Plasmatic homocysteine concentration and its relationship with complications associated to diabetes mellitus.

BACKGROUND AND METHODS: In the search for new factors of cardiovascular risk associated to diabetes mellitus (DM), special attention has been paid in recent years to hyperhomocysteinaemia. Therefore, we have established the concentration of homocysteine (Hcy) and other biochemical parameters in the plasma of a group of 57 type 1 and 32 type 2 diabetic patients and 54 control subjects and studied whether plasmatic homocysteinaemia was related to macroangiopathy, nephropathy, retinopathy and neuropathy. Because of significant differences for plasma Hcy values between men and women in the control group, we distinguished between both groups throughout the study. RESULTS: Patients with DM had higher Hcy than control subjects (11.7+/-5.4 vs. 10.1+/-2.4 micromol/l, p<0.05). Fasting hyperhomocysteinaemia was considered as the mean of the plasma Hcy for control subjects+2 SD (14.9 micromol/l in total group, 15.6 micromol/l in males and 13.9 micromol/l in females). In the studied groups with complications, we found significant differences between normohomocysteinaemic type 1 diabetic patients and those considered hyperhomocysteinaemic by us. On the other hand, patients having type 1 DM and complications had higher plasmatic Hcy concentration than those with no complications. CONCLUSIONS: We have found a relationship between high Hcy levels and prevalence of macroangiopathy, retinopathy and nephropathy in the type 1 diabetic patients, which was not been observed in the type 2 diabetic patients of our study. As a result, we consider plasmatic Hcy a complication-risk indicator in type 1 DM, and we recommend its use together with already established biochemical parameters in the control of the evolution of the disease.

[Clinical effectiveness and tolerance of acarbose in the treatment of insulin-dependent diabetic patients (type I)]. / Eficacia clínica y tolerancia de la acarbosa en el tratamiento de pacientes diabéticos dependientes de la insulina (tipo I).

BACKGROUND: Acarbose is a reversible inhibitor of the intestinal alpha-glucosidases, the oral administration of which delays or diminishes the postprandial increase of glucose and insulin. METHODS: A multicentric double-blind clinical trial (11 centers), controlled versus placebo, crossed and randomized, was carried out with 137 insulin-dependent diabetic type I patients treated with diet and insulin. During the first 3 months of the trial the patients received placebo or acarbose randomly. Following one month of wash out with placebo the patients received the inverse medication for 3 more months. During the first month of each phase the patients were given 50 mg three times per day of acarbose or placebo and the two following moths received 100 mg x 3/day. RESULTS: Upon comparison of the two treatments significant statistical differences were found in HbA1 (p = 0.0005) and in postprandial glycemia (p = 0.007). There were differences, although not statistically significant, in the amounts of triglycerides, cholesterol and fasting glycemia. One hundred and two patients referred adverse events, most being gastrointestinal (flatulence, meteorism). CONCLUSIONS: Acarbose may be useful in the treatment of insulin-dependent diabetic type I patients treated with insulin and diet since it reduces the levels significantly of HbA1 and postprandial glucose.

[Clinical efficacy and tolerance to acarbose in the treatment of non-insulin-dependent diabetic patients]. / Eficacia clínica y tolerancia de la acarbosa en el tratamiento de pacientes diabéticos no dependientes de la insulina (tipo II).

BACKGROUND: Acarbose is a pseudotetrasacaride which reversibly and competitively inhibits the intestinal alpha-glycosidases leading to a decrease in the increase of postprandial glycemia. METHODS: A multicentric double-blind clinical trial (8 centers), controlled versus placebo, crossover and randomized was carried out in 90 non insulin dependent diabetic patients under treatment with diet or with diet and sulphonilureas. During the first three months of the trial the patients received placebo or acarbose randomly. Following one months of wash-out with placebo the patients received the inverse medication for 3 more months. During the first month of each phase the patients received 3 x 50 mg/day of acarbose or placebo and the following 2 months 3 x 100 mg/day. RESULTS: Upon comparison of the two treatments significant statistical differences were observed in HbA1 (p = 0.0115) and in postprandial glycemia (p = 0.0001). There were differences, although not significant, in the levels of triglycerides, cholesterol, fasting glycemia, and postprandial insulinemia. Episodes of hypoglycemia appeared in 12 patients and 57 patients referred undesirable gastrointestinal effects. CONCLUSIONS: The results of this trial indicate that acarbose may be useful in the treatment of non insulindependent diabetic patients since it significantly reduces the amount of postprandial glycemia and HbA1.

Duodenogastric reflux in patients with biliary lithiasis before and after cholecystectomy.

Duodenogastric reflux is quantified in ten patients with biliary lithiasis and a functioning gallbladder, before and six months after performing cholecystectomy. The results are compared with those of a control group (n = 10) with similar age and gender, without gastric or hepatobiliary pathologic factors. To evaluate reflux, we used six hour continuous intravenous infusion and subsequent determination in gastric juice of 99mTc-diethyliminodiacetic acid. Our results showed that patients with cholelithiasis have higher reflux rates than those in the control group (p < 0.001). When comparing patients before and after cholecystectomy, we confirmed that removal of the gallbladder produces a significant increase (p < 0.001) in reflux rates compared with preoperative values.

Gastric surgery and bezoars.

We present a series of 56 patients with gastrointestinal bezoar following previous gastric surgery for gastroduodenal peptic ulcer. The following parameters were studied: factors predisposing to bezoar formation (type of previous surgery, alimentation, and mastication), form of clinical presentation, diagnostic tests, and treatment. A bilateral truncal vagotomy plus pyloroplasty had been performed previously on 84% of patients, 44% revealed excessive intake of vegetable fiber, and 30% presented with bad dentition. The most frequent clinical presentation was intestinal obstruction (80%). This was diagnosed mainly by clinical data and simple abdominal radiology. The main exploratory technique for diagnosing cases of gastric bezoar was endoscopy. Surgery is necessary for treating the intestinal forms, and one should always attempt to fragment the bezoar and milk it to the cecum, reserving enterotomy and extraction for cases where this is not possible. The small intestine and stomach should always be explored for retained bezoars. Gastric bezoars should always receive conservative treatment, endoscopic extraction, and/or enzymatic dissolution; gastrotomy and extraction should be performed when this fails.

[Multiple endocrine neoplasia II A syndrome: relationship between age of the patient, levels of basal calcitonin and size of the thyroid tumor]. / Sindromi di NEM II A: relazione fra l'età dei pazienti, livelli di calcitonina basale e grandezza del tumore tiroideo.

This paper presents our experience in four families having the multiple endocrine neoplasia (MEN) II-A syndrome, with a total of 19 affected patients. All had medullary thyroid carcinoma (MTC), 6 also had pheochromocytoma (PH) and 3 had hyperparathyroidism. The screening of the members of the families to measure basal and pentagastrin response calcitonin (CT) serum levels allowed an early diagnosis of medullary thyroid carcinoma, when lesions were only 1 mm in diameter. Measurement of vanillymandelic acid, catecholamines and metanephrines in 24-hour urine collections allowed the diagnosis of pheochromocytoma in patients, some of whom were asymptomatic. A clear relationship was found between the age of the patients, the basal serum calcitonin level and size of the MTC.

Antireflux mechanism of Nissen fundoplication. A manometric study.

To analyze the mechanisms by which Nissen fundoplication controls gastroesophageal reflux, the pre- and post-operative manometric findings in 34 patients were compared. The postoperative assessment showed an increase in both the infradiaphragmatic length and basal pressure of the lower esophageal sphincter and a notable improvement in esophageal motility (increase in the amplitude of the waves and decrease in the mean percentage of deglutitions without response and tertiary waves) in those who preoperatively presented with defective esophageal peristalsis.

Anatomical and functional cardiac abnormalities in type I diabetes.

To analyse the anatomy and systolic and diastolic cardiac function in a group of type I diabetics with no other abnormality and to correlate it with the duration of the disease, the presence of complications, the control of the diabetes and the abnormalities in the autonomous nervous system, 125 type I diabetics and 50 age- and sex-matched healthy controls were studied. In 112 diabetics, an echocardiographic image which enabled us to calculate the thickness, cavity dimensions and systolic function rates was obtained. A Doppler echocardiograph was done in all patients to measure 9 parameters of diastolic function. The autonomic nervous system was evaluated by the response to 4 cardiovascular reflexes. Two control groups and 4 study groups were established, based on duration and on the presence and number of microangiopathic complications. The results showed a significant increase in the septal and posterior wall thickness, although without differences between the study groups. There were no differences in the analysis of systolic function. The abnormalities in diastolic function were significant in all the groups, but greater in the groups with microangiopathy. Overall, for groups 1-4, respectively, the incidence of anatomical abnormalities was 9.6%, 17%, 28% and 57% (average 22%); systolic 0%, 0%, 4% and 4.7% (average 2.2%); and diastolic 15%, 21%, 60% and 80% (average 44%). Only 13 diabetics from group 4 presented with cardiac autonomic neuropathy. No correlation between these alterations and the glycaemic control or the duration of the disease was found, although there was a correlation between the presence or absence of complications and the anatomic and diastolic abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac anatomical and functional changes in a group of young type I diabetics with microangiopathy]. / Alteraciones anatómicas y funcionales cardíacas en un grupo de jóvenes diabéticos tipo I con microangiopatía.

BACKGROUND: There are conflicting data concerning the alteration of cardiac function in diabetics without another type of accompanying pathology. Therefore this study was designed with the aim to analyze the anatomical and functional changes and relate them with the time and control of diabetes. METHODS: Fifty-four type I diabetics with a mean age of 33.5 years and 25 healthy controls paired by age and sex were studied. The patients were rigourously selected excluding any disease or treatment other than insulin and the presence of demonstrated microangiopathy was required. M-mode and bidimensional echocardiographic studies were carried out in 46 patients to calculate thickness, cavity dimension and systolic function rates. Doppler-echo studies analyzing 9 parameters of diastolic function were performed in all the 54 patients studied. RESULTS: The results obtained demonstrated significant differences in the thickness of the posterior wall and the septum in the diabetics in comparison with the normal subjects. No differences were observed in the parameters of systolic function with the diastolic parameters being significant. Considered globally 41% of the patients demonstrated structural alterations, 4% systolic and 70% diastolic. The only significant correlation was established between the diastolic alteration and the time of evolution of the diabetes. The autonomic alteration which some patients presented did not vary the results obtained. CONCLUSIONS: In this group of selected diabetic structural and cardiac diastolic alterations appeared being attributed only to the diabetes itself in relation to the length of time of the same and possibly to the microangiopathy.

Management of the perineal wound following abdominoperineal resection: prospective study of three methods.

A prospective study was made of three procedures for treating the perineal wound and presacral cavity in 102 patients undergoing abdominoperineal excision for cancer of the rectum: (1) packing of the presacral space after suture of the pelvic peritoneum; (2) suture of the pelvic peritoneum and perineal wound, leaving two drains through the perineum; and (3) no suture of the pelvic peritoneum, and primary closure of the perineal wound, leaving drains through the abdomen for physiological saline irrigation. The parameters analysed were incidence of infection, primary healing of the perineum, extraperineal complications and mean hospital stay. Primary healing of the perineum was best with method 3, and overall incidence of infection highest with method 2. There were no differences between the methods with regard to extraperineal complications. Hospital stay was shortest with method 3.

[The cardiac anatomical and functional changes in a group of young type-1 diabetics without microangiopathy]. / Alteraciones anatómicas y functionales cardíacas en un grupo de jóvenes diabéticos tipo I sin microangiopatía.

We study 71 type I diabetics and 25 controls, trying to analyze the anatomical and functional changes due to diabetes. The diabetics, with a mean age of 18.4 +/- 8.2 years, were strictly selected excluding any disease and treatment besides insulin. In 66, and echocardiographic M mode and 2D study was done to calculate wall thickness, cavity dimensions and systolic function indexes; in all, Eco-Doppler analyzing 9 diastolic function indexes. The results showed an increase in septal thickness in diabetics (p less than 0.01 in diastole and less than 0.001 in systole). There was no difference in systolic function or posterior wall thickness, having the diabetics a significant increase of the T 1/2 (p less than 0.001), a decrease of the deceleration of E and the ratio E/A (p less than 0.001). As a group, 12.5% of the diabetics had anatomical abnormalities, and 18.3% diastolic abnormalities at least in two indexes. The only significant correlation was established between the evolution time and the T 1/2 (p less than 0.01). We conclude that in this group of selected diabetics, the anatomical and functional abnormalities found were only imputable to the diabetic abnormality.

[Subcutaneous emphysema as the initial manifestation of perforation of a hollow abdominal viscus]. / Enfisema subcutáneo como manifestación inicial de perforación de víscera hueca abdominal.

The authors reports a case of cervical and abdominal subcutaneous emphysema, associated to pneumoretroperitoneum and pneumomediastinum, with no free air in the abdominal cavity, secondary to perforated diverticulitis of the sigmoid colon. We comment the rarity of this clinical presentation, the physiopathologic mechanisms of subcutaneous air presence in cases of non instrumental perforation of abdominal viscera and the ominous significance of the subcutaneous emphysema in such perforations.

Changes in plasma high-density lipoproteins after body weight reduction in obese women.

We investigated effects of a hypocaloric diet of 5023.2 kJ (1200 kcal) on body weight and plasma lipids in 40 obese female subjects in two groups: (1) 20 obese subjects with normal plasma triglycerides at the onset (means = 148.5 mg/dl), and (2) 20 with hypertriglyceridemia (means = 225.3 mg/dl). The hypocaloric diet was instituted for a mean period of nine months and average body weight loss was 15.6 kg for Gp 1 and 14.0 kg for Gp 2. In Gp 1 there were no significant changes in total plasma cholesterol or triglycerides, but HDL-cholesterol rose significantly from a mean value of 42.5 to 53.6 mg/dl (P less than 0.001). Subjects in Gp 2 showed a significant decrease in plasma triglycerides (from 225.3 to 152.3 mg/dl, P less than 0.001) and an elevation in HDL-cholesterol from 41.2 to 48.2 mg/dl, P less than 0.001. Our results show that losing weight is associated with HDL-cholesterol elevation, independently of variation in plasma triglycerides.