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Despite recent progress in therapy and management of diabetes mellitus, diabetes remains a serious disease with life-threatening complications. It is by far the most common metabolic disease and affects 5% of the population in industrialized countries. Noninsulin-dependent diabetes mellitus (NIDDM) is a complex disorder characterized by insulin resistance and impaired insulin secretion and is associated with an increased risk of coronary heart disease, peripheral vascular disease, arterial hypertension and dyslipidemia. Predisposing factors for NIDDM are obesity and a family history of diabetes. Greater physical activity has been associated inversely with the prevalence of NIDDM in several cross-sectional studies. Physical activity increases the sensitivity to insulin, and regular endurance exercise can induce and maintain weight loss, improve glucose tolerance and ameliorate most of the abnormalities in the metabolic syndrome. Type I diabetes mellitus arises as a consequence of immunologically mediated pancreatic islet beta-cell destruction in genetically susceptible individuals. It is an insidious process that may occur over years. During the stage of disease evolution (prediabetes), individuals may be identified by the presence of immunological markers and a decline of beta-cell function. The autoimmune nature of the disease process has led to attempts to stop this process by immune intervention strategies. A variety of immune interventions has been used, some immunosuppressive and some immunomodulatory. Several screening programs are used in order to identify high-risk subjects (i.e. first-degree relatives of individuals with type I diabetes) who may benefit from an early intervention. The ultimate goal of all these efforts is to prevent the development of overt type I diabetes mellitus in those at risk for the disease, using strategies that are both safe and specific. This review summarizes the results of the various studies conducted to date and outlines the approaches currently being tested.
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PMID:[Is prevention of diabetes mellitus possible?]. 783 27

In Seattle, Washington, the prevalence of diabetes was 20% in second-generation (Nisei) Japanese-American men and 16% in Nisei women 45-74 years old, while the prevalence of impaired glucose tolerance (IGT) was 36% in Nisei men and 40% in Nisei women. Hyperglycemia was less and duration of diabetes shorter in women. Related to diabetes and IGT in Nisei were higher fasting plasma insulin levels and central (visceral) adiposity. Prevalence of diabetes was low among the younger (34-53 years old) third-generation (Sansei) men and women. Among self-reported non-diabetic Sansei, however, prevalence of IGT was 19% in men and 29% in women, and IGT was associated with both increased fasting plasma insulin levels and more visceral fat, suggesting that many Sansei are at risk of future diabetes. An important lifestyle factor in the development of NIDD in Japanese Americans appeared to be dietary saturated (animal) fat. Another factor may be physical inactivity. In Japanese-American women, menopause also appeared to be an important risk factor. These risk factors may be related to fostering the accumulation of visceral fat and the development of insulin resistance. Five-year follow-up examinations performed in non-diabetic Nisei men and women have yielded additional information concerning the prognosis of IGT. Of those women who were IGT at baseline, 34% were diabetic at follow-up while 17% returned to normal. In men who had been IGT at baseline, 18% were diabetic at follow-up while 36% returned to normal. Over the 5-yr follow-up interval, proportionally more women progressed from normal to IGT (54%) then went from IGT to normal (17%). For men, roughly equal proportions went from normal to IGT (37%) as from IGT to normal (36%). It would therefore appear that greater proportions of Nisei women are progressing to IGT and to NIDD than are Nisei men. This observation may be related to the increased risk of developing central obesity and insulin resistance following menopause. Prevalence of cardiovascular disease (hypertension, peripheral vascular disease, and/or coronary heart disease) was increased in Japanese Americans with IGT and NIDD. Neuropathy and retinopathy were associated only with NIDD.
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PMID:Diabetes and diabetes risk factors in second- and third-generation Japanese Americans in Seattle, Washington. 785 32

The purpose of this study was to evaluate the effects of the alpha 1-blocking agent terazosin on blood pressure (BP) and blood lipids in a large, variant population of patients with hypertension. A total of 16,917 patients with hypertension were evaluated at 2214 primary and community care facilities; 7808 of these patients had not been treated previously for hypertension; 3928 were switched to terazosin from another antihypertensive agent; and 5181 received terazosin in addition to an agent that had not controlled their hypertension. Terazosin produced highly significant reductions in systolic (-18.2 +/- 0.2 mm Hg) and diastolic (-13.2 +/- 0.1 mm Hg) BP when used as monotherapy (mean dose, 3.1 mg; range, 2 to 10 mg) without causing a significant increase in heart rate. Equal antihypertensive efficacy was demonstrated in men, women, blacks, and whites of all ages, with particular benefit to elderly patients (> or = 65 years of age) with systolic hypertension. Comparative studies indicated that terazosin had equal antihypertensive efficacy in combination with diuretics, beta-blockers, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors. Patients who had not responded to monotherapy with one of these classes of antihypertensive drugs showed significant reductions of BP after terazosin, in the following average doses, was added to diuretics, 3.1 mg; beta-blockers, 3.4 mg; calcium channel blockers, 3.3 mg; and ACE inhibitors, 3.4 mg. Terazosin produced highly significant reductions in blood levels of total cholesterol (-5.0%), triglycerides (-6.1%), and low-density lipoprotein cholesterol (-7.6%) without change in high-density lipoprotein cholesterol when used as monotherapy. Similar favorable effects on blood lipid levels were demonstrated when terazosin was used in combination with all other classes of antihypertensive drugs. The greatest reductions in blood cholesterol (-9.2%) were observed among patients with hyperlipidemia (total cholesterol > or = 240 mg/dL). Terazosin maintained its antihypertensive efficacy and was well tolerated by patients with a variety of concomitant diseases, including congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, benign prostatic hyperplasia, diabetes, and obesity. Adverse effects occurred in 17.9% of patients and caused 2.2% to drop out of the study. The most frequent adverse effects were dizziness (4.8%), headache (2.5%), and asthenia (2.4%). Only 0.4% suffered syncope and 0.2% impotence. These data demonstrate the usefulness of terazosin as monotherapy or add-on therapy for treatment of hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Alpha 1-blockade for the treatment of hypertension: a megastudy of terazosin in 2214 clinical practice settings. 792 16

A higher prevalence of stroke is found in the patient with both diagnosed and undiagnosed diabetes and glucose intolerance. Because of local cerebral acidosis caused by ischemia and hyperglycemia, morbidity and mortality from a stroke are increased. Most studies show that individuals with admission serum glucose > 120 mg/dl (6.7 mM) have a higher morbidity and mortality from a stroke. The prevalence of cerebral infarcts, especially lacunar infarcts, is increased and the prevalence of subarachnoid hemorrhage, cerebral hemorrhage, and transient ischemic attacks are decreased in the diabetic patient. Age, race, hypertension, and the presence of diabetic nephropathy and coronary and peripheral vascular disease are risk factors for stroke in the diabetic patient, whereas obesity, smoking, hyperlipidemia, and glycemic control are not. Investigation and treatment of the diabetic patient with a stroke is discussed.
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PMID:Stroke in the diabetic patient. 817 50

Peripheral vascular diseases, both symptomatic and asymptomatic, are strong predictors of total and cardiovascular mortality. The commonly used Rose questionnaire, although highly specific, has a low sensitivity to detecting peripheral vascular disease and is not adequate for asymptomatic subjects. Doppler ultrasound measurement of the ankle/brachial systolic blood pressure ratio is a non-invasive, reproducible and accurate method of assessment of peripheral vascular disease and has been validated by angiography. METHODS. Five hundred and ten subjects, corresponding to fifty percent of the people working as civil servants in the Catanzaro city hall, were invited to join the study by a letter. Three hundred and eighty four participated. Exclusion criterion was claudicatio intermittens as detected by Rose questionnaire. All the subjects filled a questionnaire to assess coronary heart disease risk factors and underwent a full clinical examination. Brachial blood pressure was measured on both arms with participants in supine position, just before ECG. The systolic ankle blood pressure was measured with ultrasonic technique. The blood pressure cuff was placed just proximal to the medial malleolus. The ankle-brachial systolic pressure index (Winsor Index) was determined by dividing the highest of the posterior tibial or dorsalis pedis pressures by the highest brachial pressure. A limit of 0.95 was chosen to identify subjects with peripheral arterial disease. Venous blood for serum cholesterol and triglycerides, apolipoprotein AI and B and blood glucose, was collected after an overnight fasting, into Vacutainer Tubes (Becton & Dickinson). RESULTS. No subject had claudicatio intermittens. Sixteen subjects were excluded from the statistical analysis because of missing data. Two hundred and sixty-three were males and 105 females. Twenty-one (5.7%) out of 368 participants had a Winsor Index < 0.95 in at least one leg. These subjects had higher values of systolic and diastolic blood pressure compared to normal subjects whereas no differences were observed with regard to age, BMI, lipid profile and blood glucose. Furthermore the prevalence of hypertension was higher in the group of subjects with asymptomatic peripheral arterial disease. The prevalence of other risk factors for atherosclerosis (cigarette smoking, hyperlipidemia, diabetes mellitus, obesity) was similar in subjects with or without peripheral arterial disease. DISCUSSION. In the present study the prevalence of Winsor Index < 0.95 was 5.7%, similar to that reported by other authors. Hypertension was the only risk factor for atherosclerosis associated with peripheral arterial disease. Other authors also reported a higher prevalence of cigarette smoking among subjects with peripheral disease. In our population this association was not found but the participants were younger and consequently the exposure to this risk factor was shorter. CONCLUSION. The measurement of systolic ankle blood pressure by Doppler ultrasounds is a non-invasive, well accepted, highly specific and sensitive method to detect asymptomatic peripheral arterial disease. It might be of value in better defining the cardiovascular risk profile both in epidemiologic studies and clinical practice, especially in subjects with hypertension.
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PMID:[Asymptomatic arteriopathy of the lower limbs. Prevalence and risk factors in a population of southern Italy]. 833 69

The prevalence of macrovascular disease and hyperlipidaemia was examined in 500 patients with non-insulin-dependent diabetes mellitus attending a diabetic clinic in a Sri Lankan teaching hospital and 250 controls matched for age and gender. Macrovascular disease was assessed using a modified World Health Organisation questionnaire and modified Minnesota coding of electrocardiogram recordings. Twenty-one per cent of diabetic patients and 14.3% of controls had hypercholesterolaemia (P < 0.05). Macrovascular disease was present in 13.4% of diabetic patients and 8.2% of controls. Significant differences were seen in the prevalence of hypertension (15.6% vs 4.8%, P < 0.05), obesity (16.2% vs 9.7%, P < 0.05), peripheral vascular disease (5.6% vs 2%, P < 0.05) and electrocardiographic abnormalities (12% vs 6%, P < 0.05) in diabetic patients when compared to controls. Hyperlipidaemia and macrovascular disease is common in non-insulin-dependent diabetic patients in Sri Lanka and accounts for significant morbidity.
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PMID:The prevalence of macrovascular disease and lipid abnormalities amongst diabetic patients in Sri Lanka. 841 44

In order to evaluate clinical presentation and to determinate classification criteria of type 1 diabetes in the elderly, we carried out a study in 258 diabetic patients more than 60 years old of which 100 used insulin by failure to oral hypoglycemic agents (OHA). The prevalence of ischemic cardiovascular disease was 36%, peripheral vascular disease 34% and stroke 30%. Non-proliferative retinopathy 47%, nephropathy 16% and peripheral neuropathy 37%. Cardiovascular risk factors as obesity (36%), hypertension (33%) and hypercholesterolemia (12%) were evaluated. The average duration of diabetes was 20 years. Post-glucagon C-Peptide, HLA-DR antigens and islet cell antibodies (ICA), were measured in 75 older diabetic patients on treatment of which 24 used insulin, 11 diet and 40 OHA. Older patients on treatment with insulin had longer duration of disease, less obesity, low level basal of C-Peptide and a low response to post glucagon C-Peptide (0.94 +/- 0.5 pmol/ml) compared with patients on diet (1.8 +/- 0.9 pmol/ml) and OHA (1.8 +/- 0.8 pmol/ml). Older diabetics on insulin therapy had a greater frequency of HLA-DR3 (42%) and HLA-DR4 (21%) than other older diabetics. The ICA was negative in most patients. This study shows the high prevalence of macrovascular and microvascular disease in elderly patients with diabetes mellitus and that the most reliable parameter in classifying type 1 (insulin-dependent) diabetes is the measurement of basal and post-glucagon C-Peptide. HLA-DR specific markers can be used with this parameter because their expression is partly shared. This approach appears useful in the older diabetic patients to help classify diabetes and its management.
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PMID:[Diabetes mellitus in the elderly: a study on its clinical presentation, C-peptide reserve, and immunogenetic markers of insulin dependence]. 848 59

Among the most common causes of morbidity and mortality in elderly individuals are the manifestations of the various peripheral vascular diseases. Many chronic degenerative diseases, which begin in middle age, are associated with peripheral vascular disease. Heart disease, hypertension, hyperlipidemia and diabetes are all risk factors for peripheral vascular diseases and also common degenerative conditions in our society. Other risk factors, such as diet, smoking, stress, lack of exercise, and obesity, are also closely associated with peripheral vascular disease. Aging itself is also a risk factor. Appropriate treatment for disease processes such as diabetes and hypertension and control of other preventable risk factors have been shown to reduce the morbidity and mortality seen in peripheral vascular disorders. Our rapidly aging population requires increasing amounts of medical resources, placing an enormous burden on society because the aged population are generally more dependent upon government-sponsored health care services. The podiatric practitioner is in a position as a primary care provider to influence the health practices of our aging population. The implementation of a health practice that stresses prevention and wellness as well as the appropriate management and a referral of patients with peripheral vascular disorders will limit the morbid results of peripheral vascular diseases.
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PMID:Common peripheral vascular diseases. 848 79

The clinical and biochemical characteristics of type III hyperlipoproteinemia are described in 64 patients (35 males and 29 females). Homozygosity for apolipoprotein E2, the presence of an abnormally cholesterol-rich very low density lipoprotein fraction (beta-VLDL) and an elevated ratio of very low density lipoprotein cholesterol to plasma triglycerides (> 0.3; normal ratio about 0.2) were the basis for the diagnosis. Mean serum cholesterol and triglyceride concentrations at the first visit in the clinic were 426 +/- 221 and 719 +/- 996 mg/dl, respectively. The mean age at diagnosis of the disorder was 49 years in males and 53 years in females. There was a high prevalence of obesity (72%), xanthomas (42%), and atherosclerosis (39%), especially peripheral vascular disease (31%). Early and correct diagnosis of this familial lipoprotein disorder seems necessary because of the prompt and beneficial response to therapeutic interventions.
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PMID:Clinical features of type III hyperlipoproteinemia: analysis of 64 patients. 850 5

We propose the term Profactor-H for chronic elevated circulating insulin. Profactor-H is common in atherosclerosis, essential hypertension, non-insulin dependent diabetes mellitus, some forms of obesity, some forms of cancer, cardiovascular disease, peripheral vascular disease and some forms of stroke. Profactor-H appears to be the central pathophysiologic consideration in the etiology of many diseases and health risk factors. Profactor-H's impact depends on genetic predisposition, frequency consumption of refined simple and complex carbohydrates, deficiency in dietary chromium, sedentary life style and stresses of modern day living. In many obese individuals, Profactor-H disturbs metabolic balance, favoring anabolic metabolism, and is exacerbated through chronic insulin production and impairment of insulin action. This vicious cycle also appears to be common in many apparently healthy, non-obese individuals destined to develop health risks and diseases in response to long-term adverse consequences of Profactor-H. We believe that a four-pronged program which 1) reduces the daily frequency of carbohydrate consumption, particularly refined foods and simple sugars, 2) supplements the daily dietary intake of chromium, 3) encourages activity, and 4) reduces stress, will minimize the impact of Profactor-H and thereby reduce health risks and result in improved health.
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PMID:Profactor-H (elevated circulating insulin): the link to health risk factors and diseases of civilization. 857 92


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