SCREENING AND TREATMENT FOR HYPERUPIDAEMIA IN NON-INSULIN-DEPENDENT DIABETES: A PROSPECTIVE ASSESSMENT OF 350 PATIENTS

SUMMARY This report presents experiences in screening 350 non-insulin-dependent diabetics for hypercholesterolemia and results of 1 year's treatment. Mean serum total cholesterol was 6.4 mmol/l at screening; 46 patients whose initial total serum cholesterol was above 7.0 mmol/l attended for detailed assessment and treatment. Mean total cholesterol concentrations fell between screening and review (7.8 vs 7.1 mmol/l, P<0.01). Levels fell below 7.0 mmol/l in 13 patients with diet alone. After excluding patients with secondary dyslipidaemia (including poor diabetic control), 10 patients received lipid-lowering drug treatment. Total cholesterol and triglyceride concentrations fell significantly and the HDL/non- HDL cholesterol ratio improved on treatment. Screening diabetic patients identifies a small group of hyperlipidaemic patients, whose lipoprotein profiles improve with drug treatment. Many of those screened, however, do not ultimately require drug treatment using a cut-off of 7.0 mmol/l.     

Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass

BACKGROUND: The effect of non-pulsatile, normothermic cardiopulmonary-bypass (CPB) on the splanchnic blood-flow and oxygen-transport, the hepatic function and the gastrointestinal barrier were observed in a prospective observational study in 31 adults undergoing cardiac valve replacement surgery. METHODS: The splanchnic (i.e. hepatic) blood-flow (HBF) was measured by the constant infusion of indocyanine-green (ICG) using a hepatic-venous catheter. Liver function was examined by calculation of lactate uptake, ICG extraction and the monoethylglycinexylidide (MEGX) test. A day before and after surgery the gastrioduodenal and intestinal permeability was measured by determination of sucrose and lactulose/mannitol excretion. RESULTS: Splanchnic blood flow and oxygen delivery did not decrease during and after surgery while splanchnic oxygen consumption (P < 0.0125) and arterial lactate concentrations increased. The splanchnic lactate uptake paralleled the lactate concentration. After but not during CPB an increase of systemic oxygen consumption was observed. The MEGX test values decreased on the first day after surgery. The ICG extraction was attenuated during the operation. The gastroduodenal and the intestinal permeability increased significantly postoperatively (P < 0.002, respectively, P < 0.001). There was no correlation between these findings and the duration of CPB. There was a significant correlation of the intestinal permeability but not of the gastroduodenal permeability between the prior and after surgery values (P < 0.001). CONCLUSION: Increased oxygen consumption during CPB may indicate an inflammatory reaction due to the pump beginning in the splanchnic area or a redistribution of the splanchinc blood flow during the CPB. Normothermic CPB does not lead to a significant or prolonged reduction of liver function. Normothermic CPB causes an increase of gastrointestinal permeability. The intestinal barrier function prior to surgery was accountable for the degree of loss of intestinal barrier function following surgery.     

The role of micro-inflammation in the pathogenesis of uraemic pruritus in haemodialysis patients.

BACKGROUND: Uraemic pruritus (UP) is still one of the most vexing and disabling symptoms in chronic renal failure. The pathogenesis of UP is obscure and effective therapeutic strategies are elusive. Deduced from partial successful treatment modalities, there is evidence that an alteration of the immune system with a pro-inflammatory pattern along with a deranged T-helper-cell differentiation may be involved in the pathogenesis of UP. We, therefore, investigated whether UP is related to an augmented Th1-differentiation as measured by determination of intracytoplasmatic (i.c.) cytokines and expression of chemokine receptors. Additionally, pro-inflammatory cytokines were determined in serum. METHODS: In a multicentre study, 171 patients on haemodialysis (HD) were screened for UP. Finally, 13 HD patients with and 13 HD patients without UP, as well as 15 healthy controls were enrolled in the study. Peripheral blood mononuclear cells were isolated and the proportion of Th1- and Th2-cells was determined by flow cytometry. The expression of chemokine receptors on CD4 cells (CXCR3 preferentially on Th1 and CCR4 on Th2) and i.c. cytokines (IFNgamma for Th1 and IL4 for Th2) were measured after in vitro stimulation. Serum cytokine levels (IL6 and TNFalpha) and CRP were measured by ELISA. RESULTS: Compared to HD patients without UP, those complaining of UP showed a significantly enhanced proportion of Th1-cells as measured by both techniques. Additionally, serum CRP and IL6 levels were significantly higher in HD patients with UP, compared to HD patients without UP. CONCLUSIONS: These results point to a central role of inflammation in the pathogenesis of UP in HD patients.     

Spontaneous Apoptosis of Endometrial Tissue is Impaired in Women with Endometriosis

Objective: To evaluate spontaneous apoptosis in single-cell suspensions of eutopic and ectopic endometrium from women with endometriosis and in eutopic endometrium from fertile controls without endometriosis.

Design: Paired specimens of eutopic and ectopic endometrial tissue from patients with endometriosis and eutopic endometrium from controls were assessed for spontaneous apoptosis.

Setting: Institute for the Study and Treatment of Endometriosis and university-based research laboratories.

Patient(s): Fertile controls (n = 10) and women with untreated endometriosis (n = 16).

Intervention(s): None.

Main Outcome Measure(s): Spontaneous apoptosis assessed with an ELISA-based cell death detection kit.

Result(s): Spontaneous apoptosis (monitored by absorbance) of eutopic endometrium from patients with endometriosis and fertile controls was 0.63 ± 0.1 and 1.43 ± 0.11, respectively. Among patients with endometriosis, spontaneous apoptosis of ectopic endometrium was 0.26 ± 0.06. Decreased apoptosis of ectopic versus eutopic endometrium was observed independent of cycle phase.

Conclusion(s): The susceptibility of endometrial tissue to spontaneous apopoptosis is significantly lower in women with endometriosis than in fertile controls. We suggest that decreased susceptibility of endometrial tissue to apoptosis contributes to the etiology or pathogenesis of endometriosis.     

BLOOD PRESSURE CONTROL AND CARDIOVASCULAR RISK IN PATIENTS OF INDO-ASIAN AND AFRICAN-CARIBBEAN DESCENT

SUMMARY Hypertension is a major risk factor for premature death. Large outcome studies have demonstrated reduced morbidity and mortality associated with antihypertensive therapy in mixed patient populations, but data on morbidity and mortality in defined ethnic groups are lacking. Management of cardiovascular risk factors, which frequently coexist with hypertension, presents a logical management strategy in these patients. Indo-Asian patients are particularly prone to insulin resistance and non-insulin-dependent diabetes mellitus (NIDDM), which are associated in turn with potentially atherogenic lipid profiles and poor cardiovascular outcomes. Diuretics and β-adrenoceptor blockers exert theoretically adverse effects on lipid profiles and should be used with caution in Indo-Asian patients at risk of developing NIDDM. Hypertensive African-Caribbean patients are at increased risk of stroke and tend to suffer greater target organ damage, including renal dysfunction and cardiac hypertrophy. Hypertension in African-Caribbean patients is less sensitive to β-adrenoceptor blockade or ACE inhibition than in white patients. Selective α₁-adrenoceptor antagonists and calcium channel blockers are equally effective antihypertensive agents in all races. While calcium channel blockers are metabolically neutral, α₁-adrenoceptor blockers promote a potentially less atherogenic lipid profile. Further study of the effects of antihypertensive treatment on morbidity and mortality in ethnic groups is required, particularly in Indo-Asian patients.     

Sonographie von Hals und oberem Mediastinum

Sonography of the neck and superior mediastinum is a very instructive method of investigation. However, the topographical anatomy of the region makes major demands on the investigator. In many diseases in this area, ultrasonography may be used as the first and also only imaging method (thyroid, salivary glands, lymph nodes). Pathological findings are detected with high sensitivity. The dynamic investigation with palpation, compression and observation of deglutition is especially helpful in appraising the consistency, displace-ability and topographical identification of structures. The specificity can be substantially improved by use of color Doppler sonography and ultrasound-guided biopsy. The pharyngeal and retropharyngeal space, the base of the brain and the posterior mediastinum are difficult to access by sonography. The investigator must therefore arrange for supplementary imaging procedures such as CT, MRI or thyroid scintigraphy in unclear cases, e.g. in diagnosis and staging of tumors. Mediastinal space occupations are most frequent in the anterior upper mediastinum. They can be appraised almost as reliably by transthoracic sonography as by computer tomography.