bluuebunny/crossref_metadata_2025 huggingface dataset:
Beneficial Effects of Adding Spironolactone to Recommended Antihypertensive Treatment in Diabetic Nephropathy
Authors: Rossing Kasper , Schjoedt Katrine J. , Smidt Ulla M. , Boomsma Frans , Parving Hans-Henrik
Published: March 2007

OBJECTIVE—The objective of this study was to evaluate the safety and short-term effect of adding spironolactone to conventional antihypertensive treatment including diuretics and maximally recommended doses of an ACE inhibitor or an angiotensin II receptor blocker (ARB) on albuminuria and blood pressure in type 2 diabetic patients with nephropathy.

RESEARCH DESIGN AND METHODS—Twenty-one type 2 diabetic patients with nephropathy were enrolled in a randomized, double-masked, cross-over study. Patients were treated in random order with spironolactone 25 mg once daily and matched placebo for 8 weeks, respectively, in addition to ongoing antihypertensive treatment including diuretics and maximally recommended doses of an ACE inhibitor and/or an ARB. At the end of each treatment period, albuminuria, 24-h ambulatory blood pressure (ABP), and glomerular filtration rate (GFR) were determined.

RESULTS—During the addition of placebo, values were as follows: albuminuria (geometric mean [range]) 1,566 [655–7,762] mg/24 h, ABP (mean ± SE) 138 ± 3/71 ± 1 mmHg, and GFR (mean ± SE) 74 ± 6 ml/min per 1.73 m2. During the addition of spironolactone, albuminuria was reduced by 33% (95% CI 25–41) (P < 0.001), fractional clearance of albumin by 40% (24–53) (P < 0.001), and 24-h ABP by 6 mmHg (2–10) for systolic and 4 mmHg (2–6) for diastolic (P < 0.001 for both). The change in albuminuria did not correlate with the change in systolic 24-h ABP (r = 0.19, P = 0.42) or diastolic 24-h ABP (r = 0.01, P = 0.96). Spironolactone treatment induced an insignificant reversible reduction in GFR of 3 ml/min per 1.73 m2 (−0.3 to 6) (P = 0.08). One patient was excluded from the study due to hyperkalemia. Otherwise treatment was well tolerated.

CONCLUSIONS—Our study suggests that spironolactone safely adds to the reno- and cardiovascular protective benefits of treatment with maximally recommended doses of ACE inhibitor and ARB by reducing albuminuria and blood pressure in type 2 diabetic patients with nephropathy.
The Effectiveness of β-Blockers After Myocardial Infarction in Patients With Type 2 Diabetes
Authors: McDonald Charlotte G. , Majumdar Sumit R. , Mahon Jeffrey L. , Johnson Jeffrey A.
Published: March 2007

OBJECTIVE—β-Blocker therapy has been proven to reduce mortality and reinfarction after myocardial infarction (MI), but the impact of β-blockers on cardiac outcomes in patients with type 2 diabetes in routine practice is not clear. The purpose of this study was to determine the effectiveness of β-blockers after MI in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS—Using the Saskatchewan Health Databases, 12,272 patients with newly treated diabetes were identified between 1991 and 1996; 625 patients were subsequently admitted for MI. β-Blocker exposure within 30 days of discharge was identified in 298 patients, and all were followed until death, coverage termination, or 31 December 1999. Multivariate proportional hazards models were used to assess differences in all-cause mortality, recurrent MI, and 30-day all-cause rehospitalization (the latter a proxy measure for drug safety).

RESULTS—Patients were aged 69 ± 11 years old, 66% were male, and mean follow-up was 2.7 ± 2.1 years. Overall, β-blockers were prescribed for 48% of patients. There were fewer deaths in the β-blocker group versus control subjects (55 of 298 [18.5%] vs. 126 of 327 [38.5%], respectively, P < 0.001). However, β-blockers were not associated with improved survival in multivariate analyses (hazard ratio [HR] 0.89 [95% CI 0.63–1.25]). There were no differences in rates of recurrent MI (adjusted HR 1.35 [0.93–1.95]) or rehospitalizations (adjusted odds ratio 1.40 [0.83–2.37]) between the groups.

CONCLUSIONS—β-Blocker therapy post-MI was not associated with reduced mortality or fewer recurrent events in people with type 2 diabetes in routine practice, although these medications were safe in this population.
The Effect of Insulin Antibodies on the Metabolic Action of Inhaled and Subcutaneous Insulin
Authors: Heise Tim , Bott Susanne , Tusek Corinna , Stephan Jens-Armin , Kawabata Tom , Finco-Kent Deborah , Liu Cameron , Krasner Alan
Published: March 2007

OBJECTIVE—To assess the impact of the development of high- or low-affinity insulin antibodies (IABs) on postprandial glucose tolerance, duration of insulin action, and clinical safety in patients with type 1 diabetes receiving inhaled insulin (Exubera).

RESEARCH DESIGN AND METHODS—This study consisted of a prospective, randomized, open-label, parallel-group trial in which 47 patients with type 1 diabetes received NPH insulin twice daily plus either premeal inhaled insulin (INH group; n = 24) or premeal subcutaneous regular insulin (SC group; n = 23) for 24 weeks. Meal challenge and euglycemic clamp studies were performed on consecutive days at baseline, week 12, and week 24. Adverse events were monitored.

RESULTS—For the INH and SC groups, mean (±SD) IAB levels were 3.5 ± 3.9 and 2.6 ± 4.1 μU/ml at baseline, respectively, compared with 101.4 ± 140.4 and 4.3 ± 9.4 μU/ml at week 24. At week 24, the changes from baseline were similar for the INH and SC groups for maximal plasma glucose concentration (Cmax) (adjusted ratio for treatment group difference 0.99 [90% CI 0.95–1.03]), area under the plasma glucose concentration time curve (adjusted ratio for treatment group difference 0.98 [0.88–1.08]), and duration of insulin action (adjusted treatment group difference 29 min [−49 to 108]). No adverse events were attributed to IABs.

CONCLUSIONS—In patients with type 1 diabetes treated with inhaled insulin, development of high- or low-affinity IABs did not impair postprandial glucose tolerance, alter the time-action profile of insulin, or impact tolerability. No clinical relevance of IABs was identified in this study.
Monotonicity of Nerve Tests in Diabetes
Authors: Dyck Peter J. , O’Brien Peter C. , Litchy William J. , Harper C. Michel , Klein Christopher J. , Dyck P. James B.
Published: March 2007

OBJECTIVE—The objective of this study was to test whether monotone worsening of nerve function, attributable to diabetes, can be demonstrated before criteria for diabetic sensorimotor polyneuropathy (DSPN) have been met. Which nerve tests are best?

RESEARCH DESIGN AND METHODS—From a prevalence cohort of 504 individuals in the Rochester Diabetic Neuropathy study (RDNS), we identified 238 individuals (group 1) who at first examination were without polyneuropathy (DSPN) by a sum score of the normal deviates (from percentiles) of five attributes of nerve conduction of the legs (i.e., their five nerve conduction normal deviate values were <97.5th percentile) and were followed longitudinally two or more times. Of these 238, 90 (group 2) were followed six or more times at yearly or biyearly intervals. We compared different nerve tests for the ones most sensitive and reliable in showing latent nerve dysfunction and monotone (the extent to which a variable measured repeatedly over time reveals a significant trend of worsening or improvement).

RESULTS—In group 1 patients, the mean sum score of five attributes of nerve conduction (Σ 5 NC nds) at baseline was 1.08 and at the last examination (only patients with Σ 5 NC nds <97.5th percentile) was 3.63, markedly higher than that in healthy subjects (only of individuals with Σ 5 NC nds <97.5th percentile) (−0.12), indicating a subtle latent shift of nerve conduction tests toward abnormality. Serial evaluations of many individual and especially sum scores of nerve conduction tests in group 2 patients showed statistically significant worsening with time, even when nerve conduction tests were still well within normal limits. Neurologic signs also worsened but barely to significant levels; however, symptoms and quantitative sensation tests did not. Considering the composite score Σ 5 NC nds, 42 (of 90 group 2 patients) showed significant worsening, 22 were still without DSPN by nerve conduction test criteria, and some were even below the 50th percentile at the last evaluation.

CONCLUSIONS—Subtle and latent functional worsening of nerve conduction can be demonstrated even before nerve conduction test criteria for DSPN have been met. For demonstrating monotone worsening, the order (from best to worst) of tests was: some composite scores of nerve conduction and individual attributes of nerve conduction. We did not show monotone worsening of symptoms or of quantitative sensation test results. In multivariate analysis of risk factors and their association with worsening Σ 5 NC nds, 24-h microalbuminuria (a marker of microvessel disease) was found to be a significant covariate, an indication that the asymptomatic alterations of nerve conduction are meaningful.
Quantitative Coronary Angiographic Studies of Patients With Angina Pectoris and Impaired Glucose Tolerance
Authors: Kataoka Yu , Yasuda Satoshi , Morii Isao , Otsuka Yoritaka , Kawamura Atsushi , Miyazaki Shunichi
Published: March 2007

OBJECTIVE—We investigated the morphological characteristics of coronary arteries in patients with impaired glucose tolerance (IGT) using computer-assisted quantitative coronary angiography. IGT is an independent risk factor for cardiovascular disease. However, the morphological changes developing in the coronary arteries of patients with IGT remain unknown.

RESEARCH DESIGN AND METHODS—A total of 534 patients with angina pectoris were studied. Of these, 144 patients were being treated for diabetes. The remaining 390 patients were classified as follows depending on the results of a 75-g oral glucose tolerance test: normal glucose tolerance (NGT) (n = 117), impaired fasting glucose (n = 3), IGT (n = 136), and diabetes pattern (preclinical diabetes) (n = 134). The diameters of the middle section of all major coronary artery segments were measured and averaged to determine the averaged vessel diameter (AVD). We defined segments of a diameter of ≤1.5 mm as diseased lesions and determined the averaged lesion length (ALL).

RESULTS—AVD and ALL were significantly different among patients with IGT and those with NGT. Patients with diabetes (preclinical and/or treated) had smaller AVD and longer ALL than those with IGT. By multivariate analysis, postprandial glucose levels were shown to be independently associated with an AVD <3.0 mm and an ALL >20 mm.

CONCLUSIONS—Diffuse coronary artery narrowing develops not only in patients with diabetes but also in those with IGT. This morphological change is associated with postprandial hyperglycemia.
Higher Medical Care Costs Accompany Impaired Fasting Glucose
Authors: Nichols Gregory A. , Brown Jonathan B.
Published: March 2007

OBJECTIVE—The purpose of this study was to estimate medical costs associated with elevated fasting plasma glucose (FPG) and to determine whether costs differed for patients who met the 2003 (≥100 mg/dl) versus the 1997 (≥110 mg/dl) American Diabetes Association (ADA) cut point for impaired fasting glucose.

RESEARCH DESIGN AND METHODS—We identified 28,335 patients with two or more FPG test results of at least 100 mg/dl between 1 January 1994 and 31 December 2003. Those with evidence of diabetes before the second test were excluded. We categorized patients into two stages of abnormal glucose (100–109 mg/dl and 110–125 mg/dl) and matched each of these subjects to a patient with a normal FPG test (<100 mg/dl) on age, sex, and year of FPG test. All subjects were followed until an FPG test qualified them for a higher stage, dispensing of an antihyperglycemic drug, health plan termination, or 31 December 2003.

RESULTS—Adjusted annual costs were $4,357 among patients with normal FPG, $4,580 among stage 1 patients, and $4,960 among stage 2 patients (P < 0.001, all comparisons). After removing patients with normal FPG tests whose condition progressed to a higher stage or diabetes, costs in the normal FPG stage were $3,799. Patients in both stages 1 and 2 had more cardiovascular comorbidities than patients with normal FPG.

CONCLUSIONS—Our results demonstrate that abnormal glucose metabolism is associated with higher medical care costs. Much of the excess cost was attributable to concurrent cardiovascular disease. The 2003 ADA cut point identifies a group of patients with greater costs and comorbidity than normoglycemic patients but with lower costs and less comorbidity than patients with FPG above the 1997 cut point.
Home Monitoring of Blood Glucose: New Approach to Management of Insulin-dependent Diabetic Patients in Great Britain
Authors: Sönksen P H , Judd Sue , Lowy Clara
Published: March 2007

The history of home monitoring of blood glucose by diabetic patients at St. Thomas' Hospital in London is reviewed. Initial successful experience with pregnant diabetic patients was extended to cover those with retinopathy and, subsequently, to all insulin-treated patients. Experience showed overwhelming preference by patients for blood glucose monitoring over urine tests and demonstrated improvement in blood glucose control. Experience in children 13 and older was equally (if not more) enthusiastic as in adults. Self-monitoring revealed many elementary mistakes in insulin therapy, which, when corrected, led to marked improvement in diabetic control with reduced frequency and severity of hypoglycemic attacks. Initial studies were made with Dextrostix and Eyetone. The need for a simple patient-oriented blood glucose machine was identified, and Glucochek was designed to meet it. Evaluation of Glucochek was satisfactory, and it was well liked by patients. It seems likely that blood glucose monitoring will replace urine tests in the majority of diabetic patients.
New Techniques for Changing Compliance in Diabetes
Authors: Sulway Martin , Tupling Hilary , Webb Karen , Harris Gillian
Published: March 2007

The low compliance by diabetic patients to professional recommendations is a major therapeutic challenge today. Patient education programs have been promoted as a remedy,1 but those developed to date need careful evaluation to see if they change health behavior. The knowledge-action gap has been well demonstrated in a number of chronic disorders.2 The early evaluation of our program in Sydney indicates that the educational intervention does change health behavior, especially in the difficult area of dietary compliance.3 This paper describes the evolution and the essential characteristics of the program. On completing the course, the diabetic patient is encouraged to use the home measurement of blood glucose by Eyetone meter to continue self-evaluation of control and monitor the effect of his compliance.
Assessment of the Psychological Factors and Responses in Self-Managed Patients
Authors: Dupuis Andre
Published: March 2007

In past studies on the psychological aspects of diabetes mellitus, symptoms of depression have been identified as the most common manifestation among diabetic patients. Other psychological manifestations have been anxiety, hypochondriasis, increased dependence and passivity, and poor self-image. Ten insulin-dependent diabetic patients participated in a rigorous program of self-monitored blood glucose determinations, and their emotional response to the program was studied. They were initially bewildered and tended to resist passively to the demands of the program. With continuous experimentation and assertive trials, these patients developed better self-reliance, diminished anxiety, and better acceptance of their illness. Psychiatric assessments performed at the beginning of the study and after 8 mo revealed that all patients were depressed at the beginning of the study as reflected by high scores in the Hamilton Rating Scale. After 8 mo, all 10 patients had achieved better carbohydrate control, as reflected by decreased hemoglobin A1c levels, and were found to be much less depressed.
Management of the Pregnant, Insulin-Dependent Diabetic Woman
Authors: Jovanovic Lois , Peterson Charles M
Published: March 2007

An intensive care program was offered to all insulin-dependent, pregnant diabetic women who presented to The New York Hospital Obstetrical Clinic in their eighth week or less of gestation. The patients were hospitalized for 1 wk to normalize their blood glucose and to teach the technique of self-monitored glucose determination, diet and exchange lists, and the method to titrate insulin according to the blood glucose determination. The mean blood glucose for the first 10 patients accepted to the program was 169 mg/dl at the start of the program with a mean hemoglobin A1c of 9.4% for the group (normal < 5.5%) and glucosuria up to 50 g/24 h. After discharge, mean glucose was 91 mg/dl, and urinary glucose excretion was 1.4 g/24 h. HbA1c fell into the normal range 5 wk after normoglycemia was achieved (3.4%) (nl < 5.5%). Normoglycemia was maintained as outpatients until 3 wk before delivery when the patients were readmitted for tests of fetal well-being. Mean weight gain for the mothers was 12.2 kg. Mean glucose at delivery was 87 mg/dl and HbA1c was 3%. Hormonal profiles (hCG, hPRL, estrogens, progesterone, hPL) normalized after normoglycemia was achieved and remained normal until delivery. Mean gestational age at time of delivery was 38.8 wk with a mean infant birth weight of 2988 g. No infant manifested hypoglycemia, hypocalcemia, erythremia, or respiratory disease. The use of self-monitored blood glucose allows for optimal care of the insulin-dependent, pregnant diabetic woman while she remains at home with her family.
Self-Management: An Approach to Patients with Insulin-dependent Diabetes Mellitus
Authors: Peterson C M , Forhan S E , Jones R L
Published: March 2007

Patients have been shown to be able to monitor their blood glucose and administer insulin to optimize and normalize blood glucose levels. There are now three reflectance meters available whose measurements correlate well with laboratory measurement of blood glucose, with a correlation coefficient between 0.92 and 0.97. A stepwise approach toward blood glucose control has been found to be most valuable. The initial phase of the program involves patients performing blood glucose measurements before and 1 h after each meal, in addition to times when patients feel hypo- or hyperglycemic. This phase of the program demonstrates the vagaries of glucose control and emphasizes to the patients the dichotomy between symptoms and actual glucose levels. The patient is also taught during this period the risk factors associated with hyperglycemia that may contribute to vascular disease in the future. Subsequently, insulin is adjusted so that patients are given an insulin regimen that will coordinate peaks of insulin with peaks of blood glucose associated with a meal pattern. Patients are taught by health professionals and in a group setting to calibrate insulin calories and exercise depending on blood glucose readings. Such a program is received enthusiastically by patients and physicians. The major disadvantage lies in the cost of the meter and the reagent strips. Nevertheless, such programs may be cost effective because of the avoidance of diabetes-related hospitalizations.
Effect of Alcohol Intake on Symptomatic Peripheral in Diabetic Men
Authors: McCulloch David K , Campbell Ian W , Prescott Robin J , Clarke Basil F
Published: March 2007

In a group of 541 white diabetic men aged 20–59 yr attending one clinic it was found that 91 (15%) drank heavily, while a further 39 (7%) had frank alcoholism. The prevalence of symptomatic peripheral neuropathy was much higher in the 120 men who drank excessively. It is considered important, therefore, when treating diabetic patients with peripheral neuropathy not to assume that the diabetes itself is the cause in all cases. The alcoholic intake of the patient should be ascertained and, if excessive, it should be pointed out to the patient that this may well be the predominant factor causing symptoms.
Control of Insulin-Dependent Diabetes with Portable Miniaturized Infusion Systems
Authors: Hepp K D , Renner R , Piwernetz K , Mehnert H
Published: March 2007

A method of insulin therapy that appears to achieve better control of diabetes than present conventional methods is the use of insulin infusion devices — either glucose-controlled feedback (closed-loop) systems or the preprogrammed (open-loop) infusion pump. In view of the problems with implantable glucose sensors, we have worked to develop a miniaturized, programmable infusion system. Its use in insulin-dependent diabetic patients to provide either intravenous doses or a continuous subcutaneous insulin infusion resulted in significant reductions in blood glucose levels, glycemic excursions and 24-h glucose excretion.
A Totally Implantable Drug Infusion Defice: Laboratory and Clinical Experience Using a Model with Single Flow Rate and New Design for Modulated Insulin Infusion
Authors: Buchwald Henry , Rohde Thomas D , Dorman Frank D , Skakoon James G , Wigness Bruce D , Prosl Frank R , Tucker Elton M , Rublein Tucker G , Blackshear Perry J , Varco Richard L
Published: March 2007

The Infusaid implantable infusion pump with a single delivery rate has maintained chronic intravenous heparin infusion in man for greater than 35 mo and for greater than 5 yr in the dog. Intra-arterial infuson of fluorodeoxyuridine has been maintained for greater than 8 mo in man. In a pilot study using a commercially available, transcutaneously controllable, magnetically activated valve for baseline superimposed bolus insulin infusion, the feasibility of maintaining near normal serum glucose in diabetic dogs was demonstrated. The effect of long-term intravenous cannulation was investigated; it was found that the intimal tissues of the vena cava surrounding the cannulae were largely unaltered and microemboli could not be detected in the lungs of the animals studied. Cannula plugging, which occurred on several occasions due to thrombus formation in the final centimeter of the cannula, has been solved by changes in pump design and refilling procedures. The problem of insulin precipitation in flow passages of the pump remains unsolved, but there are indications that substances entering the cannula from the blood may be involved. A new pump design for modulated insulin infusion is described.
The Memphis Diabetes Continuing Care Program
Authors: Runyan John W , Vander Zwaag Roger , Joyner M Beverly , Miller Stephen T
Published: March 2007

Since 1963 a network of nurse-operated, physician-backed decentralized clinics has provided continuing care for more than 5000 diabetic patients referred from the medical center clinics. Protocols that provide therapy goals and management details are used by the nurses and nutritionists in this network. To reduce fragmentation of care, intercurrent illnesses as well as other chronic diseases are treated using protocols in these clinics or in the home.

This study examines certain outcome data in a subset of 556 diabetic patients under continuing care over a 7-yr period in this network, with comparisons being made to care before referral. Blood glucose is maintained at comparable levels in both decentralized and hospital clinics. Blood pressure levels in hypertensive patients are maintained in a satisfactory range. Total hospitalization rates are reduced by 47%. For ketoacidosis and amputation, hospitalization is decreased by 69% compared with the experience before referral. The maintenance care costs are decreased substantially compared with costs before referral due to the less expensive ambulatory services and the reduced need for hospitalization. The data support the concept that decentralization is an effective means of providing continuing care to patients with diabetes mellitus.
Hemoglobin A1c Levels in Children and Adolescents with Diabetes Mellitus
Authors: Goldstein David E , Walker Beth , Rawlings Sharon S , Hess Randall L , England Jack D , Peth Steven B , Hewett John E
Published: March 2007

Hemoglobin A1c (HbA1c) was measured as an indicator of glucose control in 180 children and adolescents with diabetes mellitus who received two daily injections of insulin as part of a highly structured treatment program. A total of 426 HbA1c determinations was made in the group of 180 patients. HbA1c values were elevated in most patients despite the aggressive treatment. The HbA1c level was very elevated at diagnosis, fell to near normal after 60–90 days of insulin therapy, increased gradually, and reached a plateau after approximately 4 yr duration (at about twice the level in normal subjects) (mean ± SEM, 10.0 ± 0.2% and 5.34 ± 0.07%, respectively). Mean insulin dose (U/kg/24 h) paralleled both HbA1c and duration of diabetes. The relationship between endogenous insulin secretion and glucose control was examined in those patients with diabetes for longer than 5 yr. Patients were separated into three groups based on HbA1c levels: those with HbA1c less than 9% (N = 22), between 9 and 11% (N = 26), and greater than 11% (N = 28). Serum C-peptide and glucose concentrations were measured 2 h after a standard breakfast in those patients in the “low” and “high” HbA1c groups (mean HbA1c values 8.2% and 12.7%, respectively). C-peptide was detectable in all patients and the mean C-peptide levels did not differ significantly in the two groups, although postprandial glucose concentrations were significantly lower in the “low” HbA1c group (means ± SEM, 96 ± 11 and 211 ± 21 mg/dl, respectively; P < 0.001).
The Effect of Dietary Fiber on Glucose and Hormone Responses to a Mixed Meal in Normal Subjects and in Diabetic Subjects With and Without Autonomie Neuropathy
Authors: Levitt Naomi S , Vinik Arthur I , Sive Alan A , Child Pat T , Jackson W P U
Published: March 2007

We investigated the effects of fiber on responses of blood glucose, serum insulin, gastric inhibitory polypeptide (GIP), and immunoreactive pancreatic glucagon (IRG) to ingestion of a mixed meal with and without added fiber (5 g guar and 5 g pectin) in 12 normal, healthy subjects and in 12 age-, sex-, and weight-matched non-insulin-dependent, maturity-onset diabetic subjects (NIDDM). Fiber markedly enhanced glucose tolerance in the normal subjects without a change in insulin or GIP but with a significant reduction in glucagon responses. Fiber also markedly improved glucose tolerance in the NIDDMs without changing insulin or GIP but with a significant reduction in the glucagon responses. The NIDDMs were divided into two groups of six subjects, with and without autonomic neuropathy (AN). In NIDDMs without AN, glucose tolerance was improved by fiber without a change in insulin, IRG, or GIP. In diabetic subjects with AN, glucose tolerance was not improved, although glucagon levels were lowered and insulin and GIP responses were unchanged. It appears, therefore, that fiber improves glucose tolerance by altering factors other than insulin. It seems also that autonomie nervous supply to the gastrointestinal tract is important in mediating the effect.
The Value of Electrocardiogram Monitoring in Diabetic Ketoacidosis
Authors: Malone John I , Brodsky Sidney J
Published: March 2007

Electrolyte abnormalities cause fatal cardiac arrhythmias in patients with diabetic ketoacidosis. A patient is reported with electrocardiogram (ECG) abnormalities characteristic of toxic hyperkalemia and hypocalcemia. The ECG abnormalities were noted during the first hour after arriving at the hospital. The laboratory values confirming the electrolyte abnormalities were not available for more than 1 h after the ECG indicated the danger of myocardial toxicity. During the initial 2 h of therapy the patient was urinating and not in shock. ECG monitoring of this patient prevented the routine administration of intravenous potassium, which was potentially lethal. The clinical importance of electrolyte levels in the management of diabetic ketoacidosis is the prevention of cardiac arrhythmias. ECG monitoring should be a minimal standard in the management of diabetic ketoacidosis.
A Comparison of Carbohydrate Metabolism After Sucrose, Sorbitol, and Fructose Meals in Normal and Diabetic Subjects
Authors: Akgün Suat , Ertel Norman H
Published: March 2007

Sucrose, sorbitol, and fructose (35 g) were fed to normal and diabetic subjects as a component of a 400-calorie breakfast. In both normal and diabetic subjects, the mean peak increment in plasma glucose was highest after the sucrose meals (44.0 mg/dl for normal subjects; 78.0 mg/dl for diabetic subjects); lowest after sorbitol meals (9.3 mg/dl for normal subjects; 32.3 mg/dl for diabetic subjects); and intermediate after the fructose meals (29.0 mg/dl for normal subjects; 48.0 mg/dl for diabetic subjects). In normal subjects, the mean peak increment of plasma immunoreactive insulin followed a similar pattern, but in diabetic subjects there was no significant difference between the three groups. We conclude that fructose or sorbitol, given as part of a meal, results in lower glucose levels in both normal and diabetic subjects, but that the latter is not related to a difference in insulin release.
The Relationship Between the Health Belief Model and Compliance of Persons with Diabetes Mellitus
Authors: Bloom Cerkoney Kathy A , Hart Laura K
Published: March 2007

Thirty insulin-treated diabetic individuals were interviewed in their homes 6–12 mo after having attended diabetic education classes at a community hospital. Self-report as well as direct observation were used to measure these patients' level of compliance with their insulin administration, urine testing, diet, hypoglycemia management, and foot care prescriptions. All patients were complying with at least 59% of the points measured. Over one-half of the group indicated compliance with at least 70% of the 61 points measured. However, only 7% complied with every one of the 45 points considered to be necessary for good control of their disease. The group was most compliant with regard to insulin administration and least compliant regarding urine testing. The level of these patients' beliefs regarding their disease (severity and susceptibility, treatment benefits, and barriers) and cues to action were also measured. A correlation of 0.5 occurred between these patients' overall compliance levels and a composit of their level of health belief motivation. The highest levels of correlations between the areas of compliance and the motivators occurred with cues to action.
Intermediate-acting Insulin Preparations: NPH and Lente
Authors: Deckert Torsten
Published: March 2007

Physicochemically, NPH and lente insulins differ in size of crystals, content of protamine and zinc, and often in species composition, since lente always contains beef insulin. The duration of the hypoglycemic effect of lente insulin seems to be longer than 24 h, whereas that of NPH insulin does not exceed 24 h when given in amounts of 0.2–0.3 U/kg body wt. Moreover, NPH and lente insulins differ in their ability to form stable mixtures with neutral insulin solutions, since only NPH insulin can be mixed with regular insulin without changing the specific course of effect of regular insulin. Highly purified porcine NPH and the lente-like porcine insulin preparation, Monotard, do not seem to differ regarding side effects (lipoatrophy, immunogenicity). However, highly purified lente insulin (containing beef insulin) seems to be more immunogenic than highly purified porcine NPH insulin.
Incidence and Prevalence of Clinical Peripheral Vascular Disease in a Population-based Cohort of Diabetic Patients
Authors: Melton L Joseph , Kathleen M Macken , Palumbo P J , Elveback Lila R
Published: March 2007

Clinical peripheral vascular disease (PVD) was studied in an incidence cohort of 1073 residents of Rochester, Minnesota, who were found to have diabetes mellitus in the period 1945–69. About 8%; of patients already had clinical evidence of PVD at the time of diagnosis of diabetes. The proportion increased with the age at which diabetes was discovered. Among those unaffected initially, the incidence of subsequent PVD was slightly greater for men, 21.3 per 1000 person-years, than for women, 17.6 per 1000, and it increased both with age and duration of diabetes. The cumulative incidence of subsequent PVD was estimated to be 15%; at 10 yr and 45% at 20 yr after the diagnosis of diabetes. The age-adjusted prevalence of residents with diabetes and a history of PVD was 3.3 per 1000 population 30 yr of age or over on 1 January 1970.
The Influence of Renal Threshold on the Interpretation of Urine Tests for Glucose in Diabetic Patients
Authors: Walford S , McB Page M , Allison S P
Published: March 2007

A knowledge of the renal threshold for glucose is important in the interpretation of urine tests in diabetes. We describe a simple method for determining renal threshold from blood and urine tests performed by the patients themselves. In a group of 65 insulin-dependent diabetic patients there was a wide variation in renal threshold, with a mean of 130 mg/dl (range 54–180 mg/dl). Threshold tended to rise with age, and it is suggested that the higher the renal threshold, the higher is the mean blood glucose achieved by the patient (r = 0.50, P = < 0.001). The change in blood glucose required to convert urine tests from 0% to 2% is very variable and ranged from 36 to 288 mg/dl (mean 110 mg/dl). The simple method that we describe may improve understanding of the significance of urine test results without the necessity for hospital admission.
Research on Diabetes Management and the Family: A Critique
Authors: Anderson Barbara J , Auslander Wendy F
Published: March 2007

Research on diabetes management and the family has been traditionally viewed within a linear model, in which parental attitudes toward diabetes are seen as the principal influence on the child's adjustment and metabolic control. Recently the focus of research has shifted to the broader family milieu, with an emphasis on patterns of cooperation and conflict among all family members in implementing the treatment regimen. As investigators have begun to study the entire family, the linear model of parental influences has been overshadowed by a systems model of family interaction, based on the concept of mutual influences among all individuals in the family. Several methodological problems have characterized research in this area, such as inadequate assessments of family functioning, unreliable indices of metabolic control, and insensitivity to differences in age and disease variables. Future studies of diabetes management will have much to gain from consideration of the role of the father and siblings in treatment, attention to the diabetic child's impact on family functioning, and recognition of sources of support and stress outside the family that affect adaptation to diabetes.
Patient Recall of Self-Care Recommendations in Diabetes
Authors: Page Patricia , Verstraete Dorothy G , Robb Jean R , Etzwiler Donnell D
Published: March 2007

Twenty-four insulin-dependent diabetic patients were interviewed immediately after a follow-up visit to an outpatient pediatric clinic to determine which of the recorded instructions delivered by professionals were recalled by patients. The health care team reported giving an average of seven recommendations per patient, or a total of 168 items listed by team members as important. Patients recalled an average of two recommendations, or a total of 50 items, 40% of which had not been recorded by team members. Recommendations concerning diet, insulin dosage and injections, urine testing, and exercise represented 80% of those recalled by patients and only 58% of those recorded by professionals. The results were interpreted to suggest that health care teams focus on fewer items to insure communication of the most appropriate recommendations for individual patients.
Biologic Activities of Biosynthetic Human Insulin in Healthy Volunteers and Insulin-dependent Diabetic Patients Monitored by the Artificial Endocrine Pancreas
Authors: Raptis Sotos , Karaiskos Constantine , Enzmann Franz , Hatzidakis Dimitrios , Zoupas Christos , Souvatzoglou Athanasios , Diamantopoulos E , Moulopoulos Spyridon
Published: March 2007

This study investigates and compares biosynthetic human insulin (BHI) and purified pork insulin, in healthy volunteers and in insulin-dependent diabetic patients, in terms of biologic action, capacity for controlling diabetic patients, and the requirements of the patients on each insulin. The possible importance of this new insulin in the improved long-term control of diabetic patients led to the experimental design of this protocol.
Comparison of Biosynthetic Human Insulin and Pork Insulin During Rest, Food Ingestion, and Physical Work in Insulin-dependent Diabetic Subjects Using a Glucose Controlled Insulin Infusion System
Authors: Beyer J , Weber Th , Schulz G , Hassinger W , Westerburg A , Cordes U
Published: March 2007

In six insulin-dependent diabetic subjects, we investigated whether differences between biosynthetic human insulin (BHI) and pork insulin are present as measured by an automatic glucose controlled insulin infusion system (GCIIS) (Biostator). The parameters measured were basal insulin requirement and food-dependent insulin requirement, as well as the blood sugar-lowering and insulin-saving effect of standardized physical work. The results show that BHI does not reveal any differences with regard to the basal food-independent and food-dependent insulin requirement compared to pork insulin in insulin-requiring diabetic subjects. Delayed food-dependent initial rise in blood sugar and insulin during physical work, which was observed with BHI, does not show any differences in the integral over 180 min. These investigations confirm the results found in vitro and in animal experiments. At the same time, they indicate discrete differences in the activity spectrum.
Elevated Leg Systolic Pressures and Arterial Calcification in Diabetic Occlusive Vascular Disease
Authors: Emanuele Mary A , Buchanan Bernard J , Abraira Carlos
Published: March 2007

Systolic occlusion leg and brachial pressures were determined using a Doppler ultrasonic method in 24 diabetic subjects with either past or evolving gangrene due to arterial occlusive disease of the lower extremities. The leg-brachial ratios were correlated with x-ray determined leg vascular calcification. Ratios above 1.10 were invariably associated with heavy continuous calcification of the tibial vessels; lesser degrees of arterial calcification had normal or depressed leg-brachial ratios. Medial calcification might be causally related to the abnormally elevated leg systolic pressures not infrequently noted in diabetic patients. Based on the observed occurrence of reamputation in association with normal or elevated leg-brachial ratios, it appears that a Doppler pressure index above 0.90 is not a reliable indicator of adequate blood flow in severe diabetic occlusive arterial disease.
Factors Influencing the Absorption, Serum Insulin Concentration, and Blood Glucose Responses After Injections of Regular Insulin and Various Insulin Mixtures
Authors: Galloway J A , Spradlin C T , Nelson R L , Wentworth S M , Davidson J A , Swarner J L
Published: March 2007

Normal fasting subjects received regular insulin and mixtures of regular with NPH or lente to assess the effects of the combinations on serum insulin concentrations (SIC) and blood glucose responses (BGR). In addition, the influence of concentration, depth, and method and site of administration was investigated. In studies of mixtures of regular with NPH and with lente, it was observed that the regular: lente ratio needed to achieve peak SIC was higher than with the regular: NPH combination. Increased SIC, including either the peak and/or the time interval required to achieve the peak, were related to the depth and site (deltoid and abdominal greater than anterior thigh or buttocks). Assuming linear kinetics of absorption, significant quantities of insulin fail to reach the serum. Marked intra- and intersubject variations in SIC and BGR to regular, NPH, and lente insulins were observed.
Nesidioblastosis Associated with Insulin-mediated Hypoglycemia in an Adult
Authors: Nathan David M , Axelrod Lloyd , Proppe Karl H , Wald Robert , Hirsch Harry J , Martin Donald B
Published: March 2007

Nesidioblastosis, the process of differentiation of pancreatic islets from ductular epithelium, is a well-described cause of insulin-mediated hypoglycemia in neonates and infants, but not in adults. A 58-yr-old woman with characteristic clinical features of fasting hypoglycemia had inappropriately elevated plasma immunoreactive insulin levels during symptomatic episodes of fasting hypoglycemia. Angiography, palpation at laparotomy, and resection of the distal three-quarters of the pancreas provided no evidence of a tumor. Pathologic examination of the resected pancreas revealed the findings of nesidioblastosis, i.e., budding of islets from the wall of ductules, and also increased number and size of islets and abnormal shape and location of islets. An entire spectrum of islet cell abnormalities including nesidioblastosis can cause insulin-mediated hypoglycemia in adults, as it does in neonates and infants.
Hypoglycemic Coma Associated with Subcutaneous Insulin Infusion by Portable Pump
Authors: Lock Dennis R , Rigg Lee A
Published: March 2007

The incidence of hypoglycemia in insulin-dependent diabetic patients managed by continuous subcutaneous insulin infusion (CSII) has been reported to be very low. We report a case of hypoglycemia coma occurring in a highly compliant and intelligent patient while on CSII by a portable pump. Factors contributing to this episode included high risk off hypoglycemia due to tight control, failure to recognize early hypoglycemic symptoms, and maintenance of hypoglycemia for over 2 h by the open-loop device. Hypoglycemia is a complication of CSII by portable pump. We join others in recommending its use solely by experienced physicians. Constant supervision of patients while on CSII is important to eliminate this potentially lethal complication.
Study of Educational Deficits as the Cause of Hospital Admission for Diabetes Mellitus in a Community Hospital
Authors: Geller Jack , Butler Karen
Published: March 2007

Seventy-eight consecutive patients admitted to a community hospital for diabetic complications over a 1-yr period were interviewed in regard to circumstances resulting in their hospitalization. Based on this interview, patients were categorized as to the cause for admission into three groups: (1) educational deficits; (2) psycho-socio-economic deficits; and (3) unavoidable hospital admission. Twenty-seven percent of the patients had a specific educational deficit which was judged to be responsible for their hospitalization; an additional 20% of patients had combined education and psycho-socio-economic deficits accounting for their admission.
Glucose Intolerance and Aging
Authors: DeFronzo Ralph A
Published: March 2007

Glucose tolerance is known to decrease with advancing age. This decline begins in the third or fourth decade of life and is progressive throughout the entire adult life span. The primary cause of this age-related impairment in glucose metabolism results from tissue unresponsiveness to insulin. The plasma insulin response to glucose shows little change with age. Several factors, including decreased physical activity and decreased lean body mass, probably contribute to the insulin resistance. The aging process per se, however, appears to have its own deleterious effect on tissue sensitivity to insulin.
Limitation of Fasting Plasma Glucose for the Diagnosis of Diabetes Mellitus
Authors: Taylor Richard , Zimmet Paul
Published: March 2007

We have analyzed data from 3370 OGTTs performed during epidemiologic studies in three different ethnic groups (Micronesian, Polynesian, and Melanesian) in various Pacific countries to examine the value of a single fasting plasma glucose ≥ 140 mg/dl as a diagnostic test for diabetes (defined as 2-h plasma glucose ≥ 200 mg/dl). A fasting plasma glucose ≥ 140 mg/dl is a highly specific test for diabetes, specificity in the various populations ranging from 98.1% to 99.7%. On the other hand, the sensitivity of fasting plasma glucose was not high and varied greatly between the populations (46.2%–79.0%). The predictive value of fasting plasma glucose for the diagnosis of diabetes was lowest in populations with a low diabetes prevalence and improved in higher prevalence groups. These data indicate that a fasting plasma glucose ≥ 140 mg/dl is not a good screening test, apart from populations with a high prevalence of diabetes mellitus, and the 2-h postload plasma glucose is preferable.
Basal C-Peptide in the Discrimination of Type I from Type II Diabetes
Authors: Welborn T A , Garcia-Webb P , Bonser Anne M
Published: March 2007

Basal serum C-peptide concentrations in diabetic patients showed two groups. Diabetic patients with low C-peptide levels (≤ 0.16 nmol/L) have clinical characteristics of type I diabetes, and all were on insulin therapy. With long duration of diabetes, an increasing proportion had undetectable C-peptide. Diabetic patients with high C-peptide levels (< 0.16 nmol/L) resemble type II diabetes. In this group 30% were on insulin therapy but duration of known disease was not associated with any decline in the high basal C-peptide levels. The small proportion of diabetic patients with basal serum C-peptide in the range of 0.17–0.32 nmol/L have indeterminate status.
A Group Approach to the Management of Diabetes in Adolescents and Young Adults
Authors: Warren-Boulton Elizabeth , Anderson Barbara J , Schwartz Nancy L , Drexler Andrew J
Published: March 2007

An interdisciplinary team of health professionals developed a model treatment program to improve adherence, self-management, and metabolic control for five inner city, black, young adult, diabetic women. Following an initial in-hospital evaluation, the staff met with the patients as a group once a month for 18 mo. The professional approach was supportive and nonjudgmental to assist the group members in developing confidence and assuming responsibility for the successful management of their diabetes. Discussions covered the group's educational needs, insulin requirements, and psychosocial problems of adjusting to living with a chronic disease. Analysis of clinical findings showed a significant improvement in plasma glucose, hemoglobin A1c, and cholesterol levels.
Readability of Self-Care Instructional Pamphlets for Diabetic Patients
Authors: Leichter Steven B , Nieman Janice A , Moore Robert W , Collins Peggy , Rhodes Anne
Published: March 2007

The readability of written instructional materials for diabetic patients is an important consideration in their use. We assessed the readability of six commonly used patient teaching guides on diabetic self-care. In addition, two pamphlets developed by our program for diabetic patients with fifth to tenth grade reading ability were also studied as controls. The difficulty of reading each pamphlet was estimated by a novel computer program which simultaneously measures readability by seven accepted formulas. The scores derived by each formula are expressed individually, in terms of grade level difficulty, and then computed to obtain a composite mean score for each text. The composite mean scores obtained are highly reliable (a = 0.95). The six commercial pamphlets were estimated to have reading difficulty levels ranging from 5.3 to 14.1 grades. A primary factor that contributed to reading difficulty was the frequent use of polysyllabic words, including technical words. Certain individual test scores, not judged to be out of range, deviated from the mean composite scores by as much as 41.2%. The two pamphlets designed by the Kentucky Diabetes Program had composite reading difficulties of 7.5 and 8.2 grade levels, respectively. These data suggest that the use of systematic readability analysis should be carried out and reported for patient instructional material. This assessment should be carried out by multiple formulas to produce a more representative index of reading difficulty than the application of a single test.