Risk factors for type 2 diabetes in women attending menopause clinics in Italy: a cross-sectional study

OBJECTIVE

To analyze risk factors for type 2 diabetes among women attending menopause clinics in Italy for counselling about the menopause.

SUBJECTS

Women attending a network of first-level outpatient menopause clinics in Italy for general counselling about menopause or treatment of menopausal symptoms.

METHODS

Cross-sectional study with no exclusion criteria. Type 2 diabetes was defined according to National Diabetes Data Groups Indications and the fasting blood glucose at an oral glucose tolerance test within the previous year.

RESULTS

Out of the 44 694 considered in this analysis, 808 had a diagnosis of diabetes type 2 (1.8%). In comparison with women aged < 50 years, the multivariate odds ratios (OR) of type 2 diabetes were 1.31 (95% confidence interval (CI), 0.99-1.74) for women aged 50-52 years, 1.66 (95% CI, 1.27-2.17) at 53-56 years and 2.84 (95% CI, 2.20-3.67) in women aged > or = 57 years. Type 2 diabetes was less frequently reported in more educated women (OR high school/university vs. primary school = 0.44 (95% CI, 0.36-0.55)). Being overweight was associated with an increased risk of type 2 diabetes. In comparison with women reporting a low level of physical activity, the multivariate OR of type 2 diabetes was 0.67 (95% CI, 0.54-0.84) for women reporting regular physical activity. In comparison with premenopausal women, the multivariate OR of type 2 diabetes was 1.38 (95% CI, 1.03-1.84) in women with natural menopause. This finding was present also after allowing for the potential confounding effect of age. The multivariate OR of diabetes for users of hormonal replacement therapy was 0.58 (95% CI, 0.46-0.73).

CONCLUSIONS

This large cross-sectional study suggests that postmenopausal women are at higher risk of type 2 diabetes after allowance for the effect of age. Other main determinants of risk of type 2 diabetes in women around menopause were low socioeconomic status and being overweight. Diabetes was found less frequently in those taking hormone replacement therapy.

Factors associated with climacteric symptoms in women around menopause attending menopause clinics in Italy

OBJECTIVE

To obtain data on correlates of climacteric symptoms in women around menopause attending menopause clinics in Italy.

METHODS

Since 1997 a large cross sectional study has been conducted on the characteristics of women around menopause attending a network of first level menopause outpatient's clinics in Italy. A total of 66,501 (mean age 54.4 years) women are considered in the present paper.

RESULTS

The odds ratios of moderate and severe hot flashes/night sweats were lower in more educated women and (for severe symptoms only) in women reporting regular physical activity. Depression, difficulty to sleep, forgetfulness and irritability tended to be less frequent in more educated women and (depression only) in women reporting regular physical activity. Parous women reported more frequently these symptoms.

CONCLUSIONS

This large study confirms in Southern European population that low education, body mass index and low physical activity are associated with climacteric symptoms. Parous women are at greater risk of psychological symptoms.

Methods of determining plasma and tissue binding of drugs. Pharmacokinetic consequences

The available techniques for the investigation of drug binding to plasma and tissues protein are reviewed and the advantages and disadvantages of the various techniques stated. A comparison of different plasma protein binding techniques is made which shows that the size of the unbound fraction of drug may be influenced by the method used. Protein binding may be assayed by methods including equilibrium dialysis, ultrafiltration, ultracentrifugation, gel filtration, binding to albumin microspheres and circular dichroism. Tissue binding techniques can involve testing binding to isolated organs, tissue slices, homogenates and isolated subcellular particles. Details of the available methods to compute pharmacokinetic constants are given. Stereoselective binding has been investigated for a limited number of drugs and the difference in the binding of 2 enantiomers is usually modest. The measurement of the binding constants is often required to characterise the drug-protein interaction. Mathematical and graphical methods to compute the pharmacokinetic parameters are discussed. The implications of binding on the volume of distribution and clearance of drugs are examined.

Interindividual variability in the concentrations of albumin and alpha-1-acid glycoprotein in patients with renal or liver disease, newborns and healthy subjects: implications for binding of drugs

The concentrations of human plasma albumin (HPA) and alpha-1-acid glycoprotein (AAG) were measured in the serum obtained from 84 healthy subjects, 56 umbilical cords, 41 patients with renal failure, 65 patients maintained on chronic hemodialysis and 46 patients with liver cirrhosis. Severity of liver dysfunction was assessed with the use of Pugh et al. [1973] classification. Of the cirrhotic patients, 12, 22 and 12 patients were classified as mild, moderate and severe liver dysfunction, respectively. The coefficient of variation of AAG was greater than HPA in all groups of subjects, and the variability of HPA and AAG is increased in patients compared to healthy subjects. As the liver dysfunction progresses, HPA concentration decreases whereas, the average AAG concentration is not changed in mild, moderate and severe liver dysfunction. The coefficients of variation for HPA and AAG in moderate and severe liver disease is over twice those for healthy subjects. The concentration of HPA is normally distributed in all groups of subjects, with the exception of the cord serum. The frequency distribution of AAG was normal in healthy subjects whereas, it was asymmetric, being positively skewed, in newborn, in renal and liver patients. The wide interindividual variability and the not-normal frequency distribution of AAG in liver or renal patients make its mean of little value in defining a group. Neither HPA nor AAG correlated with the clearance of creatinine in renal patients. In liver disease, HPA and AAG did not correlate with GPT and GOT activities, prothrombinic activity and bilirubin concentration. HPA did not correlate with AAG in any group.

The effect of ageing on plasma albumin and plasma protein binding of diazepam, salicylic acid and digitoxin in healthy subjects and patients with renal impairment

1. Plasma albumin concentration was measured in 118 healthy subjects (aged between 18 and 87 years), in 95 renal patients with creatinine clearances between 15 and 50 ml min-1 (aged between 14 and 79 years) and in 101 uraemic patients maintained on chronic haemodialysis (aged between 27 and 83 years). 2. There was a significant (P less than 0.001) negative correlation between albumin concentration and age in healthy subjects, but no correlation in patients with low creatinine clearance or in uraemic patients. 3. The ex vivo plasma binding of diazepam (1 microM), salicylic acid (2 mM) and digitoxin (37 nM) was studied in groups of age-selected young and aged healthy subjects in patients with low creatinine clearance and in patients with uraemia. The unbound fractions of diazepam and salicylic acid were about double in old compared with young healthy subjects whereas they were similar in young and old patients with lowered creatinine clearance. In uraemic patients, ageing did not affect the binding of salicylic acid whereas the unbound fraction of diazepam was slightly but significantly greater in elderly subjects. The unbound fraction of digitoxin was independent of age in both healthy subjects and in those with renal disease. 4. Decreased plasma binding of diazepam and salicylic acid was partially corrected by extensive dialysis of plasma. The lower plasma binding of diazepam and salicylic acid associated with ageing may be ascribed to the effects of endogenous displacers and to hypoalbuminaemia. The influence of these two factors appears to be drug-dependent.

Binding of diazepam, salicylic acid and digitoxin to albumin isolated from fetal and adult serum

Albumin was isolated from pooled fetal serum obtained at normal delivery at term and from pooled adult plasma. Albumin isolation was carried out by means of PEG precipitation followed by ion exchange chromatography on DEAE-Sephadex A 50 and then on SP-Sephadex C 50. The binding of diazepam (1 microM), salicylic acid (2 mM) and digitoxin (6 nM) to albumin (40 g/l) was measured by equilibrium dialysis at 37 degrees C. The unbound fraction (mean +/- SD) for fetal and adult albumin of diazepam was 1.86 +/- 0.24 and 1.82 +/- 0.15% (NS), that of digitoxin was 3.18 +/- 0.27 and 3.36 +/- 0.04% (NS) and that of salicylic acid was 11.65 +/- 0.99 and 9.47 +/- 0.75% (p less than 0.05), respectively. With both fetal and adult albumin, a single class of binding sites was observed for diazepam and digitoxin, whereas two classes of binding sites were observed for salicylic acid. The number of binding sites (n, moles of drug per mole of albumin) for fetal and adult albumin was 0.83 and 1.02 for diazepam and 0.014 and 0.018 for digitoxin, respectively. For salicylic acid, n was 1.45 (fetal albumin) and 1.55 (adult albumin) for the higher affinity site, and 3.06 (fetal albumin) and 3.27 (adult albumin) for the lower affinity site. The association constant (Ka, M-1) for diazepam was 1.36 x 10(5) (fetal albumin) and 1.00 x 10(5) (adult albumin) and that for digitoxin was 4.12 x 10(6) (fetal albumin) and 2.7 x 10(6) (adult albumin). For salicylic acid, Ka was 38.4 x 10(3) (fetal albumin) and 35.8 x 10(3) (adult albumin) for the higher affinity site, and 2.7 x 10(3) (fetal albumin) and 4.3 x 10(3) (adult albumin) for the lower affinity site. This work shows that fetal and adult albumin have similar binding properties and corroborates our previous findings with furosemide.

Conservative surgical treatment in infertile patients with endometriosis

In the period 1985-1988 23 infertile patients with pelvic endometriosis underwent conservative surgery with microsurgical technique. 8.7% (only 2 women) of the patients were in 2nd stage, 43.5% in 3rd stage and 47.8% in 4th stage of the American Fertility Society classification (1985). Associated pathology was found in 52.2% of the patients. Surgical techniques and results are presented. We obtained 13 (56.5%) full term pregnancies. The postoperative birth rate was 50% in 2nd stage, 80% in 3rd stage and 36.4% in 4th stage. Associated pathology was present in 69.2% of pregnant patients. Ten women (43.5) did not conceive: 10% were at 2nd, 20% at 3rd and 70% at 4th stage. Associated disease was present in 30% of women that did not become pregnant.

Conjugation pathways in liver disease

1. The activities of microsomal glucuronyltransferase and thiomethyltransferase, and those of cytosolic sulphotransferase, acetyltransferase, glutathione transferase and thiomethyltransferase were measured in abnormal (cirrhosis and chronic hepatitis) and normal livers. 2. Glucuronyltransferase and sulphotransferase were investigated with 2-naphthol and ethinyloestradiol as substrates. p-Aminobenzoic acid, benzo(a)pyrene-4,5-epoxide and 2-mercaptoethanol were the substrates of acetyltransferase, glutathione transferase and thiomethyltransferase, respectively. 3. Enzyme activities are expressed as nmol min-1 incubation mg-1 protein and the averages (+/- s.d.) are given. With 2-naphthol as substrate, the glucuronyltransferase activity was 6.55 +/- 4.10 (abnormal liver, n = 33) and 7.81 +/- 4.02 (normal liver, n = 26) (NS); whereas sulphotransferase activity was 0.28 +/- 0.18 (abnormal liver, n = 35) and 0.68 +/- 0.43 (normal liver, n = 26) (P less than 0.01). Glucuronyltransferase activity towards ethinyloestradiol was 102.5 +/- 56.9 (abnormal liver, n = 30) and 107 +/- 59.9 (normal liver, n = 26) (NS), whereas sulphotransferase activity was 57.2 +/- 36.0 (abnormal liver, n = 35) and 122 +/- 67.6 (normal liver, n = 28) (P less than 0.01). Acetyltransferase activity was 0.84 +/- 0.83 (abnormal liver, n = 35) and 3.84 +/- 1.65 (normal liver, n = 26) (P less than 0.01). Glutathione transferase activity was 0.83 +/- 0.68 (abnormal liver, n = 35) and 2.90 +/- 1.59 (normal liver, n = 25) (P less than 0.01) and thiomethyltransferase activity was 1.00 +/- 0.69 (abnormal liver, n = 34) and 3.99 +/- 1.49 (normal liver, n = 25) (P less than 0.01). 4. Liver disease lowers the activities towards the substrates studied of sulphotransferase, acetyltransferase, glutathionetransferase and thiomethyltransferase but not that of glucuronyltransferase.(ABSTRACT TRUNCATED AT 250 WORDS)

Human brain sulphotransferase and glucuronyltransferase

The activities of cytosolic sulphotransferase (ST) and microsomal glucuronyltransferase (GT) were measured with 1-naphthol as the substrate in three frontal cortex, three temporal cortex, one parietal cortex, one occipital cortex and two cerebellar cortex specimens from human brain. The average activity was 11.7 +/- 4.2 pmol/min/mg protein/(ST) and 26.8 +/- 13.6 pmol/min/mg protein (GT). The kinetics of ST were studied varying the concentration of 1-naphthol in five brain specimens (temporal cortex, temporal subcortex, occipital cortex, cerebellum cortex and frontal cortex) whereas those of GT were studied in a sample obtained by pooling the microsomal fractions from the following eight brain tissues: one frontal cortex, four temporal cortex, one parietal cortex and two cerebellar cortex specimens. The Km of the first and second enzyme was 1.55 +/- 0.47 microM (mean +/- s.d.) and 121 microM, respectively. The Vmax values were 13.70 +/- 8.16 (mean +/- s.d.) pmol/min/mg protein (ST) and 103 pmol/min/mg protein (GT). Vmax/Km was ten times higher for ST than GT. These data suggest that ST is the predominant pathway at low concentrations of 1-naphthol whereas at higher concentrations, GT becomes the predominant pathway.

Plasma protein binding of frusemide in liver disease: effect of hypoalbuminaemia and hyperbilirubinaemia

The binding of frusemide was studied in the plasma of 20 healthy subjects and 45 patients with liver disease. The unbound percentage (mean +/- s.d.) of frusemide was 1.64 +/- 0.21 healthy subjects) and 2.24 +/- 0.79 (patients) (P less than 0.01). By grouping the patients on the basis of plasma albuminaemia and bilirubinaemia four clusters namely: 'normal concentrations of albumin and bilirubin' (A), 'hyperbilirubinaemia and normal albumin concentration' (B), 'hypoalbuminaemia and normal bilirubin concentration' (C) and 'hypoalbuminaemia and hyperbilirubinaemia' (D) were defined. The unbound percentage of frusemide was 1.80 +/- 0.36 in (A); 2.44 +/- 1.05 in (B); 2.23 +/- 0.38 in (C); 2.76 +/- 0.77 in (D). The figure for healthy volunteers was not different from A, whereas it was significantly lower than those for B and D (P less than 0.01) and for C (P less than 0.05). A lowered binding of frusemide was associated with hypoalbuminaemia or hyperbilirubinaemia.

Plasma protein binding of ethinyloestradiol: effect of disease and interaction with drugs

The protein binding of ethinyloestradiol (EE2) was investigated in the plasma from 14 healthy volunteers, 10 patients with hyperbilirubinemia, 10 patients with liver cirrhosis and 10 patients with renal failure. Binding assay was performed by equilibrium dialysis at 37 degrees C. The unbound fraction (mean +/- SD) of EE2 was 1.17 +/- 0.12 (volunteers), 2.74 +/- 0.77 (hyperbilirubinemics; p less than 0.001) 1.51 +/- 0.31 (cirrhotics; p less than 0.01) and 1.44 +/- 0.11 (renal failure; p less than 0.001). Studies with isolated albumin and alpha-1-acid glycoprotein showed that albumin is the major plasma protein to bind EE2. Warfarin (75 microM) and diazepam (75 microM) increased by 5.0% and 3.0%, respectively, the unbound fraction of EE2 when albumin concentration was 15 microM. Under similar conditions, digitoxin did not modify the binding of EE2. At therapeutic concentrations, warfarin and diazepam did not affect the binding of EE2 in plasma.

Plasma protein binding of alpidem in healthy volunteers, in neonates and in liver or renal insufficiency

The binding of alpidem, a new anxiolytic drug, has been studied in plasma from 6 healthy subjects, 12 patients with renal failure, 12 patients with liver cirrhosis and 12 chronic uraemics maintained on haemodialysis, as well as in 12 serum samples from the placental cord, to represent the situation in the newborn. The unbound fraction was 0.61% (healthy volunteers), 1.31% (newborns), 0.86% (cirrhotic patients), 0.72 (patients with renal failure), 0.70% (before haemodialysis) and 0.79% (after haemodialysis). Binding in the volunteers was significantly different from that in neonates and cirrhotics only. Alpidem became bound to isolated albumin (45 g.l-1) and alpha 1-acid glycoprotein (0.75 g.l-1) to 97.2% and 97.1%, respectively. The bound fraction of the drug in a mixture of two proteins was 99.1%. For alpidem, it appears that alpha 1-acid glycoprotein may balance the effect of any decrease in the albumin concentration.

Profile of drug-metabolizing enzymes in the cortex and medulla of the human kidney

The cortex and medulla were isolated from kidneys whose donors (5 men and 1 woman, aged between 44 and 68 years) were undergoing nephrectomy to remove a tumor. Kidneys with normal architecture for at least two thirds of the organ were included in the study. Tissue specimens used in our experiments were free from pathological changes. The activities of the following enzymes of phase I NADPH cytochrome c reductase, aminopyrine N-demethylase, ethoxycoumarin O-deethylase, ethoxyresorufin O-deethylase, microsomal and cytosolic epoxide hydrolases, glutathione reductase and glutathione peroxidase, and those of the following enzymes of phase II glutathione transferase, glucuronyl transferase, sulphotransferase, acetyltransferase, thiomethyltransferase, thiopurinemethyltransferase, thioltransferase and glyoxalase were measured. The activity in renal cortex was significantly higher than in medulla for NADPH cytochrome c reductase, cytosolic epoxide hydrolase, glutathione reductase and glutathione peroxidase (phase I enzymes), and glutathione transferase, acetyltransferase, thiomethyltransferase, thiopurinemethyltransferase, thioltransferase and glyoxalase (phase II enzymes). The other enzymes had similar activity in cortex and medulla. The distribution pattern of drug-metabolizing enzymes in the human kidney cannot be considered as a single pattern because of the observed enzyme-dependent differences between cortex and medulla.

Uterine fibromyoma and sterility: role of myomectomy

The role of abdominal myomectomy with regard to surgical technique, subsequent conception and term pregnancy was evaluated. Of 30 patients undergoing myomectomy 13 conceived and 10 had a good pregnancy. It should be noted that 10 of 30 patients considered in this study had a leiomyomas associated disease, representing another cause of infertility. Thus, a preoperative evaluation of the reproductive capability of the couple would allow a selection of patients who are to undergo myomectomy resulting in a better pregnancy rate. In the present series, the ages of the patients and the size of the leiomyomas did not significantly influence the pregnancy rate. The most important correlation with subsequent fertility was the duration of infertility prior to myomectomy. The general principles of reproductive microsurgery should be kept in mind when performing myomectomy.

Plasma protein binding of zolpidem in liver and renal insufficiency

Similar degree (65-66%) of binding of zolpidem (0.1 microgram/ml) was found with physiological concentrations of isolated human albumin (40 g/l) or alpha-1-acid glycoprotein (1 g/l). Zolpidem binding was studied in plasma from 6 healthy subjects, 12 patients with renal failure, 12 patients with liver cirrhosis and 12 chronic uremics maintained on hemodialysis as well as in 12 serum samples from the placental cord. The unbound fraction (mean +/- s.e.m.) was 8.1 +/- 0.2% (healthy volunteers), 10.8 +/- 0.4% (renal failure), 11.3 +/- 0.7% (liver cirrhosis); 14.9 +/- 1.0% (before hemodialysis); 9.8 +/- 0.4% (after hemodialysis) and 13.2 +/- 0.9% (placental cord). All values, except those after hemodialysis, were significantly different (Dunnett's test) from those of the volunteers. Hemodialysis significantly increased the binding of zolpidem in plasma. The kinetics of protein binding of zolpidem were investigated in plasma samples from 3 healthy subjects. The average number of binding sites was 1.83 x 10(-7) mol per gram protein and the average association constant was 4.49 x 10(5) M-1.

Plasma protein binding of clonazepam in hepatic and renal insufficiency and after hemodialysis

The plasma protein binding of clonazepam was investigated in healthy volunteers, cirrhotic patients, chronic uremic patients maintained on hemodialysis, and patients with reduced renal function. Each group consisted of six subjects. The unbound fraction of clonazepam (mean +/- SEM) was 13.9 +/- 0.2% in volunteers. 17.1 +/- 1.0% in cirrhotic patients, 1.56 +/- 0.5% before and 12.2 +/- 0.4% after hemodialysis in chronic uremic patients, and 16.0 +/- 0.7% in patients with poor renal function. The figure for the healthy subjects was significantly different from that of cirrhotic patients only. Binding of clonazepam to albumin and alpha 1-acid glycoprotein was also studied. Clonazepam bound preferentially to albumin.

Plasma protein binding of dicloxacillin: effects of age and diseases

Dicloxacillin protein binding was investigated in sera from 10 umbilical cords, 20 children (aged between 2 and 21 months) and in the plasma from 8 healthy young subjects, 7 healthy elderlies, 10 patients with liver cirrhosis, 10 patients with renal failure (glomerulonephritis) and 10 chronic uremics maintained on hemodialysis. The percentage unbound fraction (mean +/- SD) of dicloxacillin was 7.3 +/- 0.8 (healthy subjects), 9.8 +/- 0.6 (umbilical cords), 7.4 +/- 2.8 (children), 8.8 +/- 1.0 (elderlies), 11.8 +/- 6.3 (cirrhosis), 10.5 +/- 2.0 (renal failure), 12.7 +/- 2.0 (before hemodialysis) and 11.7 +/- 2.1 (after hemodialysis). Healthy subjects were different from all the groups (0.001 greater than p greater than 0.05) except children (p greater than 0.5) (Student's t-test). Human isolated albumin (45 g/l) bound dicloxacillin at the same degree as the plasma of healthy subjects. The kinetics of dicloxacillin protein binding was studied in three umbilical cord serum, three adult plasma specimens and in human serum albumin. The number of binding sites (n) and the association constant (k) were estimated by Lineweaver-Burk double reciprocal plot.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum protein binding of furosemide in newborn infants and children

The protein binding of furosemide was studied in the serum from 8 umbilical cords, in 51 children (aged between 2 weeks and 13.5 years) and in the plasma of 10 volunteers (aged between 28 and 42 years). The drug was added to the buffer to give a final concentration of 2 micrograms/ml. The unbound fraction of furosemide was 2.5 +/- 0.1% (cord serum) and 1.7 +/- 0.7% (adult plasma). These figures are different at a level of 0.001. The unbound fraction of furosemide reached the adult values during the 1st year of life. A correlation (level of significance greater than 0.01) was found between the unbound fraction and the age during the first 6 months of life. The furosemide binding kinetics were studied in 3 cord serum and in 3 adult plasma samples. The concentration of the drug in the buffer ranged between 1 and 16 micrograms/ml. The kinetic constants (mean +/- SEM) were: association constant (K = 10(5) M-1) 2.4 +/- 0.3 (cord serum), 2.0 +/- 0.2 (adult plasma); the number of binding sites per gram protein (n = 10(-6] was 3.2 +/- 0.5 (cord serum) and 3.9 +/- 0.7 (adult plasma). When the concentration of furosemide was increased up to 200 micrograms/ml buffer, the free fraction of the drug increased up to 4.8 +/- 0.2% (cord serum) and 2.9 +/- 0.4% (adult plasma).

Plasma protein binding of furosemide in the elderly

The protein binding of furosemide was investigated in plasma from 22 old and 11 young subjects by equilibrium dialysis. The unbound fraction of furosemide was 3.16% in plasma from the elderly and 1.7% in plasma from the young. A significant correlation was found between the unbound fraction of furosemide and the plasma concentration of albumin. The average number of binding sites was 3.8 (elderly) and 2.7 (young) 10(-6) mol/g albumin. The average association constant (K) was 4.3 (elderly) and 4.2 (young) 10(5) M-1. By increasing the concentration of furosemide up to 200 micrograms/ml buffer the unbound fraction of the drug rose to 5.2% (elderly) and 3.5% (young).

Effects of development, aging, and renal and hepatic insufficiency as well as hemodialysis on the plasma concentrations of albumin and alpha 1-acid glycoprotein: implications for binding of drugs

The concentrations of total proteins, albumin, alpha 1-acid glycoprotein (AGP), and nonesterified fatty acids (NEFA) were measured in the serum of 21 newborn infants and 13 children, aged 1-13 months, and in the plasma of 31 volunteers, 25 patients with renal failure, 27 patients with cirrhosis, 39 uremic patients undergoing hemodialysis, and 20 elderly subjects. The concentration of albumin in the volunteers was higher than in all other groups. The concentration of AGP in the volunteers was higher than in newborn infants but lower than in elderly subjects, patients with renal failure, and those with chronic uremia. The concentration of NEFA in volunteers was higher than in newborn infants and patients with renal failure and lower than in elderly subjects and patients with cirrhosis.