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The United Kingdom Prospective Diabetes Study (UKPDS) is the largest study ever performed in the field of diabetes. It has been carried on in more than 5000 patients with newly diagnosed type 2 diabetes and followed during almost 15 years. The main goals of the study were to investigate the effects of improving blood glucose and/or blood pressure control on diabetic complications, and to compare the advantages and inconvenients of the most important pharmacological approaches. The results of the UKPDS have been presented at the last Congress of the European Association for the Study of Diabetes (EASD) in Barcelona, September 10-11, 1998. They essentially showed that improving blood glucose or arterial blood pressure control allows to significantly reduce the incidence of complications associated to diabetes. Best results were observed in individuals in whom treatments of both hyperglycemia and hypertension were intensified. For each risk factor, no threshold has been found so that every reduction in blood glucose or arterial pressure is accompanied by a nearly linear diminution in the incidence of diabetic complications. The type of pharmacological treatment appears to have a less prominent influence, even if metformin appears to exert the most favourable effects in the group of obese patients with type 2 diabetes.
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PMID:[Lessons from the "United Kingdom Prospective Diabetes Study"]. 983 82

The measurement of blood pressure is an integral part of antenatal care. Mercury sphygmomanometry is the gold standard for the determination of indirect blood pressure and has been used in pregnancy from the time blood pressure was first associated with adverse obstetric outcome. However, there is good evidence that current practice using mercury sphygmomanometry is far from perfect. This article will describe the history of blood pressure determination, why blood pressure is important in pregnancy and the problems associated with sphygmomanometry. It will discuss the advantages and disadvantages associated with alternative methods of blood pressure determination in pregnancy. Automated equipment should always be compared with mercury sphygmomanometry following a recognized protocol, such as that published by the British Hypertension Society, before its accuracy can be assumed in clinical practice. There is now good evidence that the accuracy of these devices deteriorates in women who develop pre-eclampsia. Home monitors have the potential to improve surveillance and to reduce in-patient monitoring.
Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Mar
PMID:Measuring blood pressure in normal and hypertensive pregnancy. 1074 90

In many ways there should be no need to classify hypertensive disorders in clinical practice. The very presence of rising blood pressure should alert the clinician to seek evidence for the development of pre-eclampsia and whether there are any emerging abnormalities of fetal growth and/or maternal renal, cerebral, hepatic or coagulation functions which may necessitate specific treatment, including delivery. While such a view may be appropriate for experienced clinicians with an understanding of the pathophysiology of the hypertensive disorders of pregnancy, it is of little help to junior or less experienced medical staff. Moreover, without an agreed international classification system it is impossible to compare truly clinical outcome, intervention or basic research studies from different units as entry criteria to these studies may differ considerably across individual units and certainly across countries. In this chapter we highlight the limitations of the existing classification systems and propose a system that is based on our present understanding of the pathophysiology of pre-eclampsia. The proposed system is not a radical departure from previous classifications, with grouping of hypertensive subjects into gestational hypertension, pre-eclampsia and chronic (usually essential) hypertension. Proteinuria, while remaining a hallmark of pre-eclampsia, is no longer considered a 'sine qua non' for this disorder to be diagnosed, reflecting our greater understanding of the maternal and fetal abnormalities in pre-eclampsia since previous classification systems were developed. This classification system has been compared with the traditional system of diagnosing proteinuric pre-eclampsia in a study of 1183 women with hypertension in pregnancy: diagnosing pre-eclampsia in this new manner still stratifies a high-risk group of pregnant women and the proposed diagnosis of gestational hypertension in this system stratifies a group of women at low maternal and fetal risk, provided that continual maternal and fetal monitoring is employed. We hope that this system of classification can be adopted uniformly, permitting appropriate triage of pregnant women into higher and lower clinical risk groups while allowing us to compare 'apples with apples' in future research studies.
Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Mar
PMID:Classification of hypertension in pregnancy. 1074 91

Expert and aggressive pre-operative preparation of the woman with severe pre-eclampsia will ultimately determine her intraoperative outcome. Such considerations as the effect of endotracheal manipulation on intracranial pressure, of thrombocytopenia on the potential to produce a compressive epidural haematoma following epidural or combined spinal-epidural neuraxial block and of adequacy of invasive monitoring for Caesarean section loom large in the eyes of an anaesthetist preparing such a patient for surgery. Time spent pre-operatively in fluid volume optimization, in assessment of ventricular function, filling pressures and systemic vascular resistance, on aspiration pneumonitis and seizure prophylaxis, on control of hypertension, on correction of coagulopathy and on attenuation of pressor responses is time well spent and will have profound effects on the peri-operative course. The choice of agents and techniques for control of hypertension and reduction of vascular resistance, for induction and maintenance of general anaesthesia, for eclampsia prophylaxis and for regional anaesthesia or analgesia for operative or spontaneous delivery is, likewise, important and, at times, problematic.
Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Mar
PMID:Clinical management of established pre-eclampsia and gestational hypertension: an anaesthetist's perspective. 1074 95

Key principles underpin good midwifery care of every pregnant woman, including a sound knowledge base, meeting the woman's needs and enhancing care. Normal antenatal care, with regular measurement of blood pressure, remains the mainstay of screening for hypertension in pregnancy. The midwife's role is that of accurate assessment and communication when detecting the first signs of hypertension. The midwife will then play a major role in the ongoing monitoring of the condition, liaison with the medical team and education of the woman and her family. Continuity of care is an important principle in avoiding errors in recording blood pressure between care givers; familiarity of a known midwife may reduce the likelihood of white coat hypertension. Advocacy should be employed by the midwife as a key link between the woman, her family and the obstetric team. Every woman who has experienced pre-eclampsia should be given the opportunity to talk through her care at a later date. This may be at the postnatal appointment or through a debriefing service.
Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Mar
PMID:Care of the woman with hypertension in pregnancy: the viewpoint of the midwife. 1074 96

Hypertension is a relatively common complication of pregnancy, increasing in frequency in older women. It is not a contraindication to pregnancy, but should be fully investigated, correctable causes addressed and those with specific relevance for pregnancy identified. With close supervision and appropriate management, the majority of hypertensive pregnant women have successful outcomes. Ideally all women with chronic hypertension should be seen prior to a planned pregnancy, for explanation and discussion of the significance, risks and treatment plan and for adjustment of antihypertensive medication as necessary. Those charged with the antenatal and perinatal care of the patient should be familiar with the expected physiological changes in pregnancy and of the risks and benefits of any treatment given. Close communication among the patient, her obstetrician and consultant physician will ensure the most appropriate treatment and facilitate decisions regarding admission to hospital, timing and mode of delivery, and management issues in the early postpartum period.
Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Mar
PMID:Chronic essential and secondary hypertension in pregnancy. 1074 97

The risk of coronary heart disease and atherosclerosis is increased in both Type 2 and Type I diabetes mellitus. The dyslipidaemia of Type 2 diabetes consists of hypertriglyceridaemia and low levels of high-density lipoprotein (HDL) cholesterol. In Type I diabetes, hypertriglyceridaemia is also present, but when glycaemic control is good, HDL cholesterol levels may be normal or even increased. In both types of diabetes, nephropathy is associated with an exacerbation of hypertriglyceridaemia, a decline in HDL cholesterol level and an increase in serum cholesterol. In the absence of nephropathy, serum cholesterol levels are typically similar to those of the background non-diabetic population. The risk of coronary heart disease (CHD) associated with serum cholesterol is, however, considerably higher in diabetics than in non-diabetic people, and is much less in diabetic populations living in countries where the average cholesterol level is low, even when hypertension is present. Currently, the strongest evidence that lipid-lowering drug therapy will decrease the risk of CHD, particularly in secondary prevention, comes from trials of statins that lower cholesterol. There is growing experimental and observational evidence that hypertriglyceridaemia, because of its effects on cholesteryl ester transfer, leading to the formation of a small low-density lipoprotein susceptible to oxidation, compounds the risk of serum cholesterol in diabetes. Both fibrates and statins can decrease this cholesteryl ester transfer. Further studies of fibrates with clinical end-points should clarify their role in the prevention of CHD. In the meantime, statins should be part of routine diabetic clinical practice, fibrates having a more limited role when hypertriglyceridaemia is extreme.
Baillieres Best Pract Res Clin Endocrinol Metab 1999 Jul
PMID:Diabetic dyslipidaemia. 1076 66

Myocardial infarction (MI) is a common cause of mortality in people with diabetes. The case fatality from MI is high and may be reduced by thrombolysis and treatment with aspirin, beta-blockers and angiotensin-converting enzyme inhibitors. Poor metabolic control is common among diabetic patients with MI, but the importance of controlling blood glucose during and following an MI is debatable. Treatment with statins reduces cardiovascular end-points in diabetic patients with previous MI (secondary prevention). Large studies in diabetic patients without existing heart disease have shown statistically insignificant reductions in heart disease and MI with improved glycaemic control of the diabetes (primary prevention). The treatment of hypertension in people with diabetes prevents cardiovascular end-points, and studies on whether the treatment of hyperlipidaemia reduces heart disease and MI are proceeding.
Baillieres Best Pract Res Clin Endocrinol Metab 1999 Jul
PMID:Diabetes and myocardial infarction. 1076 70

ECG criteria for left ventricular hypertrophy (LVH) have been almost exclusively elaborated and calibrated in white populations. Because several interethnic differences in ECG characteristics have been found, the applicability of these criteria to African individuals remains to be demonstrated. We therefore investigated the performance of classic ECG criteria for LVH detection in an African population. Digitized 12-lead ECG tracings were obtained from 334 African individuals randomly selected from the general population of the Republic of Seychelles (Indian Ocean). Left ventricular mass was calculated with M-mode echocardiography and indexed to body height. LVH was defined by taking the 95th percentile of body height-indexed LVM values in a reference subgroup. In the entire study sample, 16 men and 15 women (prevalence 9.3%) were finally declared to have LVH, of whom 9 were of the reference subgroup. Sensitivity, specificity, accuracy, and positive and negative predictive values for LVH were calculated for 9 classic ECG criteria, and receiver operating characteristic curves were computed. We also generated a new composite time-voltage criterion with stepwise multiple linear regression: weighted time-voltage criterion=(0.2366R(aVL)+0.0551R(V5)+0.0785S(V3)+ 0.2993T(V1))xQRS duration. The Sokolow-Lyon criterion reached the highest sensitivity (61%) and the R(aVL) voltage criterion reached the highest specificity (97%) when evaluated at their traditional partition value. However, at a fixed specificity of 95%, the sensitivity of these 10 criteria ranged from 16% to 32%. Best accuracy was obtained with the R(aVL) voltage criterion and the new composite time-voltage criterion (89% for both). Positive and negative predictive values varied considerably depending on the concomitant presence of 3 clinical risk factors for LVH (hypertension, age >/=50 years, overweight). Median positive and negative predictive values of the 10 ECG criteria were 15% and 95%, respectively, for subjects with none or 1 of these risk factors compared with 63% and 76% for subjects with all of them. In conclusion, the performance of classic ECG criteria for LVH detection was largely disparate and appeared to be lower in this population of East African origin than in white subjects. A newly generated composite time-voltage criterion might provide improved performance. The predictive value of ECG criteria for LVH was considerably enhanced with the integration of information on concomitant clinical risk factors for LVH.
Hypertension 2000 Jul
PMID:Performance of classic electrocardiographic criteria for left ventricular hypertrophy in an African population. 1090 12

Severe obesity is a grave disease in the U.S. as well as other industrialized nations. This disease has many ramifications on both an individual and social levels. It affects 12.5 million people in the U.S., according to national survey data. The health risks of severe obesity include hypertension, hyperlipidaemia, cardiomyopathy, diabetes, hypoventilation disorders, increased risk of malignancy, cholelithiasis, degenerative arthritis, infertility, and psychosocial impairments. Medical weight reduction programmes have rarely achieved long-term success. Most authorities now agree that bariatric surgery is the treatment of choice for well-informed and motivated obese patients with acceptable operative risks, who strongly desire substantial weight loss or who have severe impairments because of their weight. Surgery is indicated for patients with a BMI greater than 40 kg/m2, or for those with serious medical co-morbidities and a BMI greater than 35 kg/m2. Three procedures, the adjustable silicone gastric banding (ASGB), vertical gastric banding (VBG), and gastric bypass (GB), have produced the best results to date. Each of these procedures is much more effective than dietary therapies. Each has advantages and disadvantages, with GB producing greater sustained weight loss in the long-term, with a slightly higher risk of metabolic complications. All can be done with surprisingly low operative mortality. The pronounced weight loss induced with these operations can relieve and bring co-morbid diseases, such as diabetes and hypertension, once thought to be only barely controllable, into full long-term remission.
Baillieres Best Pract Res Clin Endocrinol Metab 1999 Apr
PMID:Surgical intervention for the severely obese. 1093 82


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