bluuebunny/crossref_metadata_2025 huggingface dataset:
Microalbuminuria in Diabetes: A Population Study of the Prevalence and an Assessment of Three Screening Tests
Authors: Gatling W. , Knight C. , Mullee M. A. , 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. A midstream urine specimen was tested for proteinuria using Albustix (Ames) and cultured to detect bacterial infection. After the first 3 months of the survey, the aliquot of this specimen was frozen for later determination of the random albumin/creatinine ratio (R‐Alb/Creat). Patients were requested to submit a timed overnight urine collection for estimation of urinary albumin excretion rate (AER).

Of the 842 patients reviewed, 493 (59 %) submitted timed overnight urine collections; 43 were excluded because of urinary infection and/or proteinuria. One hundred and thirty‐three (30 %) of 450 diabetic patients were found to have microalbuminuria, although only 31 (7 %) had an AER >30 μg/min. Six hundred and seven urine samples were collected for R‐Alb/Creat but 68 were excluded because of infection and/or proteinuria; in 10 further samples urinary creatinine was not measured. Two hundred and four (38 %) of 532 diabetic patients were found to have an elevated R‐Alb/Creat.

There was a significant correlation between AER and R‐Alb/Creat (r=0.32, p<0.001) but a considerable number of patients showed either a normal AER and high R‐Alb/Creat or the reverse. The value of R‐Alb/Creat or an overnight urinary albumin concentration, or an overnight urinary albumin/creatinine ratio (ON‐Alb/Creat) as screening tests to predict AER > 30 μg/min was assessed. An ON‐Alb/Creat > 2.0 mg/mmol was the optimal screening test (sensitivity 96 % and specificity 99.7 %).

The proportion of diabetic patients with an AER in the range indicating a high risk of developing nephropathy is small. If an ON‐Alb/Creat > 2 mg/mmol had been used, 84 % of diabetic patients in this survey would not have been identified as being at risk. In future, this will enable further assessment to be concentrated on the high risk group.
A Comparison of Morning and Bed‐time Ultralente Administration When Using Multiple Injections in Adolescence
Authors: Smith C. P. , Dunger D. B. , Mitten S. , Hewitt J. , Spowart K. , Grant D. B. , Savage M. O.
Published: July 2009

Ten adolescents took part in a randomized sequential crossover study comparing two insulin regimes: (1) three preprandial injections of soluble insulin from a pen injector plus ultralente given before bed; (2) morning soluble insulin with ultralente, plus two preprandial injections of soluble. Nine patients completed the study. Metabolic profiles were performed at the end of each 3‐month treatment period. Glycosylated haemoglobin levels did not fall significantly on either regimen, and there were no differences between the changes in HbA1 concentration on the two regimens. However, blood glucose concentrations tended to be lower with bedtime than with morning ultralente, and were significantly different at 0800 h (13.1 ± 2.3 mmol/l vs 17.9±1.9 mmol/l, p<0.02) and 1000 h (14.5 ± 1.4 mmol/l vs 18.6 ± 0.7 mmol/l, p<0.03). Plasma free insulin concentrations were not different. Total daily insulin dose and the proportion of ultralente given in each regimen did not differ. Results indicate that the rise in early morning fasting blood glucose concentrations was less when ultralente was given at bedtime rather than in the morning.
Serum IGF‐1 Concentration in Diabetic Retinopathy
Authors: Hyer S. L. , Sharp P. S. , Brooks R. A. , Burrin J. M. , Kohner E. M.
Published: July 2009

Growth factors such as growth hormone and insulin‐like growth factor 1 (IGF‐1) may be important in the pathogenesis of diabetic retinopathy. We measured serum IGF‐1 in 371 diabetic patients attending a diabetic retinopathy clinic and in 73 non‐diabetic control subjects. No significant difference was observed in IGF‐1 level between the diabetic and control groups (168 ± 3.9 vs 177 ± 7.4 μg/l [mean ± SE]). Within the diabetic group, there was no difference between patients with no retinopathy and those with proliferative change (198.7 ± 8.8 vs 190.5 ± 11 μg/l). After adjusting for differences in age, duration of diabetes, and presence of proteinuria, only the inactive previously proliferative group showed any significant difference from the other patient subgroups (151.8 ± 11.5 μg/l; p<0.05). Serum IGF‐1 correlated with age in the control group (r = −0.49; p<0.001) and to a lesser extent in the diabetic group (r = −0.23; p<0.05). IGF‐1 levels were higher in patients with proteinuria than in those without proteinuria (196.8 ± 10.3 vs 138.8 ± 4.4 μg/l; p<0.001).
Knowledge Profile and Control in Diabetic Patients
Authors: Lockington T. J. , Farrant S. , Meadows K. A. , Dowlatshahi D. , Wise P. H.
Published: July 2009

Knowledge about diabetes was assessed using a previously described interactive computer‐based questionnaire in 79 patients with insulin‐dependent (IDDM) and 72 with non‐insulin‐dependent (NIDDM) diabetes mellitus routinely attending a single diabetic clinic. Simple linear correlation of total knowledge score with glycosylated haemoglobin (HbA1c) showed no significant relationship for either IDDM (r=‐0.12: p=0.18) or NIDDM (r=‐0.15: p=0.1). However, quintile grouping of knowledge scores showed the mean HbA1c to be significantly higher in the lowest scoring NIDDM quintile (10.6±0.5: ±SE) with respect to the pooled mean of all the higher scoring quintiles (9.0±0.3) (p=0.027). Mean HbA1c (9.6±0.5) was also higher in the least knowledgeable IDDM quintile than any other quintile group (range 8.8–9.0) but this was not significant with respect to the pooled mean of higher scoring patients (p>0.1). The mean age of the lowest scoring IDDM quintile group (60.5±13.9 years) was significantly higher (p<0.01) than higher scoring IDDM groups (mean age range 36.5–43.3 years) but age was not significantly related to HbA1c in IDDM subjects. IDDM showed greater knowledge of diabetes than NIDDM but ignorance in key areas was unacceptably high in both diabetic subtypes, indicating that regular knowledge assessment and educational reinforcement may be essential for good diabetic control as well as patient safety, particularly in older IDDM patients. This analysis provides support for the concept that for good blood glucose control, a minimum (threshold) level of knowledge is necessary above which other factors, including attitudes and motivation, are likely to be of much greater importance.
Diabetic Neuropathic Bladder Associated with Clinical Features of Iliofemoral Venous Thrombosis
Authors: Jennings A. M. , Walker M. , Ward J. D.
Published: July 2009

A 60‐year‐old female diabetic patient with autonomic neuropathy gradually developed a warm swollen left leg over a period of 12 days. She was found to have chronic retention of urine due to a neuropathic bladder. Venography did not reveal thrombus but showed compression of the ipsilateral external iliac vein by the bladder. No other cause for her warm swollen leg was found. Following the introduction of a bladder catheter, her leg gradually returned to normal.
Pneumococcal Osteomyelitis and Cellulitis in an Adult Patient with Diabetes Mellitus
Authors: Verhelst J. A. , Delvigne C.
Published: July 2009

A 48‐year‐old diabetic patient was admitted to hospital with fever and extensive infection of the tissues around the right elbow. Diagnosis was made of cellulitis and underlying osteomyelitis caused by Streptococcus pneumoniae. Although seen in patients with seriously impaired host defence mechanisms pneumococcal osteomyelitis and cellulitis has not been reported in a diabetic patient.
Insulin Antibodies in Diabetic Children Before Treatment: a Marker for Islet B‐cell Destruction?
Authors: de Beaufort C. E. , Binder C. , Bruining G. J. , Den Boer N. C. , Van Strik R.
Published: July 2009

Insulin antibodies were measured in the sera of 28 newly diagnosed diabetic children (age 8.0 ± 4.0 (±SD) years) prior to insulin therapy and after 3, 6, 9, and 12 months. The levels at diagnosis and after 12 months were compared to endogenous insulin production at onset and after 12 to 14 months. Endogenous insulin production was evaluated through the measurement of 24‐h urinary C‐peptide excretion, fasting plasma C‐peptide levels and plasma C‐peptide levels after glucagon stimulation. Insulin antibodies were detected in 29 % of the patients (8 out of 28). In all but one patient antibodies binding porcine and human insulin were detected. No relationship was found between the presence of antibodies binding human or porcine insulin at diagnosis and age. After 1 year 27 out of 28 patients presented insulin antibodies. No relationship was found between the presence of insulin antibodies before therapy and 1 year after therapy. Insulin antibodies prior to diagnosis showed no relationship with the urinary C‐peptide excretion at diagnosis (with antibodies 67 ± 27 %, without antibodies 76 ± 11 %). However, after 1 year significantly lower urinary C‐peptide excretions were found in patients with insulin antibodies prior to therapy (with antibodies, 17 ± 7 %, without antibodies, 31 ± 5 %, p<0.02). Peak plasma C‐peptide levels after 1 year were possibly lower in patients with insulin antibodies before treatment (with antibodies 0.17 ± 0.06 nmol/l, without antibodies 0.26 ± 0.04 nmol/l, p<0.1). Fasting C‐peptide levels did not differ significantly between the two groups after 1 year of therapy (with antibodies 0.11 ± 0.03 nmol/l, without antibodies 0.14 ± 0.02 nmol/l). Thus, insulin auto‐antibodies may be a marker for islet B‐cell destruction in Type 1 diabetes.
Reduced Venous Compliance and Increased Transcapillary Escape of Protein in Insulin‐dependent Diabetic Patients
Authors: Bell D. , Collier A. , Nicoll J. J. , Jackson M. , Millar A. M. , Clarke B. F. , Muir A. L.
Published: July 2009

Lower limb venous compliance and transcapillary escape rate of transferrin were measured in eight normotensive, insulin‐dependent male diabetic patients and eight control subjects using a dual isotope technique. Technetium‐99m labelled autologous erythrocytes were used to measure venous compliance and to correct for local changes in blood volume, whilst lndium‐113m labelled transferrin was used to measure trans‐capillary escape of protein. The diabetic patients were found to have reduced venous compliance 1.5 (0.7 to 3.4) × 10−2 mmHg−1 compared with controls 3.2 (2.4 to 4.1) × 10−2 mmHg−1 (p<0.01). The diabetic patients were also found to have greater transcapillary escape of transferrin −2.7 (‐ 1.5 to −5.3) × 10−3, compared with control subjects −5.2 (‐4.1 to −8.1) × 10−3 (p<0.02) in response to increasing hydrostatic pressure. These results show reduced venous compliance in patients with a mean duration of diabetes of 15 years and with only at most, early complications of diabetes, and confirm previous observations showing increased transcapillary escape of protein.
Platelet Function in Uncomplicated Insulin‐dependent Diabetic Patients at Rest and Following Exercise
Authors: Hendra T. J. , Oughton J. , Smith C. C. T. , Betteridge D. J. , Yudkin J. S.
Published: July 2009

There are conflicting reports of platelet function abnormalities in diabetic patients without vascular complications. We have studied in vitro platelet aggregation, using platelet rich plasma and whole blood techniques, in 18 patients with uncomplicated insulin‐dependent diabetes and a matched group of 24 non‐diabetic subjects. In addition we measured plasma beta‐thromboglobulin levels in these groups, as an index of in vivo platelet activation, and compared the indices of in vitro and in vivo platelet function before and after maximal bicycle exercise. Before exercise plasma beta‐thromboglobulin levels and platelet sensitivities to ADP, collagen or adrenaline, as assessed by both methods of platelet aggregation, were the same in diabetic and control subjects. Both groups showed similar increases in beta‐thromboglobulin levels and in platelet sensitivity to all agonists in whole blood following exercise. Using platelet rich plasma there were no changes in platelet sensitivity in either group after exercise. In non‐diabetic subjects, increases in noradrenaline levels after exercise correlated with increases in platelet sensitivity to adrenaline in whole blood. This was not observed in the diabetic group. Abnormalities of platelet function, using the techniques described here, are not present in diabetic patients who do not have clinical evidence of vascular disease.
An Evaluation of Multiple Choice Questionnaires for the Assessment of Knowledge in Diabetic Children and Their Families
Authors: McCowen C. , Court S. , Hackett A. F. , Parkin J. M.
Published: July 2009

The comparability of five multiple choice questionnaires was tested in 69 diabetic children and their parents. Analysis of variance showed that 68 % of the variation in the scores was due to differences between individuals, with only 8 % due to differences between questionnaires. A second study then compared results from diabetic children, their mothers and fathers, and some nurses and doctors, who each completed one questionnaire. Analysis of variance of this study showed that the mothers, fathers, and nurses scored about the same, but more than the children (p < 0.05), whilst the scores of the doctors were not significantly different from any of the other groups.
New Referrals to a Diabetic Clinic
Authors: O'Donnell M. J. , Rowe B. R. , Barnett A. H.
Published: July 2009

New referrals to a diabetic clinic were studied over 6 months. One hundred and twelve patients were referred from their General Practitioner (GP) and 49 from other hospital departments. Thirty percent of GP referrals and 10 % of hospital referrals were made on the basis of glycosuria alone. From all the patients referred six were found to be non‐diabetic and a further 19 had been prescribed drugs inappropriately (either the wrong drug or the right drug in excessive dose), some with potentially dangerous consequences. Almost half of the patients were given no dietary advice at all. There is still much ignorance concerning diagnosis and initial management of diabetes in both general and hospital medical practice.
Group Education for Obese Patients with Type 2 Diabetes: Greater Success at Less Cost
Authors: Heller S. R. , Clarke P. , Daly H. , Davis I. , McCulloch D. K. , Allison S. P. , Tattersall R. B.
Published: July 2009

It has been suggested that much effort expended in teaching diabetic diets is ineffective and wasteful. We have tested a different system by randomly allocating 75 newly diagnosed obese Type 2 diabetic patients to usual ‘unstructured’ clinic care or to group education by diabetes specialist nurses and a dietitian. Patients allocated to group education attended five 90‐min group sessions during the first 6 months. Six months after diagnosis they had lost more weight (median (95 % CI), 7 (5.5–9) vs 2 (1–5) kg, p<0.002) and were better controlled (HbA1: 7.5 (7.0–8.1) vs 9.5 (8.7–10.4) %, p<0.001) than those randomized to the usual clinic system. At 1 year (after no further visits) the difference in weight loss was less (5.5 (4–6.5) vs 3 (2–4) kg, p<0.05) and diabetic control was similar (HbA1:9.0 (8.2–9.8) vs 9.9 (8.9–10.9) %. At 1 year only 14 (39 %) of the education group and 9 (23 %) of those attending the clinic had a fasting blood glucose less than 7.0 mmol l−1.
The Abbreviated Glucose Tolerance Test in Screening for Diabetes: The Islington Diabetes Survey
Authors: Forrest R. D. , Jackson C. A. , Yudkin J. S.
Published: July 2009

The World Health Organization has recommended a single 2‐h post‐glucose load blood glucose level as a screening test for diabetes mellitus in epidemiological surveys. We have assessed its characteristics, when compared with a full supervised glucose tolerance test (OGTT), in estimating prevalence, and in diagnosing diabetes in the individual patient. A stratified sample of 223 of 1040 subjects who had participated in a diabetic survey that utilized a single capillary 2‐h blood glucose estimation as a screening test were recalled for formal glucose tolerance testing. The numbers of subjects with diabetes at screening and at recall were similar (14/212, 6.6 %; 13/216, 6.0 %) but only 9 subjects were so classified on both occasions. Thirty‐five subjects (16.5 %) were suspected of having impaired glucose tolerance (IGT) at screening, and 52 (24.1 %) at recall. There was substantial reclassification from screening IGT, with 3/35 worsening to diabetes, and 10/35 returning to normal. Capillary 2‐h glucose levels gave an accurate assessment of the prevalence of diabetes but underestimated that of IGT. On the full OGTT, little difference in classification was found when the values of fasting and 1‐h blood glucose were used in addition to those of the 2‐h blood glucose used alone. The 2‐h glucose had a within‐subject coefficient of variation of 32.4 % which produced substantial reclassification of subjects with levels close to the diagnostic levels for diabetes, and this implies that such individuals should not be classified as having diabetes on the basis of a single glucose tolerance test. This variability is similar to that previously demonstrated in repeat OGTTs, suggesting that the unsupervised drink and the timing of the 2‐h sample do not contribute substantially to the variability.
Reduced Hyperaemic Response under the Diabetic Neuropathic Foot
Authors: Newrick P. G. , Cochrane T. , Betts R. P. , Ward J. D. , Boulton A. J. M.
Published: July 2009

Diabetic neuropathic ulcers typically occur at high pressure sites. Microvascular blood flow has been assessed on the plantar surface of the foot in three matched groups each of 12 subjects free from macrovascular disease: (a) patients with diabetic neuropathy with abnormal foot pressures and previous neuropathic ulceration; (b) non‐neuropathic diabetic patients; (c) non‐diabetic control subjects. Resting flow was measured at the highest pressure point under the metatarsal heads (defined by pedobarograph) using laser doppler flowmetry, and the hyperaemic response was assessed at the same site following 3 min standing. Peak flow was significantly reduced in neuropathic patients (2.3±1.4 (SD) volts) compared with control subjects (4.0±2.0 volts; p<0.03). The time for blood flow return to baseline was significantly prolonged in neuropaths (159±72s) compared with normal subjects (93±18 s; p<0.01), with a significant delay also seen in non‐neuropaths (151±38 s; p<0.0001 compared with normal).
An Indwelling Subcutaneous FEP Cannula for Intermittent Insulin Injection: Patient Experience and Effect on Diabetic Control
Authors: Rayman G. , Wise P. H.
Published: July 2009

The acceptability and efficacy of injecting insulin through a subcutaneous FEP cannula (to reduce the frequency of needle pricks) compared with conventional multiple injection therapy was examined in a cross‐over study. Thirty‐two insulin‐dependent diabetic patients injected through the cannula for 10 weeks using a pen injector, followed by 10 weeks using the injector alone, or vice versa. Rapid‐acting insulin was given before meals and intermediate‐acting insulin at bedtime. Blood glucose control was not affected by cannula use (glycosylated haemoglobin: cannula, 8.6±0.3 %; no cannula, 8.6±0.3 %). Twenty‐two of the 30 patients completing the study preferred to use the cannula and 21 requested to continue using it. There were no complications associated with its use.
Blood Glucose Control and Visual and Auditory Attention in Men with Insulin‐dependent Diabetes
Authors: Holmes C. S. , Tsalikian E. , Yamada T.
Published: July 2009

Assessment of 16 young men with insulin‐dependent diabetes mellitus was undertaken with neuropsychological measures of attention, decision‐making, and motor tasks. Those patients in very good, or near‐normal, blood glucose control demonstrated decreased attention on visual and auditory simple reaction‐time tasks, compared with those in moderate blood glucose control. Patient groups did not differ in their decision‐making performance; nor did they differ in motor skill performance. These results replicate earlier findings of differences in visual attention in groups of patients according to degree of blood glucose control and show between‐group differences with an auditory reaction time measure. The results suggest that patients with near‐normal blood glucose control may exhibit slowed simple attention, whether information presentation is visual or aural.
The Variability in the Action of Unmodified Insulin is More Dependent on Changes in Tissue Insulin Sensitivity than on Insulin Absorption
Authors: Ziel F. H. , Davidson M. B. , Harris M. D. , Rosenberg C. S.
Published: July 2009

Eight normal subjects were studied twice for 360 min after the subcutaneous injection of unmodified insulin (0.15 U kg−1) during euglycaemic clamps. Insulin absorption was assessed by both the area under the insulin—time curve above baseline (AUC) and time course of absorption (time to 25% and 50% of total AUC). Insulin action was measured as the amount of glucose infused. The maximal serum insulin concentration was 0.27 ± 0.02 (± SE) nmol l−1at 112 ± 10 min. Fifty percent of total glucose infused occurred at 218 ± 7 min. The maximal glucose infusion rate was 5.11 ± 0.70 mg kg−1min−1and occurred at 256 ± 12 min. Intrasubject coefficients of variation (CV) for total insulin AUC (11.2%), time to 25% of maximum AUC (12.1%), and time to 50% of maximum AUC (10.2%) were considerably lower than that for total insulin action (22.6%). Total insulin AUC did not correlate with total glucose utilization (r= 0.06, NS). We conclude that when glucose concentrations are maintained by euglycaemic clamps the peak of unmodified insulin action is later and the duration longer than traditionally recognized, insulin AUC does not predict insulin action, and the higher variability of insulin action compared with the indices of absorption suggests that day‐to‐day changes in tissue insulin sensitivity contribute more to the variability in insulin action than changes in absorption.
Anti‐smoking Advice for Young Diabetic Smokers: Is it a Waste of Breath?
Authors: Ardron M. , MacFarlane I. A. , Robinson C. , van Heyningen C. , Calverley P. M. A.
Published: July 2009

The effect of health counselling on the smoking habits of 60 diabetic patients (aged < 40 years) was assessed. Measurement of breath carbon monoxide (CO) and urinary cotinine, a metabolite of nicotine, were used as objective markers of smoking. All patients wished to cease smoking and the impact of health counselling was reviewed in a ‘Stop Smoking’ clinic. In addition to routine advice on the health hazards of smoking, half the patients and their families also received further counselling during a home visit by a health visitor. After 6 months many of the 60 patients claimed to have reduced their cigarette consumption. However, the urinary cotinine concentrations did not confirm this. Only one patient actually stopped smoking and he had sustained a myocardial infarction during the study. There was a small but significant reduction of breath CO in the patients seen at home by the health visitor but the urinary cotinine concentrations were unchanged. This suggests that these patients abstained from smoking for only a few hours before attending the ‘Stop Smoking’ clinic.
Improvement in Morning Hyperglycaemia with Basal Human Ultratard and Prandial Human Actrapid Insulin — a Comparison of Multiple Injection Regimens
Authors: Davies R. R. , McEwen J. , Moreland T. A. , Durnin C. , Newton R. W.
Published: July 2009

Three ‘pen’‐administered multiple injection regimens have been compared with twice daily insulin injection regimens by means of 24‐h profiles of plasma glucose and free insulin concentrations. Ten Type 1 diabetic patients received their usual twice daily insulin regimen and were then randomized to receive the same total daily insulin dose in four divided doses using (1) 50:50 premixed soluble and isophane, (2) 30:70 premixed soluble and isophane, and (3) preprandial soluble and evening crystalline‐zinc insulins. Profiles were performed after 1 week on each regimen. Plasma glucose concentrations were similar during the twice daily regimen and the two premixed regimens, rising during the early hours of the morning to a peak between 0900 and 0930 h of 13.8 ± 2.8 (± SD) mmol l−1 on the twice daily regimen, 13.6 ± 5.3 mmol l−1 on the premixed 50:50 regimen, and 13.5 ± 4.2 mmol−1 on the premixed 30:70 regimen. With the basal and prandial regimen, overnight plasma glucose concentrations were higher than with the other regimens between 2400 and 0300 h (p < 0.05). Concentrations then fell until breakfast, and rose after this meal to a peak of 9.5 ± 4.3 mmol l−1 (p < 0.01). Mean plasma glucose concentrations were significantly lower than on the other three regimens between 0830 and 1100 h (p < 0.05). Less variability was observed in 24‐h mean plasma glucose concentrations during the basal and prandial regimen than during the other three regimens.
Sucrose Versus Saccharin as an Added Sweetener in Non‐insulin‐dependent Diabetes: Short‐ and Medium‐term Metabolic Effects
Authors: Cooper P. L. , Wahlqvist M. L. , Simpson R. W.
Published: July 2009

Seventeen non‐insulin‐dependent diabetic patients were randomly allocated to their usual diet supplemented daily with either 28 g sucrose or 30 g starch (isoenergetic with sucrose) and saccharin (equivalent sweetness). After 6 weeks, the supplements were reversed. No significant treatment effects were observed on fasting concentrations of blood glucose, plasma insulin or serum triglycerides, or on urinary excretion of glucose, sodium or potassium. Following a standard breakfast with either sucrose or saccharin and starch, no differences between meal responses were observed. This study demonstrates no medium‐term metabolic contraindications to including a moderate amount of sucrose in the diets of patients with non‐insulin‐dependent diabetes mellitus.
Extra‐laboratory Blood Glucose Measurement: A Policy Statement
Authors: Price C. P. , Burrin J. M. , Nattrass M.
Published: July 2009

The introduction of test strips for measurement of blood glucose has led to their widespread use by medical and paramedical staff outside the central laboratory. While many users have developed ad hoc schemes of training and quality control, formal guidelines have not been presented. This paper makes recommendations on various aspects of extra‐laboratory blood glucose measurement in hospitals, but not in the home, with the aim of improving the safety and reliability of results.

It is recommended that:

a formal programme of training should be devised by staff in the laboratory together with those in the diabetes service and others as appropriate;

laboratory and diabetes staff should train, assess, and approve more senior users who would then take responsibility for the training and performance of more junior colleagues;

all users should demonstrate their competence at regular intervals;

there should be a quality assurance programme arranged by the laboratory which tests the performance of the operator and the equipment;

laboratory staff, in consultation with users, should be responsible for the selection and purchase of equipment;

equipment should be cleaned and maintained on a regular basis by users.
Measuring Psychosocial Adaptation to Diabetes in Adolescence
Authors: Challen A. H. , Davies A. G. , Williams R. J. W. , Haslum M. N. , Baum J. D.
Published: July 2009

We have developed a psychometric test to assess psychosocial adaptation to diabetes in young people aged from 10 to 17 years. This includes subscales which describe emotional difficulty with, and attitude to, diabetes.

The content of the scales was drawn from unstructured discussions with 27 young people with diabetes. The scales were piloted on two further unselected groups of adolescents (n = 50, n = 99) to examine their reliability, validity, and acceptability. Highly significant correlations were found between the results of the scales and measures of psychosocial function (p < 0.001), parents' perceptions of adaptation to diabetes (p < 0.005), and to a lesser extent with paediatricians' perceptions. Performance on the scale also correlated with a number of behaviour variables and differentiated those who were reported to be restricted by their diabetes (p < 0.005) and those who had had a previous psychiatric referral (p < 0.05). The scales appear reliable within the constraints of the small population examined.
A Randomized Trial of the Efficacy and Acceptability of a Pen Injector
Authors: Murray D. P. , Keenan P. , Gayer E. , Salmon P. , Tomkin G. H. , Drury M. I. , O'Sullivan D. J.
Published: July 2009

A controlled trial of pen injection of insulin was performed in 78 patients, with assessment of metabolic control and lifestyle. After a 6‐week run‐in period, during which control was optimized, the patients were randomized, either to stay on a twice daily insulin regimen (n = 37), or to change to a three times daily pen regimen with human ultralente at night (n = 41). Over the 20 weeks, there was no significant change in mean glycosylated haemoglobin (syringe, mean ± SD, 11.1±2.5% to 10.9±2.0%; pen, 11.3±2.6% to 11.2±2.0%), in blood glucose profiles or in frequency of hypoglycaemic attacks in either group. A self‐completed questionnaire demonstrated high patient satisfaction with the pen injector (NovoPen), 78% for effect on lifestyle and 81% for increased flexibility. Ninety‐five percent preferred the pen injector regimen to conventional treatment and stayed on it.
A Mixed Meal Potentiates the Insulin Sensitivity of Glucose Transport and Metabolism in Adipocytes from Patients with Type 2 Diabetes Mellitus
Authors: Lange A. , Bak J. , Andersen P. H. , Richelsen B. , Pedersen O.
Published: July 2009

Post‐glucose enhancement of insulin action may represent a physiological mechanism for the acute regulation of insulin sensitivity of target tissues. To clarify whether a similar mechanism is operative in the insulin‐resistant diabetic state we have investigated the effects of a mixed meal on adipocyte insulin action in eight patients with Type 2 diabetes mellitus. Ninety minutes after ingestion of breakfast insulin binding to fat cells increased by 21% (p<0.05). In the fasting state 6 patients had a significant response of glucose transport and lipogenesis to insulin whereas two exhibited non‐responsiveness. In the 6 responders insulin sensitivity, as estimated by the insulin concentration at which half‐maximal effect was achieved, increased for glucose transport (before, 260±46 pmol ***l−1; after, 105±21 pmol l−1; p<0.05) and for lipogenesis (before, 36±9pmol l−1; after, 9±2 pmol l−1; p<0.05). No significant changes occurred in basal or maximal glucose transport or lipogenesis. In the two primary non‐responders intake of the meal was associated with average increases in maximal insulin responsiveness of 51% for glucose transport and 28% for lipogenesis. Intake of a mixed meal is associated with a slight increase of insulin binding to adipocytes from patients with Type 2 diabetes mellitus but a marked increase of adipocyte insulin sensitivity at the post‐binding levels of glucose transport and metabolism.
Predicting Future Treatment of Diabetes Mellitus from Characteristics Available at Presentation
Authors: Maclver D. H. , McNally P. G. , Shaw D. E. , Hearnshaw J. R.
Published: July 2009

This study was designed to identify the clinical features of a newly diagnosed diabetic patient that are most useful in deciding treatment. A secondary aim was to formulate a statistical model for predicting subsequent treatment. The following features were considered in 289 patients: age, sex, severity and duration of symptoms, degree and duration of weight loss, glycosuria, ketonuria, blood glucose concentration, body mass index (BM***I), and family history of diabetes. Three treatment groups, 6 months after diagnosis, were defined: diet alone, diet with oral hypoglycaemie agent(s), and insulin‐treated. Univariate analysis showed that symptom severity, glycosuria, ketonuria, glucose concentration, weight loss, and BMI were significantly different between the three groups. Age and rate of weight loss were significantly different between the insulin‐treated and non‐insulin‐treated groups. Multivariate analysis gave a model to calculate the probability of requiring each of the three treatments given certain characteristics. A second cohort of 174 patients was used to assess the accuracy of the model. The model predicted the actual treatment at 6 months correctly in 72%.
Insulin Antibodies do not Influence the Absorption Rate of Subcutaneously Injected Insulin
Authors: de Meijer P. H. E. M. , Lutterman J. A. , van ‘t Laar A.
Published: July 2009

The influence of insulin antibodies on absorption rate and plasma free insulin concentrations after subcutaneous injection of insulin, was studied in two groups of insulin‐treated diabetic patients, one without insulin antibodies (n= 9) and a second with high plasma concentrations of antibodies (n= 14). Except for antibody concentration there were no differences in clinical variables. During 8 h after the injection of 12 U of iodinated neutral human insulin, residual radioactivity at the injection site, plasma glucose, and free and total insulin were measured.

Significant differences in absorption rate of insulin were not found between the groups. Plasma glucose (basal value 16.8±4.4 SD vs 16.1±4.2 mmol l−1) and free insulin (basal value 8.3±1.4 vs 11.4±2.3 mU l−1maximum after 90 min 36.9±19.5 vs 30.5±18.7 mU l−1) were never significantly different between the groups, nor were areas under the curve for free insulin (191.4±69.2 vs 170.8±98.6 mU l−1h). In the high antibody group a small increase in bound insulin was found.
Association of Hypertension with Blood Viscosity in Diabetes
Authors: MacRury S. M. , Small M. , MacCuish A. C. , Lowe G. D.
Published: July 2009

Plasma and whole blood viscosity and its determinants were measured in 86 diabetic patients (29 hypertensive and 57 normotensive) and compared with 52 non‐diabetic control subjects to assess whether hypertension has an additive and adverse effect on blood viscosity. Whole blood viscosity (corrected for haematocrit), at high and low shear rates (95 and 0.95 s−1), was significantly higher in both Type 1 (5.1 ± 0.5 (± SD), 19.8 ± 2.9) and Type 2 (5.2 ± 0.3, 21.1 ± 2.0) diabetic patients compared with control subjects (4.9 ± 0.6,17.4 ± 2.6 mPa s, p < 0.01). Corrected whole blood viscosity at high shear rate was significantly higher in hypertensive than in normotensive Type 2 diabetic patients (5.5 ± 0.4 vs 5.2 ± 0.3 mPa s, p < 0.01). Plasma viscosity was significantly higher in diabetic patients compared with control subjects (1.4 ± 0.1 vs 1.3 ± 0.1 mPa s, p < 0.01), but there was no difference between hypertensive and normotensive diabetic patients (1.4 ± 0.1 vs 1.4 ± 0.2 mPa s). Fibrinogen levels were similar in all the groups.
Cell‐mediated Immunity and Symptomatic Diabetic Autonomic Neuropathy
Authors: Gilbey S. G. , Hussain M. J. , Watkins P. J. , Vergani D.
Published: July 2009

T lymphocytes have been implicated in the nerve damage observed in allergic experimental neuritis and in idiopathic polyneuritis. Symptomatic autonomic neuropathy in long‐standing Type 1 diabetes is a rare and unexplained complication, and some preliminary evidence has suggested a pathogenetic role for the immune system. We have measured levels of activated T lymphocytes in 18 Type 1 diabetic patients with symptomatic autonomic neuropathy and in 16 matched patients with uncomplicated Type 1 diabetes. Purified T lymphocytes from peripheral blood were stained with a fluorescein‐labelled monoclonal antibody directed to the activation marker HLA‐DR and counted under UV microscopy. Percent DR positive T lymphocytes were significantly raised in the patients with autonomic neuropathy when compared with long‐standing uncomplicated diabetic patients (8.2 ± 4.2 vs 4.9 ± 3.3%, p < 0.01). This finding lends support for a role of the immune system in the development of autonomic neuropathy.
Blood Glucose Control and Insulin Secretion Improved With Combined Therapy in Type 2 Diabetic Patients With Secondary Failure to Oral Hypoglycaemic Agents
Authors: Iavicoli M. , Cucinotta D. , De Mattia G. , Lunetta M. , Morsiani M. , Pontiroli A. E. , Pozza G.
Published: July 2009

The influence of combined therapy using insulin and oral hypoglycaemic agents on blood glucose control and on insulin secretion in Type 2 diabetic patients with secondary failure to oral hypoglycaemic agents was evaluated. Type 2 diabetic patients (n = 180) (98 normal‐weight, 82 over‐weight), at least 3 years from diagnosis, and having poor blood glucose control on oral hypoglycaemic agents for at least 3 months (fasting plasma glucose > 10.0 mmol l−1) despite intensive efforts at improvement, were included in the study. A single daily insulin injection (human ultralente), at a dose of 0.22 ± 0.07 U kg−1 d−1 in normal‐weight and 0.33 ± 0.10 U kg−1 d−1 in over‐weight patients, was added to the previous dietary and drug treatment for 6 months. A progressive and significant (2p < 0.001) reduction of the mean daily blood glucose was observed during the first 3 months of combined therapy (from 13.2 ± 3.2 to 8.1 ± 2.1 mmol l−1 in normal‐weight and from 13.4 ± 3.1 to 8.8 ± 2.3 mmol l−1 in over‐weight patients), with no further significant changes thereafter. A significant increase (2p < 0.001) in the mean daily C‐peptide concentration (from 0.50 ± 0.30 to 0.71 ± 0.29 nmol l−1 in normal‐weight and from 0.78 ± 0.36 to 1.00 ± 0.41 nmol l−1 in over‐weight patients) took place during combined therapy. No changes of body weight (+ 1.5 ± 1.2 kg in normal‐weight and +1.0 ± 1.0 kg in over‐weight patients) were observed.
Altered Hand Skin Blood Flow in Type 1 (Insulin‐dependent) Diabetes Mellitus
Authors: Winocour P. H. , Mitchell W. S. , Gush R. J. , Taylor L. J. , Baker R. D.
Published: July 2009

Disturbed upper limb skin blood flow has been described in insulin‐dependent (Type 1) diabetes mellitus, but the pathophysiological mechanism remains unclear. Hand skin blood flow was therefore measured at room temperature and following immersion of hands in cold and warm water in 13 healthy control subjects, in 10 patients with Type 1 diabetes mellitus and cardiovascular autonomic neuropathy, and a further 10 Type 1 diabetic patients with normal cardiovascular autonomic tone. Following cold challenge there was failure of digital artery clampdown in all diabetic patients in comparison with healthy control subjects (p < 0.005), and the index finger temperature fell less (p < 0.05). Laser Doppler flow was reduced at the palms at room temperature or following the warm challenge (p < 0.008), as well as on the dorsum at room temperature (p < 0.05), in all diabetic patients. In addition laser Doppler flow in the diabetic patients was reduced at the palms and dorsum immediately following cold water challenge (p < 0.004) and this reduction persisted 15 min (p < 0.05) and 30 min (p < 0.01) into the recovery phase. In comparison to those diabetic patients with normal cardiovascular tone, those with cardiovascular autonomic neuropathy had reduced laser Doppler flow at the pulp 15 min after cold water immersion (p < 0.05), at the nailbed immediately after cold water immersion (p < 0.01), and at the palms immediately after warm water challenge (p < 0.01).
Diabetic Autonomic Neuropathy: the Prevalence of Impaired Heart Rate Variability in a Geographically Defined Population
Authors: Neil H. A. W. , Thompson A. V. , John S. , McCarthy S. T. , Mann J. I.
Published: July 2009

The prevalence of diabetic autonomic neuropathy and its relationship with other diabetic complications were studied in a geographically defined population. Heart rate variability was measured by a computerized technique at rest and in response to both a single deep breath and a Valsalva manoeuvre. Among 43 Type 1 (insulin‐dependent) and 202 Type 2 (non‐insulin‐dependent) patients results below the 2.5 centile for age‐related normal ranges occurred in 9 Type 1 and 32 Type 2 patients (16.7, 95% Cl 12.6 to 21.9, %). Symptomatic autonomic neuropathy was uncommon but was significantly more frequent in Type 1 than Type 2 patients (5 Type 1, 1 Type 2, p < 0.001 Fisher's exact test). In Type 1 diabetes, cardiovascular autonomic dysfunction was significantly associated with impaired vibration perception and a higher logarithmic urinary albumin concentration and, in Type 2 diabetes, it was associated with a significantly higher body mass index, systolic blood pressure, and logarithm of the urinary albumin and fasting insulin concentrations. The aggregation of these factors with cardiovascular autonomic dysfunction suggests that mortality might be increased in Type 2 patients with asymptomatic autonomic neuropathy.
The Effect of Glucose and Insulin Infusion on the Fall of Ketone Bodies During Treatment of Diabetic Ketoacidosis
Authors: Krentz A. J. , Hale P. J. , Singh B. M. , Nattrass M.
Published: July 2009

During the treatment of diabetic ketoacidosis intravenous glucose is infused when blood glucose has fallen to around 14 mmol l−1. The use of hypertonic (10%) glucose has been recommended in order to hasten the clearance of blood ketone bodies. In a randomized controlled study 17 patients presenting with severe diabetic ketoacidosis were allocated to one of two regimens of intravenous glucose and insulin when blood glucose had fallen to < 14 mmol l−1. Nine patients were given 5% glucose containing 10 U l−1 insulin and 8 patients received 10% glucose with 40 U l−1 insulin. Fluid was infused at a rate of 250 ml h−1 for 6 h. At the start of the infusions blood glucose had fallen from levels at presentation to 12.8 ± 1.1 mmol l−1 (mean ± SE) in the group which subsequently received the low infusion rate and to 13.7 ± 0.9 mmol l−1 in the subsequent high infusion rate group. With glucose/insulin infusion blood glucose after 6 h was 11.5 ± 0.9 mmol l−1 (low infusion rate group) and 15.7 ± 1.3 mmol l−1 (high infusion rate group). This difference between groups at 6 h was significant (p < 0.05). Over the 6 h of infusion the fall in blood total ketone bodies was significantly greater in the group receiving the higher rate of glucose/insulin infusion (7.34 ± 0.57 vs 5.18 ± 0.57 mmol l−1; p < 0.05). Despite the greater fall in total ketone bodies in this group there was no difference in the improvement in capillary blood pH or bicarbonate. In view of the hyperglycaemic effect of the high infusion rate regimen and the absence of effect upon the acidosis we conclude that the routine use of this regimen of 10% glucose (25 g 250‐ml−1 h−1) with 10 U h−1 insulin is not indicated in the recovery phase of diabetic ketoacidosis.
Vascular Calcification, Autonomic Neuropathy, and Peripheral Blood Flow in Patients with Diabetic Nephropathy
Authors: Gilbey S. G. , Walters H. , Edmonds M. E. , Archer A. G. , Watkins P. J. , Parsons V. , Grenfell A.
Published: July 2009

The possibility that digital gangrene in patients with diabetic nephropathy might be due to abnormalities of peripheral blood flow secondary to vascular calcification has been investigated. Twenty patients with renal failure due to diabetic nephropathy were studied. Peripheral blood flow was measured using venous occlusion plethysmography, together with an assessment of medial arterial calcification on plain radiographs of the hands and feet, and transcutaneous oxygen tension (TcPO2). Hallux blood flow was markedly raised (median 22.5, range 11.5–56.5, ml min−1 100‐ml−1) compared with non‐diabetic control subjects (4.7, 1.1–10.5, ml min−1 100‐ml−1; p < 0.01) and similar to that in diabetic patients with autonomic neuropathy (29.5, 16.7–49.6, ml min−1 100‐ml−1). Although vascular calcification was common and extensive in the patients with diabetic nephropathy, TcPO2 measurements in the supine foot were normal and did not indicate tissue ischaemia. We conclude that despite extensive vascular calcification high peripheral blood flow occurs in the feet of these patients at rest together with normal transcutaneous oxygen tension.
Diabetes in the UK West Indian Community: the Wolverhampton Survey
Authors: Odugbesan O. , Rowe B. , Fletcher J. , Walford S. , Barnett A. H.
Published: July 2009

A survey was carried out to determine the prevalence of known diabetes amongst West Indians living in Wolverhampton. Two hundred and fifty‐one West Indians with diabetes were identified from a computerized register, which records all diabetic patients in the Wolverhampton area attending either the hospital diabetic clinic or general practitioner mini‐clinics, and from questionnaire data obtained through local general practitioners. An estimated 4.4% of the Wolverhampton population are of West Indian origin determined by the 1981 census, giving a prevalence of known diabetes of 2.2% compared with 1.2% in the indigenous UK white Caucasian population. Only 4% of these patients were truly insulin‐dependent but 38% were insulin‐treated, 43% were on oral hypoglycaemic agents and 19% on diet alone. Only 1.6% were diagnosed below the age of 20 years, with peak frequency of diabetes occurring in the age group 45–64 years. Thirty‐eight percent of all patients were obese, 40% were hypertensive, but only 4% had a history of angina or myocardial infarction. In UK West Indians non‐insulin‐dependent diabetes is common and is predominantly a disease of middle age, whereas insulin‐dependent diabetes is relatively uncommon.
Psychosocial Factors and the Onset of Type 1 Diabetes
Authors: Robinson N. , Lloyd C. E. , Fuller J. H. , Yateman N. A.
Published: July 2009

Stress has been proposed as a possible precipitating factor for the development of Type 1 diabetes in genetically susceptible individuals. A validated in‐depth psychometric instrument (The Life Events and Difficulties Schedule) was used to investigate the role of psychosocial factors in the onset of Type 1 diabetes in islet cell antibody (ICA)‐positive family members. Families with ICA‐positive members had higher scores for subject focused severe life events in the 5‐year period prior to the diagnosis of diabetes in a second family member compared with matched control families (1.50 ± 0.68 (± SD) vs 0.32 ± 0.37; p < 0.03). In the same time period, these families also experienced a higher mean number of severe long‐term difficulties compared with control families (1.34 ± 0.52 vs 0.14 ± 0.17; p < 0.01). Scores for current total visual social contacts were greater for control families compared with case family members (12.10 ± 1.90 vs 9.64 ± 2.70; p < 0.05). These results suggest that global family stress possibly in conjunction with a reduced number of social contacts may act as a trigger for the development of diabetes in a second family member and that social support may act as a buffer to stress and disease onset.
Reducing Acute Hyperglycaemic Mortality in African Diabetic Patients
Authors: Huddle K. R. , Gill G. V.
Published: July 2009

Acute diabetic hyperglycaemic emergencies carry a high mortality in tropical countries. Defining a ‘hyperglycaemic emergency’ as the perceived need for intravenous insulin and saline, we found a mortality of 15/60 (25%) in a 2‐month period at Baragwanath Hospital, Soweto in 1981. Following this a programme of improved diabetes care was organized, involving optimization of insulin regimens, home blood glucose monitoring, patient education and concentration of resources on young insulin‐dependent patients. Five years later, in 1986, the survey was repeated over a similiar 2‐month period. The mortality this time was 5/48 (10%), a significant reduction compared with 1981 (p < 0.05). In addition, mean admission glycosylated haemoglobin fell from 11.8 ± 2.4(± SD) to 10.5 ± 2.3% (p < 0.05). These improvements were achieved by relatively simple and inexpensive manoeuvres which could be applied elsewhere in developing countries.
Proliferative Retinopathy After 60 Years of Complication‐free Diabetes
Authors: Peck R. W. , Price D. E. , Hearnshaw J. R.
Published: July 2009

A patient developed proliferative retinopathy after more than 60 years of complication‐free diabetes. This may have been precipitated by an episode of ketosis or by cataract extraction, and emphasizes the need for persistent vigilance in examination for retinopathy.