Comparison of insulin analogue regimens in people with type 2 diabetes mellitus in the PREFER Study: a randomized controlled trial.

AIMS: Insulin analogues are widely used but few data exist comparing different analogue regimens. We compared two such regimens in type 2 diabetes mellitus (T2DM) uncontrolled by oral antidiabetic agents (OADs) with or without basal insulin. METHODS: In a 26-week multinational, multicentre, randomized treat-to-target trial, OADs were discontinued and subjects randomized to analogue basal-bolus therapy (insulin detemir once daily and insulin aspart mealtimes) or biphasic insulin aspart 30 (30% rapid-acting insulin aspart), twice daily. Insulin was titrated to targets for fasting, predinner and postprandial plasma glucose (PG), as appropriate. RESULTS: Of 719 subjects, 92% completed the study; 58% achieved haemoglobin fraction A(1c) (HbA(1c)) < or =7.0%, with reductions of 1.56% (to 6.96%) with basal-bolus therapy and 1.23% (to 7.17%) with biphasic insulin aspart. Reduction with basal-bolus therapy was superior in the overall population by 0.23% (p = 0.0052), with no difference between regimens in insulin-naive patients. Major hypoglycaemia occurred in five basal-bolus patients (0.9%) and in no patients with biphasic insulin aspart. Incidence of minor hypoglycaemia was similar in both groups. All insulin doses increased during titration, with increase in lunchtime insulin aspart dose and equal distribution of breakfast and dinner biphasic insulin aspart doses. Insulin detemir remained once daily in 87% of patients. CONCLUSIONS: Modern insulin analogue regimens, adjusted to PG targets, enable a majority of people with T2DM to reach HbA(1c)< or =7.0% after failure of OADs and OAD-basal insulin therapy. Insulin-treated patients may benefit more from transfer to analogue basal-bolus therapy, while insulin-naive individuals benefit equally well from the more convenient biphasic analogue regimen.

Transmyocardial laser revascularisation has no beneficial effect on high energy phosphates and lactate content during acute myocardial ischaemia in pigs.

OBJECTIVE: Transmyocardial laser revascularisation (TMLR) is used to treat endstage coronary heart disease. There is evidence that angina is significantly reduced after TMLR. However, the precise mechanism by which symptoms disappear remains unknown. The objective of the present study was to examine the potential effects of TMLR on high-energy phosphates and myocardial perfusion in an acute ischaemic model. METHOD: Five male landrace pigs (42 +/- 1.8 kg) had TMLR of the anterolateral wall of the left ventricle using a 1000 W CO2 laser (PLC, USA). Thereafter the anterior descending coronary artery was occluded with a tourniquet. After 90 min of ischaemia, drill-biopsies were taken from ischaemic and non-ischaemic areas as well as from laser channels. The specimens were snap-frozen in liquid nitrogen. Subsequently, methylene blue was injected into the left atrium to study tissue distribution. The hearts were excised and the patency of channels was examined visually. RESULTS: Coronary artery occlusion resulted in immediate blue discoloration in both TMLR and control areas. There was no subendocardial methylene blue staining around laser channels. Inspection of hearts showed occlusion of laser channels due to thrombus formation at both endo- and epicardial levels. ATP-metabolites significantly increased in ischaemic areas compared to non-ischaemic areas. Furthermore there was significant upregulation of purine-content in ischaemic regions even in areas with laser channels. CONCLUSIONS: In our acute model there was early occlusion of the channels after TMLR. We suggest that clinical improvement after this procedure is not due to increased myocardial oxygen delivery, since high energy phosphate levels and lactate content remained unchanged.

[Amiodarone and thyroid function: clinical implications]. / Amiodarone et fonction thyroïdienne: quelle attitude pratique?

World-wide, the incidence of amiodarone-induced thyroid dysfunction is estimated to be between 2% and 24%. More than 50% of patients who receive long-term amiodarone have abnormal results on thyroid function tests. However, most of these patients are euthyroid. In a euthyroid amiodarone-treated patient, an increase in serum thyroxine levels (total and free) and in serum reverse T3 levels and a decrease in serum T3 levels (total and free), are observed. TSH levels are within the normal range with chronic treatment (more than 3 months). The aim of this study was to identify the frequency of amiodarone prescription by cardiologists, to learn about their clinical practice in screening for thyroid dysfunction, and to formulate guidelines for clinical investigation of thyroid function before and during amiodarone treatment. A questionnaire was sent to 27 cardiologists in private practice in the Geneva area and to 12 cardiologists in Geneva University Hospital (19 and 7 questionnaires returned respectively). Cardiologists in private practice prescribe amiodarone quite frequently (once to twice per month and more). Clinical investigation prior to treatment involves history (95%), clinical examination (63%) or thyroid function tests (37% routinely, 16% where there is clinical suspicion of thyroid dysfunction). Thyroid function is investigated by determination of TSH (100%), free T4 (68%), free T3 (50%), total T3 (32%) or total T4 (26%). Antithyroid antibodies are measured only by 10% of the cardiologists in private practice. Cardiologists would restrict amiodarone prescription in cases of clinical hyperthyroidism (90%), clinical hypothyroidism (74%), in the presence of goitre in a hyper- or hypothyroid patient (79 and 63% respectively), and if antithyroid antibodies were positive (32%). During amiodarone treatment 84% of cardiologists in private practice repeat thyroid function tests occasionally and 16% only in the presence of clinical signs. Hypothyroidism is a reason for withdrawing amiodarone treatment for 58% of the cardiologists and 37% would prescribe substitution. Hyperthyroidism is a reason for immediately suspending treatment for 90% of the cardiologists, only 5% would continue and 16% would prescribe antithyroid drugs. In conclusion, there is considerable divergence of opinion among cardiologists concerning investigation and interpretation of thyroid function before and during amiodarone treatment. Simple and practicable guidelines are needed.

Interactions of insulin-like growth factor I with dexamethasone on trabecular bone density and mineral metabolism in rats.

Glucocorticoid treatment causes osteoporosis and growth retardation in humans. Insulin-like growth factor I (IGF-I) stimulates differentiation and replication of cultured osteoblast-like cells and induces longitudinal bone growth in IGF-I-deficient rats. We investigated the influence of subcutaneously infused IGF-I on bone and mineral metabolism of male rats treated with a high dose of dexamethasone. Dexamethasone was added to the drinking water in a concentration of 1 mg/l. After 30 days of dexamethasone treatment, recombinant human IGF-I (300 micrograms/day) or solvent was infused sc by osmotic minipumps for 21 days while dexamethasone was continued. Age-matched untreated male rats served as healthy controls. Dexamethasone-treated rats lost weight. Their IGF-I levels were decreased to 36% of healthy controls. Infusion of IGF-I resulted in an increase in IGF-I serum levels (582% compared to healthy controls) and allowed some weight gain. Osteocalcin and calcitriol levels were markedly decreased in dexamethasone-treated rats and were not influenced significantly by IGF-I infusion. In contrast, IGF-I treatment restored the free calcitriol concentration (molar ratio of calcitriol to vitamin D-binding protein) towards normal. Furthermore, infusion of IGF-I partially corrected the dexamethasone-induced hyperinsulinemia. Histomorphometric analysis revealed no difference in vertebral trabecular bone density (i.e. growth-independent bone remodeling) between the three groups. In contrast, mean trabecular bone density in tibial metaphyses was increased markedly by dexamethasone, presumably due to osteoclast inhibition. Insulin-like growth factor I infusion did not significantly influence these structural metaphyseal bone parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

Repopulation of the atrophied thymus in diabetic rats by insulin-like growth factor I.

Atrophy of the thymus is one of the consequences of severe insulin deficiency. We describe here that the weight and the architecture of the thymus of diabetic rats is restored towards normal not only by insulin but also by insulin-like growth factor I (IGF-I) treatment. In contrast to insulin, this effect of IGF-I occurs despite persisting hyperglycemia and adrenal hyperplasia. We also investigated the in vivo effect of IGF-I on replication and differentiation of thymocytes from streptozotocin-induced diabetic rats. Thymocytes from diabetic rats incorporated less [3H]thymidine than did thymocytes from healthy rats. Insulin, as well as IGF-I treatment of diabetic rats increased [3H]thymidine incorporation by thymocytes. Flow cytometry of thymocytes labeled with monoclonal antibodies revealed a decreased expression of the Thy-1 antigen in diabetic rats compared with control rats. In addition, a major deficiency of thymocytes expressing simultaneously the W3/25 and the Ox8 antigens (corresponding to immature human CD4+/CD8+ thymocytes) was observed. These changes were restored towards normal by insulin as well as by IGF-I treatment. The antibody response to a T cell-dependent antigen (bovine serum albumin) was comparable in normal and diabetic rats. We conclude that IGF-I has important effects on the thymocyte number and the presence of CD4+/CD8+ immature cells in the thymus of diabetic rats despite persisting hyperglycemia. However, helper T-cell function for antibody production appears to be preserved even in the severely diabetic state.

Therapeutic potential of insulinlike growth factor i.

Human recombinant insulinlike growth factor I is a promising therapeutic agent for diseases characterized by relative insulin resistance, e.g., diabetes mellitus, obesity, and hypertriglyceridemia, since it suppresses growth hormone, insulin, C-peptide, and triglyceride levels and lowers the total cholesterol to high-density lipoprotein-cholesterol ratio. Moreover, insulinlike growth factor administration increases kidney function in healthy subjects (glomerular filtration rate, renal plasma flow) and may prove useful in the treatment of degenerative disorders of cartilage and bone (arthrosis, osteoporosis) as well as in catabolic states.

The role of insulin-like growth factor I in growth of diabetic rats.

Insulin-deficient, streptozotocin-diabetic rats show severe metabolic disturbances and stop growing. Besides insulin, these animals also lack growth hormone and insulin-like growth factor-I. We examined whether or not growth parameters correlate with IGF-I serum levels in young rats with streptozotocin-diabetes of different severity. In the diabetic rats, blood glucose varied between 18.4 and 38.6 mmol/l (healthy controls between 6.1 and 9.3), IGF-I serum levels between 2.6 and 15.6 nmol/l (controls between 19.6 and 26.5), and serum insulin levels between 0.05 and 0.14 nmol/l (controls between 0.36 and 0.55). We found a highly significant linear correlation between IGF-I serum levels and the two investigated growth parameters, tibial epiphyseal width and longitudinal tibial bone growth. The finding that these indices of growth are strongly correlated with IGF-I serum levels in young rats with diabetes of different severity, suggests that IGF-I is a major determinant of growth. This is in keeping with our earlier demonstration that exogenously infused IGF-I promotes growth in diabetic rats.

Small stature and insulin-like growth factors: prolonged treatment of mini-poodles with recombinant human insulin-like growth factor I.

The short stature of mini-poodles is associated with low serum levels of IGF-I. Standard poodles are taller and have considerably higher serum levels of IGF-I. Low IGF-I serum levels may be a symptom or the cause of small stature. We, therefore, undertook a study in which serum IGF-I levels of mini-poodles were elevated over a prolonged period of time by a constant infusion of rhIGF-I and the growth rate of the mini-poodles was followed. We infused four mini-poodles from day 91 to day 221 of age with 6 mg/day of recombinant human insulin-like growth factor I (rhIGF-I). Serum levels of IGF-I rose from about 160 to about 500 micrograms/l. Blood glucose remained within normal limits. Stimulation tests with clonidine and with GHRH revealed suppression of endogenous GH secretion during the IGF-I infusion. Serum levels of IGF-II and of creatinine were lower in the IGF-I-infused animals. Radial length and body weight did not increase to a greater extent in the IGF-I infused dogs than in controls. However, 'adapted body mass index' (aBMI = gram body weight/(mm radial length)2) decreased in each of the IGF-I infused animals, whereas it increased in each of the control dogs (p less than 0.05). We conclude that long-term infusion of IGF-I does not stimulate growth in young mini-poodles, but may change body composition.

Regulation of hepatic expression of IGF I and fetal IGF binding protein mRNA in streptozotocin-diabetic rats.

Hepatic mRNA levels of insulin-like growth factor I (IGF I) and of the fetal, nonglycosylated 32 kDa IGF-binding protein (BP) were analysed in diabetic, diabetic insulin- and IGF I-treated rats as well as in age-matched, healthy control animals. IGF ImRNA levels are reduced in diabetic rats and increased by insulin treatment. In contrast, the infusion of IGF I does not significantly upregulate IGF I mRNA levels. Fetal IGF BP mRNA expression is very low in healthy control animals, but high levels are found in diabetic rats. Insulin therapy lowers fetal IGF BP mRNA levels, whereas IGF I has no effect. We propose that insulin is a major regulator of the 32 kDa IGF BP levels in adult rats.

Recombinant human insulin-like growth factor I induces its own specific carrier protein in hypophysectomized and diabetic rats.

The physiology of the specific serum binding proteins which constitute the main storage pool for insulin-like growth factors (IGFs) in mammals is still incompletely understood. We have, therefore, investigated the regulation of these proteins in (i) hypophysectomized (hypox) rats infused with recombinant human growth hormone (rhGH) or recombinant human IGF 1 (rhIGF I) and (ii) streptozotocin-diabetic rats infused with insulin or rhIGF I. The main carrier protein, a GH-dependent complex of apparent molecular mass 200 kDa, contains N-glycosylated IGF-binding subunits (42, 45, and 49 kDa) that differ in their glycosyl but not in their protein moiety. These subunits are lacking in hypox and diabetic rats. They are induced by GH and insulin, respectively, and appear in the 200-kDa complex. Infusion of rhIGF I induces the subunits in both states; however, only in diabetic, not in hypox, rats do they form the 200-kDa complex. Glycosylated carrier protein subunits do not appear before 8 hr of rhIGF I infusion. During that period, hypox rats may become severely hypoglycemic. After 16 hr, glycosylated subunits are clearly induced, and blood sugar values are normal. We conclude: (i) The N-glycosylated subunits of the 200-kDa complex reflect the IGF I status. (ii) IGF I may mediate the induction of these subunits by GH. (iii) Significant association to the 200-kDa complex occurs only in the presence of GH. It is likely that GH, but not IGF I, induces a component, which itself does not bind IGF, but associates with the glycosylated IGF-binding subunits. (iv) The glycosylated subunits protect against IGF-induced hypoglycemia and may be involved in tissue-specific targeting of IGFs.

The anti-arrhythmic effects of myocardial ischaemia. Relation to reperfusion arrhythmias?

Ventricular tachycardia was induced in the intact non-ischaemic pig heart by intramyocardial or intracoronary infusions of noradrenaline or N6, O2'-dibutyryl-cAMP. The chemically induced tachycardia was consistently stopped within 10 to 30 s by occluding the coronary artery supplying the infusion area. This ischaemic effect was readily reversed by coronary reperfusion, with ventricular tachycardia resuming within seconds after release of the occlusion. In contrast to the immediate effect of myocardial ischaemia, it took several minutes for the tachycardia to cease after the infusion of arrhythmogenic compounds was stopped. Pacing experiments showed that the effect of myocardial ischaemia on ventricular tachycardia was probably not due to a conduction block. The anti-arrhythmic property of myocardial ischaemia was separate from its known effect of decreasing the ventricular fibrillation threshold for electrical stimulation. The increased vulnerability of the acutely ischaemic myocardium to fibrillation was apparent in experiments in which ectopic activity was induced in the non-ischaemic part of the myocardium. In these experiments ventricular fibrillation consistently ensued within 6 min following distal occlusion of the anterior descending coronary artery. By contrast, ventricular fibrillation was not precipitated by coronary artery occlusion or local infusion of arrhythmogenic compounds alone. Cyclic AMP was shown to accumulate in ischaemic myocardium. An association existed between cAMP accumulation and the intensity of early ischaemic arrhythmias as well as reperfusion arrhythmias. The highest incidence of ventricular fibrillation was found during reperfusion, at peak myocardial cAMP levels. These findings suggest: (1) Noradrenaline and dibutyryl-cAMP exert arrhythmogenic effects preferentially in the intact, non-ischaemic myocardium, the effects being attenuated in ischaemic myocardium by a paradoxical anti-arrhythmic effect of ischaemia. (2) In the acutely ischaemic heart, ventricular fibrillation may be precipitated by the emergence of ectopic activity outside the ischaemic area. (3) Arrhythmias and fibrillation occurring early after reperfusion may be caused by unmasking the effects of excitants (eg, noradrenaline or cAMP) arising during the antecedent period of ischaemia.

Influence of collateral blood flow and of variations in MVO2 on tissue-ATP content in ischemic and infarcted myocardium.

The left anterior descending coronary artery was occluded for 22.5, 45, 90, 180, and 360 mins in anesthesized open-chest dogs and pigs and thereafter reperfused for 30 min. Myocardial oxygen consumption was varied in dogs by cholinergic stimulation (bradycardia) and by cutting of the right and left vagus nerve (tachycardia). Regional myocardial blood flow was measured with radioactive tracer microspheres at the end of the occlusion period and 5 and 30 min after reflow. Tissue content of adenine nucleotides and of phosphocreatine were determined in the subendo- and subepicardium of transmural biopsies at the end of reflow. Infarct size was determined with nitrobluetetrazolium and compared with risk region size. Porcine hearts developed infarcts sooner. Those canines with a high MVO2 due to tachycardia had larger infarcts than those with bradycardia and resembled infarct development in the pig. The evolution of infarcts with time depended strongly on collateral flow which was significantly higher in canine hearts. Higher collateral flow and lower MVO2 in one group of canine hearts also resulted in better preserved tissue ATP. The fall in tissue ATP with time after coronary occlusion was compared with the O2-supply via collateral flow during occlusion. Assuming that the oxygen entering ischemic myocardium was used for ADP phosphorylation, we could estimate the degree of ATP-"overspending". Overspending was highest in low-flow ischemia and it correlated well with the speed of infarction. The ATP-data are best explained by the phosphocreatine energy shuttle model and by assuming slow access of cytosolic ATP to the ATP-splitting sites at the myofibrils. In conclusion, we postulate that both collateral flow as well as myocardial oxygen consumption before and during occlusion determine infarct size.

Glass capillary gas chromatography of the serum fatty acid fraction via automatic injection of lipid extracts.

The combination of a consecutive double capillary column gas chromatographic system (Deans type) with a fully automatic injection device was developed to determine quantitatively the fatty acid fraction of serum extracts, without prior removal of the other lipids. A major difficulty arose through ghosting (memory), via reaction of methylating reagents with lipid deposits, mainly in the injection port. Use of diazomethane circumvented this, as the reagent was easily removed prior to analysis. The combination methyl iodide--potassium carbonate, convenient handling of which requires coinjection of methyl iodide, proved to be less than completely dependable. Dimethylformamide dimethylacetal is completely out of the question as a coinjectant. Lipid deposits in the injection port produced peak area drifts which could, however, be counteracted. The apparatus is capable of analyzing samples completely unattended for at least 20 hours (80 samples). It has been operated non-stop, day and night, for between 4 and 7 days with occasional reloading and servicing.