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

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

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.

Renal Dysfunction and Cardiovascular Outcomes after Myocardial Infarction

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

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.

Topical Treatments for Psoriasis

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

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.

Induction of Long-term Glycemic Control in Newly Diagnosed Type 2 Diabetic Patients is Associated with Improvement of Beta-Cell Function

Source: Li Y, et al. Diabetes Care. 2004;27:2597-2602.

Type 2 diabetes (DM2) is characterized by insulin resistance accompanied by a progressive decline in beta cell function (BCF). Sustained supranormal glucose levels appear to further impair BCF, a process labeled glucotoxicity. Insufficient insulin production also favors lipolysis, which results in lipotoxicity from accumulation of excess fatty acids. Initial data has supported the concept that early intensive glycemic control may truncate glucotoxicity, potentially preserving BCF.

In an attempt to clarify the role of early intensive glycemic control, newly diagnosed DM2 patients (n = 126) were treated with insulin by means of an insulin pump on an inpatient basis for two weeks, after which they were discharged. Subsequent to discharge patients were managed with diet only, and were monitored at 3, 6, 12, and 24 months. Ten percent of subjects, despite attempts at intensive glycemic control, failed to achieve excellent control, and were considered therapeutic failures, and dropped from followup and analysis.

Impressive numbers of patients were able to maintain near-euglycemia on diet alone at months 3 (73%), 6 (67%), 12 (47%), and 24 (42%). This persistent restoration of diet-controllable euglycemia is generally interpreted to indicate a restoration of BCF. No particular baseline characteristics (eg, pretreatment FBS, A1C, and BMI) predicted which persons would be most likely to maintain euglycemia after intensive glucose control. Whether intervention with oral agents leads to similar restoration of BCF remains to be elucidated.

Predicting Bacterial Cause in Infectious Conjunctivitis

Source: Rietveld RP, et al. BMJ USA. 2004;4:511-514.

Only about half of acute conjunctivitis cases are bacteriaI. At presentation, it is often unclear whether patients are suffering acute bacterial conjunctivitis (ABC), or acute viral conjunctivitis (AVC). Since antibiotics are not of value in AVC, distinguishing the two entities is highly relevant. In the face of diagnostic uncertainty, most patients (approximately 80%) receive antibiotics.

Study subjects comprised patients (n = 184) from general practice settings in the Netherlands. Inclusion criteria required evidence of conjunctivitis and either purulent discharge or signs of lid adhesion, designated glued eyes. All subjects underwent conjunctival cultures.

A variety of clinical markers were assessed to determine predictive value for ABC, including fever, allergy history, distribution of erythema, edema, characteristics of secretions, bilaterality, itching, foreign body sensation, burning, and glued eyes. Multivariate analysis indicated that 3 determinants—history of conjunctivitis, itch, and presence of glued eyes-predicted ABC. Glued eyes was a positive predictor (5 points for both eyes, 2 points for one), whereas history of conjunctivitis (-2 points), and itch (-1 point) were negative predictors. A total score of +2 or greater, if used as the cutoff for initiating antibiotics, would be an appropriate threshold for treatment, and would improve upon current practice of antibiotic utilization.

Angiotensin-Receptor Blockade vs Converting-Enzyme Inhibition in Type 2 Diabetes and Nephropathy

Source: Barnett AH, et al. N Engl J Med. 2004;351:1952-1961.

The most common etiology of end-stage renal disease remains type 2 diabetes (DM2). Since it is possible to reverse (in the case of diabetic microalbuminuria) or delay (in the case of frank diabetic nephropathy) deterioration of renal function by means of good blood pressure control and/or modulation of the rennin-angiotensin-aldosterone system, clinicians continually seek evidence based guidance about best therapeutic choices.

This prospective double blind study randomized patients (n = 250) with early nephropathy to either an ARB (telmisartan 80 mg/d) or ACE inhibitor (enalapril 20 mg/d). End points included decline in renal function, rates of end-stage renal disease, cardiovascular events, and mortality.

At the end of 5 years, telmisartan was found to be not inferior to enalapril for the primary study end point (decline in renal function); similarly, for all other pre-defined end points, there was no demonstrable statistically significant difference between the treatments. This information strengthens the support for the equivalence of ACE and ARB in addressing preservation of renal function in diabetes. Preference for either class of agent may depend upon cost, tolerability, or effectiveness for other therapeutic targets, since both drugs performed equally well.