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 277,896 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The majority of patients with hypertension have one or more additional risk factors for cardiovascular disease. In planning an appropriate treatment program, it is useful to identify and stratify hypertensive patients according to their risk of developing cardiovascular, cerebrovascular, or renal disease. At particular risk are the elderly, patients with diabetes, and those with target-organ damage manifested by impaired renal function. Evidence supports increased risk in these patients, and clinical trial results demonstrate the considerable benefits realized through aggressive blood pressure (BP) control. The number of elderly individuals continues to increase in the United States and other industrialized countries. The prevalence of isolated systolic hypertension (ISH) is higher in the elderly than in younger individuals. ISH is associated with significant morbidity and mortality and should not be considered a physiologic manifestation of the normal aging process. Type 2 diabetes is also increasing in prevalence. Patients with diabetes are at increased risk for coronary heart disease, stroke, renal failure, and other cardiovascular complications. Aggressive treatment of elevated BP can produce dramatic decreases in the cardiovascular complications of diabetes. The incidence of end-stage renal disease has increased 2.5-fold in the past two decades, and poorly controlled BP is a major contributor to the increase. Lowering BP to levels well below the traditional goal of 140/90 mm Hg is needed to slow the progression of renal dysfunction and prevent renal failure in hypertensive patients with renal disease, whether related to diabetes or to another etiology. Aggressive treatment of hypertension in multiple-risk populations (to the goals of JNC VI and the recent WHO-ISH Guidelines for the Management of Hypertension) can be expected to produce significant reductions in the incidence and prevalence of stroke, heart failure, coronary heart disease, chronic renal failure, and total cardiovascular mortality.
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PMID:Treating multiple-risk hypertensive populations. 1059 63

Atherosclerosis of the carotid bifurcation is an observable sign of systemic disease driven by key risk factors and resulting in an epidemic of stroke, myocardial infarction, and vascular death worldwide. Aggressive integrative preventive interventions of controlling hypertension, hyperlipidemia, diabetes mellitus, smoking, systemic inflammation/infarction, depression, and hyperhomocyst(e)imia are needed in the medical management of these high-risk patients. Surgical indications for asymptomatic surgery may be recalled through the acronym CAROTID, which emphasizes knowledge of risk benefit to a particular patient, adequate disclosure, and physician--patient equipoise.
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PMID:Indications for treatment of asymptomatic carotid stenosis. 1073 43

Autoimmunity arises when the immune system no longer tolerates self and precipitates lymphocyte reactivity against our own antigens. Although the developing T cell repertoire is constantly purging, self-recognition events do exist when such tight control is evaded and autoreactive lymphocytes escape the thymus (the sites of T cell development) and migrate to the periphery. Upon activation these autoreactive cells may exert aggressive behavior toward one's own tissues and organs leading to autoimmune disease. Multiple sclerosis, Rheumatoid arthritis, and type I diabetes are autoimmune diseases mediated by autoreactive T cells. A logical approach to prevent such autoimmunity would be to reprogram those lymphocytes to tolerate the self antigen. Injection of antigen at the neonatal stage promotes a state of tolerance such that successive encounter with antigen does not precipitate aggressive reactions. The mechanism underlying neonatal tolerance involves priming of T cells whose effector functions do not cause inflammatory reactions upon recognition of antigen but rather induce protective immunity. This form of tolerant immunity provides an attractive strategy for vaccination against autoimmunity. Herein, it is shown that neonatal exposure to a self-peptide-immunoglobulin chimera drives a tolerant immunity toward the self-peptide and protects against the autoimmune disease, experimental allergic encephalomyelitis.
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PMID:Neonatal tolerant immunity for vaccination against autoimmunity. 1076 11

Recent reports suggest that the pancreas participates in tumor necrosis factor alpha (TNF-A) production during stress, and that the islets are predominantly responsible for such synthesis. In vitro TNF-A and interleukin 1-beta (IL-1-beta) inhibit insulin release from islet beta-cells. We measured the circulating levels of IL-1-beta, TNF-A and islet cell antibody (ICA) in 30 children with IDDM (10 of them at their first presentation), 30 of their non-diabetic siblings, and 30 normal age-matched children. In the non-diabetic children we investigated the early phase of insulin release after intravenous bolus of glucose and evaluated tolerance to oral glucose (OGTT). IL-1-beta and TNF-A concentrations were significantly higher in IDDM-siblings (31.8 +/- 7.7 pg/ml and 650 +/- 155 pg/ml respectively) versus normal children (21.2 +/- 6.4 pg/ml and 383 +/- 122 pg/ml respectively). IL-1-beta and TNF-A concentrations did not differ significantly between the diabetic children and healthy age-matched controls. ICA were detected in 60% of the recently diagnosed diabetic children vs. 30% of those with longer duration of diabetes (3.1 +/- 1.2 years). Despite the significantly high prevalence of ICA in the recently diagnosed children with IDDM, their IL-1-beta and TNF-A concentrations were lower than those for the normal children. In experimental animals these cytokines can induce round cell infiltration (insulinitis) and inhibit insulin secretion by beta-cell. The presence of significantly higher concentrations of these cytokines in IDDM siblings, with high prevalence of ICA (16%), was associated with normal oral glucose tolerance and normal peak insulin response (60 +/- 10.4 mlU/ml) after i.v. glucose bolus compared to normal children (52.3 +/- 9.5 mlU/ml). However, after 2 years of follow up, one of them developed IDDM and another developed IGT but none of the normal controls developed abnormal glucose tolerance. It appears that the process of autoimmune aggression against beta-cells, and its effect on insulin release and glucose homeostasis, is a slow and chronic process. However, the production of these cytokines and consequently the degree of beta-cell destruction, in a genetically susceptible subject, might be enhanced by several factors including viral infections. In summary, IL-1-beta and TNF-A levels can be used as indicators of continuing autoimmune aggression against beta-cells before the development of extensive beta-cell destruction.
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PMID:Interleukin-1-beta, tumor necrosis factor-alpha, insulin secretion and oral glucose tolerance in non-diabetic siblings of children with IDDM. 1077 98

Several reports have demonstrated that high-protein diets may have beneficial effects on experimental models of diabetes and have raised the possibility that branched-chain amino acids could play a role in these protective effects. We investigated the effect of a normoproteic, branched-chain amino acid-enriched diet (experimental diet) on insulin secretion from C57BL/6N mice transferred with splenocytes from diabetic syngeneic donors. Mice previously fed with the experimental or control diet received three intraperitoneal injections, every other day, of 5 x 107 viable mononuclear splenocytes obtained from control or diabetic donors. Results showed that mice fed with the experimental diet and transferred with "diabetic" splenocytes presented: i) normoglycemia, and (ii) significantly higher levels in both phases of glucose-induced insulin secretion and normal values of arginine-glucose-induced insulin secretion. To evaluate the in vitro cellular immune aggression, dispersed mouse islet cells were co-cultured with splenocytes from syngeneic diabetic mice. First, dispersed islet cells from mice on the experimental or control diet were co-cultured with splenocytes from control or diabetic mice on a commercial diet. In the presence of "diabetic splenocytes, dispersed islet cells from mice on the experimental diet presented a significantly lower in vitro cellular immune aggression. On the other hand, "diabetic" splenocytes from mice fed with the experimental diet produced a significantly reduced cellular immune aggression on dispersed islet cells. Our results showed that feeding branched-chain amino acids increased the capacity of beta cells to withstand a functional assault and diminished the extent of in vitro cellular immune aggression.
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PMID:Branched-chain amino acid-enriched diet: effects on insulin secretion and cellular immune aggression. 1086 31

ESRD is always fatal unless recognized and treated appropriately. In the United States, the incidence of ESRD is increasing. Fortunately, both mortality among dialysis patients and the rate at which ESRD has been increasing over the past decade are declining. Obviously, the primary goal should be prevention of ESRD. Aggressive treatment of hypertension and hyperglycemia is likely to reduce the incidence of ESRD. Screening for diabetes and hypertension may be a fruitful approach to reduction in ESRD rates, because many patients present with renal failure after prolonged periods of undiagnosed hypertension or type 2 diabetes.
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PMID:Trends in end-stage renal disease. Epidemiology, morbidity, and mortality. 1091 23

The purpose of this study was to determine the occurrence of coronary artery disease risk factors in patients presenting with acute myocardial infarction (AMI) to a tertiary care institution in Trinidad and to determine the factors associated with increased mortality following AMI. All patients admitted to the Eric Williams Medical Sciences Complex (EWMSC) between January 1 and December 31, 1996, with a diagnosis of AMI were identified using the hospital admissions and discharge diagnosis databases. Demographic, clinical and laboratory variables were extracted from the hospital case records of patients with confirmed AMI. Sixty-one AMI patients (38 men) were admitted during the study period. Mean age at admission was 60 +/- 11 years with an ethnic case mix of thirty-nine (62%) of East Indian descent, eight (13%) of African descent, twelve (20%) mixed ethnicity and three (5%) of Caucasian descent. Thirty patients (49%) were hypertensive. Thirty-two patients (53%) were diabetic and eighteen patients (30%) gave a history of cigarette smoking. The mean left ventricular ejection fraction was 53 +/- 14%. The mean serum cholesterol from 29 patients was 228.2 +/- 49.0 mg/dl. Increasing age, female gender, an ejection fraction less than 40%, non treatment with streptokinase and in-hospital ventricular fibrillation were associated with poor survival. Multiple regression analyses identified three independent predictors of mortality. These were gender (p = 0.04), in-hospital ventricular fibrillation (p = 0.001) and an ejection fraction less than 40% (p = 0.02). Diabetes mellitus, hypertension, hyperlipidaemia and cigarette smoking were prevalent amongst patients presenting with AMI. Ventricular function was a major determinant of two-year mortality following AMI. Aggressive risk factor modification is recommended to prevent both first and recurrent coronary events.
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PMID:Two-year mortality and its determinants following acute myocardial infarction in Trinidad and Tobago. 1094 47

Hypertension and diabetes mellitus are independently associated with a high rate of target organ complications, which is particularly accentuated in the Negroid race. The aims of this study were to evaluate the mortality associated with diabetes mellitus and concurrent hypertension and diabetes mellitus in indigenous Africans, and to identify and assess the factors that are predictive of intra-hospital mortality in Non-Insulin Dependent Diabetes Mellitus (NIDDM) diabetic Nigerians. The subsequent impact of the modification of these risk factors was also evaluated. A prospective study of 51 hypertensive-diabetic (Non-Insulin Dependent Diabetics, NIDDM) Nigerians (32 males, 19 females) over a 15-month period, from 1996 to 1997 was undertaken. The mean admission blood pressures were 170/102+/-35/22 mm Hg, with a body mass index (BMI) of 25.4+/-10.2 kg/m(2). A total of 54 normotensive (BP<130/85 mm Hg)-NIDDM diabetic Nigerians (30 men, 24 women), who were concurrently admitted in the hospital, were compared to the hypertensive-NIDDM. The total mortality of all the NIDDM diabetics, as well as the mortality rates in normotensives and hypertensive-diabetics, were computed. The causes of death and associated complications were noted. Predictive indices of intrahospital mortality were statistically evaluated by comparison of proportions, chi(2) test, Fischer's exact test, logistic regression, and analysis of variance (ANOVA).Over-all mortality rate among all the diabetics (both normotensive and hypertensive) was 26.6% (28/105), which was significantly higher than the crude death rate on the Internal Medicine service of 17.8% (P=0.006) or the non-obstetric crude death rate in the hospital of 10.96% (P=0.001) Among the hypertensive-NIDDM patients (n=51) the mortality rate was 31.4% (16 deaths/51 patients). This was slightly higher than the value of 22.2% (12 deaths/54 patients) seen in normotensive -NIDDM patients. The mortality rate among the male diabetics (23/63 patients) 46.6% was significantly higher than female mortality rate of 11.6% (5/43). The 95% Confidence interval for the difference in mortality rates being 16.9% to 53.3% (P<0.0001, z=3.57). The impact of gender remained significant by the chi(2) test, chi(2)=7.17, P=0.007. 50% of the deaths in hypertensive-diabetics had associated stroke (8/16), while none of the 12 deaths among the normotensive-diabetics was stroke-related (P=0.008, Fisher's exact test). The case fatality rate for stroke in hypertensive-NIDDM men (7/7.9) was significantly greater than in hypertensive-NIDDM women (1.0/7) (P=0.04,by Fisher's exact test). Male gender, presence of Hyperosmolar Non-Ketotic Coma (HONK) (P<0. 05), associated stroke (P<0.01) and a Glasgow coma < or =10 (P<0.01) were found to be poor prognostic indices for mortality in hypertensive-NIDDM. Aggressive anti-platelet, (aspirin) anti-hypertensive, and strict glycemic control, instituted early and intensively, especially in male hypertensive-NIDDM Nigerians have resulted in reduction in the mortality rates from 26.6% in 1997 to 12.6% in 1999 [P=0.05, 95% CI -26.9% to -1.3%]. The prognosis in 1999 of hospitalized African diabetics is still dismal. Hypertensive-NIDDM represents a higher risk group for intra-hospital mortality in black Africans. Male patients appear to have significantly (P<0.001) enhanced risk, especially with thrombotic/stroke-related deaths (P<0.01). However, intervention measures can reduce the mortality rate considerably, even in developing countries. The mechanisms of the apparent male mortality excess require elucidation.
J Diabetes Complications
PMID:Prognostic indices for intra-hospital mortality in Nigerian diabetic NIDDM patients. Role of gender and hypertension. 1095 70

We demonstrated pancreatic reg gene overexpression in non-obese diabetic (NOD) mice during active diabetogenesis. The aim of this study was to determine in which part of the pancreas (endocrine and/or exocrine) the gene(s) and the protein(s) were expressed and if their localization changed with progression of the disease. In situ hybridization analysis and immunocytochemical studies were carried out on pancreas of female and male NOD mice. Both develop insulitis but diabetes develops only in females and in males only when treated by cyclophosphamide. Our results show that whatever the age, sex, and presence of insulitis and/or diabetes, the expression of reg mRNAs and of the corresponding protein(s) was restricted to exocrine tissue. Moreover, reg remains localized in acinar cells in the two opposite situations of (a) cyclophosphamide-treated males in a prediabetic stage presenting a high level of both insulin and reg mRNAs, and (b) the overtly diabetic females with no insulin but a high level of reg mRNA. These findings suggest that overexpression of the reg gene(s) might represent a defense of the acinar cell against pancreatic aggression.
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PMID:Overexpression of the reg gene in non-obese diabetic mouse pancreas during active diabetogenesis is restricted to exocrine tissue. 1099 Apr 93

The index patient is a 23-year-old female with end-stage renal disease (ESRD) secondary to chemotherapeutic agents. Continuous cycling peritoneal dialysis (CCPD) has been the renal replacement therapy for the past 5 years since a failed cadaveric renal transplant. Past medical history was significant for diabetes mellitus, hypertension, anemia, bilateral subclavian vein thrombosis with superior vena cava syndrome, secondary hyperparathyroidism, leukemia (at age 8), and hyperlipidemia. On presentation, soft tissue nodules were noted in the anterolateral surfaces of the legs. After 3 months of continued low-calcium-dialysate CCPD, calcitriol, and oral phosphate binders, a 2 x 3 cm nodule was noted on the posterior aspect of the thorax at the scapula. The only complaint at this time was shoulder pain at the acromioclavicular joint. Radiological examination revealed a 3 x 4 cm soft tissue opacity in the superior segment of the left lower lobe laterally. Despite a prior subtotal parathyroidectomy, phosphate binders, and calcitriol, the parathyroid hormone levels continued to increase, with development of tumoral calcinosis, worsening renal osteodystrophy, and calciphylaxis. Computed tomography examination revealed extensive soft tissue calcification consistent with tumoral calcinosis. An ulcerative lesion (1 cm) developed on the lateral aspect of the upper thigh owing to warfarin necrosis versus calciphylaxis. At this time, the phosphate binder was changed from calcium acetate to sevelamer hydrochloride. Aggressive wound treatment and aggressive calcium and phosphate control added to the treatment regimen has resulted in healing of the single ulcer and a decrease in the size of the tumoral lesions. In conclusion, early recognition and aggressive treatment of calciphylaxis can result in reduced morbidity and mortality from calciphylaxis in ESRD patients.
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PMID:Spectrum of complications related to secondary hyperparathyroidism in a peritoneal dialysis patient. 1104 12


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