Effectiveness of a supervisor training on quality of feedback to internal medicine residents: a controlled longitudinal multicentre study

OBJECTIVES

High-quality feedback on different dimensions of competence is important for resident learning. Supervisors may need additional training and information to fulfil this demanding task. This study aimed to evaluate whether a short and simple training improves the quality of feedback residents receive from their clinical supervisors in daily practice.

DESIGN

Longitudinal quasi-experimental controlled study with a pretest/post-test design. We collected multiple premeasurements and postmeasurements for each supervisor over 2 years. A repeated measurements ANOVA was performed on the data.

SETTING

Internal medicine departments of seven Dutch teaching hospitals.

PARTICIPANTS

Internal medicine supervisors (n=181) and residents (n=192).

INTERVENTION

Half of the supervisors attended a short 2.5-hour training session during which they could practise giving feedback in a simulated setting using video fragments. Highly experienced internal medicine educators guided the group discussions about the feedback. The other half of the supervisors formed the control group and received no feedback training.

OUTCOME MEASURES

Residents rated the quality of supervisors' oral feedback with a previously validated questionnaire. Furthermore, the completeness of the supervisors' written feedback on evaluation forms was analysed.

RESULTS

The data showed a significant increase in the quality of feedback after the training F (1, 87)=6.76, p=0.04. This effect remained significant up to 6 months after the training session.

CONCLUSIONS

A short training session in which supervisors practise giving feedback in a simulated setting increases the quality of their feedback. This is a promising outcome since it is a feasible approach to faculty development.

Flash Glucose Monitoring in the Netherlands: Increased monitoring frequency is associated with improvement of glycemic parameters

AIMS

To evaluate the association between Flash Glucose Monitoring (FLASH) frequency and glycemic parameters during real-life circumstances in the Netherlands.

METHODS

Obtained glucose readings were de-identified and uploaded to a dedicated database when FLASH reading devices were connected to internet. Data between September 2014 and March 2020, comprising 16,331 analyzable readers (163,762 sensors) were analyzed. Scan rate per reader was determined and each reader was sorted into 20 equally sized rank ordered groups (n = 817 each).

RESULTS

Users performed a median of 11.5 [IQR 7.7-16.7] scans per day. Those in the lowest and highest ventiles scanned on average 3.7 and 40.0 times per day and had an eHbA1c of 8.6% (71 mmol/mol) and 6.9% (52 mmol/mol), respectively. Increasing scan rates were associated with more time in target range (3.9-10 mmol/L), less time in hyperglycemia (>10 mmol/L), and a lower standard deviation of glucose. An eHbA1c of 7.0% (53 mmol/mol) translated in approximately 65% time in target range, 30% time in hyperglycemia and 5% time in hypoglycemia (<3.9 mmol/L).

CONCLUSIONS

These outcomes among Dutch FLASH users suggest that with higher scan rate glycemic control improves.

The importance of contextual aspects in the care for patients with functional somatic symptoms

Functional somatic symptoms refer to physical symptoms that cannot be (bio) medically explained. The pattern or clustering of such symptoms may lead to functional syndromes like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, among many others. Since the underlying pathophysiology remains unknown, several explanatory models have been proposed, nearly all including social and psychological parameters. These models have stimulated effectiveness studies of several psychological and psychopharmacological therapies. While the evidence for their effectiveness is steadily growing, effect-sizes are at most moderate and many patients do not benefit. We hypothesize that the context in which interventions for functional somatic symptoms are delivered substantially influences their effectiveness. Although this hypothesis is in line with explanatory models of functional somatic symptoms, to our knowledge, studies primarily focusing on the influence of contextual aspects on treatment outcome are scarce. Contextual research in the field of somatic symptoms has (irrespective whether these symptoms can be medically explained or not), however, just begun and already yielded some valuable results. These findings can be organized according to Duranti's and Goodwin's theoretical approach to context in order to substantiate our hypothesis. Based on this approach, we categorized empirical findings in three contextual aspects, i.e. 1) the setting, 2) the behavioural environment, and 3) the language environment. Collectively, some support is found for the fact that early identification of patients with functional somatic symptoms, starting treatment as soon as possible, having a neat appearance and an organized office interior, a warm and friendly nonverbal approach and a language use without defensiveness are contextual parameters which enhance the assessment by the patient of the physician's competence to help. Nonetheless, in vivo studies addressing the most aspects, i.e. nonverbal behaviour and language, are needed for better understanding of these contextual aspect. Moreover, future research should address to what extent optimizing contextual aspects improve care for functional somatic symptoms.

Correction to: Sex differences in the association between plasma copeptin and incident type 2 diabetes: the Prevention of Renal and Vascular Endstage Disease (PREVEND) study

The values given for copeptin levels in men in quartiles 1 and 2 (Table 1) were incorrect, and should have read.

Point-of-care Ultrasound (PoCUS) for the internist in Acute Medicine: a uniform curriculum

The use of Point-of-care Ultrasound (PoCUS) is rapidly increasing in internal medicine as it is useful in the primary assessment of acutely ill internal medicine patients for enhanced diagnostics and resuscitation. PoCUS can be taught in a modular fashion including basic core applications and advanced applications which can be combined for a symptom-based approach. Several PoCUS curriculum guidelines, especially for emergency medicine, exist throughout the world but a clear Dutch guideline for internists has not been developed. In this review we propose 'core' ultrasound competencies for internists that may also be incorporated into the European Training Requirements Internal Medicine. We suggest the use of an Entrustable Professional Activities (EPA) competencybased training system with EPAs specifically designed for ultrasound.

Effects of intraperitoneal insulin versus subcutaneous insulin administration on sex hormone-binding globulin concentrations in patients with type 1 diabetes mellitus

AIMS

Elevated sex hormone-binding globulin (SHBG) concentrations have been described in patients with type 1 diabetes mellitus (T1DM), probably due to low portal insulin concentrations. We aimed to investigate whether the route of insulin administration, continuous intraperitoneal insulin infusion (CIPII), or subcutaneous (SC), influences SHBG concentrations among T1DM patients.

METHODS

Post hoc analysis of SHBG in samples derived from a randomized, open-labeled crossover trial was carried out in 20 T1DM patients: 50% males, mean age 43 (±13) years, diabetes duration 23 (±11) years, and hemoglobin A1c (HbA1c) 8.7 (±1.1) (72 (±12) mmol/mol). As secondary outcomes, testosterone, 17-β-estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were analyzed.

RESULTS

Estimated mean change in SHBG was -10.3nmol/L (95% CI: -17.4, -3.2) during CIPII and 3.7nmol/L (95% CI: -12.0, 4.6) during SC insulin treatment. Taking the effect of treatment order into account, the difference in SHBG between therapies was -6.6nmol/L (95% CI: -17.5, 4.3); -12.7nmol/L (95% CI: -25.1, -0.4) for males and -1.7nmol/L (95% CI: -24.6, 21.1) for females, respectively. Among males, SHBG and testosterone concentrations changed significantly during CIPII; -15.8nmol/L (95% CI: -24.2, -7.5) and -8.3nmol/L (95% CI: -14.4, -2.2), respectively. The difference between CIPII and SC insulin treatment was also significant for change in FSH 1.2U/L (95% CI: 0.1, 2.2) among males.

CONCLUSIONS

SHBG concentrations decreased significantly during CIPII treatment. Moreover, the difference in change between CIPII and SC insulin therapy was significant for SHBG and FSH among males. These findings support the hypothesis that portal insulin administration influences circulating SHBG and sex steroids.

Intraperitoneal versus subcutaneous insulin therapy in the treatment of type 1 diabetes mellitus

BACKGROUND

Continuous intraperitoneal insulin infusion (CIPII), a last-resort type 1 diabetes mellitus (T1DM) treatment, has only been investigated in small or controlled studies. We aimed to investigate glycaemia and quality of life (QoL) with CIPII versus subcutaneous (SC) insulin therapy during usual T1DM care.

METHODS

A prospective, observational case-control study. CIPII-treated cases were matched to SC controls. The primary endpoint was a non-inferiority assessment (pre-defined margin of -5.5 mmol÷mol) of the baseline adjusted difference in HbA1c between groups during a 26-week follow-up. Secondary outcomes included QoL, clinical and biochemical measurements.

RESULTS

In total, 183 patients were analysed (CIPII n = 39 and SC n = 144). The HbA1c difference between treatment groups was -3.0 mmol÷mol (95% CI -5.0, -1.0), being lower in the SC group. Patients using SC insulin therapy spent less percentage of time in hyperglycaemia (-9.3% (95% CI -15.8, -2.8)) and more in euglycaemia (6.9% (95% CI 1.2, 12.5) as compared with CIPII-treated patients. Besides a 3.6 U÷l (95% CI 1.2, 6.0) lower concentration of alanine aminotransferase with CIPII, no biochemical and clinical differences were present. Most QoL scores were lower at baseline among CIPII-treated patients. However, besides lower health status, there were no differences in the baseline-adjusted general and diabetes-specific QoL and treatment satisfaction.

CONCLUSION

Although patients using CIPII had a higher glycaemic profile compared with patients using SC insulin therapy, the HbA1c difference was non-inferior. Overall, health status was lower among CIPII-treated patients, although diabetes-specific QoL and treatment satisfaction was similar to subcutaneously treated patients.

Stressful life events and leukocyte telomere attrition in adulthood: a prospective population-based cohort study

BACKGROUND

Telomere attrition might be one of the mechanisms through which psychosocial stress leads to somatic disease. To date it is unknown if exposure to adverse life events in adulthood is associated with telomere shortening prospectively. In the current study we investigated whether life events are associated with shortening of telomere length (TL).

METHOD

Participants were 1094 adults (mean age 53.1, range 33-79 years) from the PREVEND cohort. Data were collected at baseline (T1) and at two follow-up visits after 4 years (T2) and 6 years (T3). Life events were assessed with an adjusted version of the List of Threatening Events (LTE). TL was measured by monochrome multiplex quantitative PCR at T1, T2, and T3. A linear mixed model was used to assess the effect of recent life events on TL prospectively. Multivariable regression analyses were performed to assess whether the lifetime life events score or the score of life events experienced before the age of 12 predicted TL cross-sectionally. All final models were adjusted for age, sex, body mass index, presence of chronic diseases, frequency of sports, smoking status, and level of education.

RESULTS

Recent life events significantly predicted telomere attrition prospectively (B = -0.031, p = 0.007). We were not able to demonstrate a significant cross-sectional relationship between the lifetime LTE score and TL. Nor did we find exposure to adverse life events before the age of 12 to be associated with TL in adulthood.

CONCLUSIONS

Exposure to recent adverse life events in adulthood is associated with telomere attrition prospectively.

Effects of adverse life events on heart rate variability, cortisol, and C-reactive protein

OBJECTIVE

Our objective was to assess whether self-reported adverse life events during childhood or over the lifespan are associated with altered activity of the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal axis (HPA axis), and the immune system.

METHOD

This study was performed in a population-based cohort of 1094 adults aged 33-79 years, 46.3% male, average age 53 (SD 11.4). Two waves of data were collected at a 2-year interval, enabling replication of the analyses. Cumulative exposure to adverse life events was assessed by means of the List of Threatening Experiences. ANS function was assessed by spectral analysis of heart rate variability in the high-frequency band (HRV-HF). HPA axis function was assessed by 24-h urinary free cortisol (24-h UFC) excretion. Inflammation was assessed by high-sensitive C-reactive protein (hsCRP).

RESULTS

Multiple linear regression analyses did not reveal any significant associations, with the exception of one significant negative association between the lifetime score of adverse life events and HRV-HF β = -0.028; P = 0.037 at baseline, but not at follow up 2 years later.

CONCLUSION

In a large population-based cohort, adverse life events were not consistently associated with HRV-HF, 24-h UFC or (hsCRP).

Report of a 7 year case-control study of continuous intraperitoneal insulin infusion and subcutaneous insulin therapy among patients with poorly controlled type 1 diabetes mellitus: favourable effects on hypoglycaemic episodes

AIMS

Continuous intraperitoneal insulin infusion (CIPII) is a last-resort treatment option for patients with type 1 diabetes mellitus (T1DM) who fail to reach adequate glycaemic control with subcutaneous (SC) insulin therapy. Aim was to compare the long-term effects of CIPII and SC insulin therapy among patients with T1DM in poor glycaemic control.

METHODS

Patients in which CIPII was initiated in 2006 were compared with a control group of T1DM patients who continued SC therapy. Linear mixed models were used to calculate differences between the baseline (2006) and final (2013) measurements within and between groups.

RESULTS

A total of 95 patients of which 21 were using CIPII and 74 using SC insulin were included. Within the CIPII group, the number of hypoglycaemic episodes decreased with -5 (95% CI -8 to -3) per 2 weeks while it remained stable among SC patients. Over time, only the number of hypoglycaemic episodes decreased more with CIPII as compared to SC insulin treatment (difference: -6 (95% CI -9 to -4)). There were no differences between treatment groups regarding clinical parameters and quality of life scores over time. Pump or catheter dysfunction led to ketoacidosis in 6 patients: 2 using CIPII and 4 SC insulin.

CONCLUSIONS

After 7 years of follow-up, there is a persistent decline of hypoglycaemic events among CIPII treated T1DM patients. Besides less hypoglycaemic episodes with CIPII therapy, there are no differences between long-term CIPII and SC insulin therapy.

Intraperitoneal insulin infusion: treatment option for type 1 diabetes resulting in beneficial endocrine effects beyond glycaemia

Continuous intraperitoneal insulin infusion (CIPII) is a treatment option for patients with type 1 diabetes mellitus who fail to reach adequate glycaemic control despite intensive subcutaneous (SC) insulin therapy. CIPII has clear advantages over SC insulin administration in terms of pharmacokinetic and pharmacodynamic properties and has been shown to improve glycaemic regulation. Due to the delivery of insulin predominantly in the portal vein, as opposed to systemically, CIPII offers a unique research model to investigate the effects of insulin on endocrine and metabolic parameters in vivo. The aim of the present article is to provide an overview of the literature with respect to the effects of CIPII on glucose management, quality of life, complications and costs, with additional focus on metabolic and endocrine aspects. Finally, future use and research objectives are discussed.

Sex specific association between carnosinase gene CNDP1 and cardiovascular mortality in patients with type 2 diabetes (ZODIAC-22)

INTRODUCTION

Homozygosity for a 5-leucine repeat (5L-5L) in the carnosinase gene (CNDP1) has been associated with a reduced prevalence of diabetic nephropathy in cross-sectional studies in patients with type 2 diabetes, particularly in women. Prospective studies on mortality are not available. This study investigated whether 5L-5L was associated with mortality and progression of renal function loss and to what extent this effect is modified by sex.

METHODS

In a prospective cohort of patients with type 2 diabetes, a Cox proportional hazard model was used to compare 5L-5L with other genotypes regarding (cardiovascular) mortality. Renal function slopes were obtained by within-individual linear regression of the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) equation, and were compared between 5L-5L and other genotypes.

RESULTS

871 patients were included (38% with 5L-5L). After 9.5 years of follow-up, hazards ratios (HR) for all-cause and cardiovascular mortality in 5L-5L versus other genotypes were 1.09 [95% confidence interval (CI) 0.88-1.36] and 1.12 (95% CI 0.79-1.58), respectively. There was a significant interaction between CNDP1 and sex for the association with cardiovascular mortality (p = 0.01), not for all-cause mortality (p = 0.32). Adjusted HR in 5L-5L for cardiovascular mortality was 0.69 (95% CI 0.39-1.23) in men and 1.77 (95% CI 1.12-2.81) in women. The slopes of eGFR-MDRD did not significantly differ between 5L-5L and other genotypes.

CONCLUSIONS

The association between CNDP1 and cardiovascular mortality was sex-specific, with a higher risk in women with 5L-5L genotype. CNDP1 was not associated with all-cause mortality or change in eGFR.

Current concepts in the management of diabetic nephropathy

Although much progress has been made in slowing the progression of diabetic nephropathy, renal dysfunction and development of end-stage renal disease (ESRD) remain major concerns in diabetes. In addition, diabetic patients with microalbuminuria have an increased cardiovascular mortality. Therefore, new treatment modalities or strategies are needed to prevent or slow the progression of diabetic nephropathy and prevent cardiovascular disease in diabetes. In this review we describe current concepts in pathophysiology, treatment goals and we discuss future developments in the treatment of diabetic nephropathy. Common risk factors for diabetic nephropathy and its progression are longer duration, poor glycaemic control, hypertension and the presence of albuminuria. Available treatment options, especially renin-angiotensin aldosterone system (RAAS) blockade, but also better blood pressure and blood glucose control, decrease the incidence of cardiovascular disease and renal disease in diabetes. It is important that treatment goals are tailored to the individual patient with individual treatment goals of glycaemic control and blood pressure, depending on age, type of diabetes and diabetes duration. Aggressive treatment of glucose control and blood pressure might not always be best practice for every patient. Since the proportion of ESRD due to diabetic nephropathy remains high, optimisation of RAAS blockade is advocated and can be achieved by adequate sodium restriction and/or diuretic treatment. Moreover, aldosterone blockade might be a valuable strategy, which has potency to slow the progression of diabetic renal disease. Other possible future interventions are under investigation, but large clinical trials have to be awaited to confirm the safety and efficacy of these drugs.

Educational disparities in mortality among patients with type 2 diabetes in The Netherlands (ZODIAC-23)

BACKGROUND

Relative mortality differences between educational level in mortality have been reported among diabetic as well as among non-diabetic subjects in Europe, but data on absolute differences are lacking. We studied the effect of educational disparities on mortality in a Dutch prospective cohort of type 2 diabetes mellitus (T2DM) patients.

METHODS

This study was part of the ZODIAC study, a prospective observational study of patients with T2DM. Data on educational level were first collected on 19 May 1998, and from this date on, 858 patients were included in 1998; educational level was known for 656 patients. Vital status was assessed in 2009. The relationship between mortality and educational level was studied using a Cox proportional hazard model, the relative index of inequality (RII), slope index of inequality (SII) and the population attributable risk (PAR). Educational level was divided into four categories; the highest educational level was used as reference.

RESULTS

After a median follow-up time of 9.7 years, 365 out of 858 patients had died. The hazard ratio of primary education for total mortality was 3.02 (95% CI 1.44-6.34). The RII was 2.85 (95% CI 1.21-6.67), the absolute difference in the risk for mortality (SII) was 384 deaths (95% CI 49-719) per 10,000 follow-up years. PAR for patients with the lowest level of education was 51.4%.

CONCLUSIONS

A low educational level had a higher impact on mortality than having a macrovascular complication. Given the substantial differences in mortality between educational levels in T2DM, more understanding of underlying (modifiable) mechanisms is necessary.

Binary ultrasonography for the internist: yes or no, that’s the question!

The authors discuss the pros and cons with regard to ultrasound for the internist. They state that ultrasonography is seldom used by internists and they suggest several reasons for this. After a brief review of the literature they conclude that using ultrasound would probably benefit patients and would lead to a more rapid diagnosis and an increase in safety while performing invasive diagnostic and therapeutic interventions. The authors suggest that internists use ultrasound in a different way compared with radiologists, cardiologists, etc. They introduce the term binary ultrasound: ultrasound should be used to answer clinical questions with a yes or a no.

What do professionals recommend regarding the frequency of self-monitoring of blood glucose?

BACKGROUND

Patients' adherence to guidelines regarding self-monitoring of blood glucose (SMBG) is limited. However, there are no previous reports about the recommendations that are given in clinical practice concerning SMBG. The aim of this study was to investigate what healthcare providers recommend to insulin-treated patients with diabetes regarding frequency and timing of SMBG.

METHODS

In this cross-sectional descriptive study, primary care assistants, diabetes specialised nurses and doctors in the Netherlands were invited via e-mail to complete an internet survey.

RESULTS

A total of 980 (14%) professionals returned the questionnaire. Insulin pump users and patients with type 1 diabetes (T1DM) on 4 injections a day were advised to perform SMBG daily by 96% and 63% of the professionals, respectively. The majority of the professionals advised these patients to perform 3-4 measurements per day. There was less agreement on the timing (pre- and÷or postprandial). Patients with type 2 diabetes (T2DM) on four injections were advised to perform SMBG less frequently. There was a wide variation in recommendations that were given to patients with T2DM on less intensive insulin regimens.

CONCLUSION

This study investigated SMBG from a professional's perspective. A considerable and relevant variation in the recommendations about the number and timing of SMBG was observed. The most striking differences were found in patients with T2DM on less intensive insulin regimes, also with respect to the frequency of SMBG. Well-designed studies are necessary in order to give a more evidence-based advice on the basic frequency and timing of SMBG.

Sex differences in the association between plasma copeptin and incident type 2 diabetes: the Prevention of Renal and Vascular Endstage Disease (PREVEND) study

AIMS/HYPOTHESIS

Vasopressin plays a role in osmoregulation, glucose homeostasis and inflammation. Therefore, plasma copeptin, the stable C-terminal portion of the precursor of vasopressin, has strong potential as a biomarker for the cardiometabolic syndrome and diabetes. Previous results were contradictory, which may be explained by differences between men and women in responsiveness of the vasopressin system. The aim of this study was to evaluate the usefulness of copeptin for prediction of future type 2 diabetes in men and women separately.

METHODS

From the Prevention of Renal and Vascular Endstage Disease (PREVEND) study, 4,063 women and 3,909 men without diabetes at baseline were included. A total of 208 women and 288 men developed diabetes during a median follow-up of 7.7 years.

RESULTS

In multivariable-adjusted models, we observed a stronger association of copeptin with risk of future diabetes in women (OR 1.49 [95% CI 1.24, 1.79]) than in men (OR 1.01 [95% CI 0.85, 1.19]) (p (interaction) < 0.01). The addition of copeptin to the Data from the Epidemiological Study on the Insulin Resistance Syndrome (DESIR) clinical model improved the discriminative value (C-statistic,+0.007, p = 0.02) and reclassification (integrated discrimination improvement [IDI] = 0.004, p < 0.01) in women. However, we observed no improvement in men. The additive value of copeptin in women was maintained when other independent predictors, such as glucose, high sensitivity C-reactive protein (hs-CRP) and 24 h urinary albumin excretion (UAE), were included in the model.

CONCLUSIONS/INTERPRETATION

The association of plasma copeptin with the risk of developing diabetes was stronger in women than in men. Plasma copeptin alone, and along with existing biomarkers (glucose, hs-CRP and UAE), significantly improved the risk prediction for diabetes in women.

Endogenous plasma erythropoietin, cardiovascular mortality and all-cause mortality in renal transplant recipients

Cardiovascular disease (CVD) is the main cause of mortality in renal transplant recipients (RTR). Classical factors only partly explain the excess risk. We hypothesized that high EPO--a marker for inflammation, angiogenesis and hypoxia--is associated with CVD in RTR. A total of 568 RTR (51±12 years; 45% female; creatinine clearance (CrCl) 57±20 mL/min/1.73 m(2)) were included at median 6 [IQR 3-11] years after transplantation. Subjects on exogenous EPO and ferritin-depleted subjects were excluded. Median EPO level was 17.3 [IQR 11.9-24.2] IU/L. Gender-stratified tertiles of age-corrected EPO were positively associated with waist circumference (but not BMI), CVD history, time since transplantation, diuretics, azathioprine, CRP, mean corpuscular volume and triglyceride levels, and inversely with CrCl, RAAS-inhibition, cyclosporine, hemoglobin, total- and HDL-cholesterol. During follow-up for 7 [6-7] years, 121 RTR (21%) died, 64 of cardiovascular (CV) causes. Higher EPO (per 10 IU/L) was associated with total (HR1.16 [1.04-1.29], p = 0.01) and CV mortality (HR1.22 [1.06-1.40], p = 0.005), independent of age, gender, hemoglobin, inflammation, renal function and Framingham risk factors. Thus, EPO and mortality are linked in RTR, independent of potential confounders. This suggests that yet other mechanisms are involved. Dissecting determinants of EPO in RTR may improve understanding of mechanisms behind excess CV risk in this population.

Coronary artery calcification score and carotid intima–media thickness in patients with hemophilia

BACKGROUND/OBJECTIVES

The traditional view that patients with hemophilia are protected against cardiovascular disease is under debate. The aim of the present study was to evaluate the presence and extent of atherosclerosis by coronary artery calcification score (CACS) and carotid intima media thickness (IMT) in patients with hemophilia, and to evaluate their cardiovascular risk profile.

METHODS

Sixty-nine patients (51 with hemophilia A; 18 with hemophilia B) were studied [median age: 52 years (interquartile range [IQR] 43–64)]. Cardiovascular risk factors and prior major adverse cardiovascular events (MACEs) were recorded. CACS was derived from electron-beam or dual-source computed tomography, and carotid IMT was assessed by ultrasound measurements and compared with age-specific reference values.

RESULTS

The median CACS in all patients was 35 (IQR 0–110) and the geometric mean IMT was 0.80 mm (95% confidence interval [CI] 0.76–0.84); neither was different from the reference values. Patients with a previous MACE (n = 9) had significantly higher CACS and IMT than patients without a previous MACE:CACS median 1013 (IQR 530–1306) vs. 0 (IQR 0–67), and IMT geometric mean 1.09 mm (95% CI 0.95–1.26) vs. 0.76 mm (95% CI 0.73–0.79), both P < 0.001. A higher calculated 10-year cardiovascular risk was related to higher IMT and CACS.

CONCLUSION

Patients with hemophilia are not protected against the development of atherosclerosis as measured by CACS and IMT. The extent of atherosclerosis is related to the traditional cardiovascular risk factors. This suggests that traditional cardiovascular risk factors should be monitored and treated in patients with hemophilia.

A polymorphism in the gene encoding carnosinase (CNDP1) as a predictor of mortality and progression from nephropathy to end-stage renal disease in type 1 diabetes mellitus

AIMS/HYPOTHESIS

Homozygosity for a five leucine repeat (5L-5L) in the carnosinase gene (CNDP1) has been found to be cross-sectionally associated with a low frequency of diabetic nephropathy (DN), mainly in type 2 diabetes. We prospectively investigated in patients with type 1 diabetes whether: (1) 5L-5L is associated with mortality; (2) there is an interaction of 5L-5L with DN or sex for prediction of mortality; and (3) 5L-5L is associated with progression to end-stage renal disease (ESRD).

METHODS

In this prospective study in white European patients with type 1 diabetes, individuals with DN were defined by persistent albuminuria ≥ 300 mg/24 h. Controls without nephropathy were defined by persistent (>15 years) normoalbuminuria < 30 mg/24 h. Leucine repeats were assessed with a fluorescent DNA analysis system. Onset of ESRD was defined by need to start chronic dialysis or kidney transplantation.

RESULTS

The study involved 916 patients with DN and 1,170 controls. During follow-up for 8.8 years, 107 patients (14%) with 5L-5L died compared with 182 patients (13.8%) with other genotypes (p = 0.99). There was no significant interaction of 5L-5L with DN for prediction of mortality (p = 0.57), but a trend towards interaction with sex (p = 0.08). In patients with DN, HR for ESRD in 5L-5L vs other genotypes was not constant over time, with increased risk for 5L-5L beyond 8 years of follow-up (p = 0.03).

CONCLUSIONS/INTERPRETATION

CNDP1 polymorphism was not associated with mortality, and nor was there an interaction of this polymorphism with DN for prediction of mortality in patients with type 1 diabetes. CNDP1 polymorphism predicts progression to ESRD in patients with DN, but only late after baseline measurements.

Autonomic dysfunction in diabetes: a consequence of cardiovascular damage

In 1976, D.J. Ewing showed a clear survival disadvantage for diabetic patients that had 'diabetic autonomic neuropathy', as assessed by heart rate and blood pressure variations during a battery of bedside tests. However, these variations do not solely depend on autonomic nervous system function, but also and possibly to a more important extent on the integrity of cardiovascular autonomic reflex loops. Increased intima media thickness at the site of the baroreceptors, reduced vascular distensibility, endothelial dysfunction and impaired cardiac function contribute to the cardiovascular autonomic dysfunction. Interestingly, these abnormalities are closely associated with the presence of (micro-) albuminuria that is regarded as a reflection of endothelial dysfunction or vascular damage in diabetes mellitus. Modern techniques to assess cardiovascular autonomic, vascular and cardiac function have improved the ability to detect early abnormalities. Analysis of heart rate variability, baroreflex sensitivity, muscle sympathetic nervous activity, LNMAinfusions and advanced echocardiography have shown that it is the interplay between autonomic control and cardiac and vascular properties that determines cardiovascular autonomic function. Moreover, these modern techniques have improved power to predict survival in diabetic patients in comparison with the classical Ewing's bedside tests. In conclusion, cardiovascular damage may be more important in cardiovascular autonomic dysfunction than neural function.

Self-monitoring of blood glucose in tablet-treated type 2 diabetic patients (ZODIAC)

BACKGROUND

Whether self-monitoring of blood glucose (SMBG) improves glycaemic control in patients with type 2 diabetes mellitus (T2DM) not using insulin is questionable. Our aim was to investigate the effects of SMBG in patients with T2DM who were in persistent moderate glycaemic control whilst not using insulin.

METHODS

Patients were eligible when between 18 and 70 years of age, with an HbA1c between 7 and 8.5%, using one or two oral blood glucose lowering agents. Forty-one of the anticipated 52 patients were randomly assigned to receive either SMBG added to usual care, or to continue with usual care for one year. A fasting glucose value and three postprandial glucose values were measured twice weekly (including a Saturday or a Sunday). The primary efficacy parameter was HbA1c. Furthermore, health-related quality of life and treatment satisfaction were assessed using the Short-form 36 Health Survey Questionnaire (SF-36), the Type 2 Diabetes Symptom Checklist (DSC-r), the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and the WHO -Wellbeing Index (WHO-5).

RESULTS

Change in HbA1c between groups was -0.05% (95% CI: -0.51, 0.41; p=0.507). Also, there were no significant changes between groups on the DTSQ , DSC type 2, WHO-5 or SF -36, except for the SF -36 dimension 'health change' which was lower in the SBMG group (mean difference: -12 (95% CI: -20.9, -3.1).

CONCLUSION

On top of the absence of a clinical benefit, tablet-treated T2DM patients experienced some worsening of their health perception. We therefore argue that the use of SMBG in this patient group is questionable, and its unlimited use and promotion should be reconsidered.

Markers of the hepatic component of the metabolic syndrome as predictors of mortality in renal transplant recipients

Cardiovascular disease (CVD) is a leading cause of mortality in renal transplant recipients (RTRs). Metabolic syndrome (MS) is highly prevalent in RTRs. Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic component of MS. We investigated associations of NAFLD markers with MS and mortality. RTRs were investigated between 2001 and 2003. NAFLD markers, alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and alkaline phosphatase (AP) were measured. Bone and nonbone fractions of AP were also determined. Death was recorded until August 2007. Six hundred and two RTRs were studied (age 52+/-12 years, 55% men). At baseline 388 RTRs had MS. Prevalence of MS was positively associated with liver enzymes. During follow-up for 5.3[4.5-5.7] years, 95 recipients died (49 cardiovascular). In univariate Cox regression analyses, GGT (HR=1.43[1.21-1.69], p<0.001) and AP (HR=1.34[1.11-1.63], p=0.003) were associated with mortality, whereas ALT was not. Similar associations were found for cardiovascular mortality. Adjustment for potential confounders, including MS, diabetes and traditional risk factors did not materially change these associations. Results for nonbone AP mirrored that for total AP. ALT, GGT and AP are associated with MS. Of these three enzymes, GGT and AP are associated with mortality, independent of MS. These findings suggest that GGT and AP are independently related to mortality in RTRs.

Periodontitis is characterized by elevated PAI-1 activity

OBJECTIVES

Periodontitis is a chronic infectious disease and has been associated with cardiovascular diseases (CVD). We investigated whether plasma levels of markers of a prothrombotic state were elevated in patients with periodontitis in comparison with healthy controls.

MATERIALS AND METHODS

Untreated patients with moderate (n=53) and severe periodontitis (n=38) and healthy controls (n=39) were recruited. Levels of von Willebrand factor (vWF), prothrombin fragment 1+2 (F1+2), plasminogen activator inhibitor-1 (PAI-1) activity and D-dimer were measured as markers of a prothrombotic state.

RESULTS

The erythrocyte sedimentation rate (ESR), plasma C-reactive protein (CRP) and leucocyte counts (WBC) were significantly higher in patients with periodontitis. No statistically significant difference was found among the three groups for vWF (p=0.264), F1+2 (p=0.295) and D-dimer (p=0.572). However, PAI-1 was clearly elevated in the severe periodontitis group (p=0.001), even after adjusting for potential confounding factors (p(adj)=0.004). Moreover, more patients than controls were having vWF and PAI-1 levels above the respective population medians.

CONCLUSIONS

In periodontitis, elevated levels of PAI-1 activity are observed compared with healthy controls. This may increase the potential for impaired fibrinolysis, a condition that results in a prothrombotic state. We suggest that this state, if left untreated, may contribute to an increased risk for CVD.

Treatment with Intramuscular Vascular Endothelial Growth Factor Gene Compared with Placebo for Patients with Diabetes Mellitus and Critical Limb Ischemia: A Double-Blind Randomized Trial

Despite advances in revascularization techniques, limb salvage and relief of pain cannot be achieved in many diabetic patients with diffuse peripheral vascular disease. Our objective was to determine the effect of intramuscular administration of phVEGF165 (vascular endothelial growth factor gene-carrying plasmid) on critical limb ischemia (CLI) compared with placebo (0.9% NaCl). A double-blind, placebo-controlled study was performed in 54 adult diabetic patients with CLI. The primary end point was the amputation rate at 100 days. Secondary end points were a 15% increase in pressure indices (ankle-to-brachial index and toe-to-brachial index), clinical improvement (skin, pain, and Quality of Life score), and safety. In patients (n=27) treated with placebo versus phVEGF165-treated patients (n=27) the following results were found: 6 amputations versus 3 (p=not significant [NS]); hemodynamic improvement in 1 versus 7 (p=0.05); improvement in skin ulcers, 0 versus 7 (p=0.01); decrease in pain, 2 versus 5 (p=NS); and overall, 3 versus 14 responding patients (p=0.003). No grade 3 or 4 adverse effects were seen in these patients. We conclude that this small, randomized gene therapy study failed to meet the primary objective of significant amputation reduction. However, significant and meaningful improvement was found in patients treated with a VEGF165-containing plasmid. There were no substantial adverse events.

[The diagnosis of pulmonary embolism based on clinical probability: D-dimer test and spiral CT]]

Recently, an algorithm encompassing a dichotomized clinical score, D-dimer and helical CT has proved to be a valid tool in confirming or rejecting a clinical diagnosis of pulmonary embolism. The diagnosis can be rejected in the context of low clinical suspicion and a negative D-dimer test. In all other situations the diagnostic accuracy of helical CT for the diagnosis of pulmonary embolism compares favourably with pulmonary angiography, with regard to the occurrence of recurrent venous thromboembolism or fatal pulmonary embolism if anticoagulation is withheld in cases of negative findings. For final diagnosis of pulmonary embolism, pulmonary angiography is only necessary if CT-scan results are suboptimal or inconclusive. This new algorithm may increase the compliance in general practice of applying guideline recommendations in patients in whom thromboembolic disease is suspected. However the proposed clinical score must first be validated for use in general practice.

Glucose and potassium derangements by glucose-insulin-potassium infusion in acute myocardial infarction

BACKGROUND

High-dose glucose-insulin-potassium infusion (GIK) has been suggested to be beneficial in acute myocardial infarction (MI). Recently new large trials have shown no effect of GIK on mortality. To investigate whether metabolic derangement could have negated the potential beneficial effect, we studied the relation between systemic glucose and potassium levels and outcome.

METHODS

Patients with signs and symptoms of ST-segment-elevation MI and treated with primary percutaneous coronary intervention (PCI) were randomised to no infusion or high-dose GIK, i.e. 80 mmol potassium chloride in 500 ml 20% glucose at a rate of 3 ml/kg/hour and 50 units short-acting insulin in 50 ml 0.9% sodium chloride for 12 hours.

RESULTS

A total of 6991 glucose values and 7198 potassium values were obtained in 476 GIK patients and 464 controls. Mean serum glucose was significantly higher in the GIK group (9.3±4.5 mmol/l vs. 8.4±2.9 mmol/l, p<0.001). Mean potassium level was significantly higher in the GIK group (4.2±0.5 mmol/l vs. 3.9±0.4 mmol/l, p<0.001). Incidence of hyperglycaemia (glucose >11.0 mmol/l) occurred in 70.8% of GIK patients and 33.8% of controls (p<0.001). Hypokalaemia was less common in the GIK group (23.5 vs. 41.2%, p<0.001). Incidence of hyperkalaemia and hypoglycaemia did not differ significantly between the two groups. In multivariate analysis age, previous cardiovascular disease, Killip class >1, unsuccessful PCI and mean glucose after admission were associated with increased one-year mortality.

CONCLUSION

In ST-segment-elevation MI patients treated with primary PCI, high-dose GIK induced hyperglycaemia and prevented hypokalaemia. Derangement of the glucose metabolism was related to one-year mortality.

The predictive value of renal vascular resistance for late renal allograft loss

The renal artery resistance index (RI), assessed by Doppler ultrasonography, was recently identified as a new risk marker for late renal allograft loss. This finding requires confirmation since RI in that study was not measured at predetermined time points and ultrasonography is operator-dependent. We investigated the predictive value of renal vascular resistance (RVR), a less operator-dependent method as assessed by mean arterial pressure divided by renal blood flow, for the prediction of recipient mortality and death-censored graft loss. RVR was compared to commonly used risk markers such as creatinine clearance (CrCl), serum creatinine (SCreat) and proteinuria (UProt) in 793 first-time cadaveric renal transplant recipients at predetermined time points after transplantation using receiver operating characteristics (ROC) and Cox survival analyses. The present study showed that RVR is a prominent risk marker for recipient mortality and death-censored graft loss. However, the predictive value of RVR for recipient mortality owed mainly to the impact of mean arterial blood pressure. In contrast, RVR constituted more than the sum of its components for death-censored graft loss, but showed less predictive value than SCreat in univariate analysis. As the assessment of RVR is expensive and time-consuming, we believe that RVR holds no clinical merit for the follow-up of renal transplant recipients.

[Prevention of contrast nephropathy; guidelines from the Department Nephrology of the University Medical Centre Groningen]

Contrast nephropathy' is commonly defined as an increase in serum creatinine concentration of more than 44 micromol/l or 25% of the reference value within 48 hours after administration of radiological contrast media. Risk factors are pre-existing renal dysfunction, diabetes mellitus, heart failure, paraproteinaemia, advanced age, use of nephrotoxic medication, intra-arterial use of contrast media and use of large volumes of contrast media. The only form of therapy possible is supportive care, such as renal function replacement therapy. Prevention of contrast nephropathy is of great importance. For patients with risk factors, the treatment of first choice is hydration with intravenous sodium chloride 0.9% combined with oral acetylcysteine given before and after the administration of contrast media.

[Clinical reasoning and decision-making in practice. A patient with shortness of breath and hyponatraemia]

A 61-year-old man with no significant medical history was referred by the general practitioner with progressive dyspnoea despite treatment with steroids and antibiotics. The patient had severe hyponatraemia. Eventually hypervolemic hyponatraemia due to ischemic cardiac failure was diagnosed. After recompensation by fluid restriction and lisdiuretics coronary bypass surgery was carried out. The patient was discharged free of symptoms. This case is a reminder that heart failure may not present itself in a classical manner but as hypervolemic hyponatraemia.

Reliability of assessment of adherence to an antimicrobial treatment guideline

Assessment procedures for adherence to a guideline must be reliable and credible. The aim of this study was to explore the reliability of assessment of adherence, taking account of the professional backgrounds of the observers. A secondary analysis explored the impact of case characteristics on assessment. Six observers (two hospital pharmacists, two internists and two clinical microbiologists) assessed a random sample of 22 prescriptions made to infectious disease cases admitted to a department of internal medicine between February and August 2001. Agreement between observers with regard to adherence of these prescriptions to guideline recommendations concerning drug choice, duration of treatment, dosage and route of administration was measured using Cohen's kappa. Case characteristics were compared between cases where observers agreed and disagreed with two-sided Fisher's exact test. Agreement between all professionals was moderate for drug choice (0.59), fair for duration of therapy (0.36), moderate for dosage (0.48), and fair for route of administration (0.37). Agreement on drug choice was good within (0.75 and 0.83) and between (0.74) the internists and the hospital pharmacists, but was less within (0.31) the clinical microbiologists and between the clinical microbiologists and the internists (0.44) and the hospital pharmacists (0.42). Within the clinical microbiologists, agreement was good for dosage (0.79) and route of administration (0.66). There was frequent disagreement between observers regarding cases with combination therapy and non-immunocompromised patients. Despite the small number of cases, our results suggest that internists and hospital pharmacists can reliably be used to assess adherence for drug choice. The level of agreement seems to be affected by combination therapy and the immune status of the patient.

Increased accumulation of skin advanced glycation end-products precedes and correlates with clinical manifestation of diabetic neuropathy

AIMS/HYPOTHESIS

The accumulation of AGE is related to the progression of the renal, retinal and vascular complications of diabetes. However, the relationship with diabetic neuropathy remains unclear. We recently showed that skin autofluorescence, measured non-invasively with an AutoFluorescence Reader (AFR), could be used to assess skin AGE accumulation. We evaluated the relationship between skin autofluorescence and the severity of diabetic neuropathy.

MATERIALS AND METHODS

Skin autofluorescence in arbitrary units (AU) was assessed in 24 diabetic patients with a history of neuropathic foot ulceration (NP(+)), 23 diabetic patients without clinical neuropathy (NP(-)) and 21 control subjects, using the AFR. Arterial occlusive disease was excluded in all. The severity of foot ulceration was assessed by the Wagner score. Peripheral nerve function was assessed by neurography, measuring motor and sensory nerve conduction velocity and amplitude of the median, peroneal and sural nerves. Heart rate variability (HRV) and baroreflex sensitivity (BRS) were measured by Finapres to assess autonomic nervous function.

RESULTS

Autofluorescence was increased in NP(-) compared with control subjects. In NP(+) patients, autofluorescence was further increased and correlated with the Wagner score. Autofluorescence correlated negatively with nerve conduction velocity and amplitude, HRV and BRS in both NP(+) and NP(-) groups. Autofluorescence correlated with age, diabetes duration, mean HbA(1)c of the previous year, serum creatinine level, presence of microalbuminuria and severity of diabetic retinopathy.

CONCLUSIONS/INTERPRETATION

Skin autofluorescence correlates with the severity of peripheral and autonomic nerve abnormalities in diabetes, even before being clinically manifest. The AFR may be a convenient and rapid clinical tool for assessing risk of progression of long-term diabetic complications.

[Clinical reasoning and decision-making in practice. A 31-year-old woman with transient monocular blindness and polycythaemia]

A 31-year-old woman presented with recurrent transient monocular blindness. As transient ischaemic attacks were suspected further investigations were targeted at evaluation of premature atherosclerotic lesions in the internal carotid artery. Initially laboratory tests were not performed. After referral to a cardiovascular-disease prevention outpatient clinic, laboratory evaluation disclosed a marked isolated polycythaemia that turned out to be secondary to right-left shunting through multiple pulmonary arteriovenous malformations. The ultimate diagnosis was hereditary haemorrhagic telangiectasia. Later on, physical signs such as telangiectasia and central cyanosis were noticed. In the clinical decision-making process, laboratory tests associated with causes of transient monocular visual loss were not carried out and therefore clues important for the ultimate diagnosis were not obtained. In only a minority of young patients with transient monocular visual loss can this be ascribed to premature atherosclerosis. For these reasons, a proper physical examination and laboratory tests directed towards other causes must be part of the initial diagnostic work-up in young patients with visual disturbances and suspected transient ischaemic attacks.

Circulating monocytes in patients with acute coronary syndromes lack sufficient interleukin-10 production after lipopolysaccharide stimulation

Acute coronary syndromes (ACS) are associated with inflammation resulting from monocyte activation. We sought for differences in the production of pro- and anti-inflammatory cytokines by monocytes from patients with ACS. C-reactive protein (CRP) and neopterin were measured in 22 patients with acute coronary syndromes, 50 patients with stable vascular disease and 22 healthy controls. Production of tumour necrosis factor (TNF)-alpha and interleukin (IL)-10 was determined after, respectively, 6 and 24 h of incubation of full blood with lipopolysaccharide (LPS). Levels of CRP [median, interquartile range (IQR)][1.5 mg/l (0.8-4.5) ACS patient versus 2.1 (0.9-3.6) stable disease versus 0.4 (0.3-1.2) healthy controls] (P < 0.001) and neopterin [7.4 nmol/l (6.0-8.7) ACS patient versus 7.1(6.0-8.9) stable disease versus 6.4 (5.6-7.3) healthy controls] (P = 0.07) were higher in both the patient groups. IL-10 production after LPS stimulation was greatly reduced in patients with acute coronary syndromes (16 175 pg/ml, 7559-28 470 pg/ml) as opposed to patients with stable disease (28 379 pg/ml, 12 601-73 968 pg/ml) and healthy controls (63 830 pg/ml, 22 040-168 000 pg/ml) (P = 0.003). TNF-alpha production was not signi fi cantly different between the groups [7313 pg/ml (4740-12 615) ACS patient versus 11 002 (5913-14 190) stable disease versus 8229 (5225-11 364) healthy controls] (P = 0.24). Circulating monocytes in unstable coronary syndromes produce equal amounts of TNF-alpha but less IL-10 after stimulation with LPS in vitro as compared with healthy controls. We hypothesize that, in acute coronary syndromes, the production proinflammatory cytokines is not counterbalanced by anti-inflammatory cytokines such as IL-10.

Do diabetologists recognise self-management problems in their patients?

OBJECTIVE

The aim of this study was to determine whether diabetologists recognise patients' needs for additional intensive multidisciplinary care due to glycaemic and diabetes-related psychosocial difficulties.

RESEARCH DESIGN AND METHODS

We compared 114 participants in a diabetes intervention programme with 201 as yet non-referred outpatients, of whom 54 outpatients were considered eligible for the intervention by their diabetologists; thus, 147 outpatients were considered non-eligible.

RESULTS

Analysis revealed that the eligible patients had poorer glycaemic control but all other parameters were similar to non-eligible patients. Significantly, 22 (15%) of the 147 non-eligible patients clearly had diabetes distress and could potentially benefit from the intervention.

CONCLUSION

The results suggest that in regular care, patients' needs with respect to glycaemic control are recognised by their diabetologists, but patients with high psychosocial diabetes-related distress are often overlooked, though they also may be in need of additional care. Integrated monitoring of diabetes-related distress in outpatients could improve this area of diabetes care.

Simple non-invasive assessment of advanced glycation endproduct accumulation

AIMS/HYPOTHESIS

The accumulation of AGE is thought to play a role in the pathogenesis of chronic complications of diabetes mellitus and renal failure. All current measurements of AGE accumulation require invasive sampling. We exploited the fact that several AGE exhibit autofluorescence to develop a non-invasive tool for measuring skin AGE accumulation, the Autofluorescence Reader (AFR). We validated its use by comparing the values obtained using the AFR with the AGE content measured in extracts from skin biopsies of diabetic and control subjects.

METHODS

Using the AFR with an excitation light source of 300-420 nm, fluorescence of the skin was measured at the arm and lower leg in 46 patients with diabetes (Type 1 and 2) and in 46 age- and sex-matched control subjects, the majority of whom were Caucasian. Autofluorescence was defined as the average fluorescence per nm over the entire emission spectrum (420-600 nm) as ratio of the average fluorescence per nm over the 300-420-nm range. Skin biopsies were obtained from the same site of the arm, and analysed for collagen-linked fluorescence (CLF) and specific AGE: pentosidine, N(epsilon)-(carboxymethyl)lysine (CML) and N(epsilon)-(carboxyethyl)lysine (CEL).

RESULTS

Autofluorescence correlated with CLF, pentosidine, CML, and CEL ( r=0.47-0.62, p</=0.002). In 32 of 46 diabetic patients (70%), autofluorescence values were above the 95% CI of the mean value in control subjects, and correlated with age, diabetes duration, mean HbA(1)c of the previous year and creatinine levels.

CONCLUSIONS/INTERPRETATION

The AFR offers a simple alternative to invasive measurement of AGE accumulation and, to date, has been validated in non-pigmented skin. The AFR may prove to be a useful clinical tool for rapid risk assessment of AGE-related long-term complications in diabetes mellitus and in other conditions associated with AGE accumulation.

Long Term Angiotensin Converting Enzyme-inhibition in Patients after Coronary Artery Bypass Grafting Reduces Levels of Soluble Intercellular Cell Adhesion Molecule-1

OBJECTIVE

to examine the effect of angiotensin converting enzyme inhibition (ACEI) on soluble intercellular adhesion molecule 1 (sICAM-1) and C-reactive protein (CRP) in patients requiring coronary artery bypass grafting (CABG).

METHOD

subgroup analysis of 42 patients randomised to Quinapril (40 mg daily determined) and 45 to placebo. sICAM-1 and CRP were > or = 4 weeks before and 1 year after surgery.

RESULTS

there was no difference in sICAM-1 at baseline (142.2 microg/L vs 136.6 microg/L). There was significant reduction in s-ICAM-1 in patients receiving quinapril (142.2+/-10.8 microg/L vs 125.6+/-9.4 microg/L, p<0.05) but not placebo (136.6+/-10.2 microg/L vs 131.2+/-11.7 microg/L, p=NS). Levels of C-reactive protein remained unchanged in both groups (3.70+/-0.85 vs 2.73+/-0.32 mg/L, 2.85+/-0.48 vs 3.16+/-0.50 mg/L).

CONCLUSIONS

ACEI reduces sICAM-1 in patients undergoing CABG. The benefits of ACEI may partly be due to a reduction of the vascular inflammatory response.

New developments in the treatment of hypertension: are some antihypertensives more equal than others?

In 2002, a major topic of discussion in the field of clinical hypertension was the efficacy of the various types of antihypertensive agents. The results of three large endpoint studies have recently been published and it was hoped that these would provide some answers. What could be concluded from their findings is that angiotensin II receptor (A II) antagonists can now also be allowed as initial treatment for uncomplicated essential hypertension. Thiazide diuretics remain the treatment of choice in patients with uncomplicated essential hypertension because of low costs. Recent trials suggest however, that agents that interfere in the renin-angiotensin system, such as ACE inhibitors and A II antagonists, may be superior in preventing end-organ damage. We therefore propose that subgroups of patients should be defined, in which specific agents should be preferentially used because of proven efficacy.

[Treatment of hypertension: angiotensin-II antagonists potentially better than beta-blockers in the occurrence of cardiovascular and cerebrovascular damage; the LIFE study in perspective]

Current clinical guidelines state that only beta-blockers, diuretics, calcium channel antagonists and ACE inhibitors should be used for initial pharmacotherapy for uncomplicated hypertension. On basis of experience, efficacy and costs beta-blockers and diuretics are first choice. However, the importance of the renin-angiotensin-aldosterone-system in the pathophysiology of hypertensive end-organ damage is increasingly recognised nowadays, and modulation of this system may therefore exert favourable effects on cardiovascular and cerebrovascular complications. In the LIFE study, a recently published double-blinded, randomised trial, the angiotensin-II receptor (A-II) antagonist losartan was compared with the beta-blocker atenolol in patients with essential hypertension and left ventricular hypertrophy (LVH). Patients randomised to the A-II antagonist suffered statistically significantly fewer clinical end-points, specifically fewer cerebrovascular accidents, whereas both treatments resulted in a similar decrease in blood pressure. In the subset of diabetic patients, the use of the A-II antagonist yielded an even more favourable outcome. In our opinion, it should now also be permitted to prescribe A-II antagonists as initial pharmacotherapy for patients with uncomplicated essential hypertension. It might be considered to prescribe A-II antagonists as preferred treatment for patients with essential hypertension and known LVH, especially in diabetic patients.

[Acute acalculous cholecystitis: not only in the intensive care department]

In two men aged 65 and 40 years with abdominal pain, the diagnosis 'acute acalculous cholecystitis' (AAC) could be reached only after exploratory laparotomy. The first patient was initially admitted to the coronary-care department because of known atherosclerotic vascular disease; he died a few days after the operation due to sepsis. The second patient recovered satisfactorily after admission to intensive care because of haemodynamic instability. AAC is an illness with a non-specific clinical presentation and incomplete radiologic imaging. AAC is more frequently seen in outpatients than in acutely ill inpatients, especially in older male patients who have atherosclerotic vascular disease. Diagnostic and therapeutic delay leads to gangrene, empyema and perforation, resulting in a high mortality. To improve the outcome, a high and early index of suspicion is needed. Hepatobiliary scintigraphy should be included in the diagnostic pathway.

[Clinical thinking and decision making in daily practice. An elderly man with hyponatremia]

An 88-year-old man presented with nausea and vomiting. Recently a cutaneous B-cell lymphoma had been diagnosed on his right cheek. Laboratory investigation showed hyponatraemia. Fluid restriction was started, based on the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). However the hyponatraemia persisted and a diagnosis of 'reset osmostat' was made. CT of the abdomen revealed slight bilateral adrenal enlargement, which was interpreted as adrenal incidentaloma. No other localisation of the lymphoma, besides that on the right cheek, was seen. Although the symptoms initially disappeared, they recurred and were quickly followed by hypotension. The patient died. Post-mortem examination showed bilateral destruction of the adrenal glands due to lymphoma. The correct diagnosis was Addison's disease. This case shows that diseases do not always present with all the classical symptoms, and that it is important to consider test characteristics of diagnostic tests and to judge investigations in the context of the other clinical findings.

Antineutrophil cytoplasmatic antibodies in patients with premature atherosclerosis: prevalence and association with risk factors

OBJECTIVES

Autoimmunity is suggested to play a role in premature atherosclerosis. Antineutrophil cytoplasmatic antibodies (ANCA) are a group of autoantibodies found in several inflammatory disorders in which they supposedly amplify the inflammatory process. In this study the hypothesis is tested that ANCA play a role in premature atherosclerosis.

DESIGN

Cross-sectional study followed by nested case-control study. In a total of 286 consecutive patients with premature atherosclerosis (age < 55 years) ANCA were tested. Within the same cohort, a nested case-control study in 16 ANCA-positive patients and 32 ANCA-negative controls matched for sex, and site of atherosclerosis, was executed.

SETTING

University hospital outpatient clinic for lipids and premature atherosclerosis.

SUBJECTS

A total of 286 consecutive patients with premature atherosclerosis (age < 55 years).

RESULTS

Prevalence of ANCA was 5.6% (16 of 286). All cases had perinuclear ANCA (pANCA); no cytoplasmatic ANCA was found. Mean age was 42 +/- 7 in the ANCA-positive vs. 42 +/- 9 years in the ANCA-negative group (P=ns). More female parents were ANCA-positive (8M/8F vs. 200M/70F, P=0.03). Patients with ANCA had more often peripheral vascular disease (37.5 vs. 15.2%, P=0.03). In the case-control study levels of Lp(a) were higher (43.8 vs. 15.6% >300 mg x L(-1), P=0.05), whereas levels of HDL-c were lower in ANCA-positive patients (0.84 +/- 0.26 vs. 1.06 +/- 0.27 mmol x L(-1), P=0.01). Markers of inflammation, C-reactive protein (CRP) and serum amyloid A (SAA), did not differ, nor did antibodies against oxidized-LDL and malondialdehyde (MDA)-LDL, markers for the extent of atherosclerosis.

CONCLUSIONS

Our results suggest that ANCA do not appear to play a major role in premature atherosclerosis as there was no increased prevalence of the autoantibody. Moreover, no differences in the incidence of classical cardiovascular risk factors nor in serum levels of markers of inflammation were found between the ANCA-positive group as compared with the ANCA-negative group.