE) is an abnormal dilatation of the coronary artery wall. The growing number of coronary angiographies and other invasive cardiologic procedures increased the documented incidence of CAE. There is no consensus about the etiology, prognostic significance and morbidity related to this phenomenon. Atherosclerosis is most probably the main cause of primary or idiopathic ectasia. In addition, it is postulated that chronic exposure to vasodilatatory substances, and therapeutic angioplastic procedures may mediate secondary ectasia. CAE is associated with increased coronary morbidity such as coronary spasm, dissection and thrombus formation. However, its relative contribution to coronary morbidity remains unclear. This uncertainty underlies the current dispute regarding the appropriate management and treatment of patients with CAE. Further studies including prospective therapeutic trials are needed to provide answers to these pending complex questions.

Zn metabolism affects apoptosis rate and proliferative responsiveness of PBMC from patients on chronic hemodialysis

Patients with end-stage renal failure suffer from severe plasma trace metal deficiency that is not corrected by dialysis. Trace metals, including Zn(2+), are critical for cell differentiation and replication. Zn(2+)also plays important role in cell apoptosis. Both processes are known to be impaired in uremia. The present study was undertaken to evaluate the effect of Zn(2+) supplementation on apoptosis of cultured peripheral blood mononuclear cells (PBMC) from patients on chronic hemodialysis versus those from healthy control subjects, concomitantly with assessment of mitogen-induced cell proliferation. The results showed that (1) basal total cell-associated Zn(2+) was elevated in uremic PBMC, compared to normal controls (23.9 +/- 5.64 v 10.5 +/- 2.64 micromol/L/mg protein). The gap persisted following incubation in Zn(2+)-enriched medium (63.3 +/- 26.12 v 81.6 +/- 13.4 micromol/L/mg protein, P <.005). (2) Basal proliferative response to phytohemagglutinin (PHA) was significantly decreased in uremic PBMC compared to normal controls (12,000 +/- 1,560 cpm v 16,600 +/- 1,460 cpm, P <.01). Incubation of uremic PBMC in Zn(2+)-enriched medium improved their proliferative response to PHA, yielding counts per minute significantly higher compared to their normal counterparts (37,000 +/- 7,500 cpm v 22,000 +/- 3,000 cpm, P <.001). (3) Basal apoptosis rate in uremic PBMC was significantly elevated compared to normal control cells (7.6% v 2.6%, P <.05). Following incubation in Zn(2+)-enriched medium, apoptosis was increased both in normal and uremic PBMC. Percent apoptosis of uremic PBMC remained significantly elevated compared to control cells (11.7% v 5.7%). We conclude that uremic PBMC are more responsive to exogenous Zn(2+) in culture than their normal counterparts. This, among other abnormalities, might reflect an abnormal regulation of Zn(2+) transport by uremic mononuclear cell membranes. The resultant increase in total cell-associated Zn(2+) content improves poor proliferative responsiveness of uremic PBMC. On the other hand, increased total cell-associated Zn(2+) stimulates enhanced apoptosis in uremic PBMC, which, probably by eliminating defective cells, contributes to the functional capability of the population as a whole. The net effect of the 2 processes is still augmentation of cell proliferation.

The synapsins: beyond the regulation of neurotransmitter release

The synapsins are a family of five closely related neuron-specific phosphoproteins associated with the membranes of synaptic vesicles. The synapsins have been implicated in the regulation of neurotransmitter release. They tether synaptic vesicles to actin filaments in a phosphorylation-dependent manner, controlling the number of vesicles available for release at the nerve terminus. A growing body of evidence suggests that the synapsins play a broad role during neuronal development. They participate in the formation and maintenance of synaptic contacts among central neurons. In addition, each synapsin has a specific role during the elongation of undifferentiated processes and their posterior differentiation into axons and dendrites. In this review, we focus on these novel roles of synapsins during the early stages of development.

The role of the cerebellum in cognition and behavior: a selective review

The cerebellum has traditionally been seen primarily to coordinate voluntary movement, but evidence is accumulating that it may play a role in cognition and behavior as well. This is a selective review of studies assessing potential cognitive deficits and personality changes associated with cerebellar disease. Preliminary studies of the role of the cerebellum in schizophrenia, dementia, and other psychiatric disorders are also discussed. Efforts to understand the neurological substrates of behavior should consider the role of the cerebellum.