Adult-onset diabetes among Arabs and Jews in Israel: a population-based study.

AIMS: To study the age at presentation and factors associated with adult-onset diabetes (≥ 20 years) among Arabs and Jews in Israel. METHODS: Participants (n = 1100) were randomly selected from the urban population of the Hadera District in Israel. The study sample was stratified into equal groups according to sex, ethnicity (Arabs and Jews) and age. Information on age at diabetes presentation, family history of diabetes, history of gestational diabetes, socio-demographic and lifestyle characteristics was obtained through personal interviews. Self reports of diabetes were compared with medical records and were found reliable (κ = 0.87). The risk for diabetes was calculated using Kaplan-Meier survival analysis. Factors associated with diabetes in both ethnic groups were studied using Cox proportional hazard model. RESULTS: The prevalence of adult-onset diabetes was 21% among Arabs and 12% among Jews. Arab participants were younger than Jews at diabetes presentation. By the age of 57 years, 25% of Arabs had diagnosed diabetes; the corresponding age among Jews was 68 years, a difference of 11 years (P < 0.001). The greater risk for diabetes among Arabs was independent of lifestyle factors, family history of diabetes and, among women, history of gestational diabetes; adjusted hazard ratio 1.70; 95% confidence interval 1.19-2.43. CONCLUSIONS: Arabs in Israel are at greater risk for adult-onset diabetes than Jews and are younger at diabetes presentation. Culturally sensitive interventions aimed at maintaining normal body weight and active lifestyle should be targeted at this population. Possible genetic factors and gene-environmental interactions underlying the high risk for diabetes among Arabs should be investigated.

Comparison of modified preadmission glucose-lowering regimen with basal/bolus regimen for glucose control on outcome in general medicine wards.

BACKGROUND: It is undecided whether glucose control as advocated by the professional organisations and the glucose-lowering method by itself affects clinical outcome in patients with diabetes mellitus hospitalised in general medical wards. Our aim was to investigate whether a basal/bolus regimen and a modified prehospitalisation regimen have a different impact on the clinical diabetic patients in general medicine wards. METHODS: Glucose control of patients with diabetes hospitalised in two different wards of internal medicine was achieved according to their wards' policy: a modified preadmission regimen (conventional regime) or a basal/bolus regimen (intensive regime). Death and any adverse event were determined during hospitalisation and within 6 months after discharge to assess clinical outcome. RESULTS: Median fasting and daily glucose levels were similar in the conventional (n = 116) and intensive regime (n = 129) groups: 161 mg/dl (inter-quartile range: 138-201) and 176 mg/dl (152-215) vs. 155 mg/dl (133-208) and 173 mg/dl (146-208) respectively. Clinical outcome was not affected by the treatment modality. In the subgroup of patients hospitalised with infection, the median fasting glucose was significantly lower in the interventional compared with the conventional regime: 141 and 172 mg/dl respectively (p = 0.041). However, tighter control was associated with a significantly higher incidence of adverse events within 6 months after discharge: 48.9% and 21.4% respectively (p = 0.047). CONCLUSION: In general medicine wards, modified prehospital hypoglycaemic regimens and a basal/bolus insulin regimen achieve similar glucose control. The clinical outcome was not affected by the modality of glucose control.

Risk factors for development of diabetic nephropathy and retinopathy in Jewish IDDM patients.

Risk factors associated with diabetic microvascular complications, with special reference to ethnic origin, were looked for in 231 young Jewish insulin-dependent diabetes mellitus (IDDM) patients with duration of diabetes greater than or equal to 10 yr. Median age at diagnosis of diabetes was 9.2 yr (range 0.04-26.2 yr), and median duration of the disease was 15.3 yr (range 10.0-37.2 yr). Sixty-three percent of the patients were Ashkenazi Jews, and 37% were non-Ashkenazi Jews. HbA1 was evaluated every 3 mo in the last 10 yr of follow-up, and albumin excretion rate was tested in three 24-h urine collections. Direct and indirect ophthalmoscopy was performed every year since diagnosis of diabetes, and if retinal pathology was suspected, color photographs were taken. Microalbuminuria was detected in 31% and macroalbuminuria in 7% of the patients. Nonproliferative and proliferative retinopathy was found in 44 and 12% of the patients, respectively. On logistic regression analysis, two variables were significantly and independently associated with diabetic nephropathy--non-Ashkenazi origin and mean HbA1 values over the first 5 of 10 yr of follow-up. Variables significantly and independently related to diabetic retinopathy were non-Ashkenazi origin, mean HbA1 values over the last 10 yr of follow-up, and duration of diabetes. Because non-Ashkenazi Jews in Israel are of lower socioeconomic status than Ashkenazi Jews, we stratified our patients according to their socioeconomic parameters, median HbA1 values, and duration of diabetes. Non-Ashkenazi patients were at a higher risk to develop complications in all strata.(ABSTRACT TRUNCATED AT 250 WORDS)

A clinical model for diagnosis of urinary tract infection in young women.

To develop a clinical model for diagnosis of bacterial urinary tract infection, we conducted a prospective study on 266 dysuric young women, 147 of whom had urinary tract infections. Five variables were found to be significant and independent correlates to bacterial urinary tract infection on logistic regression analysis: sexual activity, absence of vaginal discharge, short duration of complaints, leukocyturia, and hematuria. An algorithm combining the logistic model and a Gram-stained urine specimen, which was used in only a third of our patients, afforded a sensitivity of 86% and a specificity of 84%. The algorithm was validated in a second set of 166 dysuric women, 77 of whom had urinary tract infections. The algorithm led to a diagnosis of bacterial urinary tract infection with a sensitivity of 91% and specificity of 79%; the only laboratory test needed except for urinalysis was a Gram's stain of urine, obtained for 30% of the patients.

Urinary tract infections and sexual activity in young women.

A group of 147 young women with symptomatic urinary tract infection (UTI) were compared with a control group of 105 symptom-free young women belonging to the same population. On logistic-regression analysis, sexual activity was the only significant and independent behavioral difference between the groups (87% of women with UTI were sexually active vs 32.7% of the control group). Of the 147 episodes of UTI, only 28.9% occurred within 24 hours of sexual intercourse; of 24 episodes that occurred during follow-up, the percentage that occurred within 24 hours of intercourse was 33.3%. This finding is in discordance with the close temporal association between UTI and sexual intercourse reported in previous studies.

Bacteremia in adult diabetic patients.

OBJECTIVE: To compare the microbiology, sources, complications, and outcome of bacteremia in diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS: A prospective study was conducted of all episodes of bacteremia in hospitalized diabetic and nondiabetic patients. The study consisted of patients greater than or equal to 18 yr of age with bacteremia detected within a 19-mo interval. RESULTS: We compared 124 episodes of bacteremia in 119 diabetic patients to 508 episodes in 480 nondiabetic patients. Diabetic patients were older than nondiabetic patients (median age 74 vs. 68 yr, P = 0.0001). In patients with an indwelling urinary catheter and bacteremic urinary tract infection, the percentage of Klebsiella in diabetic patients was 60% (6 of 10) and in nondiabetic patients was 17% (4 of 23, P = 0.04). In patients without an obvious source of bacteremia, the percentage of staphylococcal isolates in diabetic patients was 29% (10 of 35) and in nondiabetic patients was 14% (24 of 176, P = 0.04). Staphylococci were a common cause of bacteremic infections of the extremities in diabetic patients (12 of 19, 63%) and nondiabetic patients (20 of 50, 40%). Septic shock was the only complication that was more common in diabetic patients. The mortality in diabetic and nondiabetic patients was 28 and 29%, respectively. CONCLUSIONS: Our results represent elderly patients with non-insulin-dependent diabetes mellitus. In this group, empirical treatment for suspected bacteremic urinary tract infection in patients with a urinary catheter should include coverage for Klebsiella. Empiric treatment for suspected bacteremia of unknown origin or caused by infection of the extremities should include an antistaphylococcal drug. The prognosis of bacteremia in diabetic and nondiabetic patients was similar.

Thyrotoxicosis in prepubertal children compared with pubertal and postpubertal patients.

The course of Graves' thyrotoxicosis in 7 prepubertal children (6.4+/-2.4 yr) was compared with that in 21 pubertal (12.5+/-1.1 yr) and 12 postpubertal (16.2+/-0.84 yr) patients. In the prepubertal group the main complaints were weight loss and frequent bowel movements (86%), whereas typical symptoms (irritability, palpitations, heat intolerance, and neck lump) occurred significantly less often (P < 0.01). The most prominent manifestation at diagnosis was accelerated growth and bone maturation: their height SD score was significantly greater than that of the pubertal and postpubertal patients (2.6+/-0.7 us. 0.15+/-0.65 and 0.15+/-0.9, respectively, P < 0.001), and their bone age to chronological age ratio was 1.39+/-0.35 compared with 0.98+/-0.06 in the pubertal children (P = 0.02). T3 levels were also significantly higher than in the other two groups (9.9+/-2.9 nmol/L vs. 6.32+/-1.9 nmol/L and 6.02+/-2.0 nmol/L, P = 0.01). All patients were initially prescribed antithyroid drugs (ATDs). Overall, adverse reactions to ATDs occurred in 35%, with a higher rate among the prepubertal children (71%) than the pubertal (28%) and postpubertal (25%) patients (P = 0.08). Major adverse reactions were noted in two children, both prepubertal. Remission was achieved in 10 patients (28%). Although the rate of remission did not differ among the three groups, time to remission tended to be longer in the prepubertal children (P = 0.09). In conclusion, thyrotoxicosis has an atypical presentation and more severe course in prepubertal children. Considering their adverse reactions to ATD, overall low remission rate, and long period to remission, definitive treatment should be considered earlier in this age group.

A statistical comparison of different family history scores.

Family history (FH) scores are used for estimating the familial risk (FR), i.e. the level of risk for a particular disease among members of that family. An FH score is created from reports about the disease status of the relatives in each family. The most commonly used score is the dichotomous score (positive when at least one relative is affected), which does not consider the family size, number of affected relatives nor each relative's risk factor profile. Authors have proposed many other FH scores that overcome these deficiencies by using external expected risks adjusted for important risk factors. We consider the use of FH scores in studies, which investigate risk factors for a disease and where family risk is considered as a confounder, and examine through simulations the performance of a variety of FH scores in controlling the FR status. We also examine performance in predicting true FR status. For both criteria, only small differences were found between most of the FH scores, although the dichotomous score performed the poorest. Since the proportion score (the proportion of first-degree relatives of the index who have the disease) is the simplest to calculate, use of this score seems to be justified.

Characteristics of urinary tract infection caused by coagulase-negative Staphylococcus in a group of young women.

Of 147 young women, aged 17 to 34 years, with signs, symptoms and bacteriological evidence of urinary tract infection (UTI), 23 (15.6%) had an infection caused by coagulase-negative Staphylococcus (coag- neg Staph). All patients with coag- neg Staph UTI were sexually active, in contrast to 84.7% of those with UTI of other causes (one-tailed P = 0.03). The former had a higher rate of vaginal discharge (60.9 vs. 25.8% in the latter group, P = 0.003), but fewer of them used tampons as menstrual protection or oral contraceptives. A high percentage of women with coag- neg Staph UTI had commenced sexual activity recently, as compared with the rest of the group (P = 0.03). In a stepwise logistic regression analysis, the only variables that were significantly associated with coag- neg Staph UTI were vaginal discharge and recent onset of sexual activity.

PIP: Of 147 young women ages 17-34 with signs, symptoms, and bacteriological evidence of urinary tract infection (UTI), 23 (15.6%) had an infection caused by coagulase-negative Staphylococcus (coag-neg Staph). All patients with coag-neg Staph UTI were sexually active in contrast to 84.7% of those with UTI from other causes (1 tailed, P=.03). The former had a higher rate of vaginal discharge (60.9 vs. 25.8% in the latter group, P=.003), but fewer of them used tampons as menstrual protection or oral contraceptives. A high percentage of women with coag-neg Staph UTI had commenced sexual activity recently, as compared with the rest of the group (P=.03). In a stepwise logistic regression analysis, the only variables that were significantly associated with coag-neg UTI were vaginal discharge and recent onset of sexual activity.

An outbreak of measles among young adults. Clinical and laboratory features in 461 patients.

We report the clinical and laboratory characteristics of measles infection in an unselected group of 461 young adults. Otitis media was diagnosed in 9.8%, sinusitis in 4.1%, pneumonia in 3.7%, and keratitis in 3.3% of the patients. Minor T-wave changes on electrocardiogram were observed in only 0.7% and jaundice in 0.4%. Elevated liver enzymes were found in 51% of the patients. Creatine kinase (CK) MM fraction was high in 44%. Traces of myoglobin were found in the urine of 14% of those with a high CK, and of the 13 patients with the higher CKs, 12 had an abnormal serum aldolase. We emphasize several points of interest in this large and unselected group of young adults. There was 1) possible evidence of rhabdomyolisis in some of our patients; 2) a lower rate of electrocardiogram abnormalities than previously reported; 3) no evident correlation between initial laboratory values and subsequent complications; and 4) lack of a clinical or laboratory difference between patients who had been vaccinated with an attenuated virus during childhood and those who had not.

Genetic predisposition to hypertension (as detected by Na+/Li+ countertransport) and risk of diabetic nephropathy in childhood diabetes.

In order to evaluate whether insulin-dependent diabetes mellitus patients with incipient nephropathy have an overactivity of erythrocyte sodium-lithium countertransport (Na+/Li+ CT), 82 diabetic children and 38 healthy age-matched control subjects and their parents and grandparents were studied. The children were divided into two groups according to the presence of persistent microalbuminuria (MA). Diabetic children with MA had Na+/Li+ CT activity higher than normoalbuminuric diabetics and healthy controls. The parents and grandparents of microalbuminuric patients showed higher Na+/Li+ CT than parents and grandparents of normoalbuminuric diabetics and of the controls. This study demonstrates that predisposition to hypertension, as indicated by increased Na+/Li+ CT activity in erythrocytes, is more frequently detectable in patients with persistent microalbuminuria than in diabetics without persistent microalbuminuria or in healthy controls. Overactivity of Na+/Li+ CT is present also in parents and grandparents of diabetic children with MA. This study suggests that genetic predisposition to hypertension is more frequent in patients at risk of developing diabetic nephropathy, as well as in their parents and grandparents.

Factor analysis of thermal and vibration thresholds in young patients with Type 1 diabetes mellitus.

AIMS: To identify factors that represent relationships among sets of interrelated thermal and vibration threshold variables and to find clinical correlates that are significantly associated with these factors. METHODS: Thermal and vibration perception thresholds were tested in the hands and feet of Type 1 diabetic patients treated in an outpatient clinic for juvenile-onset diabetes. Factor analysis was used to identify factors that represent relationships among sets of thermal and vibration threshold variables. RESULTS: One hundred and forty-eight patients (47.3% males, median current age 22.3 years and median duration of diabetes 11.4 years) were evaluated. Three factors explained 77% of the total variance: 'hand sensation' factor, underlying cold, warmth and vibration perception thresholds in the hand; 'foot sensation' factor, underlying the same sensory thresholds in the foot; and 'heat-related pain' factor, underlying heat pain perception threshold in both limbs. The 'foot sensation' factor was the only factor that significantly correlated with diabetes-related variables (e.g. duration and cumulative glycaemic control of the disease) and concurrent diabetic microangiopathy. Male sex was associated with higher values of the 'heat-related' factor, while the 'hand sensation' factor did not correlate with any of the study variables. CONCLUSIONS: The distribution of the various thermal and vibration threshold variables according to the three factors may point at length-dependent mechanism of axonal degeneration. Cold, warmth and vibration perception thresholds in the foot may be the only valuable psychophysical parameters in the evaluation of early sensory impairment associated with diabetes.

Sodium-lithium countertransport: a predictor of diabetic nephropathy in Jewish insulin-dependent diabetes mellitus patients of different ethnic origin?

Diabetic nephropathy in Jewish insulin-dependent diabetes mellitus (IDDM) patients has been found to correlate to their ethnic origin. It has also been found that increased sodium-lithium countertransport (SLC) in erythrocytes, as a genetic marker for essential hypertension, may identify those patients at risk for diabetic nephropathy. The purpose of this study was to investigate a possible correlation between this genetic marker and the ethnic origin of Jewish IDDM patients and their parents and the risk for developing diabetic nephropathy. Although SLC was slightly increased in IDDM patients with microalbuminuria, SLC was not correlated with the existence of diabetic nephropathy nor with the ethnic origin and blood pressure of these Jewish IDDM patients. Thus, other genetic factors may play a role in the different prevalence of diabetic nephropathy in Jewish IDDM patients of different ethnic origin.

The development and progression of diabetic retinopathy in type I diabetic patients: a cohort study.

To describe the course and risk factors for development and progression of retinopathy, we studied a cohort of 333 Israeli Jewish patients with Type 1 (insulin-dependent) diabetes mellitus. The median age at diagnosis was 9.5 (range 0.04-26.2) years and the median duration of follow-up was 14 (range 1.6-30) years. Evaluation of both retinae was performed yearly since referral and HbA1 values were tested every 3 months since 1978. During a follow-up of 4070 patient-years, 162 patients developed non-proliferative retinopathy. The median retinopathy-free interval was 14.9 years and after 30 years all patients were affected. Pre-pubertal duration of diabetes was relevant. Independent and significant risk factors for early onset of non-proliferative retinopathy were: poor cumulative glycaemic control (median retinopathy-free interval in the 1st vs 4th quartiles of mean HbA1 values over all years: 18.0 vs 12.5 years, p = 0.0001); onset of diabetes during or after puberty (median retinopathy-free interval in patients with onset of diabetes before, during or after pubescence: 16.3, 13.2 and 14.0 years, respectively, p = 0.0001); and non-Ashkenazi Jewish origin (median retinopathy-free interval 15.8 years in Ashkenazi vs 14.0 in non-Ashkenazi patients, p = 0.0004). Of 162 patients with non-proliferative retinopathy, progression to proliferative retinopathy occurred in 37, during 707 patient-years. The first event of proliferative retinopathy was diagnosed within the 1st year after non-proliferative retinopathy evolved, and at 6.3 years since onset of non-proliferative retinopathy 75% of the patients were still free of proliferative changes. Risk factors significantly and independently associated with an early progression to the proliferative stage were: poor glycaemic control in the last 3 years prior to the development of proliferative retinopathy and non-Ashkenazi Jewish origin. All patients in the 4th quartile of HbA1 values were affected by proliferative retinopathy within 11.6 years after onset of non-proliferative retinopathy.