BackgroundA Danish cancer pathway has been implemented for patients with serious non-specific symptoms and signs of cancer (NSSC-CPP). The initiative is one of several to improve the long diagnostic interval and the poor survival of Danish cancer patients. However, little is known about the patients investigated under this pathway. We aim to describe the characteristics of patients referred from general practice to the NSSC-CPP and to estimate the cancer probability and distribution in this population.MethodsA cross-sectional study was performed, including all patients referred to the NSSC-CPP at the hospitals in Aarhus or Silkeborg in the Central Denmark Region between March 2012 and March 2013. Data were based on a questionnaire completed by the patient’s general practitioner (GP) combined with nationwide registers. Cancer probability was the percentage of new cancers per investigated patient. Associations between patient characteristics and cancer diagnosis were estimated with prevalence rate ratios (PRRs) from a generalised linear model.ResultsThe mean age of all 1278 included patients was 65.9 years, and 47.5 % were men. In total, 16.2 % of all patients had a cancer diagnosis after six months; the most common types were lung cancer (17.9 %), colorectal cancer (12.6 %), hematopoietic tissue cancer (10.1 %) and pancreatic cancer (9.2 %). All patients in combination had more than 80 different symptoms and 51 different clinical findings at referral. Most symptoms were non-specific and vague; weight loss and fatigue were present in more than half of all cases. The three most common clinical findings were ‘affected general condition’ (35.8 %), ‘GP’s gut feeling’ (22.5 %) and ‘findings from the abdomen’ (13.0 %). A strong association was found between GP-estimated cancer risk at referral and probability of cancer.ConclusionsIn total, 16.2 % of the patients referred through the NSSC-CPP had cancer. They constituted a heterogeneous group with many different symptoms and clinical findings. The GP’s gut feeling was a common reason for referral which proved to be a strong predictor of cancer. The GP’s overall estimation of the patient’s risk of cancer at referral was associated with the probability of finding cancer.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-015-1424-5) contains supplementary material, which is available to authorized users.
The hepatic protein mannan-binding lectin (MBL) activates the complement system on binding to carbohydrate patterns and is involved in first-line defense against invading microorganisms. Emerging evidence indicates that in some situations MBL may cause inexpedient complement activation and tissue injury through binding to endothelial glycosylations. MBL levels are suppressed by insulin treatment in critically ill patients, and, hypothetically, hepatic portal hypoinsulinemia could lead to increased levels of MBL in patients with type 1 diabetes. We measured MBL and C-reactive protein (CRP) levels in 132 normoalbuminuric type 1 diabetic patients and 66 healthy age- and sex-matched controls. The median MBL concentration was higher in diabetic patients than in healthy controls [1290 micro g/liter (interquartile range, IQR 354-2961 micro g/liter) vs. 970 micro g/liter (IQR 277-1607 micro g/liter), P = 0.025], whereas CRP concentrations were similar among patients and controls [1.42 mg/liter (IQR 0.95-2.21) vs. 1.21 mg/l (IQR 0.74-2.13), NS]. In diabetic subjects, CRP levels correlated with poor glycemic control as indicated by hemoglobin A(1c) and daily insulin dose, which was not the case with MBL. MBL concentrations were positively correlated with urinary albumin excretion (r = 0.22; P = 0.013) and increased with increasing urinary albumin excretion tertile (P = 0.036). In conclusion, our data demonstrate that circulating MBL concentrations are significantly elevated in patients with type 1 diabetes and suggest a possible role of MBL in the pathogenesis of renovascular complications in diabetes.
Increased PP and blunted diurnal BP variation are hemodynamic abnormalities associated with micro- and macrovascular complications in type 2 diabetes.
AimsTo evaluate the clinical effectiveness of switching to insulin degludec (IDeg) in insulin‐treated patients with either type 1 diabetes (T1DM) or type 2 diabetes (T2DM) under conditions of routine clinical care.Materials and MethodsThis was a multicentre, retrospective, chart review study. In all patients, basal insulin was switched to IDeg at least 6 months before the start of data collection. Baseline was defined as the most recent recording during the 3‐month period before first prescription of IDeg. Values are presented as mean [95%CI].ResultsT1DM (n = 1717): HbA1c decreased by −2.2 [−2.6; −2.0] mmol/mol (−0.20 [−0.24; −0.17]%) at 6 months vs baseline (P < .001). Rate ratio of overall (0.79 [0.69; 0.89]), non‐severe nocturnal (0.54 [0.42; 0.69]) and severe (0.15 [0.09; 0.24]) hypoglycaemia was significantly lower in the 6‐month post‐switch period vs the pre‐switch period (P < .001 for all). Total daily insulin dose decreased by −4.88 [−5.52; −4.24] U (−11%) at 6 months vs baseline (P < .001). T2DM (n = 833): HbA1c decreased by −5.6 [−6.3; −4.7] mmol/mol (−0.51 [−0.58; −0.43] %) at 6 months vs baseline (P < .001). Rate ratio of overall (0.39 [0.27; 0.58], P < .001), non‐severe nocturnal (0.10 [0.06; 0.16], P < .001) and severe (0.075 [0.01; 0.43], P = .004) hypoglycaemia was significantly lower in the 6‐month post‐switch period vs the pre‐switch period. Total daily insulin dose decreased by −2.48 [−4.24; −0.71] U (−3%) at 6 months vs baseline (P = .006). Clinical outcomes for T1DM and T2DM at 12 months were consistent with results at 6 months.ConclusionsThis study demonstrates that switching patients to IDeg from other basal insulins improves glycaemic control and significantly reduces the risk of hypoglycaemia in routine clinical practice.
OBJECTIVE -To assess and compare the long-term effects of the combination of candesartan and lisinopril with high-dose lisinopril on systolic blood pressure in patients with hypertension and diabetes.RESEARCH DESIGN AND METHODS -This was a prospective, randomized, parallel-group, double-blind, double-dummy study with a 12-month follow-up. Drug therapy was either lisinopril 40 mg once daily or dual-blockade treatment with candesartan 16 mg once daily and lisinopril 20 mg once daily. The study comprised 75 type 1 and type 2 diabetic patients aged 35-74 years. The main outcome measures were seated and 24-h ambulatory systolic blood pressure.RESULTS -Reduction in systolic blood pressure (24-h systolic blood pressure) reduction was obtained in both treatment arms (mean reduction at final follow-up: dual blockade 6 mmHg vs. lisinopril 2 mmHg), but no significant difference was found between dual-blockade and lisinopril 40 mg once daily (P ϭ 0.10). Both treatments were generally well tolerated, and similar low rates of side effects were found in the two groups.CONCLUSIONS -There was no statistically significant difference between lisinopril 40 mg once daily and lisinopril 20 mg in combination with candesartan 16 mg once daily in reducing systolic blood pressure in hypertensive patients with diabetes. Diabetes Care 28:273-277, 2005D ual blockade of the renin-angiotensin system was opted for based on the principle of obtaining the broadest and most efficient blockade of the effects of angiotensin II by using the combination of an ACE inhibitor and an angiotensin II receptor blocker (AIIA).By combining two different pharmacological principles and inhibiting both the ACE and the angiotensin II type 1 receptor, it seems possible to arrive at a treatment regimen that inhibits both the production and the action of angiotensin II and serves as an efficient antihypertensive therapy. The Candesartan and Lisinopril Microalbuminuria (CALM) study was among the first to show an additional effect from dual blockade on blood pressure in a population of type 2 diabetic patients with microalbuminuria over a 12-week follow-up period (1). Following the CALM study, several small-scale studies indicated that using dual blockade in treating type 1 and type 2 diabetic patients might produce additional clinical effects on both blood pressure and albumin excretion (2-4). Moreover, one large-scale study in nondiabetic patients with nephropathy has also shown that dual-blockade treatment has an effect in the long term (5).However, several important clinical questions remain unresolved: 1) What are the clinical effects of dual blockade compared with an efficient dosage titration of an ACE inhibitor? 2) Does the effect of dual blockade persist over a longer period of time? 3) What are the long-term safety and tolerability characteristics of the two treatment regimes?Thus, the primary objective of the CALM II study was to compare over a 12-month period the results of adding either candesartan cilexetil 16 mg or lisinopril 20 mg to concomitant antihy...
OBJECTIVE—Diabetic maculopathy (DMa) is the most prevalent sight-threatening type of retinopathy in type 2 diabetes and a leading cause of visual loss in the western world. The disease is characterized by hyperpermeability of retinal blood vessels and subsequent formation of hard exudates and macular edema, the degree of which can be estimated by measurement of retinal thickness. We examined associations between retinal thickness as evaluated by optical coherence tomography scanning (OCT), glomerular leakage as evaluated by urinary albumin excretion rate (UAE), and general vascular leakage as evaluated by the transcapillary escape rate of albumin (TERalb) in type 2 diabetic patients with and without DMa. RESEARCH DESIGN AND METHODS—In 20 type 2 diabetic patients with DMa and 20 type 2 diabetic patients without retinopathy matched for age, sex, and duration of diabetes, we performed OCT, fundus photography, fluorescein angiography, and 24-h ambulatory blood pressure measurement. UAE was determined by radioimmunoassay. TERalb was determined as the initial disappearance of intravenously injected 125I-labeled human serum albumin. RESULTS—Patients with diabetic maculopathy had higher HbA1c (8.5 ± 1.5 vs. 7.4 ± 1.2%, P < 0.05) and higher total cholesterol (5.8 ± 0.7 vs. 5.2 ± 0.9 mmol/l, P < 0.05) than patients without retinopathy. UAE was higher in the DMa group than in the group with no retinopathy (9.3 ×/÷ 3.1 vs. 3.9 ×/÷ 1.9 μg/min, P < 0.01). There was no difference in TERalb between the two groups (6.0 ± 1.6 vs. 6.6 ± 1.5%, NS). In the group with DMa, OCT, TERalb, and UAE correlated significantly (OCT versus TERalb: r = 0.55, P < 0.05; OCT versus UAE: r = 0.58, P < 0.01; UAE versus TERalb: r = 0.81, P < 0.01). Conversely, there were no correlations between these three parameters in the group without retinopathy. CONCLUSIONS—Macular edema seems to reflect a generalized vascular leakage in type 2 diabetic patients.
The diameter response was reduced in type 2 diabetic patients with retinopathy, whereas retinal thickness was increased in patients with diabetic maculopathy. This suggests that impairment of diameter response in retinal arterioles precedes the development of diabetic macular edema.
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