Unawareness of hypoglycaemia in insulin-treated diabetic patients: prevalence and relationship to autonomic neuropathy

Three-hundred and two insulin-treated diabetic patients were questioned about hypoglycaemia using a structured questionnaire interview. Two-hundred and twenty-six patients (75%) had normal symptomatic awareness, 48 (16%) had partial awareness, 21 (7%) had absent awareness of hypoglycaemia, and 7 (2%) denied ever experiencing hypoglycaemia. Patients with complete loss of awareness of hypoglycaemia had diabetes of longer duration; none had a HbA1 concentration within the non-diabetic range. Loss of awareness of hypoglycaemia was associated with an increased incidence of severe hypoglycaemia, 19 (91%) of the patients with absent awareness, and 33 (69%) with partial awareness of hypoglycaemia experiencing severe hypoglycaemia over 1 year compared with only 41 (18%) of patients with normal awareness of hypoglycaemia (p less than 0.001). Cardiovascular autonomic function tests were performed in 226 (75% of the whole group). Of the patients who had diabetes for more than 15 years, 54% (n = 39) with normal awareness of hypoglycaemia, compared with 59% (n = 10) with absent awareness of hypoglycaemia, had evidence of cardiovascular autonomic impairment (NS). Seven (41%) of the 17 patients with absent awareness of hypoglycaemia and diabetes of greater than 15 years duration had no evidence of autonomic dysfunction. Loss of hypoglycaemia awareness is a common problem in patients with insulin-treated diabetes of long duration, is associated with an increased incidence of severe hypoglycaemia, but is not invariably associated with abnormal cardiovascular autonomic function tests.     

Helicobacter pylori infection in diabetic patients: prevalence and endoscopic findings

BACKGROUND: In patients with diabetes mellitus, chronic infections are frequent and severe, due to the impairment of their immune status. However, data on the prevalence of Helicobacter pylori (H. pylori) infection in diabetics are scanty and contradictory. The aim of our study was to assess the prevalence of H. pylori infection in diabetic patients and to evaluate the association between endoscopic features and H. pylori colonization of the gastric mucosa in diabetes mellitus. METHODS: A cross-sectional study of 172 dyspeptic patients (67 diabetics and 105 nondiabetic subjects) was designed. In all cases, an upper gastrointestinal endoscopy was performed, gastroduodenal lesions were noted, and the presence of gastritis and H. pylori was assessed by histopathological examination. Differences between diabetic patients and nondiabetic subjects were evaluated. RESULTS: The difference of H. pylori prevalence between diabetics (37.3%) and nondiabetics (35.2%) was not significant (P=0.78). Nor did the prevalence of gastritis and peptic ulcer differ significantly between the two groups (59.7% vs. 49.5%, P=0.19; and 32.8% vs. 40.9%, P=0.08, respectively). Studying only H. pylori-positive patients, we found no difference between diabetics and nondiabetics with regard to the prevalence of either gastritis (80% vs. 72.9%, P=0.71) or peptic ulcer (91.8% vs. 76%, P=0.09). CONCLUSIONS: Our data do not support an association between H. pylori infection and diabetes mellitus. This is confirmed by the lack of difference between diabetics and nondiabetics with regard to the prevalence of both H. pylori infection and H. pylori-related gastroduodenal disorders.     

Prevalence of functional dyspepsia and its relationship with Helicobacter pylori infection in a Japanese population

AIM: To investigate the prevalence of functional dyspepsia and Helicobacter pylori infection and their relationship in a Japanese population. METHODS: Two thousand five hundred people who visited Shimane Institute of Health Science for their annual medical check-up from September 1998 to August 1999 were prospectively enrolled in the study. After routine medical examination, including an upper gastrointestinal study and an ultrasonographic examination, all subjects were asked standard questions to check for the presence of any symptoms that suggested dyspepsia. Helicobacter pylori infection was determined by using a serum IgG antibody concentration with an ELISA. RESULTS: Of the 2,500 persons investigated, 2,263 showed no abnormal finding in any medical examination. The presence or absence of symptoms and H. pylori infection was investigated in these 2,263 cases. Of these, 201 people (8.9%) experienced nausea, fullness and/or early satiety and were diagnosed as having dysmotility-like dyspepsia, while 118 people (5.2%) experienced pain localized to the epigastrium and were diagnosed as having ulcer-like dyspepsia. The frequency of these symptoms had a tendency to decline with age, although this was not statistically significant. In contrast, the rate of H. pylori infection increased with age. There was no significant relationship between H. pylori infection and any type of functional dyspepsia. CONCLUSIONS: Helicobacter pylori infection does not influence the prevalence of the dysmotility-like and ulcer-like dyspeptic symptoms.     

功能性消化不良与幽门螺杆菌关系的研究进展

功能性消化不良(FD)患者感染幽门螺杆菌(H.pylori)十分常见,H.pylori对于FD的发病过程有重要意义。本文旨在总结H.pylori在FD发病过程中的作用和根除H.pylori治疗对FD疾病进程影响的相关研究进展。     

High prevalence and severity of cardiac autonomic neuropathy in Vietnamese diabetic patients.

AIMS: Malnutrition is frequent in Vietnamese people and may influence cardiac autonomic neuropathy (CAN). The aim of the present study was to investigate cardiac autonomic function in healthy subjects living in Vietnam and the prevalence of CAN in Vietnamese diabetic patients. METHODS: One hundred and five diabetic patients (BMI = 19.8 +/- 0.3 kg/m(2)), 50 Type 1 and 55 Type 2, living in Hué (Vietnam) were selected and compared with 60 non-diabetic healthy Vietnamese controls (BMI = 20.8 +/- 0.2 kg/m(2)) and also European controls. CAN function was evaluated by five standardized tests: three tests for heart rate variations (HRV) which depend mainly on parasympathetic activity, and two tests for blood pressure (BP) response which depend mainly on sympathetic activity. RESULTS: With age taken into account, 41 of the 60 Vietnamese controls had at least mild CAN, as defined by one abnormal test for HRV when compared with the European control series, and 11 of them had two or three abnormal tests. Among the Vietnamese control men, those with abnormal HRV had lower BMI than those without (P = 0.036). Seven Vietnamese controls had postural hypotension and 16 had an abnormal BP response to the handgrip test. Compared with the Vietnamese controls, 71 diabetic patients (67.6%), 40 Type 1 and 31 Type 2, had at least mild CAN, 37 of them had two or three abnormal HRV tests, and 56 diabetic patients (53.3%) had an abnormal BP response to the sympathetic tests. Abnormal HRV were associated with significantly lower BMI, waist and hip circumferences, longer diabetes duration and higher fasting blood glucose. In the logistic regression analyses, abnormal HRV were associated significantly with duration of diabetes and BMI in patients with Type 2 diabetes. CONCLUSIONS: Cardiac autonomic dysfunction is frequent in normal Vietnamese subjects. CAN appears to be a more frequent complication of diabetes in Vietnam than in Western countries and diabetic parasympathetic dysfunction is frequently associated with sympathetic disorders. This confirms the deleterious effect a poor nutritional state has on cardiac autonomic function.     

Helicobacter pylori seropositivity among the patients with acute dyspepsia

Acute dyspepsia is a common gastrointestinal problem in clinical practice. This disease is due to the poor dietary behavior and there is a scientific evidence that the gastric infection by Helicobacter pylori is the cause of this medical disorder. Here, the authors report on the prevalence of Helicobacter pylori seropositivity among the patients presenting with acute dyspepsia in a primary care center.     

糖尿病患者心脏自主神经病变与尿白蛋白排泄的关系

目的探讨糖尿病患者尿白蛋白排出率（ＵＡＥ）与糖尿病自主神经病变之间的关系。方法对５６例糖尿病患者及５４例正常对照者进行了ＵＡＥ测定，并应用２４小时动态心电图心率变异性频谱分析技术测定了两组的心脏自主神经功能。结果糖尿病患者在不同ＵＡＥ阶段，其反映迷走神经功能的入睡后高频成分均显著低于对照组（Ｐ＝０．０００１）。随着ＵＡＥ的增加，心脏自主神经病变的各项指标均值呈明显的减低趋势，同时出现迷走－交感神经的联合损害。结论ＵＡＥ越高，心脏自主神经病变的各项指标越低，即自主神经病变越明显。     

Helicobacter pylori infection and dyspepsia

Dyspepsia is defined as a persistent or recurrent pain or discomfort, localised in the upper abdomen, which may or may not be related to meals. Its prevalence in the general population is extraordinarily high (20-40%). Several pathological conditions can provoke dyspepsia, although non ulcer dyspepsia is the main cause. The relationships between Helicobacter pylori and non ulcer dyspepsia are discussed, namely the prevalence of Helicobacter pylori infection and the efficacy of its eradication in non ulcer dyspepsia. The management of dyspeptic patients in the community is analysed according to the Maastricht Consensus of 1996. Our opinion is that, in Helicobacter pylori-positive dyspeptic patients, after a careful investigation with exclusion of other organic diseases, the bacterium should be eradicated.     

Symptom-based tendencies of Helicobacter pylori eradication in patients with functional dyspepsia

AIM： To investigate whether there were symptom-based tendencies in the Helicobacter pylori （H. pylori） eradication in functional dyspepsia （FD） patients. METHODS： A randomized, single-blind, placebo-controlled study of H. pylori eradication for FD was conduct- ed. A total of 195 FD patients with H. pylori infection were divided into two groups： 98 patients in the treatment group were treated with rabeprazole 10 mg twice daily for 2 wk, amoxicillin 1.0 g and clarithromycin 0.5 g twice daily for 1 wk; 97 patients in the placebo group were given placebos as control. Symptoms of FD, such as postprandial fullness, early satiety, nausea, belching,epigastric pain and epigastric burning, were assessed 3 mo after H. pylori eradication. RESULTS： By per-protocol analysis in patients with successful H. pylori eradication, higher effective rates of 77.2% and 82% were achieved in the patients with epigastric pain and epigastric burning than those in the placebo group （P 〈 0.05）. The effective rates for postprandial fullness, early satiety, nausea and belching were 46%, 36%, 52.5% and 33.3%, respectively, and there was no significant difference from the placebo group （39.3%, 27.1%, 39.1% and 31.4%） （P 〉 0.05）. In 84 patients who received H. pylori eradication therapy, the effective rates for epigastric pain （73.8%） and epigastric burning （80.7%） were higher than those in the placebo group （P 〈 0.05）. The effective rates for postprandial fullness, early satiety, nausea and belch- ing were 41.4%, 33.3%, 50% and 31.4%, respective- ly, and did not differ from those in the placebo group （P 〉 0.05）. By intention-to-treat analysis, patients with epigastric pain and epigastric burning in the treatment group achieved higher effective rates of 60.8% and 65.7% than the placebo group （33.3% and 31.8%） （P 〈 0.05）. The effective rates for postprandial fullness, early satiety, nausea and belching were 34.8%, 27.9%, 41.1% and 26.7% respectively in the treatment group, with no significant difference from those in the placebo group （34.8%, 23.9%, 35.3% and 27.1%） （P 〉 0.05）. CONCLUSION： The efficacy of H. pylori eradication has symptom-based tendencies in FD patients. It may be effective in the subgroup of FD patients with epigastric pain syndrome.     

自主神经功能与糖尿病患者左心室功能、心律失常的关系

目的 探讨糖尿病患者自主神经功能与部分心脏合并症之间的关系。方法 采用24小时动态心电图和血压同步监测102例糖尿病患者，左心室功能和结构参数用彩色多普勒超声心动图测定。结果 随SDNN（24小时内全部正常R－R间期的标准差）降低，糖尿病患者的舒张末期二尖瓣口血流频谱A峰与E峰峰值流速的比值（PVA／PVE）、室间隔厚度（IVSTd)、左心室后壁厚度（LVPWTd)、左心室重量指数（LVMI）均增加；二尖瓣前叶活动斜率（MEF）降低，IVSTd/LVPWTd则无变化；严重的心律失常如Lown‘s≥3级的室性心律失常及短阵房速、房颤的发生率也明显增加。上述变化与夜间血压的异常增高相伴随。结论 SDNN低的糖尿病患者心脏受累严重，并可能预示患者日后发生心源性猝死的危险性增加。     

Low prevalence of cardiac autonomic neuropathy in Type 1 diabetic patients without nephropathy.

AIM: To assess the prevalence of cardiac autonomic neuropathy (CAN) in Type 1 diabetic patients with and without nephropathy. METHODS: Sixty-six consecutive patients without nephropathy (n = 24), with incipient (n = 26) or overt nephropathy (n = 16) and a diabetes duration between 21 and 31 years were examined. Heart rate variability (HRV) as measure for CAN was investigated with short-term spectral analysis in the low-frequency (LF) band (0.06-0.15 Hz), reflecting sympathetic and vagal activity, and high-frequency (HF) band (0.15-0.50 Hz), reflecting vagal activity. HRV was expressed as spectral power (ms2, log-transformed). Normal, age-corresponding reference values were established in 184 controls. QTc intervals and dispersion were measured. RESULTS: After adjustment for age, there was no significant difference between healthy controls and patients without nephropathy. After further adjustment for diabetes duration, HbA1c, hypertension and treatment with beta-blockers, HRV in both frequency bands decreased with evidence of nephropathy. LF band (supine): patients without nephropathy 5.56 (4.89-6.21) (least squares means and 95% confidence interval (CI)), incipient nephropathy 5.72 (5.15-6.29) and overt nephropathy 4.11 (3.27-4.96). HF band (supine): without nephropathy 5.93 (5.26-6.60), incipient nephropathy 5.99 (5.41-6.57) and overt nephropathy 4.84 (4.00-5.68). Significant differences were found for patients without and with incipient nephropathy compared with those with overt nephropathy in the LF band and between patients with incipient nephropathy compared with those with overt nephropathy in the HF band. QTc intervals and QTc dispersion increased significantly with increasing nephropathy. CONCLUSIONS: Long-term Type 1 diabetes without nephropathy was not associated with impaired cardiac autonomic function in our study. However, in those with nephropathy, a loss of both vagal and sympathetic activity was present, and the severity of CAN correlated positively with more advanced nephropathy.     

Impaired hypoxic ventilatory drive in diabetic patients with autonomic neuropathy

The mortality of diabetic patients with autonomic neuropathy (DAN) is higher than that in those without autonomic neuropathy (DM). To test the hypothesis that this may be due to respiratory rather than cardiac dysfunction, we evaluated ventilatory responses to isocapnic-hypoxic and hyperoxic-hypercapnic conditions in 14 diabetic patients (8 DAN and 6 DM) and compared the results with those in 8 normal subjects. In all groups tested there was a significant linear correlation between end-tidal CO2 and minute ventilation and between end-tidal CO2 and mouth occlusion pressure (p100), as an index of the drive to breathe. There were no significant differences between the slopes and intercepts in the groups tested. A significant linear correlation was found between the O2 saturation and both minute ventilation and p100. There were no significant differences in the relationship between minute ventilation and O2 saturation, but the slopes and the intercepts of the regression lines of p100 vs. O2 saturation were significantly different in the DAN compared with those in normal subjects and DM. Additionally, five of eight patients with DAN lost their ventilatory drive and ventilatory responses to hypoxemia compared with only one of six DM. These findings suggest that a disorder in the ventilatory response to hypoxemia exists in some DAN.     

幽门螺杆菌对功能性消化不良粘膜病变的影响

目的阐明幽门螺杆菌（Ｈｅｌｉｃｏｂａｃｔｅｒｐｙｌｏｒｉ，Ｈｐ）在功能性消化不良（ＦＤ）中的发病地位．方法对６７例Ｈｐ阳性和２９例Ｈｐ阴性ＦＤ患者胃窦部粘膜组织学病变（粘膜炎症、粘膜微血管损伤、粘膜萎缩和肠上皮化生）做对比分析．结果Ｈｐ阳性患者胃窦部粘膜组织学病变较Ｈｐ阴性者显著（Ｐ＜００５）．结论Ｈｐ对ＦＤ的发病具有重要作用，推想根治Ｈｐ可能会对Ｈｐ阳性的ＦＤ患者粘膜组织学病变的好转有益．     

Helicobacter pylori eradication treatment does not benefit patients with nonulcer dyspepsia

OBJECTIVES: The aim of this study was to assess the still controversial role of treatment of Helicobacter pylori (H. pylori) infection in patients with nonulcer dyspepsia. METHODS: We conducted a double-blind, randomized, placebo-controlled, multicenter trial comparing the efficacy of 7 days of eradication treatment (lansoprazole 15 mg b.i.d., amoxicillin I g b.i.d., and clarithromycin 500 mg b.i.d.) with a control treatment (lansoprazole 15 mg b.i.d. and placebo) in H. pylori-infected patients with nonulcer dyspepsia. 13C breath tests were performed at baseline and during follow-up. We assessed patient symptoms, health status (based on the SF-12 questionnaire), patient satisfaction, drug consumption, health care consultation behavior, and absenteeism related to dyspepsia over a 1-yr period. RESULTS: A total of 74 patients randomized to eradication treatment and 70 patients randomized to placebo were compared. The rate of eradication of H. pylori infection was 75% in the active treatment group and 4% in the placebo group (p < 0.005). The symptom score improved to a similar extent in the group receiving active treatment (-4.0; 95% CI = -5.0 to -3.0) and placebo (-3.6; 95% CI = -4.5 to -2.7). Treatment response was not related to the severity or duration of initial symptoms or to the severity of gastritis on histology. Quality of life scores were comparable at 12 months. There was no significant difference in dyspepsia-related absenteeism or satisfaction with management of NUD. Patients receiving active treatment were more likely not to have had to use any dyspepsia treatment over the 12 months (60.8% vs 44.3%; p = 0.047). CONCLUSIONS: This study did not demonstrate any substantial benefit of curing H. pylori infection in patients with nonulcer dyspepsia. The study adds further evidence that H. pylori is not the main pathogenetic or therapeutic target in these patients.     

Helicobacter pylori infection and gastric emptying in cirrhotic patients with symptoms of dyspepsia

BACKGROUND/AIMS: Chronic gastric Helicobacter pylori infection is common in patients with dyspeptic symptoms. The effect of H. pylori infection on gastric emptying, in cirrhotic patients with dyspeptic symptoms, has never been studied. Therefore, we investigated the incidence of H. pylori infection and its relationship with gastric emptying in cirrhotic patients with dyspepsia. METHODOLOGY: A solid-phase gastric emptying study and 14C urea breath test were performed in 80 cirrhotic patients with dyspepsia. The severity of cirrhosis was assessed according to Child-Pugh's classification. RESULTS: The overall incidence of delayed gastric emptying was 75%. Delayed gastric emptying incidences according to severity of cirrhosis were 71.4% for Child-A, 73.1% for Child-B, and 80.8% for Child-C. The differences were not significant. The incidence of H. pylori infection was 52.5% overall. H. pylori infection rates were 46.4% for Child-A, 42.3% for Child-B, and 69.2% for Child-C. Although there was a tendency for the infection rate to increase with the severity of liver cirrhosis, the difference was not significant. In addition, there were no significant differences in the incidences of H. pylori infection among patients with normal and delayed gastric emptying. CONCLUSIONS: Delayed gastric emptying is common in cirrhotic patients with dyspepsia. However, the status of H. pylori infection does not seem to play a role in delayed gastric emptying in these patients.     

Helicobacter pylori infection and gastric function in patients with chronic idiopathic dyspepsia.

Helicobacter pylori infection, histological features of the gastric mucosa, and gastric motor and secretory functions were evaluated in 45 consecutive patients with chronic idiopathic dyspepsia. H. pylori infection was found in 60% of dyspeptic patients, compared with 33% of 15 healthy controls (P = 0.1). No difference was detected in basal or stimulated gastric acid secretion between dyspeptic patients and healthy controls. Gastric emptying was significantly (P less than 0.01) delayed in dyspeptic patients compared with healthy controls when standardized for age and sex. Delayed gastric emptying was associated with a low frequency of H. pylori infection, female gender, and young age. Epigastric pain or burning and postprandial fullness were, respectively, more severe in patients with H. pylori infection (P less than 0.02) and in those with delayed gastric emptying (P less than 0.01). These findings support the existence of separate subsets of patients with chronic idiopathic dyspepsia. Despite the presence of overlaps, there appear to be partially different functional derangements and clinical features in different subgroups of dyspeptic patients.