bluuebunny/crossref_metadata_2025 huggingface dataset:
A Comparison of Premixed with Patient‐mixed Insulins
Authors: Corcoran J. S. , Yudkin J. S.
Published: July 2009

Blood glucose control in 12 C‐peptide negative patients has been compared in a crossover trial of four insulin treatment regimens: (1) porcine soluble and isophane, (2) premixed porcine soluble/isophane, (3) porcine soluble and lente, all taken twice daily, and (4) once daily bovine ultralente with three porcine soluble injections before meals. Each regimen lasted 8 weeks and included home blood glucose monitoring, telephoned advice on dose adjustment during the first 2 weeks, and home collection of seven‐point capillary blood profiles for laboratory analysis. No significant differences between the regimens could be demonstrated when HbA1c 24 h mean blood glucose, and M‐values were evaluated. The average range of blood glucose values for four capillary samples taken at the same time point on different days was 8.0 mmol/l, compared with a maximum difference between regimens of 3.6 mmol/l at any time point, suggesting that blood glucose control is more heavily influenced by erratic insulin absorption than by the insulin regimen chosen. Premixed insulins offer convenience of use without significant deterioration of blood glucose control.
Glucose Intolerance and Hypertension in North London: The Islington Diabetes Survey
Authors: Forrest R. D. , Jackson C. A. , Yudkin J. S.
Published: July 2009

In a general practice‐based screening survey, 1040 (63.3%) of a randomly selected sample of 1644 people over the age of 40 years were examined for diabetes mellitus (DM) and hypertension (HT). Glucose intolerance was assessed by a single 2 h post‐load blood glucose estimation and HT (diastolic blood pressure ≥95mmHg by a single blood pressure reading) or being on anti‐hypertensive treatment.

The sample included 41 patients (2.1%) with known DM and 135 (12.5%) with known HT. Screening identified 27 (2.6%) new diabetics (16 women) and 43 subjects (4.1%) with impaired glucose tolerance (30 women). A further 30 known diabetics over the age of 40 and 12 diabetics under 40 were registered at the practice. The estimated prevalence of diabetes in the over 40s was 4.6% and in all ages was 1.6%. DM appeared to affect Afro‐Caribbeans more commonly than Caucasians among those examined (5.9% versus 2.6%) though this difference did not reach statistical significance (z = 1.1106, p=0.134).

A total of 190 subjects (17.5%) were found to have HT, of whom 55 (5.1%) were newly diagnosed; 10.2% of the sample were on anti‐hypertensive treatment, and in 79.3% of these the blood pressure was well controlled (diastolic <100 mmHg). HT was more common among known diabetics with a prevalence of 35.4%, of whom one‐third were previously undiagnosed. HT affected Afro‐Caribbeans significantly more commonly than Caucasians (z=4.206, p<0.001).

This survey shows that the prevalence of DM diagnosed according to modern diagnostic criteria appears to be similar to that found in previous surveys using older criteria. The sensitivity and specificity of the 2hBG as a screening test for DM (with 95% confidence limits) were 69.2±25.1% and 97.4±2.3%, respectively. In 49 subjects glucose tolerance status changed on formal glucose tolerance testing. The use of a single 2hBG in screening for DM gave a false negative rate of 40%. It is concluded that a single 2hBG is not sufficiently sensitive as a screening test for DM in population screening. The prevalence of HT is higher than has been noted in previous general practice surveys.
A Trial of the Calcium Antagonist Nisoldipine in Hypertensive Non‐insulin‐dependent Diabetic Patients
Authors: Odigwe C. O. , McCulloch A. J. , Williams D. O. , Tunbridge W. M. G.
Published: July 2009

The antihypertensive and metabolic effects of a new calcium antagonist nisoldipine (10 to 20 mg at night) were investigated in 14 mild to moderately hypertensive non‐insulin‐dependent diabetic patients (median age 62, range 50–70 years). In a 12‐week placebo controlled single blind study, sitting and standing blood pressure were significantly lowered (p<0.001). Heart rate was unchanged as were blood urea, creatinine, bilirubin, mmol/l (mean ± SEM) and uric acid concentrations. Plasma sodium levels fell during active therapy (142 ± 0.5 mmol/l (mean ± SEM) versus 139 ± 0.5 (p<0.001) and remained lower during the washout period. Plasma calcium concentrations increased during nisoldipine therapy (2.41 ± 0.02 versus 2.51 ± 0.03 mmol/l, p<0.001) and returned towards baseline during the washout period. Plasma ionized calcium concentrations showed similar changes but plasma sodium and calcium remained within the normal laboratory ranges in all patients at all times. Serum triglyceride concentrations fell (placebo 1.9 ± 0.02 mmol/l vs nisoldipine 1.6 ± 0.2, p<0.05), but fasting cholesterol was unchanged. Fasting blood glucose, and the blood glucose response to oral glucose challenge (75 g) showed no differences though HbA1 concentrations fell (10.6 ± 0.7 versus 9.2 ± 0.05%, p<0.05) and tended to rise when the drug was withdrawn. Haemoglobin concentrations also fell during active therapy (14.7 ± 0.4 vs 14 ± 0.32 g/dl p<0.001) and also remained lower after the washout period (13.9 ± 0.03 g/dl). Although the explanation for these changes remains to be elucidated, nisoldipine was well tolerated and the only side‐effects reported (flushing and headaches) occurred in the higher dosage regimen (20 mg daily) and became less apparent when the drug was taken with meals.
The Extent of Coronary Artery Disease in Diabetic Patients with Myocardial Infarction: an ECG Study
Authors: Oswald G. A. , Corcoran J. S. , Patterson D. L. H. , Yudkin J. S.
Published: July 2009

In 91 non‐diabetics (age 63 ± 12, mean ± SD, years range 31‐94 years) and 85 patients with known diabetes or clearly abnormal levels of HbAk (age 66 ± 10 years, range 36‐87 years) electrocardiograms were analysed sequentially after acute myocardial infarction (AMI). There was no significant difference in infarct site between the two groups. Generalized ischaemic change without ST elevation was seen in 33% of diabetics and 22% of non‐diabetics (p>0.1). In patients with transmural AMI, cardiogenic shock (CGS) was significantly commoner in diabetics (relative risk 3.1, CL 1.2‐8.1) but there was no difference in the frequency of reciprocal change between the two groups. In both diabetic and non‐diabetic patients the development of cardiogenic shock was more frequently associated with the presence of reciprocal change, the difference reaching significance in the diabetic group (χ2 = 4.4, p<0.05). Thus cardiogenic shock in both diabetic and non‐diabetic patients with AMI may be associated with the presence of extensive coronary artery disease, but differences in the prevalence of extensive disease do not explain the predisposition of diabetic patients to CGS.
The Natural History of Insulin‐Dependent Diabetes in Denmark: 2. Long‐term survival—who and why
Authors: Borch‐Johnsen K. , Nissen H. , Salling N. , Henriksen E. , Kreiner S. , Deckert T. , Nerup J.
Published: July 2009

Forty per cent of all Danish insulin‐dependent diabetic (IDDM) patients survive for at least 40 years after diagnosis. In an attempt to identify factors influencing the probability of surviving for 40 years or more, we followed all IDDM patients diagnosed before 1943 and admitted to the Steno Memorial Hospital. Patients surviving ≥ 40 years were compared with patients dying within 35 years of diabetes diagnosis. Patients dying within 35 years were characterized by male preponderance (p<0.01), poor metabolic control (p<0.05), and by less frequent attendance at a specialized care unit (p<0.0001). Death due to uraemia/diabetic nephropthy was also characterized by male preponderance, poor metabolic control, and few contacts with a specialized care unit but in patients dying from cardiovascular disease (CVD), no effect of sex was found, indicating that the protection from CVD found in the female non‐diabetic population is absent in IDDM patients. We conclude that long‐term survival with IDDM may be determined by factors susceptible to intervention such as metabolic regulation and patient attitude to their disease.
Abnormalities of Foot Pressure in Early Diabetic Neuropathy
Authors: Boulton A. J. M. , Betts R. P. , Franks C. I. , Newrick P. G. , Ward J. D. , Duckworth T.
Published: July 2009

Dynamic foot pressure has been studied in 44 diabetic subjects of mean age 52 years with no clinical evidence of neuropathy and in an age and sex matched non‐diabetic control group. Vibration perception threshold (VPT), sensory (SCV), and motor conduction velocities (MCV) were also measured in the diabetic subjects. Sixteen diabetic subjects (Group A) had abnormally high pressures under the metatarsal heads (>10 kg/cm2), whereas the remaining 28 diabetic subjects had normal results (Group B). The ratio of toe to metatarsal head loading (normal 0.112) was significantly reduced in Group A (0.077) compared to Group B (0.127: p<0.05). VPT and sural nerve SCV were also significantly abnormal in Group A subjects compared with Group B (p<0.005 and p<0.02, respectively), though there were no differences in MCV. A significant inverse correlation was obtained between toe loading and VPT. It is concluded that abnormalities of foot pressure occur in early sensory neuropathy and may precede clinical abnormalities. Assessment of the toe‐loading ratio may provide a sensitive measure of motor dysfunction in early diabetic neuropathy.
Red Cell Sorbitol Levels During Hyper and Hypoglycaemic Clamp Studies in Insulin‐dependent Diabetic Patients
Authors: Price D. E. , Grant P. J. , Airey C. M. , Stickland M. H. , Kemp J. , Wales J. K.
Published: July 2009

The red cell sorbitol concentration has been suggested as a measure of polyol pathway activity. Red cell sorbitol levels were higher in 53 patients having insulin‐dependent diabetes mellitus (IDDM) than in 16 control subjects. Six patients having IDDM underwent hyperglycaemic ‘clamp’ studies; the red cell sorbitol level returned to the normal range when the blood glucose was clamped at 5 mmol/l for 1 h and rapidly increased when it was clamped at 15 and 25 mmol/l for a further hour at each level. Seven patients with IDDM were rendered hypoglycaemic; red cell sorbitol levels rapidly fell to a level less than, but not significantly different from normal.

The results of these studies suggest that in IDDM red cell sorbitol levels are a reflection of prevailing blood glucose concentration and do not indicate long‐term sorbitol accumulation in other tissues.
Optic Disc Swelling in Young Diabetic Patients: a Diagnostic Dilemma
Authors: Heller S. R. , Tattersall R. B.
Published: July 2009

We describe four young diabetic patients presenting with swelling of one or both optica discs (‘papiloedema’). Two were asymptomatic while the others complained of blurred vision. Spontaneous resolution occurred in all within 6 months although three had developed optic atrophy within 5 years.

These four patients fit into a spectrum of acute involvment of the optic nerve in young diabetic patients, of which over 50 cases have now been reported. Most have florid ophthalmoscopic appearances which resolve within weeks or months and usually‐carry a good visual prognosis. The condition apears to be a variant of anterior ischaemic optic neuropathy though its possible pathophysiology in diabetes is uncertain. Knowledge of the condition by diabetologists and ophthalmologists is important as patients and doctors may be reassured after fairly simple investigation.
The Time Course and Diurnal Variation of Postural Hypotension in Diabetic Autonomic Neuropathy
Authors: Horrocks P. M. , FitzGerald M. G. , Wright A. D. , Nattrass M.
Published: July 2009

Nine diabetic patients (age range 23–67y) with autonomic neuropathy and symptomatic postural hypotension were studied. The time course of the postural drop in blood pressure (BP) was documented firstly at 0900h, prior to breakfast and insulin, and secondly in the afternoon. Seven patients were symptomatic in the morning but only one in the afternoon. The systolic nadir in the morning was lower (p<0.02) than in the afternoon. The mean systolic pressure in the first 3 min after standing was no different in the afternoon but it was lower in the 2nd (p<0.05), 3rd (p<0.02), and 4th (p<0.02) 3‐min intervals in the afternoon. The time taken to reach the systolic nadir was variable, ranging from 1–12 min. It is concluded that the assessment of the postural fall in BP may be underestimated if measured immediately after standing or if it is measured in the afternoon.
Evaluation of a Weekend Group for Parents of Children with Diabetes
Authors: Marteau Theresa M. , Gillespie Chris , Swift Peter C. F.
Published: July 2009

A weekend group was organized for parents of children with diabetes with the aim of teaching them an approach to identifying and tackling common problems. A total of 97 parents of 85 children participated. The effectiveness of the weekend was evaluated and measures were taken before, immediately following and 3 months afterwards. Parents rated themselves significantly more confident in looking after their child immediately following the weekend, although ratings of perceived difficulty in managing the child's diabetes did not alter. Three months later parents' confidence had further increased, although as before perceived difficulty was unchanged. The majority of parents reported making at least some changes either in daily management or other aspects of coping with their child's diabetes. Participation in such short‐term groups represents an efficient approach to increasing the confidence of parents of children with a chronic illness.
Nerve Ischaemia‐Resistance: An early Abnormality in Diabetes
Authors: Newrick P. G. , Boulton A. J. M. , Ward J. D.
Published: July 2009

Vibration perception threshold (VPT) has been measured before and 30 min after limb ischaemia in 17 newly diagnosed non‐insulin‐dependent diabetic patients and matched controls. Mean baseline VPT was higher in the diabetics than in controls (14 vs 11, p<0.01) while VPT at 30 min was lower (25 vs 30, p<0.05). The ischaemic index (VPT at 30 min/baseline VPT), calculated as a measure of nerve ischaemia‐resistance, was lower in the diabetics compared with controls (p<0.01), and correlated with blood glucose (r = −0.53, p<0.03) but not glycosylated haemoglobin at the time of testing. The difference in ischaemic index persisted even when baseline VPT measurements, rather than patients, were matched. Ischaemic index was re‐tested in 15 patients after a median interval of 17 months (range 6–19), at which time mean ±SD glycosylated haemoglobin had improved significantly (12.2%±0.4 versus 9.5%±0.05, p<0.001), but this bore no relation to changes in ischaemic index.

Peripheral nerve ischaemia‐resistance is present at the time of diagnosis of non‐insulin‐dependent diabetes, even in the absence of other neurophysiological abnormalities, and is not explicable by glycaemic control alone.
Natural History of Pancreatic Islet B‐Cell Function in Type 2 Diabetes Mellitus Studied over Six Years by Homeostasis Model Assessment
Authors: Rudenski A. S. , Hadden D. R. , Atkinson A. B. , Kennedy L. , Matthews D. R. , Merrett J. D. , Pockaj B. , Turner R. C.
Published: July 2009

Islet B‐cell function and insulin sensitivity were estimated with the aid of a mathematical model from repeated fasting plasma glucose and insulin measurements over a 6 year period in 131 patients with type 2 diabetes mellitus who could be managed satisfactorily on dietary therapy alone. They presented between the ages of 40 and 69 years, and were studied before and after one year of treatment, and then at regular intervals from 12 until 72 months later. A method of averaging the individual trends by means of a linear model regression technique was used to assess the progression of their diabetes. Dietary management over the first 12 months resulted in weight loss from 118% to 106% average body weight, and improved insulin sensitivity from 26% to 40% of normal (p<0.001). From 12 to 72 months, the fasting plasma glucose rose at a mean rate of 0.23 mmol/l per year (p<0.001) despite a rate of weight loss of 0.2% average body weight per year (p<0.01). The estimated islet B‐cell function, expressed as a percentage of normal, decreased significantly (p<0.05) at a rate of 1.5% per year, with no statistically significant change in insulin sensitivity. Extrapolation suggests the reduction in B‐cell function predated the departure of fasting plasma glucose from the normal range.
Microvascular Disease and Limited Joint Mobility in Diabetes. A Comparison of Fibrinolysis and Prostacyclin in Diabetes and Systemic Sclerosis
Authors: Larkin J. G. , Belch J. J. F. , Flanigan P. , Forbes C. D. , Frier B. M.
Published: July 2009

The pathogenesis of Limited Joint Mobility (LJM) in diabetes is unknown, but the abnormality is said to be associated with an increased incidence of microangiopathy. To examine the possibility that LJM may be a manifestation of microvascular disease, fibrinolysis and blood prostacyclin metabolites were measured in diabetic patients with and without LJM, and compared with patients who have systemic sclerosis (PSS). The concentrations of plasma fibrinogen (p<0.01) and Plasminogen Activator Activity (PAA) (p<0.02) were increased in both diabetic groups, compared with non‐diabetic controls, and were of similar magnitude to the changes observed in PSS. Antithrombin III (AT III) activity was significantly lower in diabetic patients with LJM than in those without LJM, but not significantly different from controls. Prostacyclin concentrations were raised in PSS patients compared to controls (p<0.02) but were not raised in diabetic subjects.

Thus abnormal fibrinolysis was demonstrated in diabetic patients compared to non‐diabetic controls, and prostacyclin concentrations in diabetics were lower than in PSS patients. The diabetic patients with LJM had lower AT III activity than diabetics without LJM, but overall a convincing difference between the two groups of diabetics was not proven. No sure inferences could be drawn on the vascular aetiology of LJM, while the impaired prostacyclin activity might contribute to the development of diabetic microangiopathy.
HLA‐D Region RFLPs Indicate That Susceptibility to Insulin‐dependent Diabetes in South India is Located in the HLA‐DQ Region
Authors: Hitman G. A. , Karir P. K. , Sachs J. A. , Ramachandran A. , Snehalatha C. , Viswanathan M. , Mohan V.
Published: July 2009

Recently close markers for insulin‐dependent diabetes mellitus in Western ‘Caucasoid’ subjects have been defined from DQ region (both α and β genes) restriction fragment length polymorphisms. In order to define the genetic contribution to insulin‐dependent diabetes mellitus in an Indian population we have analysed 58 unrelated Dravidian (South Indian) insulin‐dependent diabetic patients and 43 controls. In insulin‐dependent diabetes an increased frequency of the Taq 1 DQβ restriction fragment length polymorphisms designated T2omega/T6 (relative risk = 10.6), and of homozygotes for Taq 1 DQα 4.6 kb (relative risk = 11), was found in the patients. The highest relative risk for insulin‐dependent diabetes mellitus was obtained by comparing patients and control subjects who either (a) co‐inherited DQT2omega/T6 with certain DQα restriction fragment length polymorphisms or (b) were DQα 4.6 kb homozygotes, the combination of (a) and (b) accounting for 55.5% of insulin‐dependent diabetes mellitus subjects and none of the controls (relative risk = 101; 95% confidence limits 93–109).
Elevated Urinary Prostaglandin Excretion and the Effect of Indomethacin on Renal Function in Incipient Diabetic Nephropathy
Authors: Mathiesen E. R. , Hommel E. , Olsen U. B. , Parving H.‐H.
Published: July 2009

We investigated whether the glomerular synthesis of prostaglandins modulates the glomerular filtration rate and urinary albumin excretion in incipient diabetic nephropathy (defined as urinary albumin excretion between 30 and 300 mg/24 h (microalbuminuria) in two out of three sterile ketone‐free 24‐h urine collections in patients having insulin‐dependent diabetes mellitus (IDDM) without hypertension or other kidney disease). The urinary excretion of prostaglandin E2 was significantly elevated in 8 insulin‐dependent diabetic patients with incipient nephropathy as compared with 9 normoalbuminuric IDDM patients and 11 healthy controls: 317 (182–1273); 95 (67–225); 132 (54–263) pg/min, respectively (2p<0.01). Glomerular filtration rate (single bolus 51Cr‐EDTA technique) and albuminuria (radioimmuno‐assay) were measured twice within 2 weeks in 8 females having IDDM with incipient nephropathy. The study design was a randomized double‐blind trial with the patients receiving either indomethacin (150 mg/day) or placebo for 3 days prior to the kidney function studies. Indomethacin treatment induced a significant reduction in urinary prostaglandin E2 excretion (73%) (2p<0.01), urinary albumin excretion rate diminished from 207 (63–253) to 87 (49–147) mg/24 h (2p<0.01), fractional clearance of albumin declined (70%) (2p<0.01). Glomerular filtration rate remained stable (108 (88–133) versus 110 (95–142) ml/min). Blood glucose and blood pressure were comparable during the placebo and indomethacin treatment (12.6 ± 3 versus 13.4 ± 5 mmol/l and 122/79±3/9 versus 122/82±4/10 mmHg, respectively).

Our results suggest that enhanced glomerular synthesis of vasodilating prostaglandins may accelerate microalbuminuria in incipient diabetic nephropathy.
Renal Artery Stenosis in Hypertensive Diabetic Patients
Authors: Ritchie C.M. , Mcllrath E. , Hadden D. R. , Weaver J. A. , Kennedy L. , Atkinson A. B.
Published: July 2009

The prevalence of secondary forms of hypertension in diabetes is unknown. One hundred and five of 465 patients randomly selected from a diabetic clinic population were found to be hypertensive. Hypertensive patients aged less than 70 years were screened for renal artery stenosis using intravenous digital subtraction angiography. Two angiograms were technically unsatisfactory. All 18 insulin‐dependent patients successfully screened had normal renal arteriograms. Five of 24 non‐insulin‐dependent patients had unilateral renal artery stenosis but functional tests did not clearly suggest that renal artery stenosis was causing the hypertension in these cases. No patient was referred for surgery or angioplasty. We conclude that renal artery stenosis is common in hypertensive non‐insulin‐dependent diabetics but may not, in many cases, be the cause of the hypertension. The criteria for investigating diabetic hypertensives for renal artery stenosis should be no different from those used in the general hypertensive population.
Microalbuminuria in Diabetes: Relationships Between Urinary Albumin Excretion and Diabetes‐related Variables
Authors: Gatling W. , Mullee M. A. , Knight C. , Hill R. D.
Published: July 2009

A single observer reviewed 842 of the 917 known diabetic patients registered with 40 GPs in the Poole area. Fifty‐nine per cent (493) of those reviewed submitted a timed overnight urine collection to measure albumin excretion rate (AER) and overnight albumin/creatinine ratio (ON‐Alb/Creat); 43 samples were excluded because of urinary tract infection and/or proteinuria. A random urine sample was obtained in 607 diabetic patients to measure the random albumin/creatinine ratio (R‐Alb/Creat); 68 specimens were excluded because of infection and/or proteinuria, and in a further 10 samples urinary creatinine was not measured. Stepwise multiple regression analyses found significant associations with the following variables: for AER, blood glucose (p=0.001), smoking category (p=0.002), sex (p=0.034), and systolic blood pressure (p=0.035); for R‐Alb/Creat, blood glucose (p=0.001), retinopathy (p=0.004), systolic blood pressure (p=0.004), diastolic blood pressure (p=0.015), coronary artery disease (p=0.02), sex (p=0.034), and vibration sense (p=0.038). Interestingly, glycosylated haemoglobin was not a significant determinant of albuminuria in either analysis.
The Nephrotic Syndrome at Presentation of Insulin‐dependent Diabetes Mellitus; Cause or Coincidence?
Authors: Dornan T. L. , Jenkins S. , Cotton R. E. , Tattersall R. B. , Burden R. P.
Published: July 2009

Two young women developed the nephrotic syndrome within 2 weeks of presenting with diabetes and starting insulin. One had a renal biopsy which showed changes consistent with ‘minimal change nephrotic syndrome’ on electron microscopy but no evidence of diabetic glomerulosclerosis. Neither patient received steroids; in one the oedema resolved spontaneously but the other required diuretics. This patient also had severe IgA‐deficiency probably associated with epilepsy and/or phenytoin therapy and unrelated to the pathogenesis of the nephrotic syndrome. The nephrotic syndrome may rarely present coincidentally with, or soor after, insulin‐dependent diabetes mellitus (IDDM). It must be distinguished from ‘insulir oedema’ and classical diabetic nephropathy which occurs later in the course of IDDM. Al reported cases have either remitted spontaneously or responded to steroids.
Use of Memory Meters to Measure Reliability of Self Blood Glucose Monitoring
Authors: Williams C. D. , Scobie I. N. , Till S. , Crane R. , Lowy C. , Sonksen P. H.
Published: July 2009

Glucose reflectance meters equipped with memories were used in 21 insulin‐dependent diabetic patients to assess reliability of self blood glucose monitoring records. Results reported in logbooks showed widespread discrepancies when compared with corresponding meter‐held records. Discrepancy rates of at least one in five were observed in 11 patients. Unreliable reporting was usually recognized by clinical staff, and associated with high glycosylated haemoglobin levels and poor technique in measuring blood glucose at home.
Optimizing Blood Glucose Control in Type 2 Diabetes: an Approach Based on Fasting Blood Glucose Measurements
Authors: Holman R. R. , Turner R. C.
Published: July 2009

A structured approach to the management of Type 2 diabetes, aiming to reduce fasting blood glucose levels to near‐normal, can provide effective blood glucose control with minimal risk of hypoglycaemia and in a manner acceptable to most patients. When the fasting blood glucose value is maintained in the region 4–6 mmol l−1, protein glycosylation and plasma triglyceride values usually become near‐normal and this may help to prevent the development of long‐term diabetic complications. We propose a simple management strategy, based on 3‐monthly fasting blood glucose determinations, which uses not more than two therapeutic agents at any one time. If diet and maximal oral therapy fail to keep fasting blood glucose levels below 6 mmol l−1 then the addition of a basal insulin supplement, e.g. from a once daily injection of ultralente insulin, can restore near‐normal fasting blood glucose levels without the need for full insulin replacement therapy. In older patients, where long‐term prevention of diabetic complications is not such an immediate priority, less strict blood glucose control may be reasonable, aiming to keep the fasting blood glucose values below 10 mmol l−1 in order to prevent symptoms secondary to glycosuria. Patients can be seen at a monthly general practice morning diabetic mini‐clinic or with the aid of a nurse visiting elderly patients at home.
Efficacy of Dietary Regulation in Primary Health Care Patients with Hyperglycaemia Detected by Screening
Authors: Bitzén P.‐O. , Melander A. , Scherstén B. , Svensson M.
Published: July 2009

The efficacy of dietary regulation was examined in 38 consecutive primary health care patients with hyperglycaemia detected on screening. Ten weeks of dietary regulation reduced overall mean fasting blood glucose from 8.2 to 6.5 mmol ***l−1. Fasting blood glucose fell more (from 12.3 to 7.6 mmol l−1 and from 8.4 to 6.6 mmol l−1) in the two quartiles initially above the median (7.15 mmol l−1), than in the lower quartiles (6.7 to 6.1 mmol l−1 and 5.7 to 5.8 mmol l−1), even though weight reduction was similar. The reduction in blood glucose correlated (r = 0.87) with the degree of fasting hyperglycaemia before treatment. Sixteen patients (42%) reached or maintained fasting blood glucose ≤ 6.0 mmol l−1 and they had a milder degree of glucose intolerance, a higher insulin response to a meal and a greater reduction in weight than the 22 patients (58%) who did not reach ≤ 6.0 mmol l−1. Nine patients (24%) maintained fasting blood glucose ≤ 6.0 mmol l−1 for > 5 years, and showed a considerable improvement of insulin action. Dietary regulation improved glucose control mainly by reducing fasting hyperglycaemia; neither the delay in early insulin release nor the associated elevation and prolongation of the post‐prandial glucose excursions were reduced.
The Effect of Glibenclamide and Metformin on Serum Lipoproteins in Type 2 Diabetes
Authors: Rains S. G. H. , Wilson G. A. , Richmond W. , Elkeles R. S.
Published: July 2009

In a cross‐over study, the effects of 3 months treatment with metformin or glibenclamide on body weight, blood glucose control, and serum lipoproteins were compared in 35 Type 2 diabetic patients, inadequately controlled by dietary therapy alone. Glibenclamide alone increased body weight (mean change + 2.75 kg; 95% confidence intervals − 1.95 to + 3.55 kg; p < 0.0001). Glibenclamide and metformin achieved equivalent blood glucose control, independent of initial body mass index. Neither drug affected serum triglyceride concentration. Metformin alone significantly reduced low density lipoprotein cholesterol (mean change − 0.34 mmol l−1; 95% confidence intervals − 0.12 to − 0.57 mmol l−1; p < 0.01). Neither drug altered high density lipoprotein or subfraction cholesterol.
Marked Impairment of the Effect of Hyperglycaemia on Glucose Uptake and Glucose Production in Insulin‐dependent Diabetes
Authors: Arnfred J. , Schmitz O. , Hother‐Nielsen O. , Ørskova C. , Beck‐Nielsen H. , Hermansen K. , Christiansen J. S. , Alberti K. G. M. M. , Ørskov H.
Published: July 2009

The effect of hyperglycaemia per se on glucose utilization and glucose production was evaluated in 12 patients with insulin‐dependent diabetes and in 9 non‐diabetic control subjects. In diabetic patients normoglycaemia was maintained during the night preceding the study by a variable intravenous insulin infusion. During the study endogenous insulin secretion was suppressed by somatostatin (300 μg h−1) and replaced by infusion of insulin (0.2 mU kg−1 min−1). Glucose utilization and hepatic glucose production rates were quantified at two plasma glucose concentrations (6.7 and 16.7 mmoll−1) using the two‐step sequential hyperglycaemic clamp technique in combination with 3‐3H‐glucose tracer infusion. Duration of each step was 120 min. In diabetic patients glucose utilization, at a glucose concentration of 6.7 mmol ***l−1, was not different from normal (mean ± SE: 2.9±0.2 vs 3.6±0.3 mg kg−1 min−1, 0.05<p<0.10), but the response to marked hyperglycaemia was significantly reduced (5.4±0.5 vs 9.4±1.0 mg kg−1 min−1, p<0.01). Hepatic glucose production was also normal at 6.7 mmol l−1 (1.4±0.1 vs 1.4±0.1 mg kg−1 min−1, NS), but whereas in control subjects glucose production was suppressed during hyperglycaemia of 16.7 mmoll−1 (0.3±0.4 mg kg−1 min−1,p<0.01), a slight increase was observed in diabetic patients (2.0±0.2 mg kg−1 min−1, p<0.05).

In conclusion we found the effect of hyperglycaemia in both glucose utilization and hepatic glucose production to be reduced in patients with insulin‐dependent diabetes.
Additional Factors Associated with Plantar Ulcers in Diabetic Neuropathy
Authors: Crausaz F. M. , Clavel S. , Liniger C. , Albeanu A. , Assal J.‐Ph.
Published: July 2009

Patients can only examine and handle their own feet if they have adequate visual acuity and joint mobility. We therefore studied the physical capacity of patients with neuropathy to perform the preventive footcare measures previously taught. The study included three groups of diabetic oupatients, comparable for age and duration of diabetes: (1) 38 patients with neuropathic ulcers; (2) 21 patients with neuropathy, but no ulcers; (3) 30 patients without neuropathy. Visual acuity and joint mobility, expressed as minimum eye—metatarsum and heel—buttock distances, did not differ between uncomplicated neuropathic and non‐neuropathic patients: visual acuity was sufficient in 95% of neuropathic patients without ulceration and in 87% of non‐neuropathic patients; joint mobility was in the normal range in both groups. However, 71% of complicated neuropathic patients had insufficient visual acuity for correct foot examination, and their joint mobility was reduced compared with uncomplicated neuropathic and non‐neuropathic patients.
Cardiac Hypertrophy in Diabetic Nephropathy: an Echocardiographic Study
Authors: Grenfell A. , Monaghan M. , Watkins P. J. , McLeod A. A.
Published: July 2009

Echocardiography was used to study the prevalence and severity of left ventricular hypertrophy in patients with established diabetic nephropathy (persistent proteinuria for at least 2 y plus severe retinopathy). Fifteen patients had mild renal impairment (serum creatinine <150 μmol l−1), 14 patients had moderate renal impairment (serum creatinine 150–400 μmol l−1), and 20 patients had severe renal impairment (serum creatinine >400 μmol l−1). Thirty‐six of the 49 (73%) were on anti‐hypertensive treatment, despite which mean blood pressure was 161 ± 25/89 ± 9 (± SD) mmHg. Left ventricular hypertrophy was demonstrated in 42 of the 49 patients (85%), and increased in severity with increasing renal impairment. Interventricular septal + left ventricular posterior wall thickness was 25 ± 3 mm in those with mild renal impairment, 28 ± 6 mm in those with moderate renal impairment and 30 ± 4mm in those with severe renal impairment. The most severe left ventricular hypertrophy was seen in the Afro‐Caribbean patients. Left ventricular hypertrophy was present even in those with marginally raised blood pressure and was related to age and serum creatinine but not to present blood pressure or duration of proteinuria.
Acute Changes in Blood Glucose Concentration do not Promote Thrombin Generation or Fibrin Breakdown in Type 1 Diabetes
Authors: Grant P. J. , Stickland M. H. , Wiles P. G. , Gaffney P. J. , Davies J. A. , Prentice C. R. M.
Published: July 2009

To investigate the effect of blood glucose concentration on thrombin generation and fibrinolytic activity, six Type 1 patients had the blood glucose concentration maintained for 1 h at 5, 15, and 25 mmol l−1, and 8 patients underwent hypoglycaemia of 20 min duration after the blood glucose had been kept at 8 mmol l−1 for 1 h. During hyperglycaemia plasminogen activator activity rose from 214 (11–625) (median, range) to 478 (18–772) units (p < 0.05) at a blood glucose of 5 mmol l−1 and to 511 (89–816) (p < 0.05) and 535 (33–976) (p < 0.05) units at a blood glucose of 15 and 25 mmol l−1, respectively. Cross‐linked fibrin degradation products (FDP) were 45 and 53 μg l−1 at a blood glucose of 5 mmol l−1 and remained unchanged at higher glucose levels. Fibrinopeptide A was 1.3 (0.6‐2.8) nmol l−1 at a blood glucose of 5 mmol l−1, and remained unchanged with hyperglycaemia, being 1.3 (0.9‐1.3) nmol l−1 after 1 h at 25 mmol l−1. During hypoglycaemia, plasminogen activator activity rose from 155 to 745 units (p < 0.05) while both fibrinopeptide A and cross‐linked FDP remained unchanged. The results indicate that acute fluctuations in blood glucose concentration do not lead to thrombin generation. Additionally, increased fibrinolytic activity measured in vitro is not associated with an increase in cross‐linked FDP. This suggests that short‐term hyper‐ and hypoglycaemia do not affect the end‐products of the coagulation and fibrinolytic pathways.
Glycosylated Haemoglobin in Clarification of the Origin of Hyperglycaemia in Acute Cerebrovascular Accident
Authors: Topić E. , Pavliček I. , Brinar V. , Koršić M.
Published: July 2009

In 148 patients admitted to hospital with acute cerebrovascular accidents (CVA), the levels of glycosylated haemoglobin (HbA1c) and blood glucose were measured to evaluate the effect of the duration and severity of hyperglycaemia on stroke outcome. Eighty‐eight (59%) patients had clearly normal blood glucose and HbA1c concentrations (blood glucose < 5.5 mmol l−1, HbA1c < 8.6%). The remaining 60 patients were defined as hyperglycaemic. Nineteen (13%) had known diabetes, whereas in 23 (16%) hyperglycaemia was probably due to unrecognized diabetes. In 18 (12%) patients transient hyperglycaemia was observed. Recovery after CVA was best among normoglycaemic patients (good 45%, moderate 29%, poor 14%, fatal 12%) and poorest among diabetic patients (moderate 21%, poor 37%, fatal 42%). Fatal outcome in patients from the normoglycaemic group differed significantly from patients belonging to known diabetic and unrecognized diabetic groups (p < 0.05), but was not different from that in patients with transient hyperglycaemia, who did however differ from both diagnosed and unrecognized diabetic patients (p < 0.05). No significant differences were found between CVA outcome in the known diabetic and unrecognized diabetic groups.
The Treatment of Diabetic Renal Failure by Continuous Ambulatory Peritoneal Dialysis
Authors: Berisa F. , McGonigle R. , Beaman M. , Adu D. , Michael J.
Published: July 2009

During the 6‐year period 1981–1987, 309 patients started chronic ambulatory peritoneal dialysis (CAPD), of whom 75 (24%) had diabetes. Despite severe peripheral vascular problems (20%), ischaemic heart disease (90%), and complete blindness (21%) the 1‐year patient survival on CAPD was 88%. The actuarial patient survival for diabetic patients was similar to that of the non‐diabetic cohort over the first 18 months but fell to 48% (compared to 70% in non‐diabetic patients) at 3 years. Complications associated with CAPD, including the incidence of peritonitis, were no different between the diabetic and non‐diabetic patient populations. Successful treatment for end‐stage renal disease (ESRD) in diabetic patients can be achieved and justified in a liberal selection programme for the treatment of diabetic ESRD.
Symptomatic Hypoglycaemia in Childhood Diabetes: A Population‐Based Questionnaire Study
Authors: Åman J. , Karlsson I. , Wranne L.
Published: July 2009

The occurrence of severe and mild hypoglycaemic attacks and their symptoms and signs were studied in 92 insulin‐dependent diabetic children, 7–18 years old. A questionnaire was distributed to all families and they were interviewed by an experienced nurse. Severe attacks, for which the help of an adult was needed, were reported by 44 % of the children during a 12‐month period. Thirty‐seven per cent of the attacks occurred in the mornings, most often attributed to extra physical exercise, but equally often without any obvious cause. They were more common in children with strict blood glucose control measured as HbA1c. Fast‐acting carbohydrates, given by parents, relieved the attack in most children, but 15% needed a glucagon injection and 12% intravenous glucose. In all, 16 % were admitted to hospital. Mild events occurred in 97 % of the children, at least once per week in 53 % of the children, and were not related to blood glucose control. They were often attributed to extra physical exercise and occurred mainly between breakfast and lunch. Initial symptoms were tremor and hunger; during the whole event tremor and sweating were most common. Parents noted pallor as the most common sign. The frequency of severe or mild attacks could not be correlated to the age of the child, duration of diabetes, daily dose or number of insulin injections.
How Effective is the Referral Chain for Diabetic Retinopathy?
Authors: Jones R. , Larizgoitia I. , Casado L. , Barrie T.
Published: July 2009

Despite the availability of effective photocoagulation treatment, diabetic retinopathy remains the main cause of blindness in persons aged between 20 and 64 years. We have examined the effectiveness of the referral chain for retinopathy by auditing medical records for a representative sample being 226 diabetic patients (35% of attenders) referred to a special photocoagulation clinic. Patients were classified as ‘late’ or ‘not late’ by using an algorithm which accounted for the state of retinopathy at referral and the previous frequency of eye examination. Forty‐four patients (19%) were considered to have been referred late. These were mainly younger onset patients, aged between 30 and 40, and not attending a diabetic clinic. Patients not attending any other outpatient clinic were 27 times more likely to be referred late.
Patient Experience with a Jet Injector
Authors: Rayman G. , Walker R. , Day J. L.
Published: July 2009

The acceptability of a jet injector compared with disposable syringes for insulin injections was assessed in 10 people with Type 1 diabetes. The majority considered disposable syringes easier to use and either less painful or no more painful than jet injections. Given the choice only 1 of the 8 people completing the study would continue using the jet injector.
In Vivo Infection of Mice with Coxsackie B4 Virus Induces Long‐term Functional Changes in Pancreatic Islets with Minimal Alteration in Blood Glucose
Authors: Szopa T.M. , Dronfield D.M. , Ward T. , Taylor K.W.
Published: July 2009

The long‐term effects of Coxsackie B4 (CB4) infection of mice on pancreatic islet function were investigated. Mice were inoculated with various strains of CB4 virus and 2, 3 and 6 months later islet insulin synthesis and release from isolated islets were measured. Insulin release at basal glucose concentration (2 mmol I−1) was higher in islets from mice inoculated with pancreas‐adapted CB4 strains than in control islets or those from mice inoculated with tissue culture‐adapted CB4. Thus, two strains of pancreas‐adapted virus (P11 and P12) increased basal insulin release by 72% compared with control islets (p < 0.05) 1 month after inoculation. Another strain (P13) increased insulin release by 421 % at 3 months post‐inoculation (p < 0.01) and by 192 % at 6 months (p < 0.05) compared with control islets. The rate of total protein synthesis in islets from P11‐inoculated mice 1 month later was 61 % lower than in control islets at basal glucose levels (p < 0.001), and was 25% lower at 20 mmol l‐1 glucose (p < 0.01). There were no significant changes in protein synthesis in islets from infected mice at 3 or 6 months. The abnormal insulin release occurred with minimal changes in random blood glucose concentrations. Histologically the islets were unchanged and there were no detectable islet cell antibodies. These results show that CB4 infection may lead to a persistent metabolic dysfunction in islets with minimal changes in blood glucose levels.
Sensitivity and Reproducibility of Urinary C‐peptide as Estimate of Islet B‐cell Function in Insulin‐treated Diabetes
Authors: Gjessing H.J. , Matzen L.E. , Frølanda A. , Faber O.K.
Published: July 2009

The aims of the present study were to evaluate the ability of urinary C‐peptide determination to demonstrate presence of residual insulin secretion, and to evaluate the reproducibility of urinary C‐peptide excretion in 125 insulin‐treated diabetic patients. C‐peptide was determined in two consecutive 24‐h urine specimens and related to plasma C‐peptide 6 min after the intravenous injection of 1 mg glucagon. The detection limit of C‐peptide in plasma was defined analytically (≤0.02 nmol 1−1) and from pancreatectomized patients (≤0.06 nmol I−1), and in urine only analytically (≤0.1 nmol I−1). If the analytical detection limit of plasma C‐peptide was used as indicator of residual insulin secretion, islet B‐cell function was preserved in all patients. In patients with stimulated plasma C‐peptide levels from 0.02‐<0.06 nmol I−1 no increase was found in plasma C‐peptide values after stimulation with glucagon. This unresponsiveness of islet B‐cells is in good agreement with the existence of a biological detection limit of C‐peptide in plasma of 0.06 nmol I‐1. Using this biological plasma C‐peptide detection limit, 49 of 125 patients were without residual insulin secretion. In contrast to this, only 7 patients were diagnosed as C‐peptide non‐secretors using the analytical detection limit of urinary C‐peptide. Eighty‐four per cent of patients considered to have Type 1 (insulin‐dependent) diabetes with a duration of diabetes of more than 15 years had detectable C‐peptide in the urine. Only 16% of such patients had stimulated plasma C‐peptide levels above the biological detection limit. The biological detection limit of plasma C‐peptide of 0.06 nmol I−1 corresponded to a urinary C‐peptide concentration of 0.3 nmol I‐1. This value may represent a biological detection limit of C‐peptide in urine. The coefficients of variation of urinary C‐peptide expressed as nmol I−1, nmol mmol‐urinary‐creatinine−1 24 h−1 and nmol 24 h−1 were 39 %, 41 %, and 45 %, respectively. In conclusion, determination of C‐peptide in 24 h urine samples is much more sensitive as an indicator of residual insulin secretion than determination of C‐peptide in plasma using the analytical detection limit of C‐peptide in urine and the biological detection limit of C‐peptide in plasma. The final destruction of islet B‐cells may proceed more slowly than previously anticipated in Type 1 diabetes. The reproducibility of urinary C‐peptide is low.
An Evaluation of Diabetes Knowledge Amongst General Practitioners and Senior Medical Students
Authors: Hessett C. , Moran A. , Boulton A.J.M. ,   Central Manchester Health Authority Working Party on Diabetes Care
Published: July 2009

Knowledge about diabetes, its management and its complications was assessed using a questionnaire sent to 80 Central Manchester general practitioners (GPs) and 192 senior medical students. Completed questionnaires were received from 57 GPs and all medical students. Eight GPs had already established mini‐clinics and a further 10 expressed interest in starting such a clinic. GPs scored 60 (38–83)% in the test whereas students had a mean score of 50 (26–77)% (p<0.001). Deficiencies in knowledge were detected in the following areas: the management of insulin‐treated patients during acute illness, indications for insulin therapy in Type 2 diabetes, and several aspects of dietary management. This survey has demonstrated a considerable interest in diabetes amongst GPs, with a response rate of 71%, and one in three of those who responded were interested in establishing clinics. Should these results be representative of GPs elsewhere, this would suggest the need for a postgraduate course on diabetes in general practice, and emphasizes the necessity of close cooperation between hospital and general practice in diabetes care.
Effect of Enprostil on Glucose and Lipid Metabolism in Type 2 Diabetes
Authors: Davis T.M.E. , Proby C. , Strong J.A. , Thompson G.R. , Massey H. , Scott R. , Bloom S.R.
Published: July 2009

Enprostil, a dehydro‐prostaglandin E2 analogue, has been tested as treatment for peptic ulcer. Its effect on blood glucose and lipid metabolism in Type 2 diabetes was assessed in a randomized, double‐blind trial. Fifteen patients on sulphonylurea therapy received, in addition, enprostil 35 μg or placebo thrice daily for two weeks, with a 2‐week washout before crossover. Data from 12 patients were analysed. After a 530 Cal test breakfast at the end of active treatment, plasma glucose rose from a fasting concentration similar to that after the last placebo dose (10.5 ± 0.8 (± SE) and 10.6 ± 1.1 mmol l−1 respectively) to 1, 2 and 3 h concentrations which were 1.5 to 2.1 mmol l−1 lower than on placebo (2 h concentration 14.6 ± 0.9 vs 16.4 ± 1.3 mmol l−1, p < 0.05). Serum fructosamine concentrations at the end of active treatment and placebo were 3.66 ± 0.22 and 3.78 ± 0.24 respectively (p = 0.051). No changes in fasting or post‐prandial insulin concentrations were observed. After 2 weeks of enprostil, fasting serum triglyceride (1.76 ± 0.18 mmol l−1) and total cholesterol (6.27 ± 0.29 mmol l−1) concentrations were lower than after placebo (2.14 ± 0.25 and 7.35 ± 0.46 mmol l−1, p = 0.031 and p = 0.002, respectively), the latter effect being primarily due to reduced LDL‐cholesterol. More patients had gastrointestinal side‐effects on enprostil than placebo (p = 0.03), but symptoms were usually mild and transient, and caused only one patient to be withdrawn. If well‐tolerated, enprostil might prove a useful adjunct in the management of some patients with Type 2 diabetes.