Effect of metformin plus roziglitazone compared with metformin alone on glycaemic control in well-controlled Type 2 diabetes.

AIMS: To investigate the effect of metformin plus roziglitazione (RSGMET) compared with metformin alone (MET) on glycaemic control in well-controlled Type 2 diabetes. METHODS: Subjects (drug naïve or those on glucose-lowering monotherapy) were randomized (n = 526), following a 4-week placebo run-in period, to RSGMET [4 mg rosiglitazone (RSG)/500 mg MET] or MET 500 mg. From weeks 2-18, medication was escalated every 4 weeks (based on gastrointestinal tolerability), then remained at RSGMET 8 mg/2 g or MET 3 g for 14 weeks. RESULTS: RSGMET reduced HbA(1c) from 7.2 +/- 0.6 to 6.7 +/- 0.8% at week 32, compared with a reduction from 7.2 +/- 0.6 to 6.8 +/- 0.9% with MET (treatment difference -0.13%; P = 0.0357). More subjects achieved an HbA(1c) value of

[Erectile dysfunction among Norwegian men over 40 years of age]. / Erektil dysfunksjon hos norske menn over 40 år.

BACKGROUND: Erectile dysfunction (ED) is prevalent and often associated with chronic diseases and previous operations on the prostate. Our aims were to investigate the prevalence of ED among males seeking general practitioners and to register known risk factors. MATERIAL AND METHODS: During a short period in late 1998, 49 Norwegian general practitioners in the county of Østfold asked all their male patients over 40 years of age to anonymously fill in a questionnaire. RESULTS: 1,182 men completed the study. 20% stated that they had moderate ED, while 13% had complete ED. The prevalence of ED increased with age. Complete ED was found in 2% of those between 40 and 50, 5% between 50 and 60, 16% between 60 and 70, and in 37% of those above 70 years of age. The corresponding values for moderate ED was 6, 16, 32 and 28%. Moderate/complete ED was increased in the subgroups with hypertension, depression, diabetes, > one concomitant disease, and post prostate surgery. Physically "very active" individuals had less ED than the "non-active". No significant association was found with alcohol or tobacco. Most patients with ED wanted to discuss the problem with their general practitioners, but only 6% received treatment.

Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system.

OBJECTIVES: To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. METHODS: Randomized study with health center as unit. General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation). RESULTS: Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%); all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was -2.3 mm Hg (95% CI, -3.8, -0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, -0.1% (95% CI, -0.4, 0.1), systolic blood pressure, -1.2 mm Hg (95% CI, -4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, -4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, -0.8, 1.4), risk score in female +0.1 (95% CI, -5.1, 5.2), and risk score in male +2.6 (95% CI, -14.2, 19.5). CONCLUSIONS: Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

Serum lipoprotein(a) and cardiovascular disease in non-insulin-dependent diabetes mellitus.

OBJECTIVE: To examine whether lp(a) can explain a) the increased cardiovascular morbidity in patients with non-insulin-dependent diabetes mellitus (NIDDM) and b) the wide variation in the tendency for such complications to develop in the patients. DESIGN: Cross-sectional study. SETTING: General practice in a local community in Norway. SUBJECTS: One hundred and thirty NIDDM patients and a reference group drawn from a twin study. MAIN OUTCOME MEASURES: Lp(a), self-reported cardiovascular disease, urinary albumin excretion. RESULTS: The level of lp(a) was equally distributed in our NIDDM population and a reference group. We found no association between lp(a) and self-reported cardiovascular disease and urinary albumin excretion (UAE). CONCLUSION: Lp(a) cannot explain the increased risk for cardiovascular disease in NIDDM patients, nor can it explain the variation in the tendency for such complications to develop.

Oral glucose tolerance test in general practice--when is it worthwhile?

OBJECTIVE: To examine the probability of impaired glucose tolerance and diabetes, diagnosed with oral glucose tolerance test, at different levels of fasting blood glucose. DESIGN: When indicated, fasting capillary whole blood glucose was measured. Patients with blood glucose ranging from 4.4 to 6.6 mmol/l had an oral glucose tolerance test. SETTING: General practice. SUBJECTS: 355 patients had an oral glucose tolerance test. RESULTS: 33% had impaired glucose tolerance and 12% had diabetes. One or more diabetics were found at every level of fasting blood glucose. The probability of finding a diabetic was ten times larger in the fasting blood glucose stratum 6.1 to 6.6 mmol/l than in the fasting blood glucose stratum 4.4 to 4.9 mmol/l. Likelihood ratio increased 30 times from the lowest to the highest stratum. No cutoff point in the interval 4.4 to 6.6 mmol/l had both a high sensitivity and a high specificity for the diagnosis of diabetes. CONCLUSION: If it is of great importance to find every patient with impaired glucose tolerance and diabetes, one has to do an oral glucose tolerance test in every fraction of the fasting blood glucose range 4.4 to 6.6 mmol/l (according to WHO's diagnostic criteria). Using 5.2 mmol/l as a cutoff point for an oral glucose tolerance test, the sensitivity is still high (0.95), but one would miss a few with diabetes.

Fructosamine cannot replace HbA1c in the management of type 2 diabetes (NIDDM).

OBJECTIVE: To compare HbA1c, fructosamine, and blood glucose and discuss to what degree Hba1c can be replaced by fructosamine. DESIGN: Cross-sectional study. PATIENTS: 87 unselected patients coming for 112 consecutive consultations. MAIN OUTCOME MEASURES: Fructosamine, HbA1c, blood glucose. RESULTS: The following Pearson correlation coefficients were found: Blood glucose/fructosamine 0.45, HbA1c/blood glucose 0.64, and HbA1c/fructosamine 0.39. Sensitivity and specificity of fructosamine and blood glucose to detect HbA1c > or = 8.0% was shown. CONCLUSION: Our study indicates that fructosamine and fasting capillary blood glucose are poor indicators of the level of HbA1c in NIDDM patients.

Long-term randomized placebo-controlled double-blind therapeutic comparison of glipizide and glyburide. Glycemic control and insulin secretion during 15 months.

OBJECTIVE: To examine the long-term (15 months) effects on glycemic control and insulin secretion of glipizide and glyburide treatment in patients with non-insulin-dependent diabetes mellitus (NIDDM). RESEARCH DESIGN AND METHODS: Prospective, randomized, double-blind, placebo-controlled study on 46 NIDDM patients comparing fasting levels and test-meal responses of glucose and insulin during 15 months of follow-up. RESULTS: A comparable reduction in HbA1c levels by both agents versus placebo was observed throughout the study period, but after a marked initial reduction in both sulfonylurea groups, all three groups showed gradually increasing HbA1c levels. However, both glipizide and glyburide achieved and maintained lowered postprandial glucose levels and increased fasting and postprandial insulin levels compared with placebo. CONCLUSIONS: Both glipizide and glyburide may achieve and maintain glycemic reduction and stimulation of insulin secretion during long-term treatment. However, these agents do not prevent the gradual increase in overall glycemia that develops over time in NIDDM patients.

Measuring functional status in a population survey. The Dartmouth COOP functional health assessment charts/WONCA used in an epidemiological study.

In a population study, a random sample of 398 persons from 20 to 72 years answered the six item version of the Dartmouth COOP functional health assessment charts/WONCA. The results according to age and sex are presented. The charts have been developed primarily for use in clinical settings. In a cross-sectional study in a normal population, the instrument seems feasible in use and it differentiates between the sexes and age groups.

[Quality assurance of cooperation/distribution of work between primary health care and other health services. Using care for diabetics as a basis]. / Kvalitetssikring av samhandling/arbeidsfordeling mellom primaerhelsetjenesten og annenlinjetjenesten. Utgangspunkt er tatt i diabetikeromsorgen.

Chronic illnesses account for an increasing share of the work load of the health services, implying that health personnel have to face a number of different complex problems. Many of these concern co-operation between the various professionals and levels of the health services, and distribution of the load of work. How well this co-operation works will have a decisive effect on the quality of the treatment. These problems are discussed using care of diabetes patients as an example. It is important to achieve medical consensus at different levels. The authors suggest ways of establishing co-operation within the medical profession, specifically defining responsibility, ensuring good and frequent communication with patients, and promoting patient participation. The article also describes concrete solutions and includes a check list for quality assessment.