Telematic transmission of computerized blood glucose profiles for IDDM patients.

OBJECTIVE: To improve the analysis of self-monitoring of blood glucose (SMBG) and its communication between patients and physicians by a telematic transmission of computerized SMBG and to study the consequences of its use on glucose control of insulin-dependent diabetic (IDDM) patients. RESEARCH DESIGN AND METHODS: A prospective randomized crossover trial with two 3-mo periods, one with SMBG recorded on traditional booklets (booklet period) and another with computerized SMBG transmitted to a central data base through a telematic network (telematic period), comprised the study. During the latter phase, patients could receive computerized SMBG analysis on individual terminals connected to the telephone network (Minitel system). Blood glucose recordings and HbA1c were measured at inclusion and end of each period. Eleven pairs of IDDM patients on intensified insulin therapy were randomized within each pair to start with the telematic period (group A) or the booklet period (group B). RESULTS: Telematic transmissions were successful (less than 1% failure rate). Although initial HbA1c was low (6.7%), it declined during the telematic period (delta = -0.41%) compared with the booklet period (delta = +0.37%, P = 0.05). The percentage of low (less than 3.3 mM) blood glucose values correlated with HbA1c changes during the telematic period (r = 0.714, P = 0.0014) but not the booklet period. The patients favored the telematic tool to analyze SMBG. CONCLUSIONS: Telematic transmission of SMBG is feasible. It can improve SMBG analysis and perhaps glucose control, therefore offering a new way of communication between diabetic patients and their physicians.

Antihypertensive efficacy and acceptability of perindopril in elderly hypertensive patients.

The antihypertensive efficacy and acceptability of perindopril, an angiotensin-converting enzyme (ACE) inhibitor, was evaluated in 2,927 elderly (> or = 70 years) hypertensive patients in general practice, as part of an open 6-month trial conducted on a total of 23,460 patients with mild-to-moderate hypertension. Patients were ambulatory and selected if diastolic blood pressure (DBP) was between 94 and 115 mm Hg and no serious illness or ACE inhibitor intolerance was known. Perindopril was started at 2 or 4 mg once daily and, if supine DBP remained > 90 mm Hg, the daily dose could be doubled after 1 or 3 months (or a diuretic added if perindopril titration reached 8 mg). At entry, the 2,927 patients (65% females) were on average 74 years old, body weight was 68.2 kg, duration of hypertension was 9.4 years, and prior antihypertensive treatment was present in 78%. Percentage of normal DBP (< or = 90 mm Hg) was 69% at 1 month, 86% at 3 months (in patients on perindopril alone), and 94% at 6 months. At 6 months the reduction of systolic blood pressure and DBP was 28 and 16.6 mm Hg, respectively. Of the 2,927 patients at entry, 8.6% dropped out during the trial, including 6.1% due to side effects. Cough was the most common symptom (8.9%) leading to withdrawal in 3.4% of cases. In one patient, serum creatinine increased (3-fold at 1 month), but overall no significant variation of renal function occurred, as shown by stable plasma creatinine and potassium levels.

[Effect of pre-existing hypertension on the prevalence and incidence of microalbuminuria in non insulin-dependent diabetic patients]. / Influence d'une hypertension artérielle préexistante sur la prévalence et l'incidence de la microalbuminurie chez les diabétiques non insulinodépendants.

Microalbuminuria predicts increased rate of hypertension and mortality in insulino-dependent diabetics. In non insulin-dependent diabetes, hypertension often exists before onset of diabetes. To study effects of preexisting hypertension on prevalence and occurrence of elevated urinary albumin excretion (UAE), we collected datas from 614 non insulin-dependent diabetics, in a cross sectional survey: age was 60 +/- 10.4 years, (range 40-75 years), body mass index (BMI) 29 +/- 5.8 kg/m2, hemoglobin A1C 8 +/- 1.9%, systolic blood pressure (SBP) 134 +/- 18 mmHg, diastolic blood pressure (DBP) 76 +/- 10 mmHg, and serum creatinine 91 +/- 44 mumol/l. In the whole group, prevalence of hypertension was 59%. Microalbuminuria (EUA 20-200 mg/l) was present in 25.9% of the cases, microalbuminuria (EUA greater than 200 mg/l) in 7.5%. Cases with hypertension existing before or at onset of diabetes were 243 (HT group), cases without hypertension at onset were 371 (non HT group). In HT group, prevalence of microalbuminuria in increasing class of duration of diabetes were: 31% (0-4 years), 25% (5-9 years), 35% (10-14 years), 21% (15-19 years). Prevalence of macroalbuminuria was respectively: 3%, 11%, 15% and 4%. In the non HT group, microalbuminuria was present in 14% of the cases (0-4 years), 24% (5-9 years), 30% (10-14 years), 25% (15-19 years); prevalences of macroalbuminuria were: 1%, 8%, 6%, 15%. Mean values of UAE, compared to values of the class 0-2 years, were significantly higher in class 12-14 years (32.3 +/- 8 vs 14.4 +/- 3.7 mg/l; p = 0.02] in the HT group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of 3 methods of measurement of blood pressure in insulin-dependent diabetic patients with or without incipient diabetic nephropathy]. / Comparaison de trois méthodes de mesure de la pression artérielle chez des diabétiques insulino-dépendants avec ou sans néphropathie diabétique débutante.

Incipient diabetic nephropathy is characterized by a urinary albumin excretion (UAE) between 30-300 mg/24 h and a slightly elevated blood pressure. We measured blood pressure in 14 insulin-dependent diabetic subjects (IDDs) with persistent microalbuminuria (group A) and 50 IDDs with persistent normoalbuminuria (group B) using 3 different methods: 1) Sphygmomanometer, by a nurse, on supine position since 10 min, on the third day of hospitalization; 2) automatic device (Dinamap), on supine position, every 5 min, during 30 min; 3) ambulatory blood pressure (Spacelab 90202 every 15 min between 8 a.m. and 8 p.m.; values obtained with this last method were compared to the mean values of healthy subjects of same age. Recorded UAE was the median value of 3 twenty-four-hours urines. Blood pressure was not different among the two groups with any of the three methods: 1) SBP/DBP A: 136 +/- 14/81 +/- 9 vs B: 131 +/- 13/78 +/- 8 mmHg; ns; 2) SBP/MBP/DBP A: 134 +/- 17/96 +/- 12/79 +/- 10 vs B: 127 +/- 13/90 +/- 10/74 +/- 10 mmHg; ns; 3) A: 132 +/- 12/97 +/- 11/84 +/- 9 vs B: 127 +/- 11/91 +/- 9/82 +/- 12 mmHg; ns. There were no concordance between microalbuminuria/normoalbuminuria and systolic or diastolic blood pressure higher/lower than the mean of the healthy subjects (X2 = 1.6; ns). However, UAE was significantly related to MBP measured with 1): r = 0.29; p = 0.027, but not with 2): r = 0.24; ns, nor with 3): r = 0.26; ns. These results suggest that: 1-blood pressure of IDDs should be measured in standardized conditions; 2-diurnal ambulatory blood pressure recording does not predict incipient nephropathy in these subjects.

[Increase of activity of angiotensin-converting enzyme in insulin-dependent diabetic patients with permanent microalbuminuria]. / Elévation de l'activité de l'enzyme de conversion chez des diabétiques insulino-dépendants présentant une microalbuminurie permanente.

Angiotensin I Converting Enzyme (ACE), which is synthesized by vascular endothelial cells, can be elevated in some diabetic subjects. To study if serum ACE can be elevated in subjects with high risk for malignant microangiopathy, 34 normotensive type I, insulin-dependent diabetic subjects with persistent microalbuminuria (30-300 mg/24 h) were compared for serum ACE activity (Liebermann's method) with 30 normotensive, normoalbuminuric type I, insulin-dependent diabetic subjects of same age (33 +/- 15 (M +/- SD) vs 39 +/- 14 years), sex (13 F/21 M vs 15 F/15 M), stage of retinopathy (14 vs 16 nil/11 vs 7 background/6 vs 4 preproliferative/3 vs 3 proliferative), HbA1c (7.7 +/- .9 vs 8.2 +/- 1.0%). Serum ACE activity of diabetic subjects were also compared with 120 age and sex related healthy controls. Serum ACE activity was higher in type I, insulin-dependent diabetic subjects with microalbuminuria than in those with normoalbuminuria (406 +/- 114 vs 359 +/- 97 IU/l; p = 0.05), or in controls (307 +/- 95 IU/l; p = 0.0001). Normoalbuminuric subjects also had higher ACE activity than controls (p = 0.02). In diabetic subjects, serum ACE activity was not related to diabetes duration (r = 0.1; ns), stage of retinopathy (r = 0.06; ns), HbA1c (r = 0.02; ns), or to blood pressure (r = 0.03; ns), but was related to urinary albumin excretion (r = 0.28; p = 0.03) in diabetic subjects. However, stage of retinopathy was related to diabetes duration (r = 0.74; p = 0.0004) and to age (r = 0.42; p = 0.003) in these subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

[Increase of angiotensin converting enzyme activity during oral load of glucose]. / Augmentation de l'activité de l'enzyme de conversion au cours d'une charge en glucose par voie orale.

Elevated serum angiotensin I-converting enzyme activity may occur in diabetic subjects. This may signal alteration of vascular endothelium. To study the effect of acute glucose change on serum Angiotensin Converting Enzyme (ACE), we performed an oral glucose tolerance test in 17 obese subjects (7M/10F), (Body Mass Index, (BMI): 31 +/- 1 kg/m2), aged 48 +/- 3 years. We measured serum ACE activity (Lieberman's method), active renin (RIA Pasteur kit), and aldosterone (RIA, Cis-International kit), before and 2 hours after oral glucose intake (75 g), and plasma glucose and insulin every 30 min. After oral glucose tolerance test, subjects were classified as 6 Non Insulin-Dependent Diabetic (NIDD), 8 Glucose intolerant (GI), and 3 NormoGlycaemic (NG) subjects. Active renin did not vary after glucose loading (14 +/- 2 vs 15 +/- 2 pg/ml) nor aldosterone (104 +/- 14 vs 133 +/- 18 pg/ml), while ACE activity rose significantly (229 +/- 25 vs 277 +/- 28 IU/l; p = 0.02). Serum ACE activity were different in the 3 groups before glucose loading (NIDD: 266 +/- 37, GI: 252 +/- 32, NG: 90 +/- 21 IU/l; Kruskal-Wallis H = 7.03; p = 0.03), but not after 2 hours (NIDD: 297 +/- 42, GI: 275 +/- 36, NG: 204 +/- 113 IU/l; ns).(ABSTRACT TRUNCATED AT 250 WORDS)

[Urinary excretion of albumin and lipid abnormalities in hypertensive insulin-dependent diabetics]. / Excrétion urinaire d'albumine et anomalies lipidiques chez les diabétiques insulinodépendants hypertendus.

Patients with insulin dependent diabetes mellitus (IDDM) often suffer from cardiovascular diseases as renal failure occurs. Elevated albumin excretion rate (AER) is a predictive value of this event. Relations between AER, blood pressure, serum lipids and apoproteins concentrations in 100 patients with IDDM have been surveyed. Twenty one hypertensive patients (HT group) were compared to 21 patients without hypertension (n HT group), matched for sex, age, diabetes duration, and metabolic control, assessed by glycosylated haemoglobin. Comparison of both groups showed HT group had elevated systolic blood pressure (137 +/- 12 vs 126 +/- 20 mmHg; p less than .05), elevated diastolic blood pressure (80 +/- 7 vs 71 +/- 8 mmHg; p less than .001), increase in AER (27 range 3-4023 vs 6 range 2-51 mg/day; p less than .001), slightly elevated serum creatinine (95 +/- 32 vs 78 +/- 15 mumol/l; p less than .05). In HT group, serum lipid composition showed: raise in total cholesterol (251 +/- 43 vs 221 +/- 41 mg/dl; p less than 0.5), elevated apoprotein B (130 +/- 30 vs 99 +/- 21 mg/dl; p less than .001) elevated apoprotein B/apoprotein A1 ratio (.91 +/- .32 vs .66 +/- .27; p less than .001), elevated triglycerides (157 +/- 53 vs 98 +/- 43 mg/dl; p less than .005) and elevated LDL-cholesterol (170 +/- 42 vs 143 +/- 33 mg/dl; p less than .05). Levels of apoprotein A1 and HDL-cholesterol were not significantly different. Body mass index, daily insulin requirement and tobacco usage were similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Adrenaline and beta 2 adrenergics]. / Adrénaline et beta 2 adrénergiques.

Adrenalin is the drug for anaphylactic shock. The product is usable directly by the patient in the form of an auto-injectable kit, by the physician who treats by the sublingual or subcutaneous routes, in a resuscitation unit extra and inter-hospital by the intra-veinous route with cardiac monitoring. Precaution have to be observed (in angina especially), but it is without formal contra-indications. The beta 2 adrenergics are non-specific bronchodilators. Two categories are available: short action molecules, crisis drugs, prolonged activity molecules (greater than 12 hours). Several routes of administration are useable: spray or powder (inhalation) sub-cutaneous, taking by mouth.

Polycythaemia after myeloid metaplasia with fibrosis: an unusual sequence.

In November 1981, a 77-yr-old woman consulted for myeloid metaplasia with fibrosis. A persistent hyperleucocytosis was treated with hydroxyurea from March, 1985 to March, 1989. At that time facial dyskinesia and polycythaemia developed. Investigations revealed a regression of myelofibrosis and a predominance of myeloid metaplasia in the liver. The mechanism of this event, rarely observed in myeloproliferative syndromes, is discussed in this new case.

Serum lipids and urinary albumin excretion in non insulin-dependent diabetics.

The increase of urinary albumin excretion has a predictive value for cardiovascular disease in insulin-dependent and non insulin-dependent diabetics. To study the relationship between urinary albumin excretion and serum lipids, 380 non insulin-dependent diabetics, 40 to 75 yr old, with urinary albumin excretion from 0 to 200 mg/l, and normal serum creatinine (less than 150 mumol/l), were surveyed. Urinary albumin excretion, was related positively to age (r2 = 0.014; p = 0.02), to systolic blood pressure (r2 = 0.073, p = 0.0001) and diastolic blood pressure (r2 = 0.052, p = 0.0001); a negative correlation existed with HDL-cholesterol (r2 = 0.043, p = 0.0001) and Apoprotein A1 (r2 = 0.044, p = 0.0001). A stepwise regression analysis was performed and resulted in three independently contributing variables related to urinary albumin excretion: First systolic blood pressure (F = 36), second Apoprotein A1 (F 24), third hemoglobin A1C (F = 6). The presence of hypertension or insulin therapy did not modify these findings. In conclusion, serum lipid seems an important determinant of urinary albumin excretion in non insulin-dependent diabetics.

Relationship between fat intake and glomerular filtration rate in normotensive insulin-dependent diabetic patients.

Glomerular hyperfiltration is a candidate marker for diabetic nephropathy in insulin-dependent diabetic patients since it can reflect elevated glomerular capillary pressure, a cause of glomerulosclerosis. We studied the potential contribution of several dietary components to glomerular hyperfiltration during a cross-sectional study of 110 consecutive normotensive, non-proteinuric insulin-dependent patients with respect to glomerular filtration rate (GFR) and food intake. GFR was measured using the 51Cr-EDTA plasma disappearance technique. Glomerular hyperfiltration was defined as GFR > 137 ml.min-1 1.73 m-2 (mean +2 SD of age-matched healthy controls). Food intake was recorded with a computer-assisted programme. Thirteen patients displaying glomerular hyperfiltration ingested more protein (1.60 +/- 37 vs 1.38 +/- 0.34 g.kg-1 body weight.day-1; p = 0.032) and more fat (1.70 +/- 0.54 vs 1.39 +/- 0.44 g.kg-1 body weight.day-1; p = 0.022) than other subjects, although their total energy intakes were similar. Univariate regression analysis showed that GFR was positively related to both protein (r = 0.28; p = 0.003) and fat (r = 0.25; p = 0.007) intakes and negatively related to age (r = -0.29; p = 0.002). Stepwise multivariate regression analysis indicated 2 independent determinants for GFR: age (F = 15.26) and fat intake (F = 13.15). Excess fat intake may contribute to glomerular hyperfiltration in insulin-dependent diabetes.

Non-coordinated biosynthesis of early complement components in a deficiency of complement proteins C1r and C1s.

We report on a 60-year-old woman with systemic lupus erythematosus and a total (95%) C1r and a partial (36%) C1s deficiency. The patient complained about cutaneous lesions on forearms and legs without other systemic involvement. Elevated anti-nuclear, anti-native DNA and anti-SSA antibodies were present. The finding of persistently depressed levels of haemolytic complement activity (CH50) on both serum and plasma, associated with normal levels of C3, C4 and C2 components, and normal alternative pathway haemolytic activity showed a deficiency of an early component of the classical pathway. Indeed C1r component was below the limits of detection whereas C1s component was lowered (36%). The depressed CH50 was only corrected by purified C1r. Biosynthesis of C1r and C1s by patient's monocytes was spontaneously normal but not up-regulated by interferon-gamma for C1r alone, whereas the biosynthesis of C1s, but also of interleukin-6, was increased, indicating a specific disregulation of C1r. The deficiency was associated with a lupus syndrome and a fatal assumed septic shock. This is in agreement with other reported cases.