The use of broad-range bacterial PCR in the diagnosis of infectious diseases: a prospective cohort study.

OBJECTIVES: Broad-range PCR has the potential to detect virtually any bacterial species via amplification and nucleotide sequencing of a DNA region common to all bacteria. We aimed to evaluate its usefulness and clinical relevance when applied to a wide variety of primary sterile materials. METHODS: A prospective study including 1370 samples (75 heart valves, 151 joint tissue samples, 230 joint aspirates, 848 whole blood samples and 66 culture-negative cerebrospinal fluid samples) were studied by using a commercial PCR system for detecting 16S rDNA (Molzym). The PCR results were compared with culture and were considered to provide added diagnostic value only if the PCR approach revealed new pathogens that were missed by culture. RESULTS: The added value of PCR was evident in 173 of 555 PCR-positive samples (0.126; 0.109-0.144 (proportion from all tested samples; 95% confidence interval)), most frequently in examinations of heart valves (0.56; 0.448-0.672) and joint tissue samples (0.219; 0.153-0.284). In contrast, the lowest rate of PCR with added value was noted for blood samples, regardless of the patient cohort they had been drawn from (nononcologic patients from intensive care: 0.065; 0.043-0.087, haematooncologic children: 0.048; 0.027-0.070). Moreover, PCR missed up to 7.1% of blood culture findings (0.071; 0.048-0.095) regarded as clinically relevant, which was the second highest failure rate after joint tissue samples (0.099; 0.052-0.147). CONCLUSIONS: Broad-range PCR substantially increases detection rate of pathogens, especially from heart valves and joint samples. However, a concurrent risk of false-negative PCR results justifies the need for parallel culture.

A missense variant in GLP1R gene is associated with the glycaemic response to treatment with gliptins.

Gliptins act by increasing endogenous incretin levels. Glucagon-like peptide-1 receptor (GLP1R) and glucose-dependent insulinotropic peptide receptor (GIPR) are their indirect drug targets. Variants of GLP1R and GIPR have previously been associated with the incretin effect. The aim of the present pilot study was to examine associations of the GLP1R and GIPR gene variants with the glycaemic response to gliptins. A total of 140 consecutive patients with type 2 diabetes were followed-up 6 months after initiation of gliptin treatment. GLP1R rs6923761 (Gly168Ser) and GIPR rs10423928 genotyping was performed using real-time PCR, with subsequent high-resolution melting analysis. The main study outcome was reduction in glycated haemoglobin (HbA1c) after treatment. GLP1R Gly168Ser variant was significantly associated with reduction in HbA1c in an additive model (ß = -0.33, p = 0.011). The mean reduction in HbA1c in Ser/Ser homozygotes was significantly lower compared with Gly-allele carriers [0.12 ± 0.23% vs. 0.80 ± 0.09% (1.3 ± 2.5 mmol/mol vs. 8.7 ± 1.0 mmol/mol); p = 0.008]. In conclusion, GLP1R missense variant was associated with a reduced response to gliptin treatment. The genotype-related effect size of ∼0.7% (8 mmol/mol) is equal to an average effect of gliptin treatment and makes this variant a candidate for use in precision medicine.

Determinants of preclinical atherosclerosis are different in type 1 and type 2 diabetic women.

Diabetes mellitus type 2 ranks among the strongest predictors of cardiovascular diseases (CVD) while the association of type 1 diabetes with CVD is more complex. We studied differences between type 1 and 2 diabetic women regarding association of cardiovascular risk factors with preclinical atherosclerosis expressed as intima-media thickness of common carotid (IMT CCA) and femoral arteries (IMT CFA) measured by high resolution ultrasound. Women with type 1 (n=203) and type 2 diabetes (n=123) were examined with regard to the presence of cardiovascular risk factors. In type 1 diabetic women strong association between IMT CCA and body mass index, waist circumference, and total body fat was found in contrast to type 2 diabetic women. In type 2 diabetic women strong association between IMT CCA and fasting glucose, glycated hemoglobin, and atherogenic index of plasma (log TG/HDL cholesterol) was observed in contrast to type 1 diabetic women. In type 1 diabetic women, IMT CFA was associated with body fat in contrast to type 2 diabetic women. Preclinical atherosclerosis in type 1 diabetic women was strongly associated with factors reflecting body fat and its distribution, while in type 2 diabetic women preclinical atherosclerosis was associated with markers reflecting glucose and lipid metabolic disorders.

[RESOLUTE Study in the Czech Republic: insulin glargine improves the compensation of type 2 diabetes in patients with unsatisfactory results of therapy with a combination of insulin detemir and oral antidiabetics. Results of the nonintervention RESOLUTE Project in the Czech Republic]. / Studie RESOLUTE v Ceské republice: inzulin glargin zlepsuje kompenzaci diabetu 2. typu u pacientu s dosud neuspokojivým výsledkem terapie kombinací inzulin detemir a perorální antidiabetika. Výsledky neintervencního projektu RESOLUTE v Ceské republice.

INTRODUCTION: The RESOLUTE was a multinational, non interventional, 6 month prospective observational project evaluating in clinical practice, whether patients with type 2 diabetes mellitus (T2DM) inadequately controlled with detemir in combination with oral antidiabetic drugs (OADs) may benefit from switching to glargine. In Czech Republic 200 patients, for whom the participating physician according to their own consideration, had decided to prescribe insulin glargine in replacement of insulin detemir, were included in this project. OBJECTIVES: The primary endpoint was to assess the change in HbA1c over the 6- month period in T2DM patients treated with insulin glargin after switch from insulin detemir. Secondary endpoints included the evaluation of the change in fasting plasma glucose, insulin dose, body weight over the 6-month period after starting insulin glargine , the evaluation of the number of hypoglycemia during the last month of therapy which each basal insulin and the frequency of adverse events (AE) during treatment with insulin glargine. RESULTS: Insulin glargine therapy resulted in a statistically significant improvement in compensation of diabetes characterized by a mean HbA1c decrease of about 0.82 (± 0.93) % (p < 0.001) and a mean decrease of recorded fasting glycemia about 1.91 (± 2.81) mmol/ l (p < 0.001). No significant change in the mean body weight was recorded du-ring study [+0.12 (± 2.98) kg; p = NS]. The mean daily insulin glargine dose used at the end of the observation increased in comparison with last mean daily dose of insulin detemir [+2.99 (± 7.54) U; p < 0.001]. The improvement in glycemic control was accompanied by low risk of hypoglycemia. The percentage of patients with documented symptomatic (5.0%), nocturnal (2.5%) and severe (0%) hypoglycemia in the last month of glargine therapy was consistently lower compared with the last month of previous treatment with detemir (14.6%, 9.5% and 2.5%, respectively). Other adverse events were reported in 3.0% of patients on glargine therapy. No adverse events were considered as adverse event related to insulin glargin treatment. No serious adverse or no serious adverse events leading to treatment discontinuation or death were documented during the course of the study. CONCLUSION: Under reallife conditions, switching from insulin detemir to once daily insulin glargine in poorly controlled T2DM patients resulted in clinically relevant improvements in glycemic control without an increase in weight and hypoglycemia risk.

[New drugs in type 2 diabetes mellitus therapy]. / Nové léky v terapii diabetes mellitus 2. typu.

The objective in developing a new type 2 diabetes therapy is to achieve greater safety and better efficacy. Newly registered drugs include lixisenatide, QW exenatide, dapagliflozin and insulin degludec. Once weekly gliptins and other substances are under development.

[What has the largest study in the history of diabetology brought us?]. / Co nám prinesla nejvetsí studie v historii diabetologie?

UNLABELLED: The main objective of the ORIGIN study was an observation of the effects of treatment with insulin analogue, insulin glargine on cardiovascular complications in patients with severe atherosclerosis and early stages of well-compensated diabetes and prediabetes. The authors expected that a long-term reduction of glycaemia on an empty stomach will reduce the number of occurrences of cardiovascular complications. The study, which was conducted over a period of more than six years, showed neither a positive nor a negative effect of insulin treatment on cardiovascular complications. The second main objective of the study was the following: to compare the effect of the omega-3 fatty acid treatment versus placebo on the development of cardiovascular complications. However, no influence of n-3 fatty acids on the development of cardiovascular complications was found. The study investigated whether the insulin glargine treatment leads to an increased number of cancer occurrences. No correlation between cancer and the insulin glargine treatment was proven in this study. Long-term insulin treatment in the early stages of diabetes led to a minimal increase in weight through the course of six years (1.5 kg) and to three times more hypoglycaemia occurrences compared to placebo. However, the number of hypoglycaemia occurrences was very small. CONCLUSION: The study has confirmed the safety of the insulin glargine treatment combined with metformin in the early stages of diabetes, without an increased number of atherosclerosis or cancer occurrences, and with minimal weight gain.

[Incretin therapy and diabetic retinopathy]. / Inkretinová terapie a diabetická retinopatie.

Therapy based on incretins presents a new group of medicinal substances designated for an intervention in patients with type 2 diabetes. It includes a therapy that is efficient, safe and effective. Its advantage is a low risk of hypoglycaemia and a positive effect on body weight. The analyses that have been published so far consistently indicate a positive impact on cardiovascular risk factors. The first studies conducted on animal models prove a favourable influence ofincretin therapy on the pathophysiology of diabetic retinopathy.

[Incretins have changed and continue to change treatment strategy for type 2 diabetes]. / Inkretiny zmenily a dále mení strategii lécby diabetu 2. typu.

Incretins are a novel class of drugs indicated for therapeutic intervention in patients with type 2 diabetes. They provide effective and safe therapy. Their advantages include low risk of hypoglycaemia and positive effect on body weight. Literature published so far consistently evidences reduced cardiovascular risk. If long-term prospective studies confirm such an effect, incretin therapy will, together with metformin, become the first line treatment for type 2 diabetes.

Common carotid artery intima-media thickness is not increased but distensibility is reduced in normotensive patients with type 2 diabetes compared with control subjects.

This study evaluated carotid artery parameters in normotensive patients with type 2 diabetes compared with non-diabetic control subjects. Using a high-resolution B-mode ultrasound scanner, common carotid artery intima-media thickness (IMT) and carotid tree atheroma thickness were measured in 82 patients with type 2 diabetes and 41 controls. The distensibility of the common carotid artery was calculated using the Reneman equation. Distensibility was significantly decreased and atheroma thickness was significantly increased in the diabetes group. There was no significant difference in IMT between the two groups. Stepwise linear regression analysis revealed an association between common carotid artery distensibility and post-ischaemic dilatation of the brachial artery (a measure of endothelial function), body mass index and diabetes duration in patients with type 2 diabetes. In conclusion, common carotid artery IMT in normotensive patients with type 2 diabetes is comparable to that of control subjects, whereas atheroma thickness is higher and arterial stiffness more pronounced in those with type 2 diabetes, indicating the existence of atherosclerotic changes in normotensive type 2 diabetes patients.

Circulating serum matrix metalloproteinase-3 and metalloproteinase-9 are not associated with echocardiographic parameters of diastolic function in asymptomatic type 2 diabetic patients.

Serum concentrations of matrix metalloproteinase (MMP) 3 and MMP9 were evaluated in 82 asymptomatic type 2 diabetes mellitus patients without cardiovascular complications and in 41 non-diabetic control subjects. In the asymptomatic diabetic patients, the correlations of these concentrations with diabetes duration, selected biochemical parameters such as glycated haemoglobin (HbA(1c)), and echocardiographic parameters of diastolic function were also assessed. Pulsed and tissue Doppler echocardiography was performed in the two groups. Mean ± SD age was 61 ± 6 years for the asymptomatic diabetic patients and 61 ± 5 years for controls. Mean ± SD concentrations of MMP3 and MMP9 were significantly higher in the asymptomatic diabetic patients (67.5 ± 10.4 and 77.8 ± 28.8 µg/l, respectively) than in controls (47.2 ± 6.1 and 51.1 ± 13.7 µg/l, respectively). In the asymptomatic diabetic patients, MMP3 correlated only with albuminuria (r = 0.341) and MMP9 only with HbA(1c) (r = 0.262); neither MMP was correlated with echocardiographic parameters of diastolic function. Thus, in asymptomatic type 2 diabetic patients without cardiovascular complications, serum MMP3 and MMP9 were elevated, MMP9 was associated with HbA(1c) and MMP3 was associated with albuminuria, however, MMP3 and MMP9 were not associated with echocardiographic parameters of diastolic function.

Comparison of soybean oil- and olive oil-based lipid emulsions on hepatobiliary function and serum triacylglycerols level during realimentation.

This study compared the effects of soybean oil- versus olive oil-based lipid emulsions on hepatobiliary function and serum triacylglycerols in patients who required transient parenteral nutrition support for significant weight loss. Patients who received a parenteral ready-to-use industry admixture including either soybean oil- (n = 10) or olive oil-based lipid emulsion (n = 11) for 2 weeks were retrospectively analysed. Cholestatic and cytolytic enzymes, conjugated bilirubin and serum triacylglycerols were sampled before and 1 day after completing parenteral nutrition support. Significant deterioration of cholestatic enzymes occurred in five patients in the soybean oil group and in one in the olive oil group. Serum triacylglycerols significantly deteriorated in seven patients in the soybean oil group and in one patient in the olive oil group. No differences were recorded for cytolytic enzyme abnormalities. In conclusion, the olive oil-based emulsion induced abnormalities of cholestatic enzymes and serum triacylglycerols significantly less frequently than the soybean oil-based emulsion.

Changes in the plasma amino acid profile in anorexia nervosa.

We evaluated and measured by high performance liquid chromatography the plasma amino acid levels in 11 female patients with anorexia nervosa during a period of significant loss of body weight, compared with 11 healthy age-matched controls. Total amino acid and total branched-chain amino acid levels were similar in both groups, however significantly higher levels of glycine and ornithine were found in anorexia nervosa patients, as well as significantly lower levels of leucine, tyrosine and lysine compared with controls. The glycine/valine and phenylalanine/tyrosine ratios were significantly higher in anorexia nervosa patients than in control subjects. The levels and ratios of other amino acids were within the normal range, with no significant differences between the two groups. Changes in the plasma amino acid profile in anorexia nervosa patients can be explained by chronic severe malnutrition and prolonged stress.

The effect of ramipril therapy on cytokines and parameters of incipient diabetic nephropathy in patients with type 1 diabetes mellitus.

We compared the levels of transforming growth factor beta1 (TGF-beta1), vascular endothelial growth factor (VEGF) and other biochemical parameters in patients with type 1 diabetes mellitus with and without incipient diabetic nephropathy (iDN) and compared them with healthy control subjects. We also measured the effect of 3 and 6 months of ramipril treatment in diabetes patients with iDN. Compared with healthy controls, TGF-beta1 levels were increased in both groups of diabetes patients, whereas VEGF was only elevated in patients with iDN. Ramipril did not have a significant effect on TGF-beta1 or VEGF levels. We observed a significant decrease in microalbuminuria and cystatin C following ramipril treatment. Increased VEGF levels in patients with iDN suggest a role for this cytokine in the pathogenesis of diabetic nephropathy. Cystatin C would make a suitable marker for the screening and assessment of iDN, and for the evaluation of the therapeutic efficacy of drugs.

[Differences in ulcer location in diabetic foot syndrome]. / Vliv etiologie syndromu diabetické nohy na lokalizaci defektu.

UNLABELLED: The foot ulcerations are among the most debilitating complications in diabetic patients. The main risk factors leading to the ulcer development are diabetic neuropathy (sensoric, autonomic), limb ischemia (angiopathy), limited joint mobility and teh plantar pressure; the infection plays a role in difficulty of ulcer healing. The aim of our study was to assess the possible differences in location of diabetic ulcers with regard to their origin. In 502 patients during 5 year interval 835 new diabetic ulcers were diagnosed. METHODS: Ulcers were divided into 3 groups according to their origin: neuropathic, neuroischemic and ischemic. RESULTS: In the neuropathic group most ulcers were found in the plantar surface of toes (40.4%) and in the plantar metatarsal heads region (39.1%); in contrast, the ischemic group had the most frequent location in the toe tips (63.6%), while the neuroischemic group had most ulcers distributed in both plantar surface and tips of the toes (51.8%). The ulcer distribution was statistically significant different in all groups and depended on the etiology of ulcers (p < 0.0001; Fisher's exact test, modification Monte Carlo). Totally more than 75% of all ulcer were located in the toe and forefoot area. The patients in the neuroischaemic group had more often revascularisation procedures. The patients in ischaemic group were more often after high amputation. These patients had always less microvascular diabetic complication (all p < 0.01; ANOVA chi2). CONCLUSION: The location of diabetic foot ulcers differs significantly according to their cause. In addition more than 75% of all ulcerations were localisated in toes and forefoot area. This fact could change focus of the preventive strategy in the diabetic foot.

X-linked dominant chondrodysplasia punctata (CDPX2): multisystemic impact of the defect in cholesterol biosynthesis.

Chondrodysplasia punctata represents clinically and genetically a heterogeneous group of disorders characterized by the presence of multiple congenital anomalies and stippled epiphyses. We present clinical course of the disease and the results of metabolic, X-ray and molecular analyses in 19-months old girl with X-linked dominant chondrodysplasia punctata with intrauterine growth retardation, craniofacial dysmorphy, cataracts, cutaneous anomalies including ichthyosis, asymmetric rhizomesomelic shortness of the limbs, deformity of the spine, club foot, polydactyly, syndactyly, epiphyseal stippling and low cholesterol (2.29 mmol/l). Spectrophotometric analysis revealed the presence of abnormal pattern of cholesterol precursors in blood. The increased level of 8-dehydrocholesterol (42.2 micromol/l, controls < 1) and 7-dehydrocholesterol (25.5 micromol/l, controls < 1) recognised with GC/MS suggested an endogenous defect of cholesterol biosynthesis. The diagnosis of X-linked dominant chondrodysplasia punctata (CDPX2) was confirmed by the molecular analysis. Sequencing of the EBP gene encoding for 3beta-hydroxysteroid-delta8,delta7-isomerase revealed the presence of "de novo" heterozygous mutation c.327C>T (p.Arg110Stop). High cholesterol diet normalized cholesterol level (3.28 mmol/l) but it had no influence on the unfavourable prognosis of the disease. Low level of cholesterol with abnormal sterol profile in a child with congenital development anomalies represent an important laboratory marker suggesting an inherited defect of cholesterol biosynthesis.

[Effects of specific cycloxygenase-2 inhibition on the renal functions of ederly patients with renal function impairment]. / Vliv specifické inhibice cyklooxygenázy 2 na ledvinové funkce u starsích pacientu s poruchou ledvinové funkce.

BACKGROUND: Elderly patients suffering from nociceptive pain of locomotive organs and concomitantly from renal impairment represent a target population for painkilling drugs. That is why they are predisposed to nephrotoxic effects non-steroidal anti-inflammatory drugs. The aim of our study was to evaluate cycloxygenase-2 (COX-2) inhibition effect on renal function in elderly with moderate impairment of renal function. METHODS AND RESULTS: Based on 24-h urine collection we assessed creatinine clearance (C(Cr), fractional excretion of sodium (FE(Na)), potassium (FE(K)), chloride (FE(Cl)), osmotic active solutes (FE(OSM)) and 24h urinary excretion of prostaglandin PGE2 and PGF(2 alpha). Under conditions of sub-maximal water load fractional excretion of electrolytes, inulin clearance (C(in)), serum cystatin C (S(cyst)) were assessed. In addition basal and stimulated plasma renin activity (PRA) and plasma aldosteron (P(aldo)) were examined. Using comparison of parameters before and at the end of 7-days rofecoxib treatment we found out C(in) 0,82 +/- 0,34 vs 0,74 +/- 0,18 ml/s/l,73 m2, FE(Na) 1,0 +/- 0,3 vs 1,2 +/- 0.4 (p=0,02), FE(OSM) 2.9 +/- 0,7 vs 3,7 +/- 1,2% (p=0,03), U(PGE2 alpha),V 663 +/- 528 vs 414 +/- 195 (p=0,059), U(PGD2) V (559 +/- 625) vs 205 +/- 174 eta g/24h (p=0,02), stimulated PRA 0.94 +/- 0,73 vs 0,4 +/- 0,27 +/- pg/l/h (p=0,019), P(aldo) 104,56 +/- 50,15 vs 56,94 +/- 27,08 eta g/l/h (p=0,008). CONCLUSIONS: Short-term COX-2 inhibition in patients with moderate renal impairment was associated with significant decrease of tubular transport of sodium, without changing GFR and water excretion.

[Chronic nephropathies and disorders of renal function--is it sufficiently diagnosed in patients hospitalised on department of internal medicine and cardiology?]. / Jsou chronická onemocnení ledvin a poruchy ledvinné funkce na standardním luzku interních oboru dostatecne diagnostikovány?

We have found out that nephropathies and renal dysfunctions are diagnosed insufficiently. At the same time, it has been observed that patients are sent to nephrology out-patient clinics too late. The aim of our study was to identify how nephropathy and renal dysfunction are diagnosed and how these diagnoses are recorded in diagnostic summary of hospital discharge report in patients hospitalized in department of internal medicine and cardiology of a big teaching hospital. Also, we studied the incidence of risk diseases (arterial hypertension and diabetes mellitus) and serious cardiovascular complications in individual stages of renal dysfunction. We analysed 325 medical records of patients hospitalized and discharged in the course of one month. Renal dysfunction was classified according to Kidney Disease Outcomes Quality Initiative. Glomerulal filtration rate was calculated via simplified Levey's formula. Nephropathy and renal dysfunction were diagnosed, and properly recorded in diagnostic summary, only in 5 % of patients in the Stage I of renal dysfunction (Stage II = 2%, Stage III = 28%, Stage IV = 88% and Stage V = 88%). The incidence of risk diseases and cardiovascular complications increased linearly with progression of renal insufficiency. The results of our study prove that nephropathy and renal dysfunction are diagnosed insufficiently, particularly in early stages when it is still possible to use targeted therapy and early control of specific complications of renal insufficiency.

Biphasic insulin aspart 30 plus metformin: an effective combination in type 2 diabetes.

AIM: This study compared glycaemic control achieved with biphasic insulin aspart 30 (BIAsp 30) monotherapy, BIAsp 30 plus metformin and glibenclamide plus metformin in patients with type 2 diabetes not adequately controlled with metformin. METHODS: In this multinational, open-labelled, parallel group, 16-week trial, 341 patients (patients not adequately controlled with metformin for at least 1 month) with type 2 diabetes were studied. Patients were randomized to receive BIAsp 30, twice daily (n = 107 exposed to treatment), or BIAsp 30, twice daily, plus metformin (n = 108) or glibenclamide plus metformin (n = 114). The primary endpoint was HbA(1c) at end of trial; adverse events, hypoglycaemia episodes, blood lipids and weight were also monitored. RESULTS: In the total population (HbA(1c) 7.5-13.0% at screening), end-of-trial HbA(1c) levels were lower in patients receiving BIAsp 30 plus metformin compared with those receiving BIAsp 30 only [mean treatment difference (+/-s.e.m), 0.39 +/- 0.15%, p = 0.007]. In a subpopulation (HbA(1c) > or = 9.0% at baseline, n = 193), patients receiving BIAsp 30 plus metformin had significantly lower HbA(1c) levels at the end of the trial compared with those receiving glibenclamide plus metformin (treatment difference, 0.46 +/- 0.21%, p = 0.027). Mean body weight (+/-s.d) at the end of the trial was significantly lower in patients receiving glibenclamide plus metformin compared with those receiving BIAsp 30 only (84.3 +/- 13.3 kg vs. 88.9 +/- 16.9 kg, p < 0.001). No major hypoglycaemic episodes were recorded during the trial, and incidence rates for minor and symptoms-only hypoglycaemia were low and similar between treatment groups (0.03-0.04 events/patient/week). CONCLUSION: BIAsp 30 added to metformin could be an appropriate therapeutic option for achieving good glycaemic control, compared with the addition of a second oral agent, particularly where HbA(1c) > or = 9%.

The association between left ventricle diastolic dysfunction and endothelial dysfunction and the results of stress myocardial SPECT in asymptomatic patients with type 2 diabetes.

Diabetes mellitus is associated with a poor cardiovascular prognosis. Stress myocardial single-photon emission computed tomography (SPECT) reliably detects coronary ischaemia in asymptomatic patients. Our study aimed to evaluate the association between systolic and diastolic left ventricular function, left ventricular hypertrophy, endothelial function and the results of stress myocardial SPECT in 126 patients with type 2 diabetic patients with no cardiovascular symptoms. Thirty-three patients (26%) had abnormal SPECT results, 33 patients (26%) had intermediate (equivocal) results, and 60 patients (48%) had normal results. We found a significant association between an abnormal SPECT result, left ventricular diastolic dysfunction and impaired post-ischaemic dilatation of the brachial artery. No association was found between the SPECT result and systolic function and left ventricular hypertrophy, however. An abnormal SPECT result was significantly associated with left ventricular diastolic dysfunction and the deterioration of post-ischaemic dilatation of the brachial artery in asymptomatic patients with type 2 diabetes.