Starting insulin in type 2 diabetes: continue oral hypoglycemic agents? A randomized trial in primary care

OBJECTIVE: To evaluate the effects of insulin 30/70 twice daily or bedtime isophane (NPH) insulin plus continued sulfonylurea and metformin in patients with type 2 diabetes in primary care. STUDY DESIGN: Open-label, randomized trial. POPULATION: Persons younger than 76 years with type 2 diabetes whose disease had not been controlled with oral hypoglycemic agents alone. A total of 64 insulin-naive patients treated with maximal feasible dosages of sulfonylurea and metformin (baseline glycosylated hemoglobin [HbA1c]=8.5%) were randomly assigned to insulin monotherapy (IM group; n=31) or insulin in addition to unchanged oral hypoglycemic medication (IC group; n=33) for 12 months. Insulin doses were adjusted to obtain fasting glucose <7.0 mmol/L and postprandial glucose <10.0 mmol/L. OUTCOMES MEASURED: Outcome measures included HbA1c, treatment failure, weight, hypoglycemic events and symptoms, satisfaction with treatment, general well-being, and fear of injecting insulin and testing. RESULTS: HbA1c improved from 8.3% to 7.6% in the IC group, and from 8.8% to 7.6% in the IM group (P=NS). The IC group had 24% treatment failures, compared with 2% in the IM group (P=.09). Patients in the IC group had less weight gain than those in the IM group (1.3 vs 4.2 kg; P=.01), and they reported fewer hypoglycemic events (2.7 vs 4.3; P=.02). Increased satisfaction with treatment was equal in the 2 groups, and general well-being improved by 3.0 points more in the IC group (P=.05). Fear of self-injecting and self-testing did not differ. CONCLUSIONS: Bedtime NPH insulin added to maximal therapy with sulfonylurea and metformin is an effective, simple, well-tolerated approach for patients with uncontrolled type 2 diabetes.     

Ultrasound measurements of intraabdominal fat estimate the metabolic syndrome better than do measurements of waist circumference

BACKGROUND: We recently developed an ultrasound technique to estimate intraabdominal fat (IAF). This method is more accurate than measurement of waist and hip circumferences and is simpler and less expensive than computed tomography or magnetic resonance imaging. OBJECTIVE: We compared the associations of ultrasound and waist-circumference (WC) measurements of IAF with other components of the metabolic syndrome. DESIGN: IAF was determined in 600 consecutive participants in the Secondary Manifestations of Arterial Disease (SMART) study. The mean (+/- SD) age was 56.1 +/- 12.6 y, 30.0% of participants were women, and the mean body mass index (BMI; in kg/m2) was 26.6+/- 4.1. RESULTS: IAF increased with age (ultrasound: r = 0.28; WC: r = 0.25; P < 0.001 for both). Higher IAF, as measured by ultrasound but not by WC, was independently associated with higher metabolic risk factors. The correlation coefficients between IAF measured by ultrasound and plasma glucose, total cholesterol, HDL cholesterol, and triacylglycerol were 0.13, 0.16, -0.13, and 0.25, respectively (all P < 0.001; adjusted for age, sex, and BMI). The corresponding coefficients for IAF measured by WC were 0.17 (P < 0.001) and 0.01, -0.06, and 0.05 (all NS). CONCLUSIONS: These results confirm the findings of computed tomography and magnetic resonance imaging investigations. When IAF is measured by ultrasound, the associations are more pronounced than when WC measurements are used and are independent of BMI. This suggests that IAF can be more reliably assessed by ultrasound measurements than by WC measurements.     

Severe impairment of postprandial cholecystokinin release and gall-bladder emptying and high risk of gallstone formation in acromegalic patients during Sandostatin LAR

BACKGROUND: Acromegalic patients treated three times daily with subcutaneous injections of the somatostatin analogue octreotide frequently develop gallstones, due to suppressed cholecystokinin release and impaired gall-bladder emptying. AIM: To elucidate the effects of a new long-acting octreotide formulation (Sandostatin LAR) on gall-bladder emptying, cholecystokinin release and gallstone formation. METHODS: Postprandial gall-bladder and gastric emptying were determined by ultrasonography and cholecystokinin release was measured in seven patients on days 0, 14, 28, and 75 (Sandostatin LAR, 20 mg intramuscularly on days 1, 30, and 60). RESULTS: During treatment, fasting gall-bladder volumes increased from 26.5 +/- 3.2 mL to 61.4 +/- 7.5 mL, but postprandial cholecystokinin release and gall-bladder emptying (from 63.9 +/- 3.8% to 12.3 +/- 3.5%) were severely suppressed. Gallstones formed in six out of seven patients within 8 months of treatment. Gastric emptying did not change during the therapy. CONCLUSIONS: The risk of gallstone formation is greatly increased during Sandostatin LAR. This is probably related to profound suppression of cholecystokinin release and gall-bladder emptying.     

The relative bioavailability of metoprolol following oral and rectal administration to volunteers and patients

The pharmacokinetics, efficacy and safety of metoprolol tartrate 25 mg fatty suppositories were studied in 5 healthy volunteers and in 8 patients suffering from instable angina pectoris. Metoprolol 25 mg capsules were used as a control oral dosage form. Metoprolol showed a considerable rectal bioavailability (AUC, C max) and was absorbed quickly from the rectum (T max). In both groups rectal bioavailability was comparable. However, oral bioavailability was much lower in the volunteer group than in the patient group. Furthermore, ratios of metoprolol/aOHmetoprolol concentrations in plasma and urine gave an indication for a partial avoidance of the first pass effect after rectal administration. Further research is necessary to define an exact rectal dosage of metoprolol. In all patients, a substantial drop in heart rate, systolic and diastolic blood pressure was seen after administration of the first suppository. Metoprolol suppositories appear to be an effective, safe and suitable alternative for patients who are in need for beta blocking medication and who are unable to take oral medication for a certain amount of time.     

Does physical activity modify the risk of obesity for type 2 diabetes: a review of epidemiological data

Obesity and physical inactivity are both risk factors for type 2 diabetes. Since they are strongly associated, it has been suggested that they might interact. In this study, we summarized the evidence on this interaction by conducting a systematic review. Two types of interaction have been discerned, statistical and biological interaction, which could give different results. Therefore, we calculated both types of interaction for the studies in our review. Cohort studies, published between 1999 and 2008, that investigated the effects of obesity and physical activity on the risk of type 2 diabetes were included. We calculated both biological and statistical interaction in these studies. Eight studies were included of which five were suitable to calculate interaction. All studies showed positive biological interaction, meaning that the joint effect was more than the sum of the individual effects. However, there was inconsistent statistical interaction; in some studies the joint effect was more than the product of the individual effects, in other studies it was less. The results show that obesity and physical inactivity interact on an additive scale. This means that prevention of either obesity or physical inactivity, not only reduces the risk of diabetes by taking away the independent effect of this factor, but also by preventing the cases that were caused by the interaction between both factors. Furthermore, this review clearly showed that results can differ depending on what method is used to assess interaction.     

Pneumothorax preceding pulmonary blastoma in a child

Serial plain radiographic, ultrasound and CT findings of an unusual case of pulmonary blastoma are described with a review of the literature.     

Hodgkin's disease presenting as a parasternal chest wall mass.

A 53 year-old Moroccan woman presented with a tender parasternal mass. Computerized tomography showed a mediastinal mass protruding through the sternum. Cytologic examination of fluid collected from the mass repeatedly showed acute inflammation. Tuberculostatics were started. Since patient did not improve on tuberculostatics, a small supraclavicular lymph node was removed. Histologic examination showed Morbus Hodgkin of the nodular sclerosing type. Ultimately, cytologic examination of fluid from the parasternal mass showed atypical cells. Response on chemotherapy was excellent with complete disappearance of the parasternal mass. This is a very unusual extranodal presentation of Hodgkin's disease.