Harold Cohen

Influence of proteinuria on vascular disease, blood pressure, and lipoproteins in insulin dependent diabetes mellitus

Patients with insulin dependent diabetes mellitus who develop proteinuria may die prematurely, whereas those who do not develop this complication have a comparatively normal life span. The excess mortality in diabetics with proteinuria is from cardiovascular as well as renal disease, but the reason is unclear. Risk factors for vascular disease were therefore assessed in 22 insulin dependent diabetics with proteinuria, but not renal failure, who were matched for sex, age, duration of diabetes, and glycated haemoglobin (HbA1) values with a similar number who had normal urinary albumin excretion rates. Macrovascular disease (ischaemic heart disease and peripheral vascular disease) was present in 10 patients with proteinuria but in only three with normal albumin excretion rates, and proliferative retinopathy was detected in 11 and four patients in the two groups. There was no significant excess of smokers in the group with proteinuria. Blood pressure was, however, higher in the patients with proteinuria--mean systolic pressure 161 (SD 18) mm Hg compared with 135 (19) mm Hg (95% confidence interval of difference between means 15 to 38 mm Hg); mean diastolic pressure 90 (SD 12) mm Hg compared with 79 (15) mm Hg (confidence interval 3 to 19 mm Hg). The concentration of serum high density lipoprotein (HDL) cholesterol isolated by precipitation was lower in the patients with proteinuria (confidence interval 0.02 to 0.41 mmol/l). Their concentration of HDL2 cholesterol isolated by ultracentrifugation was also decreased (confidence interval 0.02 to 0.40 mmol/l), whereas HDL3 cholesterol tended to be increased (confidence interval -0.01 to 0.23 mmol/l). There was also a trend for serum cholesterol concentrations to be higher in the presence of proteinuria (confidence interval -0.39 to 1.20 mmol/l). The aggregation of risk factors for atherosclerosis in insulin dependent diabetes mellitus complicated by proteinuria helps to explain the increased prevalence of ischaemic heart disease and peripheral vascular disease reported in these patients. Early renal disease in insulin dependent diabetes may have an important role in hypertension and altered lipoprotein metabolism.

Effect of Physical Exercise on Alimentary Lipaemia

After initial enthusiasm, two adverse reports on the efficacy of iproniazid in angina pectoris have appeared (Dewar et al., 1959; Snow and Anderson, 1959). Both papers were based on controlled double-blind clinical trials. It seems unlikely that the drug will benefit many patients with angina pectoris. Angina patients are particularly liable to develop cardiac infarction and to be admitted to hospital under the care of physicians not fully acquainted with their previous medical histories, and may be given pethidine for the relief of their pain. It is suggested, in the light of the two cases reported here and that reported by Papp -and Benaim, that iproniazid be reserved for the most intractable cases of angina, and be given only where all other measures have failed. If a patient on iproniazid has to be admitted to hospital for any reason, his introductory letter should state, No pethidine, please.

Peripheral Gangrene in a Case of Myocardial Infarction

In my patient, as a result of experience of the good results I have achieved in a series of adults with achalasia of the oesophagus, I decided to perform Hellers operation through the abdominal route. I always perform the operation in this way, for it provides an easy and adequate exposure of the lower 5 cm. of the oesophagus and the fundus of the stomach. I consider that drugs are of no real value in the treatment of achalasia. Dilatation, using a pneumatic dilator, may give temporary relief, but many patients

Peripheral Gangrene and Myocardial Infarction

should be made with a red-hot needle in the blind end and another in the side of the teat. Both ends of the lymph tube should be removed with an ampoule-file and the tube should be pushed into the hole in the end of the teat, taking care that the side hole is unobstructed or the lymph will be ejected. .To deliver small quantities of lymph the teat is gently squeezed, with the-finger occluding the side hole. Lymph is much less likely to be sucked back into the teat, between patients, if one rolls theF teat until the side hole is exposed before releasing pressure.I am, etc.,