bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of Diabetes Care by Medical Record Review: The Indian Health Service Model
Authors: Mayfield Jennifer A , Rith-Najarean Stephen J , Acton Kelly J , Schraer Cynthia D , Stahn Ruggles M , Johnson Mildred H , Gohdes Dorothy
Published: March 2007

OBJECTIVE

To evaluate the adherence to minimum standards for diabetes care in multiple primary-care facilities using a uniform system of medical record review.

RESEARCH DESIGN AND METHODS

In 1986, the Indian Health Service (IHS) developed diabetes care standards and an assessment process to evaluate adherence to those standards using medical record review. We review our assessment method and results for 1992. Charts were selected in a systematic random fashion from 138 participating facilities. Trained professional stai reviewed patient charts, using a uniform set of definitions. A weighted rate of adherence was constructed for each item.

RESULTS

Medical record reviews were conducted on 6,959 charts selected from 40,118 diabetic patients. High rates of adherence (>70%) were noted for blood pressureand weight measurements at each visit, blood sugar determinations at each visit, annual laboratory screening tests, electrocardiogram at baseline, and adult immunizations. Lower rates of adherence (≤50%) were noted for annual eye, foot, and dental examinations.

CONCLUSIONS

IHS rates of adherence are similar to rates obtained from medical record reviews and computerized billing data, but are less than rates obtained by provider self-report. Medical record review, using uniform definitions and inexpensive software for data entry and reports, can easily be implemented in multiple primary-care settings. Uniformity of data definition and collection facilitates the aggregation of the data and comparison over time and among facilities. This medical record review system, although labor intensive, can be easily adopted in a variety of primary-care settings for quality improvement activities, program planning, and evaluation.
Differential Regulation of Counterregulatory Hormone Secretion and Symptoms During Hypoglycemia in IDDM: Effect of glycemic control
Authors: Kinsley Brendan T , Widom Barbara , Simonson Donald C
Published: March 2007

OBJECTIVE

To determine 1) if there was a differential effect of glycemic control on individual counterregulatory hormone responses to hypoglycemia in patients with insulin-dependent diabetes mellitus (IDDM), 2) whether these modifications affect hypoglycemic symptom perception, and 3) if there was a level of glycemic control below which counterregulatory and symptomatic responses to hypoglycemia become consistently altered.

RESEARCH DESIGN AND METHODS

We performed hypoglycemic clamp studies on 38 patients with IDDM and 38 healthy control subjects. Glucose was lowered from 5.0 to 2.2 mmol/1 over 3 h in decrements of 0.6 mmol/1 each 30 min. Epinephrine, cortisol, growth hormone (GH), glucagon, and symptom score were measured at each glucose plateau.

RESULTS

In IDDM patients, HbA1 levels were positively correlated with incremental epinephrine (r = 0.58, P < 0.001) and cortisol (r = 0.52, P < 0.01) responses, but inversely correlated with GH responses (r = –0.31, P < 0.05). The increase in symptom score correlated with the epinephrine response in the IDDM patients (r = 0.57, P < 0.001), but not in the healthy control subjects (r = –0.02, NS). In IDDM patients with HbA1 ≤7.8% (n = 7), the epinephrine, cortisol, and symptomatic responses to hypoglycemia were blunted, but GH secretion was preserved.

CONCLUSIONS

These data suggest that 1) there is differential regulation of counterregulatory hormone secretion that is dependent on the level of glycemic control, 2) epinephrine is an important determinant of symptom perception in IDDM patients, but not in healthy control subjects, and 3) multiple defects in counterregulatory hormone secretion and symptom perception are consistently observed in patients with HbA1 levels ≤7.8%.
Promotion and Acceleration of Diabetic Ulcer Healing by Arginine-Glycine-Aspartic Acid (RGD) Peptide Matrix
Authors: Steed David L , Ricotta John J , Prendergast J Joseph , Kaplan Robert J , Webster Marshall W , McGill Janet B , Schwartz Sherwyn L ,   The Rgd Study Group
Published: March 2007

OBJECTIVE

To determine the effectiveness and safety of arginine-glycine-aspartic acid (RGD) peptide matrix in the treatment of diabetic foot ulcers.

RESEARCH DESIGN AND METHODS

This randomized placebo-controlled investigator- and patient-blinded prospective multicenter investigation was conducted at three institutional and three private U.S. clinics providing ambulatory care. Sixty-five diabetic patients with chronic full-thickness neurotrophic foot ulcers were enrolled. Six discontinued the study because of adverse events. RGD peptide matrix (Argidene Gel; formerly Telio-Derm Gel) was applied topically twice weekly for up to 10 weeks in patients who otherwise received standard care. Control group patients received topical saline as a placebo plus standard care. The primary method of assessment was the incidence and rate of ulcer closure. All patients enrolled were included in the data analysis.

RESULTS

The percentage of patients whose ulcers healed completely in the RGD peptide matrix group (35%; 14 of 40 patients) was over fourfold greater (P = 0.02) than that in the placebo group (8%; 2 of 25 patients). By the study end point (either day of healing or week 10), 30 of 40 (75%) RGD peptide matrix patients had achieved >50% ulcer closure compared with 12 of 25 (48%) placebo patients (P = 0.03). RGD peptide matrix also significantly (P = 0.03) increased the rate of ulcer closure over the 10 weeks of the study.

CONCLUSIONS

RGD peptide matrix treatment promoted and accelerated the healing of chronic diabetic foot ulcers to a significant degree.
Incidence of Diabetes Among Dependents of the U.S. Military Forces Admitted to U.S. Army Treatment Facilities, 1971-1991
Authors: Tiwary Chandra M , Michalek Joel E
Published: March 2007

OBJECTIVE

To determine the national incidence of diabetes in children by studying a group representing all parts of the country: the dependent children of U.S. military personnel.

RESEARCH DESIGN AND METHODS

Dates of admission, diagnosis of diabetes, age, and gender were collected for all 522,326 children, age 21 or younger, of active duty military personnel admitted to U.S. Army treatment facilities during fiscal years 1971-1991. Incidence rates were expressed as cases per 100,000 person-years.

RESULTS

A total of 2,308 cases of diabetes were diagnosed in 14.3 million person-years of follow-up over the 21 years. The overall incidence rate of diabetes in this population is 16.2 (95% confidence interval 15.5–16.9). For 1987–1991, the age-specific rates were 8.1 (0–4 years), 15.9 (5–9 years), 25.6 (10–14 years), 23.9 (15–19 years), and 23.4 (20–21 years).

CONCLUSIONS

The rates may be biased because of exclusion of people with diabetes from entering military service, and are limited by lack of age adjustment. The racial admixture of our study population does not match the U.S. population as a whole.
Manufactured Shoes in the Prevention of Diabetic Foot Ulcers
Authors: Uccioli Luigi , Faglia Ezio , Monticone Giovanna , Favales Fabrizio , Durola Laura , Aldeghi Antonio , Quarantiello Antonella , Calia Patrizia , Menzinger Guido
Published: March 2007

OBJECTIVE

To evaluate the efficacy of manufactured shoes specially designed for diabetic patients (Podiabetes by Buratto Italy) to prevent relapses of foot ulcerations.

RESEARCH DESIGN AND METHODS

A prospective multicenter randomized follow-up study of patients with previous foot ulcerations was conducted. Patients were alternatively assigned to wear either their own shoes (control group, C; n = 36) or therapeutic shoes (Podiabetes group, P; n = 33). The number of ulcer relapses was recorded during 1-year follow-up.

RESULTS

Both C and P groups had similar risk factors for foot ulceration (i.e., previous foot ulceration, mean vibratory perception threshold > 25 mV). After 1 year, the foot ulcer relapses were significantly lower in P than in C (27.7 vs. 58.3%; P = 0.009; odds ratio 0.26 [0.2–1.54]). In a multiple regression analysis, the use of therapeutic shoes was negatively associated with foot ulcer relapses (coefficient of variation = −0.315; 95% confidence interval = −0.54 to −0.08; P = 0.009).

CONCLUSIONS

The use of specially designed shoes is effective in preventing relapses in diabetic patients with previous ulceration.
The Interrelationship Between Ethnicity and Gestational Diabetes in Fetal Macrosomia
Authors: Homko Caril J , Sivan Eyal , Nyirjesy Paul , Reece E Albert
Published: March 2007

OBJECTIVE

To determine the possibility of an ethnic influence on the development of macrosomia (birth weight > 90th percentile for gestational age) in gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

We prospectively followed all African-American and Latino women enrolled in the Temple diabetes-in-pregnancy program. GDM was diagnosed in 103 African-American and 36 Latino women during the study period (1991–1994) according to the criteria of Carpenter and Coustan. All women were treated according to our previously published protocols. Data were collected on gestational weight gain, previous history of macrosomia, body mass index (BMI), and level of maternal glycemic control.

RESULTS

Insulin therapy was required in 53 women (37.5%) to maintain fasting blood glucose levels at < 95 mg/dl and 2-h postprandial levels at < 120 mg/dl. Macrosomia developed in 50% of the neonates of Latino women versus 19% of neonates of African-American women (relative risk 2.68; 95% confidence interval 1.57–4.59). Potential confounding factors were not significantly different between the Latino and African-American women: mean blood glucose 96.6 ± 15.7 vs. 96.5 ± 22.4 mg/dl; BMI 29.0 ± 5.5 vs. 31.5 ± 8.2 kg/m2; pregnancy weight gain 29.2 ± 12.7 vs. 30.9 ± 20.5 lb; and parity 1.8 ± 1.5 vs. 1.6 ± 1.4, respectively.

CONCLUSIONS

We have demonstrated that Latino women with GDM are at higher risk for having macrosomic infants in comparison with African-American women. This ethnic variation in fetal growth may be due to varying influences of in utero growth promoters among these populations as well as underlying genetic factors.
Atropine Inhibits the Increase in Gastric Emptying During Hypoglycemia in Humans
Authors: Schvarcz Erik , Palmér Mats , Åman Jan , Berne Christian
Published: March 2007

OBJECTIVE

To study the effect of a cholinergic muscarinic blockade on the gastric emptying rate during insulin-induced hypoglycemia in healthy subjects.

RESEARCH DESIGN AND METHODS

In eight healthy subjects, the rate of gastric emptying of an isotope-labeled meal was assessed by a scintigraphic technique during normoglycemia and hypoglycemia with simultaneous infusion of either atropine or saline. Blood glucose concentrations were controlled by an insulin-glucose clamp.

RESULTS

The median time for emptying 50% of the liquid phase from the stomach (T50) was 24.9 min (range 13.9−120.0) during normoglycemia compared with 8.1 min (range 3.6−16.5) during hypoglycemia without atropine infusion (P = 0.0005). The T50 for the solid phase was 26.8 min (range 9.7−74.0) and 43.1 min (range 29−57.8), respectively (P = 0.007). During hypoglycemia with atropine infusion, T50 was 40.7 min (range 10.0−120.0) for the liquid phase and 111.4 min (range 38.9−120.0) for the solid phase, not statistically different from normoglycemic examinations.

CONCLUSIONS

Cholinergic muscarinic blockade with atropine inhibits the increase in gastric emptying during hypoglycemia. Vagal activity seems to be an important determinant of gastric emptying during hypoglycemia.
Resource Utilization and Costs of Care in the Diabetes Control and Complications Trial
Authors:   The Diabetes Control and Complications Trial Research Group
Published: March 2007

OBJECTIVE

To describe in detail the resources used and costs incurred in the clinical management of patients with insulin-dependent diabetes mellitus (IDDM) in the Diabetes Control and Complications Trial (DCCT).

RESEARCH DESIGN AND METHODS

The resources used for intensive and conventional therapy and to deal with the side effects of therapy were assessed at each of the 29 DCCT clinics and summarized. Unit costs were derived from the DCCT, manufacturers, and Medicare and chosen to reflect what an item would cost to a single-payer national health system. Costs were calculated as the product of resources used and unit costs. The costs of the research component of the DCCT were not included.

RESULTS

In the DCCT, the annual cost of intensive therapy ($4,000 and $5,800/year for multiple daily injections and continuous subcutaneous insulin infusion, respectively) was ∼ three times the cost of conventional therapy ($1,700/year). A large portion of the difference in cost was related to the greater frequency of outpatient visits and the greater resources used in self-care.

CONCLUSIONS

DCCT intensive therapy is more expensive than conventional therapy, but it offers the hope of cost savings as a result of averted complications.
Cyclosporin A Does Not Delay Insulin Dependency in Asymptomatic IDDM Patients
Authors: Rakotoambinina Benjamin , Timsit Jose , Deschamps Ingeborg , Laborde Kathleen , Jos Joseph , Boitard Christian , Assan Roger , Robert Jean Jacques
Published: March 2007

OBJECTIVE

To measure the effects of cyclosporin A (CyA) with no insulin therapy on glucose tolerance and β-cell function in the preclinical phase of insulin-dependent diabetes mellitus (IDDM).

RESEARCH DESIGN AND METHODS

β-cell responses to the intravenous glucose tolerance test (IVGTT), hyperglycemic clamp, intravenous arginine, and intravenous glucagon were evaluated before and after a 6-month course of CyA in seven patients (mean age 19.6 years) with asymptomatic IDDM.

RESULTS

Initial insulin secretory responses were severely decreased when the patients were compared with eight healthy control subjects: IVGTT (1 + 3 min): 106 ± 16 vs. 884 ± 190 pmol/l (P < 0.001); hyperglycemic clamp: 102 ± 16 vs. 310 ± 42 pmol/l (P < 0.001); intravenous arginine: 346 ± 72 vs. 1104 ± 168 pmol/l (P < 0.01); and intravenous glucagon: 170 ± 37 vs. 247 ± 35 pmol/l (NS). The β-cell responses remained markedly abnormal after 6 months of CyA, although the response to intravenous glucose and oral glucose tolerance tests improved in three subjects. All the patients became insulin-dependent after 5–36 months.

CONCLUSIONS

CyA alone is not a suitable treatment for asymptomatic IDDM. Earlier identification of subjects with substantial β-cell secretory capacity and newer nontoxic intervention strategies are required for the prevention of IDDM.
Morbidity and Mortality in the Wolfram Syndrome
Authors: Kinsley Brendan T , Swift Michael , Dumont Raymonde H , Swift Ronnie G
Published: March 2007

OBJECTIVE

To determine the major causes of morbidity and mortality in the autosomal recessive Wolfram syndrome, which is defined by diabetes and bilateral progressive optic atrophy with onset in childhood or adolescence.

RESEARCH DESIGN AND METHODS

We abstracted and reviewed the medical records of 68 confirmed cases of Wolfram syndrome identified through a nationwide survey of endocrinologists, ophthalmologists, institutes, and homes for the blind. We also reviewed all available autopsy records.

RESULTS

The most common causes of morbidity and mortality were the neurological manifestations of this syndrome and the complications of urinary tract atony. There was a lower frequency of diabetic ketoacidosis, no histologically proven diabetic glomerulosclerosis, and less severe, more slowly progressive, diabetic retinopathy than in classic type I diabetic patients. Mortality in Wolfram syndrome is much higher than in type I diabetes; 60% of Wolfram syndrome patients die by age 35. Recognition of these clinical differences from classic type I diabetes is important for the proper management of Wolfram syndrome patients.

CONCLUSIONS

Identification of Wolfram syndrome patients among all diabetic patients presenting in childhood or adolescence is important because the management of patients with this syndrome is different from that of patients with classic type I diabetes.
Exercise Testing as a Long-Term Predictor of the Development of Microalbuminuria in Normoalbuminuric IDDM Patients
Authors: O'Brien Sheila F , Watts Gerald F , Powrie Jake K , Shaw Kenneth M
Published: March 2007

OBJECTIVE

To determine the association between exercise-induced albuminuria and the development of microalbuminuria over 10 years in subjects with insulin-dependent diabetes mellitus (IDDM) who were initially normoalbuminuric.

RESEARCH DESIGN AND METHODS

Thirty-two patients with IDDM and a resting urinary albumin/creatinine ratio (UA/UC) <2.1 mg/mmol (< 15 μg/min) were exercised after water loading on a treadmill for 20 min at double their resting heart rate. UA/UC was determined before and after exercise. The exercise test was considered positive if the UA/UC was >4.3 mg/mmol (>30 μg/min). Results were compared with resting UA/UC after a 10-year follow-up. Persistent microalbuminuria was defined as a UA/UC >2.1 mg/mmol (> 15 μg/min) in each of two early-morning urine collections.

RESULTS

Five patients developed persistent microalbuminuria after 10 years, and four patients were predicted by a positive exercise test. Two patients with positive exercise tests did not develop persistent microalbuminuria. The sensitivity of the exercise test for the development of microalbuminuria was 80% (95% confidence interval [CI] 65.8–94.2%) and the specificity was 92.9% (95% CI 83.9–100%). The postexercise UA/UC was positively associated with the UA/UC after 10 years (P = 0.005, R2 = 0.31). This association was independent of HbA1, systolic blood pressure, body mass index, and duration of diabetes, but HbA1 remained an independent predictor (P = 0.02) of UA/UC at follow-up.

CONCLUSIONS

Exercise testing may be useful for identifying normoalbuminuric IDDM patients who are susceptible to the later development of microalbuminuria.
Anti-Bovine Serum Albumin Antibodies: Genetic Heterogeneity and Clinical Relevance in Adult-Onset IDDM
Authors: Krokowski Marcin , Caillat-Zucman Sophie , Timsit José , Larger Etienne , Pehuet-Figoni Martine , Bach Jean Francois , Boitard Christian
Published: March 2007

OBJECTIVE

To evaluate the prevalence of anti-bovine serum albumin (BSA) antibodies in patients with adult-onset insulin-dependent diabetes mellitus (IDDM) and investigate a possible link between their presence and genetic susceptibility or resistance determined by human leukocyte antigen (HLA) complex.

RESEARCH DESIGN AND METHODS

Sera from 60 recent-onset diabetic patients, 5 prediabetic subjects, and 102 healthy control subjects were tested using a radioimmunoprecipitation assay. HLA-DRB and -DQB alleles were determined by means of allele-specific oligonucleotide typing. Islet cell antibodies (ICAs) were assayed by indirect immunofluorescence.

RESULTS

Levels of anti-BSA antibodies were significantly higher in IDDM patients (18.1 ± 3.5%, n = 60) than in healthy control subjects (7.5 ± 1.2%, n = 102) (P < 0.001), but in only 16.6% of IDDM patients (10 of 60) were the titers above the 95th percentik of control values. Anti-BSA antibody titers were higher in HLA-DR3 and/or -DR4 patients (23.4±4.9%, n = 41) compared with DR3 and/or DR4 control subjects (3.1 ± 1.0%, n = 10) (P < 0.001). DR3 IDDM patients showed higher levels of anti-BSA antibodies (26.3 ± 6.3%, n = 30) than non-DR3 patients (9.9 ± 2.6%, n = 30) (p < 0.01) and healthy control subjects. Only two out of five prediabetic subjects had significant anti-BSA levels before clinical onset of diabetes.

CONCLUSIONS

Our data confirm that antibodies to BSA are present in adult-onset IDDM patients, particularly in HLA-DR3-positive patients. However, the prevalence of anti-BSA antibodies was lower than previously reported in children, and there was a considerable overlap with healthy control subjects. Only two out of the five prediabetic patients demonstrated anti-BSA antibodies. Taken together, these results do not bring strong support to the clinical usefulness of anti-BSA antibodies as a relevant marker in diabetes prediction or diagnosis.
Insulin Sensitivity and Lp(a) Concentrations in Normoglycemic Men
Authors: Haffner Steven M , Karhapaa Pauli , Rainwater David L , Mykkanen Leena , Aldrete Gilbert , Laakso Markku
Published: March 2007

OBJECTIVE

Increased lipoprotein(a) [Lp(a)] concentrations have been recognized as a risk factor for coronary heart disease. Little data exists on the relationship of Lp(a) concentrations to insulin resistance.

RESEARCH DESIGN AND METHODS

We examined insulin resistance (as determined by the euglycemic clamp) together with indirect calorimetry in relation to Lp(a) concentrations, apolipoprotein(a) [apo(a)] molecular weight, and apo(a) phe-notype in 87 normoglycemic men.

RESULTS

Lp(a) concentrations were significantly related to total (r = 0.225) and nonoxidative (r = 0.256) whole-body glucose disposal. These results suggest a positive but weak association between insulin sensitivity (restricted to the nonoxidative whole-body glucose disposal) and Lp(a) concentrations. However, after adjustment for apo(a) molecular weight [which accounts for some of the genetic influences on Lp(a) levels], total and nonoxidative body glucose disposal were not significantly related to Lp(a) concentrations.

CONCLUSIONS

Normoglycemic insulin-resistant subjects do not have elevated Lp(a) concentrations.
Digoxin Does Not Accelerate Progression of Diabetic Retinopathy
Authors: Gardner Thomas W , Klein Ronald , Moss Scot E , Ferris Frederick L , Remaley Nancy A
Published: March 2007

OBJECTIVE

To test the hypothesis that digoxin, an inhibitor of Na+ -K+ -ATPase activity, accelerates the progression of diabetic retinopathy.

RESEARCH DESIGN AND METHODS

We compared the incidence and risk of retinopathy in 120 digoxin-taking vs. 867 non-digoxin-taking diabetic participants in the Wisconsin Epidemiologie Study of Diabetic Retinopathy (WESDR) and in 117 digoxin-taking vs. 1,883 non-digoxin-taking diabetic subjects in the Early Treatment Diabetic Retinopathy Study (ETDRS). In both studies, retinopathy was detected by grading stereoscopic color photographs using the modified Airlie House classification scheme, and a two-step difference in baseline retinopathy grade was considered significant.

RESULTS

After controlling for other risk factors, we found no statistically significant association with either 4-year incidence of retinopathy (WESDR) or progression of retinopathy (WESDR and ETDRS) in patients taking digoxin at baseline compared with those not taking digoxin.

CONCLUSIONS

These data suggest that digoxin therapy does not adversely affect the course of diabetic retinopathy.
Lower Limb Venous Pressure in Diabetic Neuropathy
Authors: Purewal Tejpal S , Goss David E , Watkins Peter J , Edmonds Michael E
Published: March 2007

OBJECTIVE

Distended turgid veins have been noted in the feet of patients with diabetic neuropathy. This study assessed the supine venous pressure and its correlation with diabetic neuropathy and arteriovenous (AV) shunting in the feet of type I and type II diabetic subjects.

RESEARCH DESIGN AND METHODS

Seventeen patients with chronic Charcot joints, 11 patients with a history of neuropathic foot ulceration, 14 diabetic control subjects, and 11 normal control subjects were studied. Neuropathy was assessed by vibration and thermal thresholds and standard cardiovascular autonomie neuropathy tests. Supine venous pressure was measured by insertion of a 21-gauge needle connected to a strain gauge manometer into the veins on the dorsum of the foot. Venous Po2 was used as a measure of AV shunting.

RESULTS

Venous pressure was raised in the group with chronic Charcot joints (18.9 ± 4.2mmHg, P < 0.001 vs. the diabetic control group [11.3 ± 2.6mmHg]), the normal control group (12.3 ± 2.3 mmHg, mean ± SD), and the diabetic group with a history of neuropathic foot ulceration (16.0 ± 3.7 mmHg, P = 0.008 vs. diabetic control subjects and P = 0.04 vs. normal control subjects), with a maximum of 28 mmHg. Venous pressure was correlated with heart rate variation to deep breathing, r = −0.61 (P = 0.001), vibration threshold, r = 0.56 (P = 0.001), Valsalva ratio, r = −0.64 (P = 0.001), warm threshold, r = 0.69 (P = 0.001), and venous Po2, r = 0.43 (P = 0.02). There was no correlation with skin temperature, duration of diabetes, age, HbAlc, random blood glucose, ankle/brachial Doppler index, height, or serum creatinine.

CONCLUSIONS

Venous pressure is much higher in the neuropathic diabetic limb and is correlated with the severity of neuropathy and with AV shunting.
A New and Simple Questionnaire to Identify People at Increased Risk for Undiagnosed Diabetes
Authors: Herman William H , Smith Philip J , Thompson Theodore J , Engelgau Michael M , Aubert Ronald E
Published: March 2007

OBJECTIVE

To develop a simple questionnaire to prospectively identify individuals at increased risk for undiagnosed diabetes.

RESEARCH DESIGN AND METHODS

People with newly diagnosed diabetes (n = 164) identified in the Second National Health and Nutrition Examination Survey and those with neither newly diagnosed diabetes nor a history of physician-diagnosed diabetes (n = 3,220) were studied. Major historical risk factors for undiagnosed non-insulin-dependent diabetes were defined, and classification trees were developed to identify people at higher risk for previously undiagnosed diabetes. The sensitivity, specificity, and predictive value of the classification trees were described and compared with those of an existing questionnaire.

RESULTS

The selected classification tree incorporated age, sex, history of delivery of a macrosomic infant, obesity, sedentary lifestyle, and family history of diabetes. In a representative sample of the U.S. population, the sensitivity of the tree was 79%, the specificity was 65%, and the predictive value positive was 10%.

CONCLUSIONS

This classification tree performed significantly better than an existing questionnaire and should serve as a simple, noninvasive, and potentially cost-effective tool for diagnosing diabetes in the U.S.
Immunogenicity of Long-Term Intraperitoneal Insulin Administration With Implantable Programmable Pumps: Metabolic consequences
Authors: Lassmann-Vague Véronique , Belicar Pauline , Raccah Denis , Vialettes Bernard , Sodoyez Jean Claude , Vague Philippe
Published: March 2007

OBJECTIVE

To assess immunogenicity of intraperitoneal insulin infusion via implanted pumps by two methods and to evaluate the possible influence of an increased antibody level on metabolic and clinical parameters.

RESEARCH DESIGN AND METHODS

We studied insulin antibody levels in 17 type I diabetic patients before and until 24 months after implantation of a programmable pump delivering insulin intraperitoneally. Antibody levels were determined by radioimmunoassay (RIA) and enzyme-linked immunosorbent assay (ELISA). They were correlated with HbA1c, insulin requirements, free insulin, and the incidence of hypoglycemia.

RESULTS

Insulin antibodies increased as soon as the 3rd month after implantation. This increase was sustained throughout the study period (month 0, 25.4 ± 16.2%; month 3, 41.2 ± 23.5%; month 12, 45.9 ± 26%; month 24, 48.7 ± 25%). The data was correlated with the two assay methods (RIA and ELISA). Postimplantation level was correlated with preimplantation level, which could indicate a predictive value of the latter. No correlation was observed with any metabolic parameters, particularly the number of hypoglycemic episodes.

CONCLUSIONS

Our results indicate that intraperitoneal insulin administration by implantable programmable pumps leads to an increase of insulin antibodies, which are probably high-affinity antibodies (recognized by both RIA and ELISA). This increase in insulin immunogenicity did not induce significant metabolic consequences, which is reassuring for the future of programmable insulin pumps.
Decreased Erythrocyte Membrane Fluidity in Poorly Controlled IDDM: Influence of ketone bodies
Authors: Candiloros Harilaos , Muller Sylvaine , Zeghari Nezha , Donner Mireille , Drouin Pierre , Ziegler Olivier
Published: March 2007

OBJECTIVE

To examine the factors that might alter the fluidity of erythrocyte membrane in insulin-dependent diabetes mellitus (IDDM) patients.

RESEARCH DESIGN AND METHODS

The subjects were 10 health men and 30 IDDM mem: 10 with good blood glucose (BG) control (HbA1c 5.88 ± 0.60% [mean ± SD]), 10 with poor BG control (HbA1C 9.48 ± 1.05%), and 10 with poor BG control and mild to moderate diabetic ketoacidosis (DKA) (HbA1C 9.12 ±2.25%, strongly positive ketonuria 3+ and elevated plasma β-hydroxybutyrate). Erythrocyte membrane fluidity was determined by fluorescence polarization using 6-(9-anthroyloxy stearic acid as fluorescent probe.

RESULTS

Membrane fluidity was normal in the diabetic patients with good BG control but significantly lower in the two groups of patients with poor BG control than in the healthy subjects (P < 0.01). The membrane fluidity in the poor BG control groups was also lower in the patients with DKA than in those without DKA (P < 0.01).

CONCLUSIONS

The factors that most influence membrane fluidity in IDDM patients appear to be hyperglycemia and ketone bodies.
Alterations in the Patterns of Insulin Secretion Before and After Diagnosis of IDDM
Authors: O'Meara Niall M , Sturis Jeppe , Herold Kevan c , Ostrega Diane M , Polonsky Kenneth S
Published: March 2007

OBJECTIVE

To study the natural history of β-cell dysfunction in an individual who developed insulin-dependent diabetes mellitus (IDDM) over a 13-month period while under observation.

RESEARCH DESIGN AND METHODS

Insulin secretion rates (ISR) in response to intravenous glucose and mixed meals were estimated by deconvolution of C-peptide levels.

RESULTS

When fasting glucose and glycosylated hemoglobin concentrations were still within the normal range, insulin secretory responses to intravenous glucose infusion were reduced, but 80- to 100-min secretory oscillations could still be detected. Sequential glucose infusion studies over a 3-month period demonstrated a progressive reduction in insulin secretion. The tight temporal coupling between ultradian oscillations in ISR and glucose observed in nondiabetic subjects was lost. In response to mixed meals, the oscillatory pattern of secretion was preserved, but the magnitude of the secretory responses was reduced.

CONCLUSIONS

Our results indicate that despite the lower absolute secretory rates, ultradian ISR oscillations persist in the period before and immediately after the onset of IDDM in this subject, but they are less tightly coupled to glucose than in nondiabetic subjects.
Vessel Wall Properties of Large Arteries in Uncomplicated IDDM
Authors: Kool Mirian J , Lambert Jan , Stehouwer Coen D , Hoeks Arnold P , Boudier Harry A Struijker , Bortel Luc M Van
Published: March 2007

OBJECTIVE

Patients with insulin-dependent diabetes mellitus (IDDM) are at high risk for cardiovascular disease. Arterial distensibility and compliance are vessel wall properties of large arteries. Altered large artery wall properties can be an early feature of vascular dysfunction. This study investigates vessel wall properties in 30 patients with uncomplicated IDDM and 30 matched healthy control subjects.

RESEARCH DESIGN AND METHODS

Vessel wall properties of the elastic common carotid (CCA) and the muscular femoral (FA) and brachial arteries (BA) were measured with a vessel wall movement detector system. Blood pressure and heart rate were recorded simultaneously with a semiautomated device. Aortic pulse wave velocity was estimated from the carotido-femoral transit time.

RESULTS

Blood pressure (IDDM patients: 118 ± 10/69 ± 5 mmHg), pulse pressure (IDDM patients: 49 ± 8 mmHg), and heart rate (IDDM patients: 65 ± 9 beats/min) were similar in IDDM patients and control subjects. No statistically significant changes between IDDM patients and control subjects were found for diameter, distensibility, and compliance of the elastic CCA and the muscular BA. Distensibility (IDDM patients: 16.9 ± 6.4 10-3/ kPa; control subjects: 22.4 ± 11.8 10-3/kPa) of the muscular FA was decreased in IDDM (P < 0.05). However, FA compliance (IDDM patients: 0.80 ± 0.23 mm-2/kPa; control subjects: 0.94 ± 0.41 mm2/kPa) and FA diameter (IDDM patients: 7.87 ±1.10 mm; control subjects: 7.57 ±1.11 mm) did not differ statistically between IDDM patients and control subjects. Aortic pulse wave velocity was the same in IDDM patients and control subjects (IDDM patients: 5.1 ± 0.6 m/s). No relation was found between vessel wall properties and duration of disease, actual glucose level, and HbA1c for all three arteries (CCA, BA, and FA). But the groups might have been too small to draw conclusions.

CONCLUSIONS

The results of the present study show that in this group of patients with uncomplicated IDDM, vessel wall properties of elastic and muscular large arteries were not obviously reduced when compared with healthy control subjects. However, distensibility of the FA was lower in IDDM patients. Early atherosclerotic changes in IDDM frequently occur at this site. A difference related to the duration of diabetes could not be excluded.
Evaluation of a Structured Outpatient Group Education Program for Intensive Insulin Therapy
Authors: Pieber Thomas R , Brunner Gernot A , Schnedl Wolfgang J , Schattenberg Susanne , Kaufmann Peter , Krejs Guenter J
Published: March 2007

OBJECTIVE

To determine the efficacy and safety of a structured diabetes teaching and treatment program (DTTP) in patients with insulin-dependent diabetes mel-litus (IDDM) in an outpatient setting.

RESEARCH DESIGN AND METHODS

All patients with IDDM who completed a structured 5-day outpatient DTTP were reevaluated after a mean follow-up of 3 years. A standardized interview was used to assess frequency of severe hypoglycemia, type of insulin treatment, self-monitoring, and other diabetes-related parameters. HbA1c was measured by high-performance liquid chromatography.

RESULTS

Of 205 patients, 4 (2%) died during the observation period. HbA1c in the 201 surviving patients decreased significantly from 8.7 ± 2.0 to 7.5 ± 1.2% at follow-up (P < 0.001); frequency of severe hypoglycemia decreased from a mean of 0.46 to 0.13 per patient per year (P < 0.001). Hospital admission due to acute metabolic disturbances decreased from 4.5 ± 11.1 to 1.4 ± 6.7 days/patient-year (P < 0.001). At follow-up, intensive insulin therapy was carried out by 98% of the patients, and 80% of the patients reported three or more measurements of blood glucose per day. Diabetes-related knowledge had a positive (P < 0.01) and body mass index a negative (P < 0.02) influence on improving HbA1c assessed by multiple regression analysis. Severe hypoglycemia after DTTP was associated with a history of severe hypoglycemia before DTTP (P < 0.001) and the existence of overt diabetic nephrop-athy (P < 0.05).

CONCLUSIONS

A structured outpatient DTTP as used in this study is able to improve overall metabolic control and decrease the frequency of severe hypoglycemia in patients with IDDM.
Metabolic Control and Progression of Retinopathy: The Diabetes in Early Pregnancy Study
Authors: Chew Emily Y , Mills James L , Metzger Boyd E , Remaley Nancy A , Jovanovic-Peterson Lois , Knopp Robert H , Conley Mary , Rand Lawrence , Simpson Joe L , Holmes Lewis B , Aarons Jerome H ,   National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study
Published: March 2007

OBJECTIVE

To evaluate the role of metabolic control in the progression of diabetic retinopathy during pregnancy.

RESEARCH DESIGN AND METHODS

We conducted a prospective cohort study of 155 diabetic women in the Diabetes in Early Pregnancy Study followed from the periconceptional period to 1 month postpartum. Fundus photographs were obtained shortly after conception (95% within 5 weeks of conception) and within 1 month postpartum. Glycosylated hemoglobin was measured weekly during the 1st trimester and monthly thereafter.

RESULTS

In the 140 patients who did not have proliferative retinopathy at baseline, progression of retinopathy was seen in 10.3, 21.1, 18.8, and 54.8% of patients with no retinopathy, microaneurysms only, mild nonproliferative retinopathy, and moderate-to-severe nonproliferative retinopathy at baseline, respectively. Proliferative retinopathy developed in 6.3% with mild and 29% with moderate-to-severe baseline retinopathy. Elevated glycosylated hemoglobin at baseline and the magnitude of improvement of glucose control through week 14 were associated with a higher risk of progression of retinopathy (adjusted odds ratio for progression in those with glycohe-moglobin ≥ 6 SD above the control mean versus those within 2 SD was 2.7; 95% confidence interval was 1.1-7.2; P = 0.039).

CONCLUSIONS

The risk for progression of diabetic retinopathy was increased by initial glycosylated hemoglobin elevations as low as 6 SD above the control mean. This increased risk maybe due to suboptimal control itself or to the rapid improvement in metabolic control that occurred in early pregnancy. Excellent metabolic control before conception may be required to avoid this increase in risk. Those with moderate-to-severe retinopathy at conception need more careful ophthalmic monitoring, particularly if their diabetes was suboptimally controlled at conception.
HLA-DQβl Typing and Non-Asp57 Alleles in the Aborigine Population of Senegal
Authors: Chauffert Maryline , Cisse Aynina , Chevenne Didier , Parfait Béatrice , Michel Simone , Trivin François
Published: March 2007

OBJECTIVE

To investigate, in Senegalese subjects, the frequency of human leukocyte antigen (HLA)-DQβ1 alleles and their role in susceptibility to insulin-dependent diabetes mellitus (IDDM).

RESEARCH DESIGN AND METHODS

HLA-DQβ1 typing was done in 55 IDDM subjects and 118 nondiabetic control subjects by means of polymerase chain reaction restriction fragment length polymorphism.

RESULTS

All;eles bearing a codon for an Asp residue at position 57 in the DQ β-chain were associated with a significantly lower risk of IDDM. Alleles 0201 and 0302 (Ala57) were positively associated with diabetes, but allele 0501 (Val57) was less frequent in IDDM subjects than in control subjects.

CONCLUSIONS

HLA-DQβl alleles may be genetic susceptibility markers for IDDM in the Senegalese population, as they are in Caucasian populations.
Short-Term and Long-Term Memory in Elderly Patients with NIDDM
Authors: Helkala Eeva-Liisa , Niskanen Leo , Viinamaki Heimo , Partanen Juhani , Uusitupa Matti
Published: March 2007

OBJECTIVE

To determine cognitive and memory dysfunction associated with non-insulin-dependent diabetes mellitus (NIDDM) and its relationship with depression, metabolic control, and serum lipids.

RESEARCH DESIGN AND METHODS

We studied a well-characterized group of 20 elderly patients with NIDDM and 22 control subjects with normal glucose tolerance recruited from a larger population-based sample. In addition to clinical and laboratory examinations, self-rating questionnaires that assess minor psychiatric disorder (General Health Questionnaire) and depression (Zung scale) were completed by patients and control subjects. Memory was examined with digit and block-span tests, word-list learning, Heaton Visual Memory Test, and Moss Visual Span Test. Executive functions were examined by Trail-Making A and A and B test and by Verbal and Category Fluency Tests. Visuoconstructive reasoning was examined with the block design subtest of the Wechsler Adult Intelligence Scale.

RESULTS

The NIDDM patients showed preserved memory span, but poor performance in learning tasks compared with control subjects. The patients recalled no fewer words than the control subjects, but the process of learning seemed to be different in the two groups. The recognition of the learned words was not impaired. Elevated serum total and very-low-density lipoprotein triglyceride levels, measured either before examinations or 5 or 10 years earlier, were associated with effects on retrieval from semantic memory in NIDDM patients.

CONCLUSIONS

The NIDDM patients had impaired control of their learning processes. Elevated serum triglyceride levels may be related to control of mental processing in diabetic patients.
Mortality Risk by Body Weight and Weight Change in People with NIDDM: The WHO Multinational Study of Vascular Disease in Diabetes
Authors: Chaturvedi Nishi , Fuller John H ,   The WHO Multinational Study Group
Published: March 2007

OBJECTIVE

Care guidelines for people with non-insulin-dependent diabetes mellitus (NIDDM) emphasize the importance of weight loss in reducing mortality risk. However, existing evidence regarding the relationship between weight and mortality and the effects of weight change is conflicting. We examined these relationships in the World Health Organization Multinational Study of Vascular Disease in Diabetes.

RESEARCH DESIGN AND METHODS

This was a cohort study of 1,416 men and 1,544 women. Baseline examinations were performed in 1975 through 1977, a morbidity follow-up was performed in 1983, and a mortality follow-up continued until 1988. Data were analyzed according to geographical groups: Europeans, East Asians, and Native Americans. The relationship between weight change and mortality was analyzed for Europeans only.

RESULTS

Generally, body mass index (BMI) was positively associated with age, blood pressure, and cholesterol but was negatively associated with duration of diabetes, prevalence of retinopathy, and use of insulin. There was no clear relationship between BMI and mortality across the geographical groups. In Europeans, weight loss in the leanest subjects at baseline (BMI < 26 kg/m2) was associated with a threefold increase in mortality risk compared with those who had maintained a steady weight (relative risk [RR] 3.05, 95% confidence interval [CI] 1.26–7.36). Only in the most obese group was weight loss associated with a reduction in mortality risk (BMI > 29 kg/m2, RR 0.84, 95% CI 0.40–1.74).

CONCLUSIONS

The positive association of BMI with age, blood pressure, and cholesterol and the negative association with duration of diabetes, retinopathy, and use of insulin may explain why there is no strong relationship between BMI and mortality in NIDDM. Weight loss, particularly in the relatively lean diabetic person, may be associated with an increased mortality risk.
Daily Walking Combined With Diet Therapy Is a Useful Means for Obese NIDDM Patients Not Only to Reduce Body Weight But Also to Improve Insulin Sensitivity
Authors: Yamanouchi Kunio , Shinozaki Takashi , Chikada Kiwami , Nishikawa Toshihiko , Ito Katsunori , Shimizu Shoji , Ozawa Norihito , Suzuki Yoichiro , Maeno Hitoshi , Kato Katsumi , Oshida Yoshiharu , Sato Yuzo
Published: March 2007

OBJECTIVE

To evaluate the effects of walking combined with diet therapy (1,000–1,600 kcal/day) on insulin sensitivity in obese non-insulin-dependent diabetes mellitus (NIDDM) patients.

RESEARCH DESIGN AND METHODS

Subjects were divided into two groups: 10 patients were managed by diet alone (group D), and 14 patients were placed in the diet and exercise group (group DE). Group DE was instructed to walk at least 10,000 steps/day on a flat field as monitored by pedometer (19,200 ± 2,100 steps/day), and group D was told to maintain a normal daily routine (4,500 ± 290 steps/day). A glucose clamp procedure at an insulin infusion rate of 40 mU · m−2 · min−1 was performed before and after the 6-; to 8-week training program. Mean serum insulin concentrations ranged from 720 to 790 pmol/l.

RESULTS

While body weight (BW) in groups D and DE decreased significantly (P < 0.01) during the study, the amount of BW reduction in group DE was > that in group D (7.8 ± 0.8 vs. 4.2 ± 0.5 kg, P < 0.01). After training, glucose infusion rate (GIR) and metabolic clearance rate (MCR) in group D did not significantly increase; however, GIR and MCR increased significantly in group DE, from 17.21 ± 1.11 to 26.09 ± 1.11 μmol·kg−1 · min−1 (P < 0.001) and from 3.0 ± 0.3 to 5.3 ± 0.4 ml·kg−1 · min−1 (P < 0.001), respectively. The analysis of variance showed significant effects of exercise (time × exercise, P = 0.0005) for the improvement of MCR. Significant correlations were also observed between Δ MCR and average steps per day (r = 0.7257, P < 0.005) in group DE.

CONCLUSIONS

Walking, which can be safely performed and easily incorporated into daily life, can be recommended as an adjunct therapy to diet treatment in obese NIDDM patients, not only for BW reduction, but also for improvement of insulin sensitivity.
Role of Metformin Accumulation in Metformin-Associated Lactic Acidosis
Authors: Lalau Jean D , Lacroix Christian , Compagnon Patricia , Cagny Bertrand de , Rigaud Jean P , Bleichner Gérard , Chauveau Paul , Dulbecco Patricia , Guérin Claude , Haegy Jean M , Loirat Philippe , Marchand Bruno , Ravaud Yves , Weyne Philippe , Fournier Albert
Published: March 2007

OBJECTIVE

To investigate the role of metformin accumulation in the pathophysiology of metformin-associated lactic acidosis.

RESEARCH DESIGN AND METHODS

We used high-performance liquid chromatography to measure plasma metformin concentrations in 14 patients who experienced lactic acidosis (pH <7.35 and lactate concentration >5 mmol/l) while receiving chronic metformin treatment. Their treatment was generally based on alkalinization and dialysis therapy.

RESULTS

Clinical shock and/or evidence of tissue hypoxia was found in all patients with the exception of one who had a nonsteroidal anti-inflammatory drug-induced anuria. Ten patients had significant metformin accumulation (plasma metformin concentrations 4.1-84.9 mg/l, normal value 0.6 ± 0.5 mg/l before drug intake), generally because of failure to withdraw metformin despite intercurrent pathological conditions affecting its renal elimination (serum creatinine concentrations ranging from 269 to 1,091 μmol/l). There was no metformin accumulation (plasma metformin 0.03–0.7 mg/l) in the four other patients, who had less severe renal failure (serum creatinine 140–349 mumol/l). The severity of the patient's general condition did not predict early hospital mortality (death before discharge from the intensive care unit) even in patients in shock. Whereas it was high in those without metformin accumulation (only 1 of 4 patients recovered), early hospital mortality was low in the 10 patients with metformin accumulation and was not related to its extent (3 patients died with end-stage hepatic failure or cardiac failure). Correlation studies showed a positive correlation between serum creatinine and plasma metformin and between plasma metformin and arterial lactate but, for the latter correlation, only in patients with metformin accumulation.

CONCLUSION

Metformin-associated lactic acidosis is not necessarily due to metformin accumulation; true type B (aerobic) lactic acidosis, i.e., without an apparent associated hypoxic factor, seems exceptional. Neither the severity of the clinical picture nor the degree of metformin accumulation predicted survival; rather, the prognosis was dependent upon the severity of the associated pathological conditions.