Aart H. Bootsma

Genetic Variation, C-Reactive Protein Levels, and Incidence of Diabetes

C-reactive protein (CRP) has been shown to be associated with type 2 diabetes, but whether CRP has a causal role is not yet clear. We examined the association in the Rotterdam Study, a population-based prospective cohort study. The association of baseline serum CRP and incident diabetes during follow-up was investigated, and a meta-analysis was conducted on the BMI-adjusted relation of CRP and diabetes. Furthermore, the association of CRP haplotypes with serum CRP and risk of diabetes was assessed. The age- and sex-adjusted hazard ratio for diabetes was 1.41 (95% CI 1.29–1.54) per 1 SD increase in natural logarithm of CRP, and it was 1.88, 2.16, and 2.83 for the second, third, and fourth quartiles of CRP, respectively, compared with the first quartile. The risk estimates attenuated but remained statistically significant after additional adjustment for obesity indexes, which agreed with the results of the meta-analysis. The most common genetic haplotype was associated with a significantly lower CRP level compared with the three other haplotypes. The risk of diabetes was significantly higher in the haplotype with the highest serum CRP level compared with the most common haplotype (OR 1.45, 95% CI 1.08–1.96). These findings support the hypothesis that serum CRP enhances the development of diabetes.

Somatostatin-receptor scintigraphy in primary breast cancer

Somatostatin-receptor (SS-R) scintigraphy successfully shows primary cancers and distant metastases in most patients with carcinoids, islet cells tumours, and paragangliomas. Previous in-vitro studies indicated that somatostatin receptors are present in human breast cancers. We report positive scintigraphy with [111In-DTPA-D-Phe1]-octreotide in 39 of 52 primary breast cancers (75%). Parallel in-vitro autoradiography with [125I-Tyr3]-octreotide of 30 of these showed a corresponding somatostatin-receptor status in 28. Significantly more invasive ductal cancers could be shown than invasive lobular carcinomas (85% vs 56%; p < 0.05). Also the number of T2 cancers which were shown was higher than T1 (86% vs 61%; p < 0.05). Imaging of the axillae showed non-palpable cancer-containing lymph nodes in 4 of 13 patients with subsequently histologically-proven metastases. In the follow-up after a mean of 2.5 yr, SS-R scintigraphy in 28 of the 37 patients with an originally SS-R-positive cancer, was positive in the 2 patients with clinically-recognised metastases, as well as in 6 of the remaining 26 patients who were symptom-free. Raised carcinoembryonic antigen (CEA) and CA 15-3 values were observed in only 2 and 1, respectively, of these patients. Most primary breast cancers can be shown by SS-R scintigraphy, especially invasive ductal cancers. This technique may be of value in selecting patients for clinical trials with somatostatin analogues or other medical treatments. Furthermore, SS-R scintigraphy is more sensitive than measurements of the usual serum cancer markers for detecting recurrences of SS-R-positive breast cancer.

Effect of losartan on microalbuminuria in normotensive patients with type 2 diabetes mellitus - A randomized clinical trial

Context Angiotensin-receptor antagonists reduce renal and cardiovascular complications in patients with type 2 diabetes and hypertension. The effect of these drugs on normotensive patients with type 2 diabetes is not known. Contribution This 10-week randomized, placebo-controlled trial showed that in normotensive diabetic patients receiving losartan, albumin excretion rate was significantly reduced and blood pressure slightly decreased. Cautions The study included patients with systolic blood pressure up to 150 mm Hg and was too brief to evaluate progression of clinical renal disease. Angiotensin-receptor antagonists hold promise in preserving renal function in patients with type 2 diabetes without marked hypertension, but they warrant further study. The Editors Diabetes mellitus is an important cause of nephropathy, end-stage renal disease, and cardiovascular events. Nephropathy occurs in about 40% of patients with type 2 diabetes, and 25% to 40% of diabetic patients in Europe and the United States develop end-stage renal disease. Increased urinary albumin excretion, the first marker of kidney damage, carries an increased risk for renal as well as cardiovascular disease (1-5). Because reduction in microalbuminuria is associated with marked renal protection, the delay or retardation of the disease process is important in the management of diabetes mellitus (1). Angiotensin-converting enzyme (ACE) inhibitors reduce albumin excretion in both normotensive and hypertensive patients with type 1 or type 2 diabetes. The antiproteinuric effects appear to be at least partly independent of the reduction in blood pressure caused by these agents (6-11), although some studies have not confirmed this finding (12). Angiotensin II is thought to play a prominent role in the pathogenesis of diabetic nephropathy. Therefore, both preventing the formation of angiotensin II by ACE inhibition and blockade of the angiotensin receptor might be renoprotective. The trials of angiotensin-receptor antagonists in hypertensive patients with type 1 or 2 diabetes mellitus and microalbuminuria showed a reduction in albumin excretion, regardless of pretreatment levels (13-20). Recently, the angiotensin-receptor antagonist irbesartan retarded progression from microalbuminuria to overt proteinuria in hypertensive patients with type 2 diabetes (21). In RENAAL (The Reduction of Endpoints in NIDDM [noninsulin-dependent diabetes mellitus] with the Angiotensin II Antagonist Losartan study) and IDNT (Irbesartan Diabetic Nephropathy Trial), losartan and irbesartan, respectively, reduced proteinuria and slowed the progression of diabetic nephropathy in hypertensive patients with type 2 diabetes (22-24). Therefore, therapy that interferes with the reninangiotensinaldosterone system should probably be initiated when microalbuminuria develops in order to reduce albumin excretion and the associated risk for overt nephropathy. All previous studies on this subject investigated hypertensive patients. Therefore, we conducted a multicenter randomized, double-blind, placebo-controlled, clinical trial with forced dose titration to investigate the effects of losartan on urinary albumin excretion rate in normotensive patients with type 2 diabetes and microalbuminuria. Secondary objectives were to determine the time course of the antiproteinuric effect, the optimal dose of losartan, effects on creatinine clearance and blood pressure, and the safety and tolerability of losartan in normotensive patients. Methods Study Design In 19 outpatient clinics in the Netherlands, we conducted a 20-week randomized, placebo-controlled trial. The trial consisted of a 5-week screening and washout period, a 10-week double-blind treatment period, and a 5-week placebo washout period. The study was performed according to the guidelines of good clinical practice and was approved by the institutional review board at each center. All patients gave written informed consent. Patients From March 1999 through August 2001, all outpatients with type 2 diabetes mellitus, microalbuminuria, and a sitting blood pressure of 150/90 mm Hg or less were invited to participate. Type 2 diabetes mellitus was defined as diabetes diagnosed at age older than 30 years or controlled by diet or blood glucoselowering agents for at least 6 months. Microalbuminuria was defined as a urinary albumin excretion rate of 20 to 200 g/min. The current definition of normotension is a blood pressure less than 140/90 mm Hg, with a blood pressurelowering target of less than 130/80 mm Hg in hypertensive adults with diabetes mellitus (25, 26); however, we developed the protocol for this study in 1998, when normotension was defined as a sitting blood pressure of 160/90 mm Hg or less. Because of this and the fact that the mean baseline blood pressures appeared to be 135.9/78.8 mm Hg for the losartan group and 138.3/80.3 mm Hg for the placebo group, our study sample can be considered normotensive. We excluded patients with a myocardial infarction in the preceding 6 months, cerebrovascular events within the past year, unstable angina pectoris, or symptomatic heart failure; patients with electrocardiographic abnormalities (atrioventricular conduction disturbances, sick sinus syndrome, atrial fibrillation, or other clinically significant rhythm disturbances), acute renal failure, chronic glomerulonephritis, polycystic kidney disease, or a serum creatinine level greater than 150 mol/L (1.7 mg/dL); and patients with a glycosylated hemoglobin level greater than 10% or other relevant laboratory abnormalities. Concomitant use of antihypertensive agents, ophthalmic preparations containing -blocking agents, steroids, or lithium was not allowed. Eligible patients were included in the screening and washout period (weeks 5 to 0). In patients not taking blood pressurelowering or renoprotective medication, microalbuminuria was assessed by two sequential 24-hour urine collections before the randomization visit (week 0). Patients could be randomly assigned if the average of these two measurements confirmed microalbuminuria as defined above. Eligible patients who were receiving ACE inhibitors, angiotensin-receptor antagonists, or other antihypertensive agents first entered a 5-week washout period. In these patients, microalbuminuria was assessed after this period. If therapy with such medication had been initiated to normalize known hypertension, the patient was excluded. Interventions Patients who met all study criteria were randomly assigned in a double-blind fashion to receive losartan, 50 mg once daily, or matching placebo (week 0). After 5 weeks of treatment, patients initially assigned to receive 50 mg of losartan had fixed-dose titration to 100 mg of losartan; patients initially assigned to receive placebo continued to receive placebo. Treatment was continued at this dose for another 5 weeks, after which all patients were switched to single-blind placebo for the last 5 weeks. At the end of this washout period, patients returned for their final visit (week 15). The study sponsor, Merck, Sharpe & Dohme, provided each center with the study medication and randomly assigned the patients in blocks of four. The investigators dispensed the study medication and provided the patient with the first available allocation number. In each center, the allocation numbers were assigned in consecutive order. The patients had an equal probability of assignment to either group. The randomization list was inaccessible to all investigators. No randomization code was broken, so all investigators and participants remained blinded to treatment assignment during the entire study. Throughout the study, patients received the standard of care for diabetes. They were instructed not to change their physical exercise patterns significantly because doing so may influence proteinuria. Outcomes The primary end point was the change in urinary albumin excretion rate from baseline to week 10. Secondary end points were change in albumin excretion rate at week 5, change in creatinine clearance from baseline to week 10, and change in systolic and diastolic blood pressures at weeks 5 and 10. Tertiary end points were safety and tolerability of losartan. Measurements At each visit, the same investigator measured blood pressure and pulse. Blood pressure was measured by a sphygmomanometer, with the patient seated for 5 minutes before the first measurement. Three replicate measurements, obtained 1 minute apart, were averaged. In each center, microalbuminuria was measured just before every visit in two sequential 24-hour urine collections by using an immunonephelometric assay on an automated analyzer (Beckman Coulter, Brea, California). The measurements of the two samples were averaged. Complete laboratory evaluations (biochemistry, hematology) were conducted at weeks 0 and 10; at weeks 5 and 15, only renal function and electrolytes were checked. A virtual central laboratory recalculated all laboratory results, including microalbuminuria, and corrected them for possible bias. At weeks 0, 5, 10, and 15, adverse events were recorded, and medication use and adherence were checked by counting pills. Patients were considered adherent if at least 75% of the study drug had been taken. Statistical Analysis Primary and secondary end points were analyzed in the full-analysis study sample, which consisted of all patients randomly assigned (intention-to-treat analysis). The statistical method used was the generalized linear mixed model for longitudinal data, which compares the differences in trends over time between both treatment groups (27). Baseline values were used as covariates in this model, and outcomes were adjusted by using treatment, visit, center, and the corresponding interaction terms as fixed effects. A generalized linear mixed model was also applied to evaluate whether the observed changes in albumin excretion rate were consistent across different baseline blood pressures. Furthermore, an

Normotensive women with type 2 diabetes and microalbuminuria are at high risk for macrovascular disease

OBJECTIVE—The excess risk of macrovascular disease and death associated with diabetes seems higher in women than in men. The pathogenesis for this risk difference has not been fully elucidated. We investigated whether female sex was associated with macrovascular disease and death, independently of known risk factors related to type 2 diabetes, nephropathy, or retinopathy in normotensive patients with type 2 diabetes and microalbuminuria. RESEARCH DESIGN AND METHODS—We conducted a prospective, prolonged follow-up study of a subgroup of 67 diabetic patients (46 men and 21 women) without established cardiovascular disease who participated in a larger clinical trial. Data were collected on current and past health, medication use, blood pressure, renal function, and HbA1c during the follow-up period of 4.7 ± 0.8 (means ± SE) years. The end point was a composite of death, cardiovascular disease, cerebrovascular events, and peripheral artery disease. RESULTS—Of the women, eight (38.1%) met the end point compared with six (13.4%) of the men (P = 0.02 for difference in event-free survival). The hazard ratio of women relative to men was 3.19 (95% CI 1.11–9.21), which further increased after adjusting for age, systolic blood pressure, BMI, smoking, total-to-HDL cholesterol ratio, urinary albumin excretion, and retinopathy. CONCLUSIONS—In our study population of normotensive patients with type 2 diabetes and microalbuminuria, female sex was associated with increased risk of fatal and nonfatal cardiovascular disease, independent of the classical cardiovascular risk factors, the severity of nephropathy or presence of retinopathy, or health care utilization.

High fat intake in hyperlipidaemic patients is related to male gender, smoking, alcohol intake and obesity

BACKGROUND In individuals at high cardiovascular risk, such as patients with hyperlipidaemia, low dietary fat intake is used to reduce this risk. The aim of the present study was to identify determinants of (saturated) fat intake in hyperlipidaemic patients. METHODS Cross sectional study in a lipid clinic of a tertiary referral centre. A total of 1169 patients (714 males and 455 females) with hyperlipidemia were studied. Food frequency questionnaires were present of 1026 patients. In 615 patients a detailed diet analysis was performed. The main outcomes measures were determinants of fat intake, indicated by a regression coefficient (beta-coefficient). RESULTS The following variables were independently related to fat intake: present smoking (beta-coefficient 3.7), male gender ((beta 1.6), familial hypercholesterolemia (beta -1.6), alcohol (beta 0.6 per glass of alcohol), body mass index (beta 0.6). No interaction between gender and smoking or between gender and alcohol intake was observed in relation to fat intake. The percentage of energy from fats were higher in males than in females, 34.2+/-8.3% and 31.7+/-8.3%, respectively (P<0.001). The higher total and saturated fat intake in males is due to a larger consumption of cheese, meat products, bread and potato products. Women had a higher relative intake of carbohydrate 48.5+/-8.7% versus 46.5+/-8.8% in males (P<0.05), due to a relatively higher intake of fruit, milk products and pastry and biscuits. CONCLUSIONS A specific gender-oriented approach may improve the results of dietary counselling of hyperlipidaemic patients.

The IGF‐I system and the renal and haemodynamic effects of losartan in normotensive patients with type 2 diabetes mellitus: a randomized clinical trial

Objective  Losartan has been shown to protect the diabetic kidney, at least partly independent of changes in blood pressure. Imbalances in the IGF‐I system are associated with the development of diabetic nephropathy. We investigated whether renal as well as haemodynamic effects of losartan are associated with changes in the IGF‐I system in normotensive patients with type 2 diabetes mellitus (T2DM).

Genetic changes in somatostatin receptor positive breast tumors

Forty-nine primary breast tumors were analyzed for the expression of the somatostatin receptor (SSR) and genetic changes in the RB tumor suppressor gene. Twenty-four tumor samples were shown to contain receptors for somatostatin and in eight of these SSR-positive tumors we observed a mutation in the RB gene. However, since also in the group of SSR-negative tumors in eight of the 25 cases an alteration of the RB gene was observed, loss of this tumor suppressor gene is not specific for the SSR-positive subgroup of breast tumors. A similar, equal distribution between SSR-positive and SSR-negative breast tumors was observed for the six tumor samples which showed amplification of the neu proto-oncogene.

High saturated fat intake in hyperlipidemic patients is related to male gender, smoking, alcohol intake and obesity

BACKGROUND: In individuals at high cardiovascular risk, such as patients with hyperlipidaemia, low dietary fat intake is used to reduce this risk. The aim of the present study was to identify determinants of (saturated) fat intake in hyperlipidaemic patients. METHODS: Cross sectional study in a lipid clinic of a tertiary referral centre. A total of 1169 patients (714 males and 455 females) with hyperlipidemia were studied. Food frequency questionnaires were present of 1026 patients. In 615 patients a detailed diet analysis was performed. The main outcomes measures were determinants of fat intake, indicated by a regression coefficient (beta-coefficient). RESULTS: The following variables were independently related to fat intake: present smoking (beta-coefficient 3.7), male gender ((beta 1.6), familial hypercholesterolemia (beta -1.6), alcohol (beta 0.6 per glass of alcohol), body mass index (beta 0.6). No interaction between gender and smoking or between gender and alcohol intake was observed in relation to fat intake. The percentage of energy from fats were higher in males than in females, 34.2+/-8.3% and 31.7+/-8.3%, respectively (P<0.001). The higher total and saturated fat intake in males is due to a larger consumption of cheese, meat products, bread and potato products. Women had a higher relative intake of carbohydrate 48.5+/-8.7% versus 46.5+/-8.8% in males (P<0.05), due to a relatively higher intake of fruit, milk products and pastry and biscuits. CONCLUSIONS: A specific gender-oriented approach may improve the results of dietary counselling of hyperlipidaemic patients.