bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Magnesium Supplementation in Increasing Doses on the Control of Type 2 Diabetes
Authors: de Lourdes Lima Maria , Cruz Thomaz , Pousada Judith Carreiro , Rodrigues Luiz Erlon , Barbosa Karyne , Canguçu Valquiria
Published: March 2007

OBJECTIVE

Hypomagnesemia occurs in 25–38% of patients with type 2 diabetes. Several studies have suggested an association between magnesium (Mg) depletion and insulin resistance and/or reduction of insulin secretion in these cases. Our purpose was to evaluate if Mg supplementation (as magnesium oxide [MgO]) would improve metabolic control in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We studied 128 patients with type 2 diabetes (32 men, 96 women, aged 30–69 years), treated by diet or diet plus oral antidiabetic drugs, in the Bahia Federal University Hospital, Brazil. Patients at risk for hypomagnesemia or with reduced renal function were excluded. This study was a clinical randomized double-blind placebo-controlled trial. Patients received either placebo, 20.7 mmol MgO, or 41.4 mmol MgO daily(elementary Mg) for 30 days. Mg concentrations were measured in plasma, in mononuclear cells, and in 24-h urine samples. Fasting blood glucose, HbA1, and fructosamine were used as parameters of metabolic control.

RESULTS

Of the patients, 47.7% had low plasma Mg, and 31.1% had low intramononuclear Mg levels. Intracellular Mg in patients with diabetes was significantly lower than in the normal population (62 blood donors; 1.4 ± 0.6 vs. 1.7 ± 0.6 μg/mg of total proteins). No correlation was found between plasma and intracellular Mg concentrations (r = −0.179; P = 0.15) or between Mg concentrations and glycemic control (r = −0.165; P = 0.12). Intracellular Mg levels were lower in patients with peripheral neuropathy than in those without (1.2 ± 0.5 vs. 1.5 ± 0.6 μg/mg). Similar findings were observed in patients with coronary disease (1.0 ± 0.5 vs. 1.5 ± 0.6 μg/mg). In the placebo and in the 20.7 mmol Mg groups, neither a change in plasma and intracellular levels nor an improvement in glycemic control were observed. Replacement with 41.4 mmol Mg tended to increase plasma, cellular, and urine Mg and caused a significant fall (4.1 ± 0.8 to 3.8 ± 0.7 mmol/1) in fructosamine (normal, 1.87–2.87 mmol/1).

CONCLUSIONS

Mg depletion is common in poorly controlled patientswith type 2 diabetes, especially in those with neuropathy or coronary disease. More prolonged use of Mg in doses that are higher than usual is needed toestablish its routine or selective administration in patients with type 2 diabetes to improve control or prevent chronic complications.
The Effects of Metformin on Glycemic Control and Serum Lipids in Insulin-Treated NIDDM Patients With Suboptimal Metabolic Control
Authors: Robinson Adam C , Burke John , Robinson Stephen , Johnston Desmond G , Elkeles Robert S
Published: March 2007

OBJECTIVE

To test the hypothesis that metformin therapy, given as an adjunct to insulin therapy, improves metabolic control in insulin-treated NIDDM patients with suboptimal glycemic control.

RESEARCH DESIGN AND METHODS

A total of 33 subjects with insulin-treated NIDDM were investigated; all had commenced insulin after secondary failure of antihyperglycemic agents. Two randomized double-blind placebo-controlled crossover studies were run. In study 1 (n = 19), insulin-treated subjects with suboptimal glycemic control received 12 weeks of metformin 1 g b.i.d. and 12 weeks of placebo. In study 2 (n = 14), subjects already established on adjunctive metformin/insulin therapy stopped the metformin component and received 12 weeks of metformin at their baseline dosage (range 1–2.5 g) and 12 weeks of equivalent placebo. Fasting plasma glucose, HbA1c, and serum lipids were measured at baseline and midway through and at the end of each treatment phase. The effect of 12 weeks of metformin treatment was compared with the effect of 12 weeks of placebo in each study and in both studies combined.

RESULTS

In study 1, metformin treatment was associated with significant improvements in fasting plasma glucose (mean 12-week difference fromplacebo [95% CI]: 5.8 mmol/1 [3.5–8.1], P < 0.001) and HbA1c (1.6% [0.9–2.4], P < 0.001). In study 2, metformin treatment was associated with significantly lower fasting plasma glucose (5.3 mmol/1 [0.6–9.9], P = 0.029) and lower HbA1c(2.4% [1.0–3.8], P = 0.003) compared with those for placebo. Study 2 also showed metformin treatment to be associated with significantly lower total cholesterol than that for placebo (1.0 mmol/1 [0.1–1.9], P = 0.032) and lower LDL cholesterol (1.0 mmol/1 [0.1–1.9], P = 0.028). This significant difference in serum lipids seen in study 2 was not seen in study 1, but was present when both sets of data were combined (n = 33, mean total cholesterol difference at 12 weeks [95% CI]: 0.6 mmol/1 [0.1–1.1], P = 0.015). Metformin had no significant effect on triglyceride, HDL cholesterol, weight, or blood pressure. Twosubjects on metformin withdrew because of side effects.

CONCLUSIONS

Metformin, when given as adjunctive therapy, was well tolerated and improved glycemic control and lipid concentrations in patients with insulin-treated NIDDM whose diabetes was poorly controlled. These improvements could be maintained over the long term.
Development and Application of a Model to Estimate the Impact of Type 1 Diabetes on Health-Related Quality of Life
Authors: Wu Shin-Yi , Sainfort François , Tomar Russell H , Tollios James L , Fryback Dennis G , Klein Ronald , Klein Barbara EK
Published: March 2007

OBJECTIVE

To develop a simulation model to assess the impact of type 1 diabetes and its associated complications on health-related quality of life of a population.

RESEARCH DESIGN AND METHODS

The methodology builds upon 1) an existing population model of type 1 diabetes progression, 2) an empirical study designed to measure state- and age-specific health statuses of type 1 diabetes, and 3) existing literature to quantify quality of life of the corresponding health status. Health statuses were measured in a group of type 1 diabetic patients using the Medical Outcomes Study short form 36 (SF-36). A published empirical regression equation was then used to predict corresponding Quality of Well-Being Index (QWB) scores from these assessments. The QWB scores were incorporated into a previously developed type 1 diabetes progressionand cost simulation model. Sensitivity analyses on key parameters were performed, and the model was found to be robust.

RESULTS

The augmented model can estimate quality-adjusted life years (QALYs) as well as costs associated with type 1 diabetes on any population of interest over any period of time. The model is used to compare intensive versus conventional treatment strategies using a simplified set of assumptions regarding the relative effects of these alternative treatments. With these assumptions, intensive strategy produces more QALYs than does conventional strategy and is cost-beneficial after 5 years.

CONCLUSIONS

The model enables health planners to perform cost-effectiveness analyses to compare alternative treatment strategies for type 1 diabetes and support subsequent decision making.
Patterns of Expenditures and Use of Services Among Older Adults With Diabetes: Implications for the transition to capitated managed care
Authors: Krop Julie S , Powe Neil R , Weller Wendy E , Shaffer Thomas J , Saudek Christopher D , Anderson Gerard F
Published: March 2007

OBJECTIVE

To examine health care use and expenditures among older adults with diabetes, investigate factors that are associated with higher expenditures, and describe the policy implications of caring for this population under managed care.

RESEARCH DESIGN AND METHODS

A cross-sectional analysis of expenditures for individuals with diabetes over age 65 years from a nationwide 5% random sample of Medicare beneficiaries was conducted during 1992. All components of medical care covered under Medicare were examined. Multivariate analysis was used to assess the contribution of age, race, sex, number of diabetic complications, and comorbidity (Charlson Index) on total expenditures.

RESULTS

On average, individuals with diabetes (n = 188,470) were 1.5 times (P < 0.0001) as expensive as all Medicare beneficiaries (n = 1,371,960). However, there were wide variations, with the most expensive 10% of beneficiaries with diabetes accounting for 56% of expenditures for individuals with diabetes and the least expensive 50% accounting for 4% Acute carehospitalizations accounted for the majority (60%) of total expenditures, whereas outpatient and physician services accounted for 7 and 33%, respectively. There were no differences in the number of complications for all older adults with diabetes compared with those with the highest expenditures. However, the average number of hospitalizations was 1.6 times (0.53 vs. 0.34; P < 0.0001) higher, and the average length of stay was 2 days longer, among older adults with diabetes (P < 0.0001). In the regression model, age and male sex (factors currently used to set payment rates for Medicare managed care enrollees), and number of diabetic complications, but not race, were positively related to expenditures, yet had minimal predictive power (R2 = 0.0006). The addition of the Charlson Index, also positively related to expenditures, was able to explain up to 20% of the variation in total expenditures (R2 = 0.196).

CONCLUSIONS

There are large variations in expenditures among older adults with diabetes. Because elderly beneficiaries with diabetes are more expensive than the average older adult, current Medicare capitation rates may be inadequate. To avoid selection bias and undertreatment of this vulnerable population under managed care, methods to construct fair payment rates and safeguard quality of care are desirable.
Use of the Therapeutic Footwear Benefit Among Diabetic Medicare Beneficiaries in Three States, 1995
Authors: Sugarman Jonathan R , Reiber Gayle E , Baumgardner Greg , Prela Cecilia M , Lowery Joseph
Published: March 2007

OBJECTIVE

To determine the extent to which Medicare provided reimbursement for therapeutic footwear to diabetic Medicare beneficiaries in Washington, Alaska, and Idaho in 1995.

RESEARCH DESIGN AND METHODS

Using inpatient, outpatient, and durable medical equipment claims data, we selected a cohort of diabetic Medicare beneficiaries. Therapeutic footwear claims were identified using a set of billing codes intended only for the diabetes footwear benefit. People at “high risk” or “possibly increased risk” for foot problems who might benefit from therapeutic footwear were identified using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification (1CD-9-CM) diagnostic codes in any of the databases.

RESULTS

Among 608,804 beneficiaries, 10.2% (62,170) met the inclusion criteria for diabetes. Of the diabetic beneficiaries, 13.0% (8,079) had at least one “high risk” diagnosis, and 14.0% (8,686) had at least one “possibly increased risk” diagnosis. The percentage of diabetic beneficiaries with therapeutic footwear claims was 2.9% among those with diagnoses high risk, 0.7% among those with diagnoses indicating possibly increased risk, and 0.1% among those with no diagnosis from the list. Altogether, only 0.6% of beneficiaries meeting the diabetes case ascertainment criteria had a therapeutic footwear claim in 1995.

CONCLUSIONS

Few diabetic Medicare beneficiaries in Washington, Alaska, and Idaho had claims for reimbursement for therapeutic footwear in 1995. The low utilization of the footwear benefit may represent an important opportunity to improve care for Medicare beneficiaries with diabetes. Further work should be done to characterize the use of the benefit in other regions and to assess whether the low level of usage reflects underutilization.
Objective Assessment of Smoking Habits by Urinary Cotinine Measurement in Adolescents and Young Adults With Type 1 Diabetes: Reliability of reported cigarette consumption and relationship to urinary albumin excretion
Authors: Holl Reinhard W , Grabert Mathias , Heinze Eberhard , Debatin Klaus-Michael
Published: March 2007

OBJECTIVE

To examine the relationship of objective smoking status to age, sex, longterm metabolic control, and urinary albumin excretion. Patients with type 1 diabetes who smoke are at increased risk to develop diabetic microvascular and macrovascular complications. While this has repeatedly been demonstrated in adults, smoking habits have rarely been investigated in adolescents.

RESEARCH DESIGN AND METHODS

Urinary cotinine excretion has been determined by radioimmunoassay in 238 adolescents and young adults with type 1 diabetes. This biochemical parameter of nicotine use was related to age, to the number of cigarettes allegedly consumed per day, and to urinary albumin excretion.

RESULTS

A total of 46 patients (19.3%) with urinary cotinine values >500 ng/ml were classified as smokers. In 26 patients (10.9%), cotinine values between 100 and 500 ng/ml were found (infrequent smokers or environmental nicotine exposure), while the remaining 166 patients excreted <100 ng/ml of cotinine in the urine (nonsmokers). Smokers were significantly older (20.2 ± 0.6 years [mean ± SE]) compared with the intermediate group (18.3 ± 0.7 years) or with nonsmokers (15.9 ± 0.4 years; P < 0.0001, Wilcoxon's signed-rank test). Of 46 smokers, 12 denied smoking cigarettes entirely, and among biochemically defined smokers, no correlation was present between urinary cotinine excretion and the reported number of cigarettes consumed per day. Urinary albumin excretion was significantly higher in smokers compared with nonsmokers (P < 0.003).

CONCLUSIONS

These data demonstrate that cigarette smoking is common among German adolescents and young adults with type 1 diabetes in this study. Many patients deny nicotine use or refuse to disclose their smoking habits. Increased urinary albumin excretion is consistent with an increased risk of nephropathy in subjects with diabetes who smoke. Pediatricians in charge of adolescents with type 1 diabetes should actively discuss the risk of nicotine consumption with their patients.
Troglitazone Decreases the Proportion of Small, Dense LDL and Increases the Resistance of LDL to Oxidation in Obese Subjects
Authors: Tack Cees JJ , Smits Paul , Demacker Pierre NM , Stalenhoef Anton FH
Published: March 2007

OBJECTIVE

Insulin resistance is associated with a predominance of small, atherogenic LDL particles that are more prone to oxidative modification. Treatment with the insulin-sensitizer troglitazone may improve LDL composition and resistance to oxidation.

RESEARCH DESIGN AND METHODS

In a randomized double-blind crossover design, 15 obese subjects were treated with either 400 mg troglitazone daily or placebo for 8 weeks. Insulin sensitivity (clamp), (apo)lipoproteins, LDL subclass pattern, plasma TBARS, and ex vivo LDL oxidation were determined.

RESULTS

Troglitazone treatment improved insulin sensitivity. LDL cholesterol increased from 2.58 ± 0.18 to 2.77 ± 0.20 mmol/1 (P = 0.03) because of an increase in large (buoyant) LDL1 (from 0.45 ± 0.04 to 0.62 ± 0.09 mmol/1, P = 0.008). Because small (dense) LDL3 decreased, LDL1:LDL3 ratio increased (P = 0.02). Plasma TBARS concentration declined significantly, and the lag time of ex vivo LDL oxidation showed a small but significant increase.

CONCLUSIONS

In obese subjects, treatment with troglitazone improves insulin sensitivity, increases the ratio of large buoyant to small dense LDL, and appears to enhance the resistance of the LDL particle to oxidation. These qualitative changes in lipoproteins may have a beneficial effect on cardiovascular risk profile and compensate for a small increase in LDL cholesterol.
Hyperhomocyst(e)inemia and Endothelial Dysfunction in IDDM
Authors: Hofmann Marion A , Kohl Brigitte , Zumbach Martina S , Borcea Valentin , Bierhaus Angelika , Henkels Mechthild , Amiral Jean , Schmidt Ann Marie , Fiehn Walter , Ziegler Reinhard , Wahl Peter , Nawroth Peter P
Published: March 2007

OBJECTIVE

Considering that elevated blood levels of homocyst(e)ine represent a known independent risk factor for macrovascular disease, we assessed the link between hyperhomocyst(e)inemia and diabetic microvascular complications.

RESEARCH DESIGN AND METHODS

Homocyst(e)ine and thrombomodulin plasma levels, a marker of endothelial cell damage, were measured before and 3 h after oral methionine loading in 75 patients with stable, well-controlled IDDM and 40 healthy control subjects matched for sex and age. Exclusion criteria were hyperlipidemia, hypertension, smoking, or positive family history for cardiovascular disease.

RESULTS

IDDM patients had higher pre- and postload homocyst(e)ine plasma levels than did healthy control subjects (12.0 vs. 7.7 umol/1 and 27.6 vs. 16.0 umol/1; P < 0.001). Of 75 IDDM patients, 26 had homocyst(e)ine plasma levels above the normal range (defined as mean ± 2 SD of values obtained in the control group). The IDDM patients with hyperhomocyst(e)inemia had higher thrombomodulin plasma levels (62.2 vs. 38.2 ng/ml; P < 0.001), higher albumin excretion rates (485 vs. 115 mg/1; P < 0.005), and a higher prevalence of late diabetic complications (nephropathy 76 vs. 33%; retinopathy 69 vs. 51%; neuropathy, 57 vs. 41%; macroangiopathy 57 vs. 33%) compared with IDDM patients with normal plasma homocyst(e)ine. In vitro experiments with human umbilical vein cells show an increased release of thrombomodulin into the culture supernatant only when endothelial cells were pretreated with advanced glycation end product (AGE)-albumin before L-homocystine was added. A synergistic action of homocyst(e)ine and AGEs might contribute to vascular complications of patients with diabetes.

CONCLUSIONS

Hyperhomocyst(e)inemia is common in nephropathic diabetic patients and may contribute to the enhanced morbidity and mortality from cardiovascular diseases characteristically observed in IDDM patients with diabetic nephropathy.
Validation of a Diabetic Wound Classification System: The contribution of depth, infection, and ischemia to risk of amputation
Authors: Armstrong David G , Lavery Lawrence A , Harkless Lawrence B
Published: March 2007

OBJECTIVE

To validate a wound classification instrument that includes assessment of depth, infection, and ischemia based on the eventual outcome of the wound.

RESEARCH DESIGN AND METHODS

We evaluated the medical records of 360 diabetic patients presenting for care of foot wounds at a multidisciplinary tertiary care foot clinic. As per protocol, all patients had a standardized evaluation to assess wound depth, sensory neuropathy, vascular insufficiency, and infection. Patients were assessed at 6 months after their initial evaluation to see whether an amputation had been performed.

RESULTS

There was a significant overall trend toward increased prevalence of amputations as wounds increased in both depth (χ2trend = 143.1, P < 0.001) and stage (χ2trend = 91.0, P < 0.001). This was true for every subcategory as well with the exception of noninfected, nonischemic ulcers. There were no amputations performed within this stage during the follow-up period. Patients were more than 11 times more likely to receive a midfoot or higher level amputation if their wound probed to bone (18.3 vs. 2.0%, P < 0.001, χ2 = 31.5, odds ratio (OR) = 11.1, CI = 4.0–30.3). Patients with infection and ischemia were nearly 90 times more likely to receive a midfoot or higher amputation compared with patients in less advanced wound stages (76.5 vs. 3.5%, P < 0.001, χ2 = 133.5, OR = 89.6, CI = 25–316).

CONCLUSIONS

Outcomes deteriorated with increasing grade and stage of wounds when measured using the University of Texas Wound Classification System.
Carotid Atherosclerosis in Adolescents and Young Adults With IDDM: Relation to urinary endothelin, albumin, free cortisol, and other factors
Authors: Peppa-Patrikiou Melpomeni , Scordili Maria , Antoniou Aristidis , Giannaki Maria , Dracopoulou Maria , Dacou-Voutetakis Catherine
Published: March 2007

OBJECTIVE

To investigate 1) alterations of carotid intimal-plus-medial thickness (IMT) in subjects with IDDM and 2) the relation of IMT to indexes of diabetic angiopathy and to risk factors of atherosclerosis.

RESEARCH DESIGN AND METHODS

IMT was assessed by ultrasound B-mode imaging in 39 subjects with IDDM (23 male, 16 female young adults aged 17.5 ± 5.2 years, diabetes duration 8.8 ± 5.9) and in 22 control subjects (healthy siblings of the IDDM subjects) of comparable age. Urinary endothelin (UET1) and urinary free cortisol (UFC) were determined by radioammunoassay (RIA), urinary albumin by nephelometry, HbA1c by high-performance liquid chromatography (HPLC), and plasma renin by immunoradiometric assay (IRMA).

RESULTS

The IMT values were greater in IDDM subjects than in control subjects (0.49 ± 0.1 mm, 0.44 ± 0.09 mm, respectively; P = 0.048) and greater in IDDM male subjects than in control male subjects (0.52 ± 0.09 and 0.44 ± 0.06 mm, respectively; P = 0.015), with no difference between IDDM and control female subjects. The IMT values were greater in diabetic male subjects than in female subjects (0.52 ± 0.09 and 0.45 ± 0.1 mm, respectively; P = 0.017). In IDDM subjects, but not in control subjects, there was a positive correlation of IMT to urinary albumin (P = 0.008), systolic blood pressure (P = 0.023), UET1 (P = 0.016), UFC (P = 0.002), and BMI (P = 0.021). Multiple regression analysis demonstrated that in IDDM subjects the variable that interacts independently with IMT was the BMI (P = 0.001).

CONCLUSIONS

IMT, an index of atherosclerosis (macroangiopathy), is increased in IDDM subjects quite early (already in adolescence), and it is positively related to urinary albumin, UET1, blood pressure, and UFC.
Elevated Concentrations of Soluble E-Selectin and Vascular Cell Adhesion Molecule-1 in NIDDM: Effect of intensive insulin treatment
Authors: Albertini Jean-Paul , Valensi Paul , Lormeau Boris , Aurousseau Marie-Hélène , Ferrière Francoise , Attali Jean-Raymond , Gattegno Liliane
Published: March 2007

OBJECTIVE

To evaluate the effects of a 14-day intensive insulin therapy and short-term improvement of glycemic control on serum levels of soluble forms of adhesion molecules, i.e., intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), and E-selectin (sE-selectin) in NIDDM patients with poor glycemic control.

RESEARCH DESIGN AND METHODS

A total of 16 NIDDM patients were compared with 23 healthy subjects (control group) and investigated before and after intensive insulin treatment.

RESULTS

On day 0, sE-selectin and sVCAM-1 levels were significantly higher in NIDDM patients than in nondiabetic control subjects (median 87, range 63–115; median 544, range 408–797 vs. 58, 43–80; 443, 395–573 ng/ml, respectively) (P < 0.008 in both cases). On day 15, the fall in sE-selectin levels was significant (P < 0.0001) and at a lesser extent in sVCAM-1 levels (64, 48–85; 506, 417–678 ng/ml, respectively); these levels reached values that no longer differed from those of control subjects (P = 0.23 and 0.15, respectively). Moreover, the fall in sE-selectin was positively associated with the change in LDL cholesterol and the improvement of glycemia.

CONCLUSIONS

In poorly controlled NIDDM patients, sE-selectin levels are increased and significantly fall to normal after short-term improvement of glycemic control. This suggests that assaying sE-selectin makes it possible to detect endothelium activation and to follow its reversal with euglycemia.
Influence of Interindividual Variability of Aldose Reductase Protein Content on Polyol-Pathway Metabolites and Redox State in Erythrocytes in Diabetic Patients
Authors: Hamada Yoji , Nishimura Chihiro , Koh Naoki , Sakakibara Fumihiko , Nakamura Jiro , Tanimoto Tsuyoshi , Hotta Nigishi
Published: March 2007

OBJECTIVE

To clarify the influence of interindividual difference in the level of aldose reductase on the polyol pathway-related metabolism in diabetic patients.

RESEARCH DESIGN AND METHODS

The enzyme protein content was determined by a two-site enzyme-linked immunosorbent assay using monoclonal and polyclonal antibodies to recombinant human aldose reductase in erythrocytes from 35 diabetic patients and 11 healthy volunteers. Patients were stratified into two groups by the median of aldose reductase content, and the erythrocyte sorbitol level, the fructose level, and the lactate-to-pyruvate ratio were compared between the two groups. We also examined the correlation of the enzyme content with these metabolic parameters.

RESULTS

The group of patients whose enzyme content was above the median showed a significant increase in the levels of sorbitol (34.7 ± 4.9 vs. 20.4 ± 2.0 nmol/g Hb, P < 0.05) and fructose (99.8 ± 17.2 vs. 45.9 ± 4.6 nmol/g Hb, P < 0.05), along with an elevated lactate-to-pyruvate ratio (28.6 ± 6.1 vs. 11.7 ± 1.2, P < 0.05), compared with patients with low enzyme levels. The aldose reductase content in erythrocytes was well correlated with its activity, and there was a significant correlation between the enzyme content and the erythrocyte sorbitol (r = 0.58, P < 0.001) or fructose (r = 0.57, P < 0.001) levels as well as between the enzyme level and the lactate-to-pyruvate ratio (r = 0.38, P < 0.05).

CONCLUSIONS

These results suggest that the interindividual variability of aldose reductase content may contribute tangibly to the polyol-pathway flux and cytoplasmic redox alteration in diabetic patients.
Enhanced Progression of Urinary Albumin Excretion in IDDM During Puberty
Authors: Barkai László , Vámosi Ildikó , Lukács Katalin
Published: March 2007

OBJECTIVE

To determine whether the progression of urinary albumin excretion rate (AER) is higher during puberty than before or after this period.

RESEARCH DESIGN AND METHODS

A prospective study was conducted in which normoalbuminuric prepubertal (n = 20), pubertal (n = 28), and postpubertal (n = 26) IDDM groups matched for diabetes duration and long-term metabolic control were followed for 3 years. At 6-month intervals, 24-h urine collection was used to determine AER.

RESULTS

AER increased significantly over a period of 3 years in the pubertal (P = 0.001) and postpubertal (P = 0.003) subjects but not in prepubertal subjects. The annual progression of AER was significantly higher in the pubertal group than in the prepubertal (P = 0.001) or postpubertal (P = 0.001) groups. Six pubertal, two postpubertal, and none of the prepubertal subjects developed microalbuminuria (AER ≥ 20 μg/min on two consecutive occasions) over a 3-year period (P = 0.047). Multiple logistic regression analysis showed that the risk of development of microalbuminuria was increased in pubertal subjects compared with the prepubertal and postpubertal subjects (adjusted relative risk [95% CI]: 4.3 [1.5–9.3], P = 0.012, and 2.1 [1.1–5.0], P = 0.023, respectively).

CONCLUSIONS

Puberty represents an independent risk of the development of microalbuminuria in diabetes. This findings suggests that the endocrine changes of puberty lead to an accelerated process of early kidney damage in diabetes. In pediatric diabetes care, screening for microalbuminuria is needed soon after the onset of puberty.
Patient Choice in Diabetes Education Curriculum: Nutritional versus standard content for type 2 diabetes
Authors: Noël Polly Hitchcock , Larme Anne C , Meyer Julie , Marsh Genevieve , Correa Alicia , Pugh Jacqueline A
Published: March 2007

OBJECTIVE

To examine the effects of patient choice between two education curriculums that emphasized either the standard or nutritional management of type 2 diabetes on class attendance and other outcomes among a mostly Hispanic patient population.

RESEARCH DESIGN AND METHODS

A total of 596 patients with type 2 diabetes were randomly assigned to either a choice or no choice condition. Patients in the choice condition were allowed to choose their curriculum, while patients in the no choice condition were randomly assigned to one of the two curriculums. Outcomes were assessed at baseline and at a 6-month follow-up.

RESULTS

When given a choice, patients chose the nutrition curriculum almost four times more frequently than the standard curriculum. Contrary to our hypothesis, however, patients who had a choice did not significantly increase their attendance rates or demonstrate improvements in other diabetes outcomes compared with patients who were randomly assigned to the two curriculums. Patients in the nutrition curriculum had significantly lower serum cholesterol at a 6-month follow-up, whereas patients in the standard curriculum had significant improvements in glycemic control. Of the randomized patients, 30% never attended any classes; the most frequently cited reasons for nonattendance were socioeconomic. Hispanic patients, however, were just as likely as non-Hispanic patients to attend classes and participate at the follow-up. Patients who attended all five classes of either curriculum significantly increased their diabetes knowledge, gained less weight, and reported improved physical functioning compared with patients who did not attend any classes.

CONCLUSIONS

Although providing patients with a choice in curriculums at the introductory level did not improve outcomes, differential improvements were noted between patients who attended curriculums with different content emphasis. We suggest that diabetes education programs should provide the opportunity for long-term, repetitive contacts to expand on the modest gains achieved at the introductory level, as well as provide more options to match individual needs and interests and to address socioeconomic barriers to participation.
Short-term Effects of Coping Skills Training as Adjunct to Intensive Therapy in Adolescents
Authors: Grey Margaret , Boland Elizabeth A , Davidson Maryanne , Yu Chang , Sullivan-Bolyai Susan , Tamborlane William V
Published: March 2007

OBJECTIVE

Given the urgent need to develop effective programs that improve the ability for adolescents to achieve metabolic control equivalent to programs studied in the Diabetes. Control and Complications Trial, we have undertaken a clinical trial to determine if a behavioral intervention (coping skills training [CST]) combined with intensive diabetes management can improve metabolic control and quality of life in adolescents implementing intensive therapy regimens.

RESEARCH DESIGN AND METHODS

A total of 65 youths between the ages of 13 and 20 years, who elected to initiate intensive insulin therapy, were randomly assigned to one of two groups: the intensive management with CST group and the intensive management without CST group. CST consists of a series of small group efforts designed to teach adolescents the coping skills of social problem-solving, social skills training, cognitive behavior modification, and conflict resolution. Data were collected at pre-intervention and at 3 months following the use of the Self-Efficacy for Diabetes scale, Children's Depression Inventory, Issues in Coping with IDDM scale, and the Diabetes Quality of Life: Youth scale. Clinical data (HbA1c, adverse effects) were collected monthly.

RESULTS

The experimental and control groups were comparable on all measures at baseline. Results show that adolescents who received CST had lower HbA1c and better diabetes self-efficacy and were less upset about coping with diabetes than adolescents receiving intensive management alone. In addition, adolescents who received the CST found it easier to cope with diabetes and experienced less of a negative impact of diabetes on quality of life than those who did not receive CST.

CONCLUSIONS

CST is useful in improving not only an adolescent's metabolic control, but also their quality of life. As more pediatric providers aim for improved control, in adolescents with diabetes, the addition of this behavioral intervention may be helpful in achieving metabolic and life goals.
Well-Being and Symptoms in Relation to Insulin Therapy in Type 2 Diabetes
Authors: Sonnaville Jeroen J J De , Snoek Frank J , Colly Louisa P , Devillé Walter , Wijkel Dirk , Heine Robert J
Published: March 2007

OBJECTIVE

To determine the influence of insulin therapy on physical symptoms, emotional and general well-being, and treatment satisfaction in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A descriptive prospective 2-year cohort study was performed. The study population consisted of 272 eligible NIDDM patients of Dutch origin ≥ 40 years of age who had a known diabetes duration ≥ 3 months and who were treated with diet and/or oral hypoglycemic agents. Dependent variables in the logistic regression analysis were scores on the Type 2 Diabetes Symptom Checklist, the Profile of Mood States, and questions regarding general well-being and treatment satisfaction. Potential determinants under study were age, sex, known diabetes duration, insulin dose, duration of insulin therapy, comorbidity, baseline and change in metabolic parameters and cardiovascular risk factors.

RESULTS

A baseline and 2-year questionnaire were available for 157 patients (58%). During follow-up, 39 of them (24.8%) were treated with insulin. Initiation of insulin therapy was significantly associated with improved glycemic control (mean HbA1c 8.2 ± 1.4 [SD] to 7.4 ± 0.9%, P = 0.001) and weight gain (BMI 27.1 ± 3.9 to 28.6 ± 4.3 kg/m2 P = 0.000). Of all symptom and well-being scores, only feelings of emotional fatigue worsened significantly, although modestly (0.4–1.7 on a scale of 0.0–10.0, P = 0.02). Although diabetes management with insulin was experienced as more demanding (P = 0.04), treatment satisfaction scores were not adversely influenced (2.5–1.9, P = 0.39). High insulin doses were significantly and independently associated with high symptom scores (total score, hypoglycemic score) and with low mood (displeasure score, anger, tension, emotional fatigue) and perceived state of health.

CONCLUSIONS

Initiation of insulin therapy in type 2 diabetes improves glycemic control effectively, has little influence on physical and psychological well-being dimensions, and does not affect treatment satisfaction.
Evidence That the Age at Diagnosis of IDDM Is Genetically Determined
Authors: Fava Danila , Gardner Stephen , Pyke David , Leslie R David G
Published: March 2007

OBJECTIVE

The aim of this study was to determine the impact of genetic or environmental factors on the age or time of onset of IDDM by studying pairs of twins and siblings concordant for the disease.

RESEARCH DESIGN AND METHODS

From 404 twin pairs referred to a diabetic twin study, we selected pairs concordant for IDDM: 1) 116 identical pairs with an index twin diagnosed diabetic under age 60 years and 2) 12 identical and 12 nonidentical matched twin pairs. From 972 families referred to a population-based diabetic family study, we selected sibling pairs with IDDM: 33 pairs with an index case diagnosed diabetic under age 21 years. Twin and sibling pairs were analyzed for intraclass correlations for age and time of diagnosis.

RESULTS

Of twins concordant for IDDM, the age at diagnosis correlated 1) in 116 identical pairs (R = 0.94; P < 0.000001) and 2) more closely in 12 identical twins (R = 0.96, P < 0.000001) than 12 nonidentical twins (R = 0.59, P = 0.046). Of 33 sibling pairs with IDDM, the age, but not the time, of diagnosis was correlated (R = 0.53, P = 0.0016).

CONCLUSIONS

Correlations within pairs of twins and siblings for age, not time, at diagnosis suggest that much of the variability of the age at diagnosis of IDDM is genetically determined.
Clustering of Cardiovascular Risk Factors in Urban Asian Indians
Authors: Ramachandran A , Snehalatha C , Latha E , Satyavani K , Vijay V
Published: March 2007

OBJECTIVE

To study the prevalence of cardiovascular risk factors in native urban Asian Indians and to look for the occurrence of clustering of these factors.

RESEARCH DESIGN AND METHODS

The study included 953 subjects (532 men and 421 women), aged ≥ 40 years, selected from a population survey for diabetes, which was conducted in 1994 in Madras, Tamil Nadu, India. Measurements of anthropometry, blood pressure, plasma lipid profile, glucose tolerance, plasma insulin response, and electrocardiogram were made. Based on the normal ranges derived from the population study, abnormalities in anthropometric values, plasma lipids, and insulin values were determined. Age-adjusted prevalences of the abnormalities were calculated using data from a 1991 urban census in Madras. The expected prevalences of the abnormalities in isolation and in combinations were calculated and compared with the corresponding observed figures.

RESULTS

The prevalences of risk factors were in the order of central adiposity > dyslipidemia > hyperinsulinemia (2-h) > glucose intolerance > obesity > hypertension. The age-adjusted prevalence of coronary heart disease (CHD) was 3.9% (3.5% in men and 4.5% in women, NS), and T wave inversion was seen in an additional 10.3%. Isolated prevalences of all factors, except hypertension, were in lower frequency than expected. Combinations of each risk factor with one or two more risk factors occurred more frequently (1.3–4 times) than expected by chance. Impaired glucose tolerance and dyslipidemia showed association with hyperinsulinemia, whereas hypertension did not show such an association.

CONCLUSIONS

Clustering of the cardiovascular risk factors or the components of insulin resistance syndrome occurs in the native Asian Indian population. This finding under-scores the need for preventive aspects of metabolic disorders and CHD.
Improvement of HbA1c and Blood Glucose Stability in IDDM Patients Treated With Lispro Insulin Analog in External Pumps
Authors: Melki Vincent , Renard Eric , Lassmann-Vague Véronique , Boivin Sophie , Guerci Bruno , Hanaire-Broutin Héléne , Bringer Jacques , Belicar Pauline , Jeandidier Nathalie , Meyer Laurent , Blin Patrick , Augendre-Ferrante Béatrice , Tauber Jean-Pierre
Published: March 2007

OBJECTIVE

To compare the efficacy of the short-acting insulin analog lispro (LP) with that of regular insulin in IDDM patients treated with an external pump.

RESEARCH DESIGN AND METHODS

Thirty-nine IDDM patients (age, 39.4 ± 1.5 years; sex ratio, 22M/17W; BMI, 24.4 ± 0.4 kg/m2; diabetes duration, 22.5 ± 1.6 years) who were treated by external pump for 5.1 ± 0.5 years were involved in an open-label, randomized, crossover multicenter study comparing two periods of 3 months of continuous subcutaneous insulin infusion with LP or with Actrapid HM, U-100 (ACT). Boluses were given 0–5 min (LP) or 20–30 min (ACT) before meals. Blood glucose (BG) was monitored before and after the three meals every day.

RESULTS

The decrease in HbA1c was more pronounced with LP than with ACT (−0.62 ± 0.13 vs. −0.09 ± 0.15%, P = 0.01). BG levels were lower with LP (7.93 ± 0.15 vs. 8.61 ± 0.18 mmol/l, P < 0.0001), particularly postprandial BG levels (8.26 ± 0.19 vs. 9.90 ± 0.20 mmol/l, P < 0.0001). Standard deviations of all the BG values (3.44 ± 0.10 vs. 3.80 ± 0.10 mmol/l, P = 0.0001) and of postprandial BG values (3.58 ± 0.10 vs. 3.84 ± 0.10 mmol/l. P < 0.02) were lower with LP. The rate of hypoglycemic events defined by BG < 3.0 mmol/l did not significantly differ between LP and ACT (7.03 ± 0.94 vs. 7.94 ± 0.88 per month, respectively), but the rate of occurrences of very low BG, defined as BG < 2.0 mmol/l, were significantly reduced with LP (0.05 ± 0.05 vs. 0.47 ± 0.19 per month, P < 0.05). At the end of the study, all but two (95%) of the patients chose LP for the extension phase.

CONCLUSIONS

When used in external pumps, LP provides better glycemic control and stability than regular insulin and does not increase the frequency of hypoglycemic episodes.
Application of a Diabetes Managed Care Program: The feasibility of using nurses and a computer system to provide effective care
Authors: Peters Anne L , Davidson Mayer B
Published: March 2007

OBJECTIVE

Treatment of patients with diabetes often falls short of recommended process and outcome guidelines. To improve the quality of the provided diabetes care, a program (the Comprehensive Diabetes Care Service [CDCS]) using a computerizing tracking and recall system in conjunction with nurses following protocols was implemented in a managed care setting. The impact of this program was studied and compared to the care provided to patients in another managed care setting.

RESEARCH DESIGN AND METHODS

Patients followed in the CDCS who completed a diabetes education course were compared with patients followed in a group model health maintenance organization (GMH) who also completed a diabetes education course. CDCS patients received routine care in the program. GMH patients came to the CDCS yearly to have a diabetes evaluation. A chart review was also performed on their GMH outpatient records.

RESULTS

Initial HbA1c levels were higher in the CDCS group than in the GMH group (median of 11.9 vs. 10.0%). In the CDCS patients, HbA1c levels not only fell significantly but were also significantly lower (P < 0.05) than in the GMH patients during the 2nd and 3rd year of follow-up care. There were no significant changes in HbA1c levels in the GMH patients. When CDCS patients were divided into compliant and noncompliant patients, the median HbA1c levels in compliant patients was 8.2%, compared with 11.5% in the noncompliant group. The CDCS patients who needed treatment for hypercholesterolemia were more likely to have a lowering of their cholesterol levels than the GMH patients. All process measures, such as yearly measurement of HbA1c levels, lipid levels, and foot and retinal exams, occurred much more frequently in the CDCS patients.

CONCLUSIONS

The system developed and implemented for managing diabetes improved both outcome and process measures. The comparison group, followed at another managed care setting, received the care consistent with the average (suboptimal) quality of care provided to patients with diabetes in the U.S. Therefore, by using innovative systems of management, the treatment of patients with diabetes can be greatly improved.
Successful Treatment With Insulin Analog Lispro in IDDM With Delayed Absorption of Subcutaneously Applied Human Regular Insulin and Complicated Intraperitoneal Insulin Infusion: A case report
Authors: Meier Matthias , Brand Johann , Standl Eberhard , Schnell Oliver
Published: March 2007

OBJECTIVE

To subcutaneously administer the insulin analog lispro in a patient with delayed absorption of subcutaneously applied human regular insulin whose continuous intraperitoneal insulin infusion (CIPII) with a percutaneous access device had required multiple surgical interventions because of complications.

RESEARCH DESIGN AND METHODS

In a 35-year-old woman with long-term IDDM and delayed absorption of subcutaneously applied human regular insulin, a 3-year CIPII with human regular insulin via a percutaneous access device was complicated by three catheter obstructions and one subcutaneous abscess. Each complication required the implantation of a new percutaneous access device. During a 2-day trial with continuous subcutaneous insulin infusion (CSII) of the insulin analog lispro at basal infusion rates of 0.5–1.1 U/h, stable metabolic control was achieved. A 5-h intermediate attempt with human regular insulin in CSII, however, increased blood glucose concentrations from 6.0 to 28.8 mmol/1, despite identical basal rates and additional injection of 16 U of human regular insulin. Restarting with CSII of the insulin analog lispro reinforced stable metabolic control.

CONCLUSIONS

It is suggested that the insulin analog lispro is a promising approach in the treatment of IDDM with delayed absorption of subcutaneously applied human regular insulin and a suitable alternative therapy for patients with complications attributed to percutaneous access devices for CIPII.
Development of a Scale to Measure Adherence to Self-Monitoring of Blood Glucose With Latent Variable Measurement
Authors: Wagner Julie A , Schnoll Robert A , Gipson Martin T
Published: March 2007

OBJECTIVE

Adherence to self-monitoring of blood glucose (SMBG) is problematic for many people with diabetes. Self-reports of adherence have been found to be unreliable, and existing paper-and-pencil measures have limitations. This study developed a brief measure of SMBG adherence with good psychometric properties and a useful factor structure that can be used in research and in practice.

RESEARCH DESIGN AND METHODS

A total of 216 adults with diabetes responded to 30 items rated on a 9-point Likert scale that asked about blood monitoring habits. In part I of the study, items were evaluated and retained based on their psychometric properties. The sample was divided into exploratory and confirmatory halves. Using the exploratory half, items with acceptable psychometric properties were subjected to a principal components analysis. In part II of the study, structural equation modeling was used to confirm the component solution with the entire sample. Structural modeling was also used to test the relationship between these components. It was hypothesized that the scale would produce four correlated factors.

RESULTS

Principal components analysis suggested a two-component solution, and confirmatory factor analysis confirmed this solution. The first factor measures the degree to which patients rely on others to help them test and thus was named “social influence.” The second component measures the degree to which patients use physical symptoms of blood glucose levels to help them test and thus was named “physical influence.” Results of the structural model show that the components are correlated and make up the higher-order latent variable adherence.

CONCLUSIONS

The resulting 15-item scale provides a short, reliable way to assess patient adherence to SMBG. Despite the existence of several aspects of adherence, this study indicates that the construct consists of only two components. This scale is an improvement on previous measures of adherence because of its good psychometric properties, its interpretable factor structure, and its rigorous empirical development.
Proteinuria Is Still Useful for the Screening and Diagnosis of Overt Diabetic Nephropathy
Authors: Zelmanovitz Themis , Gross Jorge L , Oliveira Jarbas , De Azevedo Mirela J
Published: March 2007

OBJECTIVE

To assess the performance of urinary total protein measurements in timed 24-h urine collection (24-h UP) and in a diurnal random urine specimen (RUS) for the screening and diagnosis of overt diabetic nephropathy.

RESEARCH DESIGN AND METHODS

A total of 167 diabetic patients (20 type 1 and 147 type 2 diabetic patients; 78 women and 89 men), aged 20–84 years, collected 217 timed 24-h urine specimens. Albumin was measured by immunoturbidimetry, total protein by sulfosalicylic acid technique, and creatinine by Jaffe's method. According to the timed 24-h urinary albumin excretion rate (UAER), samples were divided into three groups: normoalbuminuric (NORMO) (UAER <20 μg/min; n = 84), microalbuminuric (MICRO) (UAER 20–200 μg/min; n = 78), and macroalbuminuric (MACRO) (UAER ≥200 μg=min; n = 55). Eighty-six patients also collected 105 RUSs (NORMO, n = 47; MICRO, n = 37; MACRO, n = 21), and urinary protein concentration (UPC) and urinary protein-to-creatinine ratio (UPCR) were measured. The receiver operating characteristics (ROC) curve approach was used to analyze the performance of the diagnostic tests.

RESULTS

Spearman's coefficient of correlation of 24-h UAER versus 24-h UP was 0.95 (P < 0.001), and of 24-h UAER versus UPC and UPCR were 0.77 and 0.72, respectively (P < 0.001). The calculated areas (±SEM) under the ROC curve for the diagnosis of overt diabetic nephropathy were 0.9987 ± 0.001 for 24-h UP, 0.9926 ± 0.006 for UPC, and 0.9751 ± 0.014 for UPCR. In the ROC curves, the first points with 100% sensitivity were 541 mg (95.7% specificity) for 24-h UP, 431 mg/1 (92.9% specificity) for UPC, and 0.2 (76.2% specificity) for UPCR.

CONCLUSIONS

Measurements of proteinuria presented almost perfect accuracy for the screening and diagnosis of overt diabetic nephropathy. Protein measurement in spot urine is a reliable and simple method for the screening and diagnosis of overt diabetic nephropathy.