Clinical Briefs

By Louis Kuritzky, MD

Incidence of Diabetes in Middle-Aged Men is Related to Sleep Disturbances

The consequences of sleep deprivation, as measured in otherwise healthy men, include elevations of sympathetic activity, increased levels of cortisol, and altered glucose metabolism. Although sleep abnormalities such as sleep apnea have been associated with cardiovascular risk, less information is available to describe the association of sleep disturbances and diabetes.

Study subjects comprised male participants in the Malmo Preventive Project (n = 22,444) originally enrolled from 1974 to 1984, and then followed for a mean of 15 years. Sleep disturbances were solicited by querying: "Do you have difficulties in falling asleep?" and, "Do you generally use sleeping pills more than 3 times a week?"

At baseline, 9.3% of subjects answered affirmatively to one of the sleep disturbance questions (Group 1); 2.4% answered affirmatively to both questions (Group 2). At followup, the percentage of individuals who ultimately developed diabetes was statistically significantly greater in Group 1 vs control (15.3% vs 9.1%, P < 0.005) and Group 2 vs control. (4.6% vs 2.3%, P < 0.034).

These data support the concept that sleep disturbance is linked not only with vascular pathology, but with long-term likelihood of the development of diabetes.

Nillson PM, et al. Diabetes Care. 2004; 27(10):2464-2469.

Renal Dysfunction and Cardiovascular Outcomes after Myocardial Infarction

Although marked alteration in renal function can be anticipated to compromise lifespan, whether less substantial decrements in renal function are associated with adverse outcomes, particularly cardiovascular, is not well defined. Renal failure doubles the risk of mortal myocardial infarction when compared with MI in the general population without kidney disease.

VALIANT (Valsartan in Acute Myocardial Infarction Trial) studied adults (n = 14,527) with a recent MI complicated by CHF, excluding those with a baseline creatinine > 2.5. Subjects were randomized to valsartan, captopril, or both and followed for a mean of 2 years.

One third of subjects met National Kidney Foundation guidelines for chronic kidney disease (GFR < 60 mL/min). As soon as the GFR fell to 80 mL/min or less, every GFR reduction of 10 units was associated with a 10% increase hazard for death and nonfatal cardiovascular events.

Although overt renal insufficiency often prompts clinician intervention, these data support more vigilance for even mild-moderate decline in GFR. Relying upon simple elevation of creatinine to identify persons at risk may not be sufficient. Clinicians are encouraged to calculate a GFR for at-risk persons.

Anavekar NG, et al. N Engl J Med. 2004;351:1285-1295.

Topical Treatments for Psoriasis

The prevalence of psoriasis (PSR) in the US adult population is as high as 3%, usually beginning during adolescence. Although there is no available cure for PSR, most patients can enjoy disease control with topical agents, phototherapy, or systemic treatment.

Initial treatment of PSR is dictated by severity and degree of surface area involvement. In persons with less than 5% total body surface involvement, topical treatments (steroids, vitamin D analogs, coal tar, retinoids, and anthralin) are all considered appropriate and effective. More severe disease, which will generally require specialist consultation, is treated with UV B light, psoralen plus UV A light, oral retinoids, or methotrexate (especially if PSR is coincident with psoriatic arthritis). The most commonly used topicals are steroids and calcipotriene.

Generally, steroids have been found to be superior to calcipotriene ointment, but combining therapies has been found more efficacious than either therapy alone.

Anthralin and tazarotene (a topical retinoid) also are effective for treatment of PSR. Because the administration of these two medications is more complex and associated with adverse local effects, they are more likely to be utilized in specialty settings. Coal tar topically has been shown to be statistically significantly effective, but cosmetic disadvantages limit its use to patients who have failed or been in tolerant of other agents.

Mikhail M, Scheinfeld N. Adv Stud Med. 2004;4(8):420-429.

Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.