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and Diabetes Mellitus
Diabetes increases the risk of heart disease and stroke1, with heart
patients, such that each increase of 1 m/s has an 8% increased risk of
disease being the leading cause of death. In addition, many people
mortality10. Elevated aortic PWV and Aortic Augmentation Index (AIx) have
with Type 2 diabetes have co-existing risk factors, such as high blood
been shown to be associated with Type 1 and Type 2 diabetes7, 8, 9, 10, 11.
pressure and high cholesterol3, further increasing their cardiovascular
Assessment of a cohort of patients in the FIELD (Fenoﬁbrate
risk. Diabetes is also associated with long-term complications that
Intervention and Event Lowering in Diabetes) Study showed a
affect almost every part of the body including heart and vessel
signiﬁcant association between Augmentation Pressure (AP) and AIx
disease, kidney failure, stroke, blindness, nerve damage and
and carotid IMT, an established marker of atherosclerosis, in Type 2
amputations. The SphygmoCor® system non-invasively provides
diabetics, suggesting that arterial stiffness may contribute to the
measurements illustrating the progression of macrovascular disease
accelerated atherosclerosis in Type 2 diabetes and that measures of
driving the patient’s risk of cardiovascular disease, thus providing a
central blood pressure and large artery stiffness may be superior to
tool for assisting with early identiﬁcation of high risk patients and
other conventional risk factors in determining the presence of
subsequent management of the disease.
vascular wall thickening in Type 2 diabetes4. A substudy of the FIELD
investigation is ongoing and is expected to provide prospective dataon the predictive values of AP and AIx for cardiovascular morbidity
In the United States, 20.8 million people are considered to have
and mortality in Type 2 diabetic patients.
diabetes – 7% of the population. This consists of 14.6 million that
In previous studies, AP and AIx have also been shown to be strongly
have been diagnosed with diabetes and 6.2 million suspected of
correlated with carotid IMT and plaque score in diabetic patients12, 13
having diabetes that has not yet been diagnosed2. Each year,
and coronary artery disease14, the latter being commonly associated
approximately 1.3 million people aged 20 years or older are
with diabetes. The CURES (Chennai Urban Rural Epidemiology Study)
diagnosed with diabetes and more than 60% of diabetics will die
study showed that Type 2 diabetic patients with retinopathy had
from heart disease1. Patients with Type 2 diabetes have a 2–7 times
signiﬁcantly higher AIx and IMT values than for those without
increased risk of cardiovascular mortality and morbidity4 and patients
retinopathy, suggesting an association between early atherosclerosis
with Type 1 diabetes also have an increased risk of cardiovascular
and diabetic retinopathy in Asian Indians, a high risk group for both
disease5. Furthermore, diabetes has been reported to be one of the
diabetes and coronary artery disease13.
leading causes of end stage renal disease1 which also carries anincreased risk of cardiovascular disease6.
Children as young as 10 years old with Type 1 diabetes have alsobeen observed to have increased arterial stiffness (AIx) when matched
with control subjects15. This highlights the potential for markers ofarterial stiffness such as those available from the SphygmoCor®
The increased cardiovascular risk of patients with diabetes remains
system for providing additional information for cardiovascular risk
largely unexplained. Part of this increased risk relates to cardiovascular
stratiﬁcation and optimisation of therapy in children with conditions
risk factors such as hypertension, dyslipidaemia, hyperglycaemia and
such as Type 1 diabetes that have a high risk of developing
obesity, but some of the increased risk appears to be independent of
cardiovascular and non-cardiovascular complications later in life.
these factors and may be different for Type 1 and Type 2 diabetes.
With increased arterial stiffness, central systolic pressure increases
Increased arterial stiffness has been associated with both Type 17, 8
resulting in an increase in cardiac workload and therefore myocardial
and Type 2 diabetes9, 10, 11, and may be a contributor to the high
demand. Increased arterial stiffness can contribute to the development
morbidity and mortality. The impact of this increased arterial stiffness
and progression of hypertension, left ventricular hypertrophy and
on cardiovascular function can be examined by parameters provided
dysfunction and decrease in myocardial perfusion. The progression of
these conditions is preventable and the use of key central cardiac
Peripheral pulse pressure, a surrogate marker for arterial stiffness,
function parameters provided by the SphygmoCor® system may assist
has been shown to be associated with Type 1 diabetes and compared
with this. The SphygmoCor® Pulse Wave Analysis and Pulse Wave
with non-diabetics, age related blood pressure increases seem to
Velocity Systems allow for assessment of these important parameters
shift to a 15–20 year younger age in Type 1 diabetes, suggesting
of arterial stiffness, AIx and PWV. Once these conditions have
developed, the system may assist with assessment of progressionand the tailoring of drug therapies to the individual patient.
Aortic stiffness, as measured by aortic pulse wave velocity (PWV) hasbeen shown to be an independent predictor of mortality in diabetic
SphygmoCor and Diabetes Mellitus
Decreases in arterial stiffness in patients with cardiovascular disease,
ascorbic acid has been shown to signiﬁcantly lower AIx over a 4-week
including those with diabetes, have been demonstrated following
period in diabetic patients21. The SphygmoCor® system allows the
pharmacological interventions, often independent of changes in cuff
physician to see the effects of their patient’s treatment regimen
BP. Insulin is known to acutely decrease AIx independent of peripheral
through changes in the key central cardiac function parameters.
vascular resistance16, 17, however this action is defective in insulin-
The SphygmoCor® system provides a clinically valuable cardiovascular
resistant obese18, type 118 and type 219 diabetic patients. One study,
risk assessment in these high-risk patients, enabling better informed
however, has observed an improvement in AIx after six months of
treatment and patient management decisions.
insulin therapy20. Among a number of pharmacological interventionsshown to improve arterial stiffness, supplementation with oral
12 Fukui M, Kitagawa Y, Nakamura N, et al
. Augmentation of central arterial
National Institute of Diabetes and Digestive and Kidney Diseases. National
pressure as a marker of atherosclerosis in patients with Type 2 diabetes.
Diabetes Statistics Fact Sheet: general information and national estimates on
diabetes in the United States, 2003.
13 Rema M, Deepa R, Mohan V, Ravikumar R. Association of carotid intima-
National Institute of Diabetes and Digestive and Kidney Diseases. National
media thickness and arterial stiffness with diabetic retinopathy. Diabetes
Diabetes Statistics. NIH Publication No 06-3892 November 05.
Williams B. The unique vulnerability of diabetic subjects to hypertensive
14 Weber T, Auer J, O’Rourke MF, et al
. Arterial stiffness, wave reﬂections, and
injury. J Hum Hypertens 1999;13:S3-S8.
the risk of coronary artery disease. Circulation 2004;109:184-9.
Westerbacka J, Leinonen E, Salonen JT, et al
. Increased augmentation of
15 Haller MJ, Schwartz RF, Samyn M, et al
. Radial artery tonometery
central blood pressure is associated with increases in carotid intima-media
demonstrates arterial stiffness in children with Type 1 diabetes. Diabetes
thickness in type 2 diabetic patients. Diabetologia 2005;48:1654- 1662.
5. Ronnback M, Fagerudd J, Forsblom C, et al
. Altered age-related blood
16 Westerbacka J, Wilkinson I, Cockcroft J, et al
. Diminished wave reﬂection in
pressure pattern in Type 1 diabetes. Circulation 2004;110:1076-1082.
the aorta. A novel physiological action of insulin on large blood vessels.
6. U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-stage
renal disease in the United States. National Institutes of Health, National
17 Westerbacka J, Seppala-Lindroos A and Yki-Jarvinen H. Resistance to acute
Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2004.
insulin decreases in large artery stiffness accompanies the insulin resistance
Brooks B, Molyneaux L, Yue DK. Augmentation of central arterial pressure in
syndrome. J Clin Endocrinol Metab 2001;86:5262-8.
Type 1 diabetes. Diabetes Care 1999;22:1722-1727.
18 Westerbacka J, Uosukainen A, Makimattila S, et al
. Insulin-induced decrease
Wilkinson IB, MacCallum H, Rooijmans DF, et al
. Increased augmentation
in large artery stiffness is impaired in uncomplicated Type 1 diabetes
index and systolic stress in Type 1 diabetes mellitus. QJM 2000;93:441-8.
mellitus. Hypertension 2000;35:1043-8.
Schram MT, Henry RMA, van Dijk AJM, et al
. Increased arterial stiffness in
19 Tamminen M, Westerbacka J, Vehkavaara S, Yki-Jarvinen. Insulin-induced
impaired glucose metabolism and Type 2 diabetes. The HOORN study.
decreases in aortic wave reﬂection and central systolic pressure are impaired
in Type 2 diabetes. Diabetes Care 2002;25:2314-9.
10 Cruickshank K, Riste L, Anderson SG, et al
. Aortic pulse-wave velocity and its
20 Tamminen MK, Westerbacka J, Vehkavaara S, Yki-Jarvinen H. Insulin therapy
relationship to mortality in diabetes and glucose intolerance. Circulation
improves insulin actions on glucose and aortic wave reﬂection in Type 2
diabetic patients. Eur J Clin Invest 2003;33:855-60.
11 Smith A, Karalliedde J, De Angelis L, Goldsmith D, Viberti G. Aortic pulse
21 Mullen BA, Young IS, Fee H, McCance DR. Ascorbic acid reduces blood
wave analysis and albuminuria in patients with Type 2 diabetes. J Am Soc
pressure and arterial stiffness in Type 2 diabetes. Hypertension
AtCor Medical Pty LtdSuite 11, 1059–1063 Victoria Road, West Ryde, NSW 2114, Australia.
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Copyright 2006 AtCor Medical, SphygmoCor® is a registered trademark of AtCor Medical
AtCor Medical reserves the right to modify the design and speciﬁcations contained within without prior notice.
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