Office management of cardiac disease in the diabetic.

Atherosclerotic vascular disease is very common in diabetic patients. It often occurs at an earlier age and is more severe than in nondiabetic individuals. The medical management of cardiac disease in diabetics is much the same as in nondiabetics. Risk factors such as obesity, hypertension, and hyperlipidemia must be vigorously treated, and smoking should be restricted.     

Cardiovascular and alcohol-related deaths in abnormal glucose tolerant and diabetic subjects

Summary The aim of this study was to compare the causes of death and parameters related to alcohol consumption, between subjects diagnosed as diabetic, clinically by their general practitioner, or glucose intolerant and in particular as diabetic, using the epidemiological criteria of an abnormal glucose level following an oral glucose tolerance test. The subjects in this study were 7035 working men, aged between 44 and 55 years, who attended the first follow-up examination of the Paris Prospective Study, between 1968 and 1973. They were classified as clinically diagnosed diabetic or, following an oral glucose tolerance test and the World Health Organisation criteria, as having oral glucose tolerance test diagnosed diabetes, impaired glucose tolerance or normoglycaemia. The relative risk of death by cirrhosis, in comparison with the normoglycaemic group, was 21 (95 % confidence interval: 9.1–49) in the group diagnosed diabetic by the oral glucose tolerance test, significantly different (p < 0.02) from the group diagnosed diabetic clinically 3.1 (0.41–24); factors indicative of excessive alcohol consumption at baseline differed accordingly. In contrast, the relative risks for death by coronary heart disease were similar, 2.1 (1.0–4.1) and 2.7 (1.4–5.4) respectively; all of the factors defining the insulin resistance Syndrome X (hyperglycaemia, hyperinsulinaemia, hypertension, hyperlipidaemia and also central obesity) and predictive of coronary heart disease were elevated in both groups of diabetic subjects. Diabetes, as diagnosed by the oral glucose tolerance test, might be the consequence of excessive alcohol consumption which could lead to insulin resistance, then to coronary heart disease, as well as to alcohol-related diseases.     

Unexplained deaths of type 1 diabetic patients.

The suggestion of an increase in the number of sudden deaths of young people with Type 1 diabetes in the UK has been investigated. It was suggested that such deaths were due to hypoglycaemia and related to the increasing use of human insulin. In total we were notified of 50 deaths of people with Type 1 diabetes under age 50 years in the UK in 1989 which our informants (relatives, physicians, and pathologists) considered sudden and unexpected. An autopsy had been done in all cases and we supplemented this with detailed clinical information from relatives and case records. Of the 50 cases we excluded five with a definite cause of death, 11 suicides or self-poisonings, six cases of ketoacidosis, and four in which there was insufficient information about the circumstances of death to drawn any conclusions. Of the other 24 cases, two patients had been found with irreversible hypoglycaemic brain damage and died after a period of artificial ventilation. The most puzzling group were 22, aged 12-43 years, most of whom had gone to bed in apparently good health and been found dead in the morning. Nineteen of the 22 were sleeping alone at the time of death and 20 were found lying in an undisturbed bed. Most had uncomplicated diabetes and in none were anatomical lesions found at autopsy. There are major difficulties in diagnosing hypoglycaemia post-mortem, but the timing of death and other circumstantial evidence suggests that hypoglycaemia or a hypoglycaemia-associated event was responsible. All patients were taking human insulin at the time of death but most had been changed from animal insulin between 6 months and 2 years earlier and there was nothing to implicate the species of insulin as a factor in these deaths.     

Drug Abuse in the Medical Profession: Addict Doctors and the Home Office

Drug abuse and alcoholism by medical practitioners raises special issues of their fitness to practice and of medical discipline. This paper explores the issue of drug abuse by medical practitioners, using the information about addict doctors kept by the Home Office Drugs Branch. The addict doctors found in this study were most often discovered through police activity, had often been convicted for drug offences, had appeared on disciplinary charges before the General Medical Council, and suffered severe occupational consequences.     

Painful diabetic neuropathy--providing the best patient service

Painful diabetic neuropathy is just one of a myriad of secondary conditions that may result from poor glycaemic control. Educating the patient to suspect diabetic complications, understanding why they may occur, what their progression is likely to be and what measures can be taken to avoid them can significantly improve outcomes. Education within the diabetes management framework needs to be consistent, prioritised, tailored to the needs of each patient and ongoing in order to be maximally effective, with tight glycaemic control playing the anchoring central role. The specialist diabetes nurse is in the ideal situation to coordinate this education and to ensure that the patient with diabetes receives the care and support needed to take dual responsibility for their condition.     

糖尿病患者住院费用分析

应用总后勤部卫生部规范化的病历管理软件对306医院2000至2004年所有的住院糖尿病患者2794例的资料进行分析.与2000年的费用相比,2001至2004年的总费用分别增长了5%、26%、47%和80%,药费增长了17%、19%、47%和96%,检查费用增长了5%、29%、56%和92%.与无合并症的糖尿病患者相比,糖尿病合并脑梗死时的住院总费用、药费以及检查费分别增加了1.01、1.14和1.10倍;合并高血压时分别增加了1.16、1.37和1.12倍;合并胆囊炎和(或)胆结石时分别增加了1.24、1.11和1.18倍.     

Autonomic neuropathy,QT interval lengthening,and unexpected deaths in male diabetic patients

Summary QT intervals were measured over RR intervals ranging from 500 ms to 1000 ms in 13 normal male subjects, 13 male diabetic subjects without and 13 with autonomic neuropathy. There was a close linear relationship between QT and RR in all subjects. The slope of the regression line was significantly greater in the autonomic neuropathy group than the normal group. Thirty-two male diabetic subjects with varying degrees of autonomic dysfunction had repeat QT measurements 3 (range 2–6) years later. QT and QTC lengthened significantly at the second visit, unrelated to age or time between recordings, but which corresponded with changes in autonomic function. Of 71 male diabetic subjects under 60 years followed for 3 years, 13 had died, 8 unexpectedly. Of those with autonomic neuropathy, QT and QTC were significantly longer in those who subsequently died, despite similar ages and duration of diabetes. We conclude that QT/RR interval relationships are altered in diabetic autonomic neuropathy, and that changes in QT length with time parallel changese in autonomic function. There may be an association between QT interval prolongation and the risk of dying unexpectedly in diabetic autonomic neuropathy.     

Medical management of diabetic retinopathy.

Although current treatment and prevention of diabetic retinopathy with laser photocoagulation, and tight metabolic and blood pressure control has reduced the risk of visual loss, there is still a need for additional therapies. A literature review on medical therapies for diabetic retinopathy has been performed, and the following classes of drugs are discussed: blockers of the renin-angiotensin system, protein kinase C-beta inhibitors, glitazones, somatostatin analogues, lipid-lowering drugs and anti-inflammatory drugs. There is experimental and clinical data suggesting beneficial effect from several classes of drugs on diabetic retinopathy, and results from large clinical trials are awaited within the next 3-4 years.     

An epidemiologic and histopathological study of sudden cardiac death in Osaka Medical Examiner's Office

From 1982 to 1986, 1230 sudden death cases were autopsied in Osaka Medical Examiner's Office. Among them, 810 cases were sudden cardiac deaths (SCD) including coronary heart disease (77%), cardiomyopathy (7%), valvular disease (3%). All SCD cases were dead within 24 hours of the appearance of the fatal symptoms, and most of them (72%) were considered instantaneous death. Many of the fatal symptoms began in bed (31%), at bath (17%), at toilet (8%), or at work (8%). Thirty-four percent of them were thought by themselves or by their families to be healthy before the death. Hypertension (38%), coronary heart disease (13%) and diabetes mellitus (11%) were the major past history recorded. Microscopic observation of the hearts of 200 cases autopsied in 1986 showed various cardiac lesions: hypertrophy, atrophy, degenerations of myocytes, cellular and fatty infiltrations of the interstitium. According to their cardiac lesions and degrees of severity of coronary sclerosis, patients who died suddenly were divided into 8 groups as follows: 1. myocardial infarction (41) 2. myocarditis (6) 3. hypertrophic cardiomyopathy (19) 4. chronic ischemia with severe coronary sclerosis (65) 5. chronic ischemia with moderate coronary sclerosis (27) 6. small vessel disease (18) 7. amyloidosis (1) 8. unknown (23). These results suggest that coronary heart disease and hypertension play an important role in SCD.     

A district screening and treatment service for diabetic retinopathy

A District Screening and Treatment Service for diabetic retinopathy using diabetic clinic staff is described. From 1978 to 1984 a total of 1195 diabetics entered the screening programme in a district with a population of 136 700. From 1982, when laser treatment became available locally, the average number of patients from the district requiring treatment for the first time per year was 14.0 for proliferative retinopathy and 11.3 for maculopathy. The laser was also used to treat patients from two other districts and the results of treatment from all three districts are reported. Regression of new vessels was achieved in 86% of 72 patients with proliferative retinopathy but 12 of these were also seen at the regional eye centre. Visual acuity was the same or better in 79% of the 104 eyes in 76 patients treated for maculopathy. Effective treatment can be given by a trained hospital practitioner at district level. This reduces demands on the regional centre but good liaison is necessary for difficult cases.     

Increased sickness absence in diabetic employees: what is the role of co‐morbid conditions?

AIMS: Diabetes is thought to be associated with increased risk of sickness absence in working populations. We examined the contribution of co-morbidity to this association. METHODS: Records of physician-certified sickness absence episodes (> 3 days) over a 1-year period were obtained from employers' records after a survey of chronic diseases and risk factors in 638 diabetic and 32 510 non-diabetic public sector employees in Finland (the Public Sector Study). RESULTS: Diabetic employees had a 2.15-fold (95% confidence interval 1.92-2.40) age- and sex-adjusted excess risk of sickness absence compared with their colleagues with no chronic disease. In absolute terms, diabetes was related to 59 extra absence episodes per 100 person years. Of this excess risk, 55% was attributable to co-occurring non-cardiovascular diseases, such as depression, prolapsed intervertebral disc and bronchitis. The contribution of cardiovascular complications to the excess sickness absence was small (7%). CONCLUSIONS: In this occupational cohort, the excess risk of sickness absence in diabetic employees was largely accounted for by non-cardiovascular co-morbidity. Intervening multiple chronic conditions may be important in programmes to reduce sickness absence in diabetic employees.     

四个地市耐多药肺结核医疗服务包费用分析

目的 制定标准化耐多药肺结核医疗服务包,为推广耐多药肺结核免费医疗政策提供依据。方法 采用专家会议头脑风暴法建立耐多药肺结核医疗服务包,服务包包括七大类服务项目,分别为诊断、住院前检查、住院治疗、出院后随访检查、心理支持、并发症和不良反应处理、患者督导,并根据重庆市、呼和浩特市、开封市和连云港市的定点医疗机构、结核病防治机构和社区卫生服务机构的2010年各项医疗服务及药品实际价格,分析医疗服务包费用。 结果 耐多药肺结核患者全疗程医疗服务包治疗费用均值为32 617元,在各服务类别的费用中,最高的为药品费用,平均为13 722元,占平均总费用的42.07％(13 722/32 617)。在各机构的费用中,最高的为地市级定点医院费用,平均费用为26 527元,占平均总费用的81.33％(26 527/32 617)。按耐多药肺结核患者全疗程24个月,分别统计各月份费用,费用最高的是需要住院治疗的第1个月和第2个月,第1个月的平均费用为5879元,占总费用的18.02％（5879/32 617）,第2个月的平均费用为2651元,占总费用的8.13％（2651/32 617）。 结论 耐多药肺结核医疗服务包主要用于规范医疗服务行为,限制医疗费用的支出,对于全国推广规范化耐多药肺结核治疗管理工作有参考作用。