bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimization of Evening Insulin Dose in Patients Using the Short-Acting Insulin Analog Lispro
Authors: Ahmed Abu Baker E , Mallias John , Home Philip D
Published: March 2007

OBJECTIVE

A three-way, crossover, open-label, randomized study was designed to compare the evening and night (1800–0800) glycemic control when the evening premeal lispro dose was reduced by 20% and the bedtime basal NPH dose increased by 25%, or when the basal NPH dose was moved to before dinner at 1800, compared with the control arm on standard premeal human regular insulin and pre-bedtime NPH insulin.

RESEARCH DESIGN AND METHODS

A total of 13 type 1 diabetic patients who use a premeal plus basal insulin regimen were studied on three separate days, with identical meals and snacks at the same times on each study day. On the control study day, patients received human regular insulin before dinner and NPH at bedtime in their usual doses. On another day, lispro was given before dinner with a dose reduction of 20%, and NPH at bedtime at 125% of usual dose. In the third regimen, the lispro and NPH were administered together in their usual dose before the evening meal by separate injections. The three regimens were tested in random order.

RESULTS

Postprandial (1800–2200) blood glucose concentrations were lower after reduced-dose lispro compared with human regular insulin (6.0 ± 0.3 [SEM] vs. 7.4 ± 0.3 mmol/1, P < 0.05). Nighttime (2400–0400) blood glucose concentrations were not different (8.6 ± 0.3 vs. 9.2 ± 0.3 mmol/1, NS), and prebreakfast concentrations were also unchanged (7.7 ± 0.9 vs. 8.7 ± 0.8 mmol/1) after lispro with increased-dose NPH compared with standard insulin. By contrast, both nighttime (10.0 ± 0.3 mmol/1, P < 0.05) and fasting glucose concentrations (10.8 ± 0.6 mmol/1, P < 0.05) were significantly higher with dinnertime usual-dose lispro plus dinnertime usual-dose NPH compared with standard human insulin. Hypoglycemia at night (blood glucose <3.0 mmol/1) did not differ between study days, but it was more frequent postprandially after dinner usual-dose lispro plus early NPH (2 vs. 7 patients, P = 0.062).

CONCLUSIONS

With lower mealtime and higher basal bedtime insulin doses, patients using insulin lispro may be able to gain an overall improvement in evening blood glucose control without deteriorated nighttime glucose levels. Earlier basal NPH dosage alone does not ameliorate the nighttime hyperglycemia of short-acting insulin analog regimens.
Stiffness Indexes β of the Common Carotid and Femoral Arteries Are Associated With Insulin Resistance in NIDDM
Authors: Emoto Masanori , Nishizawa Yoshiki , Kawagishi Takahiko , Maekawa Kiyoshi , Hiura Yoshikazu , Kanda Hiroyuki , Izumotani Kyoko , Shoji Tetsuo , Ishimura Eiji , Inaba Masaaki , Okuno Yasuhisa , Morii Hirotoshi
Published: March 2007

OBJECTIVE

To investigate the association between arterial wall stiffness indexes β of the common carotid artery (CCA) and the femoral artery (FA) and insulin resistance in NIDDM subjects in a cross-sectional study.

RESEARCH DESIGN AND METHODS

We evaluated the arterial stiffness indexes β of CCA and FA using an ultrasonic phase-locked echo-tracking system in 60 NIDDM subjects attending the diabetes center in Osaka City University Hospital, compared with 120 ageand sex-matched control subjects. Insulin sensitivity indexes were evaluated using a euglycemic-hyperinsulinemic clamp.

RESULTS

Stiffness indexes β of both CCA and FA were significantly higher in NIDDM subjects than in control subjects (CCA 18.1 ± 0.9 vs. 11.7 ± 0.3, respectively, P < 0.001; FA 35.7 ± 2.3 vs. 23.7 ± 0.8, respectively, P < 0.001). The mean insulin sensitivity index in NIDDM subjects was 4.69 ± 0.29 mg · kg−1 · min−1 · mU−1 · 1. The stiffness indexes β of both CCA and FA were inversely correlated with insulin sensitivity indexes (CCA r = −0.393, P = 0.002; FA r = −0.329, P = 0.010), as well as with age, duration of diabetes, and mean blood pressure. In stepwise multiple regression analyses, insulin sensitivity index and duration of diabetes were identified as significant independent variables for stiffness indexes 3 in both CCA and FA (CCA R2 = 0.249, P = 0.0003; FA R2 = 0.336, P < 0.0001).

CONCLUSIONS

Arterial stiffness indexes β of CCA and FA were associated with insulin resistance in NIDDM subjects.
Diabetes Care for Medicare Beneficiaries: Attitudes and behaviors of primary care physicians
Authors: Drass Jan , Kell Sherron , Osborn Morris , Bausell Barker , Corcoran James , Moskowitz Alan , Fleming Barbara
Published: March 2007

OBJECTIVE

To obtain information related to primary care physician (PCP) attitudes, knowledge, and practice patterns, as well as perceptions about barriers to care and the use of materials to assist in the delivery of diabetes care for elderly patients in the office setting.

RESEARCH DESIGN AND METHODS

A survey was mailed to a random sample (n = 900) of PCPs (internal medicine, family practice, and general practice physicians and endocrinologists) from the states of Alabama, Iowa, and Maryland who met selection criteria and provided diabetes care to ≥25 Medicare beneficiaries during calendar year 1993.

RESULTS

Respondents provided self-reported information regarding diabetes care for elderly patients. PCP respondents (n = 370) considered blood glucose control to be the most important treatment goal. Most respondents (92%) considered acceptable GHb values to be those < 8%. Blood pressure measurement and foot inspections for the detection of ulcers and infection were the most commonly reported routine procedures performed as part of an office visit. Laboratory tests reported to be frequently ordered included GHb, serum creatinine, and proteinuria tests. Patient nonadherence to the treatment regimen was reported to be the most common barrier to care. The majority of respondents reported using two treatment aids in caring for patients with diabetes.

CONCLUSIONS

The results of this study provide some evidence that PCP self-reported attitudes, knowledge, and practice patterns in delivering diabetes care for elderly patients in the office setting more closely reflect current recommended practice than reported in previous physician surveys. Opportunities for improvement still exist.
Hydroperoxides in Plasma Are Reduced by Intensified Insulin Treatment: A randomized controlled study of IDDM patients with microalbuminuria
Authors: Berg Tore Julsrud , Nourooz-Zadeh Jaffar , Wolff Simon P , Tritschler Hans J , Bangstad Hans-Jacob , Hanssen Kristian F
Published: March 2007

OBJECTIVE

An association between reactive oxygen species and diabetic micro- and macrovascular complications has been proposed. In the present study, we have examined the effect of an improved blood glucose control on plasma levels of hydroperoxides in patients with IDDM.

RESEARCH DESIGN AND METHODS

Subjects included 30 young IDDM patients with microalbuminuria who were randomized to receive either continuous subcutaneous insulin infusion (CSII) by a portable insulin pump (n = 15) or conventional insulin treatment (CIT) (n = 15) for 24 months. Plasma levels of hydroperoxides were measured by the ferrous oxidation with Xylenol Orange, version 2 (FOX2) assay. This method measures total lipid hydroperoxides and, unlike other methods, does not suffer from extraction losses.

RESULTS

The mean HbA1c level was lower in the CSII group at the end of the study than in the CIT group: (mean [95% CI]) 8.6 (8.1–9.1) vs. 9.6 (9.0–10.3)%, respectively (P < 0.002). The level of plasma hydroperoxides was very similar at the start of the study but was significantly lower in the CSII group compared with the CIT group at the end of the study: 2.9 (2.1–3.7) vs. 4.3 (3.2–5.4) μmol/l, respectively (P < 0.02). In the CSII group, hydroperoxides were reduced by 31% from baseline (P < 0.001), whereas there was no change in levels of hydroperoxides in the CIT group. Mean hydroperoxide levels correlated with mean HbA1c during the study (r = 0.39, P < 0.04). Hydroperoxide levels were associated with the levels of microalbuminuria (r = 0.45, P < 0.02).

CONCLUSIONS

This study provides support for the hypothesis that hyperglycemia is an important factor in the generation of hydroperoxides, and, thus, reactive oxygen species, in the circulation of IDDM patients.
Diabetic Peripheral Neuropathy: Effectiveness of electrotherapy and amitriptyline for symptomatic relief
Authors: Kumar Dinesh , Alvaro Michael S , Julka Inderjeet S , Marshall Howard J
Published: March 2007

OBJECTIVE

To evaluate the efficacy of combining electrotherapy with amitriptyline for the management of chronic painful peripheral neuropathy in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Patients (n = 26) with peripheral neuropathy were treated with amitriptyline. After 4 weeks, those patients (n = 23) who failed to respond to amitriptyline or who only had partial relief were randomized between a sham treatment group (control) or an electrotherapy group. Transcutaneous electrotherapy was given for 12 weeks by a portable unit (H-wave machine) that generated a biphasic exponentially decaying waveform (pulse width 4 ms, 25–35 V, ≥ 2 Hz). The degree of pain and discomfort was graded on a scale of 0–5. An analog scale was used to record the overall change in symptoms.

RESULTS

Amitriptyline produced some degree of symptomatic relief in 15 (60%) of the 26 patients by the 4th week; pain scores decreased from 3.8 ± 0.1 to 2.9 ± 0.2 (P < 0.1) and the overall reduction in pain was 26 ± 5% on an analog scale. In the amitriptyline plus sham treatment group (n = 9), pain scores declined from 2.8 ± 0.3 to 1.9 ± 0.5 (P < 0.03) and the overall reduction in pain was 55 ± 12%, suggesting a procedure-related placebo effect. In the group receiving combined electrotherapy and amitriptyline (n = 14), symptomatic improvement occurred in 12 (85%) patients. Five (36%) of the patients in this group became asymptomatic. Pain scores declined from 3.2 ± 0.2 to 1.4 ± 0.4 (P < 0.01) and the overall reduction in pain was 66 ± 10%. The degree of reduction in pain scores and the incremental relief (above the amitriptyline effect) were significantly greater (P < 0.03) with electrotherapy as compared with sham treatment. The outcomes indicate a substantial beneficial effect of electrotherapy over and above any placebo influence.

CONCLUSIONS

Our clinical observations suggest that transcutaneous electrotherapy is effective in reducing the pain associated with peripheral neuropathy. This form of therapy may be a useful adjunctive modality when it is combined with a pharmacological agent, such as amitriptyline, to augment symptomatic relief.
Ultrasonographic Manifestations of Carotid Atherosclerosis and Glucose Intolerance in Elderly Eastern Finnish Men
Authors: Tuomilehto Jaakko , Qiao Qing , Salonen Riitta , Nissinen Aulikki , Salonen Jukka T
Published: March 2007

OBJECTIVE

To study the association of ultrasonographic manifestations of common carotid atherosclerosis with glucose intolerance in survivors of the cohort of men born in 1900–1919 in eastern Finland.

RESEARCH DESIGN AND METHODS

Carotid ultrasonography was carried out for 182 men in 1989. Glucose tolerance status classified based on an oral glucose tolerance test in 1984 and 1989 surveys was used in both prospective and cross-sectional analyses.

RESULTS

Carotid atherosclerosis was common in men aged 70–89 years. There was no significant difference in the maximal carotid intimal-medial thickness between diabetic and nondiabetic men and over different age-groups; it was 1.28, 1.33, and 1.36 mm in subjects with diabetes, impaired glucose tolerance, and normal glucose tolerance, respectively (P = 0.69). No association between the presence of a nonmineralized or a mineralized atherosclerotic lesion with diabetes was found. Fasting plasma insulin did not relate to ultrasonographically detectable atherosclerotic lesions.

CONCLUSIONS

Hyperglycemia and hyperinsulinemia may not be main contributors to atherosclerosis in elderly men, partly because smoking is less common and total and LDL cholesterol concentrations are lower in diabetic men than in men with normal glucose tolerance.
Resistance Training Improves Insulin Sensitivity in NIDDM Subjects Without Altering Maximal Oxygen Uptake
Authors: Ishii Tomofusa , Yamakita Tetsuya , Sato Toshihiko , Tanaka Shiro , Fujii Satoru
Published: March 2007

OBJECTIVE

To examine the effect of resistance training on insulin sensitivity in nonobese NIDDM patients.

RESEARCH DESIGN AND METHODS

Previously sedentary nonobese NIDDM patients were enrolled in a resistance training group (RT; n = 9) or used as sedentary control subjects (SED; n = 8). SED subjects did not perform exercise training because of orthopedic disorders. The training program consisted of two sets of nine exercises with 10–20 repetitions. Subjects trained five times a week for 4–6 weeks. Insulin sensitivity, as assessed by the hyper-insulinemic-euglycemic clamp technique, HbAIc, and body composition, was measured before and after the training period. Maximal oxygen uptake (VO2max) and quadriceps strength were measured in the RT group.

RESULTS

The two groups did not differ significantly on any variables before participation in the program. The glucose disposal rate during the hyperinsulinemic-euglycemic clamp increased 48% in the RT group (6.85 ± 1.86 to 10.12 ± 3.15 mg · kg−1 lean body mass · min−1; P < 0.05), but remained unchanged in the SED group (5.95 ± 1.63 to 6.36 ± 1.61 mg · kg−1 lean body mass · min−1). There was no significant change in body composition in either group. In the RT group, a 16% increase in quadriceps strength (191.1 ± 45.8 to 216.9 ± 42.8 Nm; P < 0.05) but no significant change (27.6 ± 5.0 to 28.6 ± 6.5 ml · kg−1 · min−1) in VO2max was observed.

CONCLUSIONS

Moderate-intensity, high-volume resistance training improves insulin sensitivity in nonobese NIDDM without altering VO2max.
Population-Based Assessment of the Level of Care Among Adults With Diabetes in the U.S
Authors: Beckles Gloria LA , Engelgau Michael M , Narayan KM Venkat , Herman William H , Aubert Ronald E , Williamson David F
Published: March 2007

OBJECTIVE

To estimate the levels of use of preventive care and to identify correlates of such care among people with diabetes in the U.S.

RESEARCH DESIGN AND METHODS

A cross-sectional study was conducted using a sample of 2,118 adults, age ≥18 years, with self-reported diabetes in 22 states that participated in the 1994 Behavioral Risk Factor Surveillance System. Most subjects were age ≥45 years (83%), women (51%), and white (75%) and were diagnosed at ages ≥30 years (83%), had type 2 diabetes (89%), and were not using insulin (66%).

RESULTS

Among all people with diabetes, 78% practiced self-monitoring of blood glucose, and 25% were aware of the term “glycosylated hemoglobin” or “hemoglobin A one C” (HbA1c). In the last year, 72% of the subjects visited a health care provider for diabetes care at least once, 61% had their feet inspected at least once, and 61% received a dilated eye examination. Controlled for age and sex, the odds ratios (ORs) for insulin use were for self-monitoring (OR [95% CI]; 4.0 [2.6–6.1]); having heard of HbA1c or receipt of a dilated eye examination (1.9 [1.4–2.5]); at least one visit to a provider (3.4 [1.9–7.2]); and feet inspected at least once (2.1 [1.5–2.9]). In addition, people <45 years, those who did not complete high school, and those without insurance coverage were high-risk groups for underuse of preventive care. Only 3% of insulin users and 1% of nonusers met all five of the American Diabetes Association standards in the previous year.

CONCLUSIONS

Underuse of recommended preventive care practices is common among people with diabetes.
Sympathetic Function Test of Vasoconstrictor Changes in Foot Arteries in Diabetic Patients
Authors: Takahashi Tatsuji , Nishizawa Yoshiki , Emoto Masanori , Kawagishi Takahiko , Matsumoto Naoki , Ishimura Eiji , Inaba Masaaki , Okuno Yasuhisa , Shimada Hiroyuki , Morii Hirotoshi
Published: March 2007

OBJECTIVE

We studied the relationship between vasoconstrictor changes in foot arteries (pedal, metatarsal, and digital arteries) and autonomic neuropathy in diabetic patients to estimate the degrees of sympathetic dysfunction.

RESEARCH DESIGN AND METHODS

Sixty-two patients and nineteen age-matched control subjects were studied. The resistance index (RI) and pulsatility index (PI) were measured as vascular hemodynamic parameters using Doppler sonography, and the increases in these hemodynamic parameters (%RI and %PI) from rest to a deep breath were measured as indexes of the degrees of sympathetic vasoconstrictor function. Cardiovascular autonomic function tests (AFTs) were performed and the score was compared to %RI and %PI values obtained.

RESULTS

Of the 62 diabetic patients, 51 had various degrees of autonomic neuropathy. Both %RI and %PI in the diabetic patients were significantly < those in the control subjects for all foot arteries tested (all P < 0.001). There were strongly inverse correlations between the %RI and %PI of foot arteries and the AFT score (r = −0.556 to −0.846, P < 0.0001). The %RI of the digital artery was the most strongly correlated with AFT score (r = −0.846, P < 0.0001) among foot arteries tested. The abnormality of sympathetic vasoconstriction was detectable in the majority of the diabetic patients with the early phase of autonomic neuropathy (%RI: 89.5%; %PI: 94.5%).

CONCLUSIONS

We conclude that the %RI of the digital artery is a useful and reliable sympathetic function test of early phase in diabetic patients.
Effect of Hypoglycemia on β-Adrenergic Sensitivity in Normal and Type 1 Diabetic Subjects
Authors: Fritsche Andreas , Stumvoll Michael , Grüb Matthias , Sieslack Sonja , Renn Walter , Schmülling Reinhold-Michael , Häring Hans-Ulrich , Gerich John E
Published: March 2007

OBJECTIVE

The purpose of this study was to assess the potential role of reduced tissue sensitivity to catecholamines in the pathogenesis of hypoglycemia unawareness in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

The effect of a single episode of hypoglycemia on β-adrenergic sensitivity was studied in 10 type 1 diabetic patients with apparently normal awareness of hypoglycemia (age 29 ± 5 years, diabetes duration 13 ± 8 years, HbA1c 7.3 ± 0.9%) and 10 age-matched healthy control subjects. β-adrenergic sensitivity was measured with the isoproterenol test after a hyperinsulinemic euglycemic clamp and after a hyperinsulinemic hypoglycemic clamp. β-adrenergic sensitivity was expressed as the dose of intravenous isoproterenol that increased the heart rate by 25 beats/min (IC25).

RESULTS

During hypoglycemia, diabetic subjects had an impaired plasma epinephrine response compared with that of the control subjects (16.7 ± 5.0 vs. 40.1 ± 6.8 ng/ml, P = 0.02). In control subjects, the IC25 was lower after hypoglycemia than after euglycemia (0.83 ± 0.22 vs. 1.13 ± 0.21 μg, P = 0.02) indicating an increase in β-adrenergic sensitivity. In diabetic subjects, on the other hand, the IC25 was greater after hypoglycemia than after euglycemia (1.00 ± 0.26 vs. 0.65 ± 0.14 μ, P = 0.04), indicating a decrease in β-adrenergic sensitivity.

CONCLUSIONS

In normal subjects, a single episode of hypoglycemia increases β-adrenergic sensitivity. In diabetic subjects, in contrast, hypoglycemia reduces β-adrenergic sensitivity. These results provide evidence that in type 1 diabetic patients, some maladaptation of tissue sensitivity to catecholamines contributes to the development of hypoglycemia unawareness. A unifying hypothesis is presented for the pathogenesis of hypoglycemia unawareness in type 1 diabetic patients incorporating the concepts of both a reduced catecholamine response and reduced adrenergic sensitivity.
Plasma Lipoprotein(a) Levels Are Not Influenced by Glycemic Control in Type 1 Diabetes
Authors: Pérez Antonio , Carreras Gemma , Caixàs Assumpta , Castellví Agustina , Caballero Agueda , Bonet Rosa , Ordóñez-Llanos Jordi , de Leiva Alberto
Published: March 2007

OBJECTIVE

To determine the influence of glycemic control improvement with intensive therapy on lipoprotein(a) [Lp(a)] concentrations in type 1 diabetic patients.

RESEARCH DESIGN AND METHODS

A total of 105 poorly controlled type 1 diabetic patients (60 men, 45 women) without diabetic complications participated in a longitudinal study performed in a tertiary referral center, to compare lipid, lipoprotein, and Lp(a) levels before and after 3 months of intensive therapy with multiple insulin doses. Lp(a) levels were measured by the Terumo method. Differences between the two periods were assessed by the paired t test and Wilcoxon's test.

RESULTS

After 3 months of intensive therapy, all patients exhibited improved glycemic control. HbA1c decreased from 8.9 ± 2.4 to 6.5 ± 1.6% (P < 0.0001), being ≤6% in 47% of patients. However, although a more favorable lipoprotein profile was obtained, no changes in Lp(a) concentrations were observed in the whole group of patients (16.7 ± 17.3 vs. 17.2 ± 17.7 mg/dl) or in patients with baseline Lp(a) levels above 30 mg/dl (47.1 ± 14.8 vs. 47.4 ± 18.9 mg/dl) or below 30 mg/dl (9.6 ± 7.3 vs. 10.2 ± 6.7 mg/dl). In addition, patients reaching HbA1c ≤6 or >6% presented similar Lp(a) levels (19.7 ± 18.0 vs. 15.0 ± 17.4 mg/dl), and changes in Lp(a) did not correlate with those observed in HbA1c.

CONCLUSIONS

These data demonstrate that the improvement of glycemic control does not influence plasma Lp(a) concentrations in type 1 diabetic patients independently of baseline Lp(a) levels and the degree of glycemic control.
Hyperglycemia Is a Factor for an Increase in Serum Ceruloplasmin in Type 2 Diabetes
Authors: Daimon Makoto , Susa Susa , Yamatani Keiichi , Manaka Hideo , Hama Kiyoko , Kimura Mamoru , Ohnuma Hiroshi , Kato Takeo
Published: March 2007

OBJECTIVE

To examine if there is a correlation between high blood glucose and serum ceruloplasmin (Cp) levels.

RESEARCH DESIGN AND METHODS

Serum Cp levels were measured in 637 patients with type 2 diabetes (all type 2 diabetes group). For the follow-up type 2 diabetes group, 161 patients who had not had any changes in their situation during the last year that are known to influence serum Cp levels were reexamined 1 year later. The control group was composed of 158 healthy individuals. Serum Cp and blood HbA1c levels were measured by radial immunodiffusion and high-performance liquid chromatography assays, respectively.

RESULTS

Serum Cp levels in the all type 2 diabetes group were significantly higher than those in the control group (P < 0.0001), although the serum Cp levels did not correlate with the blood HbA1c levels in the all type 2 diabetes group (r = 0.055, P = 0.351). Then we evaluated those factors (Δ-log Cp and Δ-HbA1c) in the follow-up type 2 diabetes group to minimize changes from the genetic differences and to exclude any known factors influencing serum Cp levels. This indicated that the Δ-HbA1c had a positive correlation to the Δ-log Cp (r = 0.304, P < 0.0001).

CONCLUSIONS

A persistent high blood glucose (namely HbA1c) is associated with an increase in serum Cp levels over 1 year.
Association of NIDDM and Hearing Loss
Authors: Dalton Dayna S , Cruickshanks Karen J , Klein Ronald , Klein Barbara EK , Wiley Terry L
Published: March 2007

OBJECTIVE

To evaluate the association of NIDDM with hearing loss in a large population-based study.

RESEARCH DESIGN AND METHODS

Data from population-based longitudinal studies of aging conducted in Beaver Dam, Wisconsin, were used in these analyses. Hearing thresholds were determined by pure-tone air- and bone-conduction audiometry performed by trained technicians following American Speech-Language-Hearing Association specifications. Hearing loss was defined as the pure-tone average of the frequencies 500, 1,000, 2,000, and 4,000 Hz > 25 decibels hearing level in the worse ear. Diabetes status was determined by self-report of physician-diagnosed diabetes or by elevated glucose or glycated hemoglobin levels at examination.

RESULTS

Of 3,571 study participants, 344 were classified as having NIDDM. Subjects with NIDDM were more likely to have a hearing loss than were subjects without diabetes (59 vs. 44%). After results were adjusted for age, this difference was not statistically significant. After individuals with hearing loss patterns inconsistent with presbycusis were excluded, there was an association between NIDDM and hearing loss when controlling for potential confounders (odds ratio [OR] 1.41, 95% CI 1.05–1.88). There was no association between duration of diabetes or glycemic control and hearing loss. Individuals with NIDDM and nephropathy were more likely to have a hearing loss than were those with NIDDM but no nephropathy (OR 2.28, 95% CI 1.04–5.00).

CONCLUSIONS

These data are suggestive of a weak association between NIDDM and hearing loss.
Increased Familial History of Arterial Hypertension, Coronary Heart Disease, and Renal Disease in Brazilian Type 2 Diabetic Patients With Diabetic Nephropathy
Authors: Canani Luís H , Gerchman Fernando , Gross Jorge L
Published: March 2007

OBJECTIVE

To evaluate whether there is a familial association of arterial hypertension, coronary heart disease, renal disease, and stroke with diabetic nephropathy

RESEARCH DESIGN AND METHODS

There were 115 outpatients and 34 patients with end-stage renal disease treated by hemodialysis (61 men, age range 41–81 years) and having at least one sibling with type 2 diabetes studied. The positive or negative history of siblings (n = 765) was assessed by a standard questionnaire. The urinary albumin excretion rate (UAER) was measured by radioimmunoassay in 24-h sterile urine (three samples). The subjects were grouped as normoalbuminuric (UAER <20 μg/min, n = 59), microalbuminuric (UAER 20-200 μg/min, n = 35), macroalbuminuric (UAER >200 μg/min, n = 21), and end-stage renal disease (n = 34).

RESULTS

Patients with microalbuminuria, macroalbuminuria, or end-stage renal disease had an increased prevalence of sibling history of arterial hypertension (33.2, 37.3, and 33.8 vs. 23.4%, P < 0.001) and coronary heart disease (15.2, 17.0, and 19.4 vs. 10.2%, P = 0.044) compared with the normoalbuminuric group. The renal disease history was increased only in the siblings of patients with macroalbuminuria or end-stage renal disease (12.8 and 15.6 vs. 7.6 and 6.1%, P = 0.005). The presence of sibling arterial hypertension strongly increases the prevalence of sibling renal and coronary heart disease independent of patient renal status.

CONCLUSIONS

There is an association of diabetic nephropathy and sibling history of arterial hypertension and renal and coronary heart disease in type 2 diabetic patients. These associations are not independent, and arterial hypertension may be their main determining factor.
Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes.
Authors: Sikka R , Waters J , Moore W , Sutton D R , Herman W H , Aubert R E
Published: March 2007

OBJECTIVE: To examine baseline renal screening practices and the effect of nurse case management of patients with diabetes in a group model health maintenance organization (HMO). RESEARCH DESIGN AND METHODS: We performed both 1-year retrospective and 1-year prospective studies of renal assessment practices and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a randomized controlled trial of a diabetes nurse case management program in a group model HMO. In accordance with American Diabetes Association recommendations, urine dipstick and quantitative protein and microalbuminuria testing rates were calculated. RESULTS: At baseline, 77% of patients were screened for proteinuria with dipsticks or had quantitative urine testing. Of patients with negative dipstick findings, 30% had appropriate quantitative protein or microalbumin follow-up at baseline. Baseline ACE inhibitor usage was associated with decreased follow-up testing (relative risk = 0.47). Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing (relative risk = 1.65 and 1.60, respectively). CONCLUSIONS: We found a higher degree of adherence to recommendations for renal testing than has been reported previously. Nurse case management intervention further increased renal screening rates. The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways.
Fasting and post-methionine homocysteine levels in NIDDM. Determinants and correlations with retinopathy, albuminuria, and cardiovascular disease.
Authors: Smulders Y M , Rakic M , Slaats E H , Treskes M , Sijbrands E J , Odekerken D A , Stehouwer C D , Silberbusch J
Published: March 2007

OBJECTIVE: The increased cardiovascular risk in subjects with NIDDM is partly explained by an association with established risk factors like hypertension, dyslipidemia, and obesity. Mild hyperhomocysteinemia has emerged as a new risk factor for cardiovascular disease. The purpose of this study was to assess its role in NIDDM. RESEARCH DESIGN AND METHODS: We studied predictors of homocysteine levels and correlations between homocysteine and (micro-)albuminuria, retinopathy, and history of cardiovascular disease in normotensive NIDDM subjects under stable metabolic control. This was done in 85 NIDDM subjects by measuring fasting and post-methionine-loading homocysteine levels together with blood pressure, BMI, serum cholesterol, triglyceride, HDL cholesterol, folate, vitamin B12, pyridoxal-5-phosphate, HbA1c, and (micro-)albuminuria and creatinine clearance in triplicate 24-h urine samples. The relationship between micro- and macrovascular complications and fasting homocysteine only was studied in an additional 65 subjects, giving a total of 150 subjects. RESULTS: In multiple regression analysis, significant (P < 0.05) predictors of fasting homocysteine were low-normal values of creatinine clearance (threshold effect at < 80 ml.min-1 .1.73 m-2), folate (< 20 nmol/l), and vitamin B12 (< 350 pmol/l), and postmenopausal status in women. Determinants of post-methionine homocysteine were pyridoxal-5-phosphate levels < 80 nmol/l, creatinine clearance, and sex (higher levels in women). Hyperhomocysteinemia did not cluster with other cardiovascular risk factors, like hypertension, obesity, or dyslipidemia. Regarding cardiovascular complications, fasting homocysteine, but not post-methionine homocysteine, was higher in subjects with a history of cardiovascular disease. There was a stepwise increase in the prevalence of subjects with cardiovascular disease with increasing fasting homocysteine. The prevalence of cardiovascular disease was 19.4% in the bottom quartile of fasting homocysteine, versus 55.0% in the top quartile (P for trend < 0.01). Neither fasting homocysteine nor post-methionine homocysteine correlated with (micro-)albuminuria or with retinopathy. CONCLUSIONS: The findings suggest that homocysteine levels in NIDDM rise even with modest deterioration of renal function and when vitamin status is in the low to low-normal range. Fasting homocysteine correlates with macrovascular disease, but we found no evidence of a correlation with retinopathy or (micro-)albuminuria. Post-methionine homocysteine levels do not show a correlation with micro- or macrovascular complications.
Accuracy of pen injectors versus insulin syringes in children with type 1 diabetes.
Authors: Lteif A N , Schwenk W F
Published: March 2007

OBJECTIVE: To compare the accuracy and precision of insulin syringes and pen devices used by children with type 1 diabetes and their parents. RESEARCH DESIGN AND METHODS: There were 48 subjects (32 patients, a parent of an additional 16 patients) instructed to measure out morning insulin doses three times from vials and/or cartridges containing saline mixed with small amounts of [14C]glucose (solution used as regular insulin) and [3H]glucose (solution used as NPH insulin) and to dispense the contents into a scintillation vial. Statistical analysis was used to determine the accuracy and precision of both methods of insulin delivery. RESULTS: The absolute error in measuring out doses of regular insulin < 5 U was greater with insulin syringes compared with pen injection devices (9.9 +/- 2.4 vs. 4.9 +/- 1.6%, respectively). Both were comparable for regular insulin doses > 5 U (3.2 +/- 0.6 vs. 2.2 +/- 0.4% for syringes and pens, respectively). The accuracy in drawing up NPH doses was similar for low and high insulin doses (mean percent error of 7.5 +/- 1.5 vs. 5.6 +/- 1.1%). CONCLUSIONS: Pen devices are more accurate than insulin syringes in measuring out insulin at low insulin doses. The accuracy of insulin syringes improves when higher doses of regular insulin are measured out and becomes comparable to pen devices.
Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers.
Authors: Kalani M , Brismar K , Fagrell B , Ostergren J , Jörneskog G
Published: March 2007

OBJECTIVE: The present study was undertaken to compare the predictive values of transcutaneous oxygen tension (TcPO2) and toe blood pressure (TBP) measurements for ulcer healing in patients with diabetes and chronic foot ulcers. RESEARCH DESIGN AND METHODS: Investigated prospectively were 50 diabetic patients (37 men) with chronic foot ulcers. The age was 61 +/- 12 (mean +/- SD), and the diabetes duration was 26 +/- 14 years. TBP (mmHg) was measured in dig I and TcPO2 (mmHg) at the dorsum of the foot. Ulcer healing was continuously evaluated by measuring the ulcer area every 4-6 weeks. After a follow-up time of 12 months, the patients were divided into three groups according to clinical outcome: healed with intact skin, improved ulcer healing, or impaired ulcer healing. RESULTS: Of the 13 patients who deteriorated, 11 had TcPO2 < 25 mmHg, while 34 of the 37 patients who improved had TcPO2 > or = 25 mmHg. The sensitivity and specificity for TcPO2 were 85 and 92%, respectively, when a cutoff level of 25 mmHg was used for determination of outcome of ulcer healing (healing or nonhealing). The corresponding values for TBP at 30 mmHg were 15 and 97%. Measurement of TcPO2 provided a higher positive predictive value (79%) than TBP (67%). CONCLUSIONS: The results indicate that TcPO2 is a better predictor for ulcer healing than TBP in diabetic patients with chronic foot ulcers, and that the probability of ulcer healing is low when TcPO2 is < 25 mmHg.
First 20 months' experience with use of metformin for type 2 diabetes in a large health maintenance organization.
Authors: Selby J V , Ettinger B , Swain B E , Brown J B
Published: March 2007

OBJECTIVE: To assess adherence to prescribing guidelines, continuation rates, population effects on glycemic control, and occurrence of lactic acidosis during the first 20 months of the availability of metformin in a large health maintenance organization. RESEARCH DESIGN AND METHODS: A retrospective cohort study was performed in the 90,000-member diabetes registry of Kaiser Permanente, northern California. Principal study measures were the proportions of patients started on metformin who met prescribing guidelines (previously on sulfonylureas, HbA1c, obesity, creatinine), the change in HbA1c at 6 months after starting metformin, and hospitalization rates for lactic acidosis. RESULTS: A total of 9,875 patients received metformin during this interval. At least 74% were previously treated with sulfonylureas alone, 81% had baseline HbA1c > or = 8.5%, 71% were obese, and 99% had a serum creatinine < or = 1.5 mg/dl. Among patients on sulfonylureas at baseline, those starting metformin had significantly lower HbA1c levels 6 months later than those not started, after adjustment for age, sex, and the higher baseline levels in those started (adjusted difference: 0.5%, P < 0.0001). Patients starting metformin as initial monotherapy also improved significantly, but patients previously treated with insulin (with or without sulfonyl-ureas) had slightly higher follow-up HbA1c levels than similar patients not starting metformin. Continuation of metformin at 12 months was significantly higher for patients previously treated with sulfonylureas than other groups. One probable case of lactic acidosis was identified during 4,502 person-years on metformin. CONCLUSIONS: Adherence to prescribing guidelines was relatively high during metformin's first 20 months of availability. Glycemic control improved substantially for patients previously treated with sulfonylureas. Lactic acidosis was rare.
Clinical, immunological, and genetic heterogeneity of diabetes in an Italian population-based cohort of lean newly diagnosed patients aged 30-54 years. Piedmont Study Group for Diabetes Epidemiology.
Authors: Bruno G , De Salvia A , Arcari R , Borra M , Grosso N , Carta Q , Trovati M , Veglio M , Pagano G
Published: March 2007

OBJECTIVE: In lean diabetic patients, the presentation of the disease does not allow one to easily distinguish between type 1 and type 2. Aims of this study were to describe clinical, immunological, and genetic features of lean newly diagnosed diabetic patients. RESEARCH DESIGN AND METHODS: A population-based cohort of 130 lean (BMI < 25 kg/m2) newly diagnosed patients, aged 30-54 years, was identified among residents of the province of Turin. Islet cell antibodies (ICAs), anti-GAD, fasting and glucagon-stimulated C-peptide values, and HLA DQA1-DQB1 susceptibility genotypes were assessed within 2 months of the diagnosis. RESULTS: A total of 45 (34.6%) and 29 (22.3%) patients were, respectively, ICA+ and anti-GAD+, with 15 (11.5%) having both antibodies. In 59 patients, ICAs and/or anti-GAD antibodies were detected, giving a high prevalence of autoimmunity (45.4%, 95% Cl 36.8-54.0); relative to patients without markers (n = 71), they were younger (40.8 +/- 7.5 vs. 45.0 +/- 6.5 years, P < 0.001) and showed lower values of fasting C-peptide (0.56 +/- 0.33 vs. 0.79 +/- 0.41 nmol/l, P < 0.001) and stimulated C-peptide (1.03 +/- 0.56 vs. 1.42 +/- 0.69 nmol/l, P < 0.001). The lowest stimulated C-peptide values were found in patients with both ICA and anti-GAD antibodies. Frequencies of adult-onset type 1 and type 2 diabetes were, respectively, 49.2 and 50.8%. Clinical and genetic features were not useful in the classification of patients. CONCLUSIONS: Almost 50% of lean young and middle-aged patients were ICA+ and/or anti-GAD+, suggesting a high prevalence of a slowly evolving form of type 1 diabetes. The evaluation at diagnosis of both beta-cell secretory capacity and markers of autoimmunity is recommended to provide a pathogenetic classification of the disease.
Sex differences in African-Americans regarding sensitivity to insulin's glucoregulatory and antilipolytic actions.
Authors: Sumner A E , Kushner H , Sherif K D , Tulenko T N , Falkner B , Marsh J B
Published: March 2007

OBJECTIVE: The purpose of this study was to determine if there are sex differences in African-Americans regarding the effect of obesity on sensitivity to insulin as a glucoregulatory and antilipolytic hormone. RESEARCH DESIGN AND METHODS: Data from study participants, 127 nondiabetic African-Americans (mean age 32 +/- 4 years), included anthropometric measurements, an oral glucose tolerance test (OGTT), a 2-h euglycemic-hyperinsulinemic clamp, and a fasting triglyceride level. Sensitivity to insulin as a glucoregulatory hormone was determined by M/FFM, where M is the mean glucose infusion rate during the second hour of the clamp and FFM is fat-free mass. Sensitivity to insulin's antilipolytic action was assessed during the OGTT by the percent suppression of free fatty acid (FFA) concentrations between 0 and 120 min. The higher the suppression of FFAs, the greater the sensitivity to insulin's antilipolytic action. RESULTS: The participants were classified by BMI into three groups: nonobese (31 men, 24 women), obese (17 men, 14 women), and severely obese (12 men, 29 women). The women had higher percentages of body fat (P < 0.001), and the men had greater FFM (P < 0.001). The M/FFM values for men versus women in each BMI group were nonobese, 8.8 +/- 2.8 vs. 10.8 +/- 4.4; obese, 7.2 +/- 3.4 vs. 8.5 +/- 3.4; and severely obese, 4.7 +/- 2.1 vs. 6.1 +/- 2.2. The difference between the BMI groups was significant (P < 0.001), as was the difference between men and women (P < 0.01). In addition, there was a significant sex difference in percent suppression of FFAS (P < 0.001). The men and women had similar fasting insulin and FFA concentrations; however, in the men only, the percent suppression of FFA declined with increasing obesity (nonobese, 83 +/- 15%; obese, 73 +/- 18%; and severely obese, 69 +/- 19%; P = 0.02). The women in all three BMI groups had lower FFA levels of 86-88%. CONCLUSIONS: Obese African-American men and women are resistant to insulin as a glucoregulatory hormone, but only obese men are resistant to insulin's antilipolytic action; obese African-American women are sensitive to insulin's antilipolytic action. The combined presence of sensitivity to insulin's antilipolytic action with resistance to insulin's glucoregulatory action in obese African-American women may contribute to their high prevalence of obesity and type 2 diabetes.
Improvements in diabetic care as measured by HbA1c after a physician education project.
Authors: Deichmann R E , Castello E , Horswell R , Friday K E
Published: March 2007

OBJECTIVE: To measure the quality of diabetic care as indicated by HbA1c testing frequency and HbA1c values and to demonstrate improvement in care after an appropriate quality improvement intervention. RESEARCH DESIGN AND METHODS: The quality improvement project used computerized claims and laboratory data relating to HbA1c testing among the private practices of nine physicians caring for diabetic Medicare patients. Nine indicators evaluated three main areas: HbA1c testing frequency, HbA1c values, and frequency of office visits. A quality improvement intervention consisting of a physician component and a patient component was implemented. RESULTS: There were 835 patients and 4,367 visits studied. After the intervention, statistically significant improvements in HbA1c testing frequency and values were noted. Rates of seized opportunities for testing HbA1c improved from 17.7 to 33.9% (P < 0.0001). The percentage of patients with a current HbA1c value improved from 31.3 to 47.6% (P < 0.0001). The median HbA1c values fell from 8.5 to 7.8% (P < 0.006). Patients achieving good or fair control (HbA1c < or = 8%) improved from 43.8 to 56.9% (P = 0.007). The median time between physician visits fell from 70 days to 60 days (P < 0.0001). CONCLUSIONS: The study revealed that HbA1c testing was underused but that after a quality improvement initiative, a significant increase in testing use could be achieved. The quality improvement initiative also resulted in significant improvements in glycemic control. The techniques and interventions used in this study could be used to intervene in larger populations and practice settings to improve medical care for diabetic patients.
Effects of exercise training on oxygen uptake kinetic responses in women with type 2 diabetes.
Authors: Brandenburg S L , Reusch J E , Bauer T A , Jeffers B W , Hiatt W R , Regensteiner J G
Published: March 2007

OBJECTIVE: Women with uncomplicated type 2 diabetes have both a decreased maximal oxygen consumption (VO2max) and slowed oxygen uptake (VO2) kinetics at the onset of exercise compared with nondiabetic women. These abnormalities are seen not only at maximal workloads, but also at the onset of low-level exercise. To evaluate the hypothesis that VO2max and VO2 kinetics would improve with exercise training in untrained people with type 2 diabetes, we measured these parameters in premenopausal sedentary women before and after 3 months of supervised exercise training. RESEARCH DESIGN AND METHODS: A total of 8 women with type 2 diabetes, 9 overweight nondiabetic women, and 10 lean nondiabetic women were studied. At baseline and after 3 months of exercise training, subjects underwent bicycle ergometer testing to obtain VO2max and VO2 kinetics data. RESULTS: On entry, women with type 2 diabetes had the lowest VO2max and slowest VO2 kinetics of the three groups. After exercise training, the women with type 2 diabetes improved their VO2max more than the lean and overweight control women: 28 vs. 5 and 8%, respectively (P < 0.05 for the diabetic group vs. both control groups). In the group with diabetes, VO2 kinetics improved by 39 and 22% at 20 and 30 W, respectively. For the control subjects, VO2 kinetics did not improve at any workload in either group. CONCLUSIONS: Despite beginning with the lowest VO2max and slowest VO2 kinetics, subjects with type 2 diabetes benefited more from an exercise training program than did control subjects. These findings suggest that in addition to its known metabolic effects, exercise training in individuals with type 2 diabetes may be an effective therapy to improve the cardiovascular response to exercise and to overcome low-level exercise impairment as reflected by improved VO2max and VO2 kinetics. If the ability to make circulatory adjustments at the beginning of exercise at low workloads is improved by an exercise training program, as suggested by the VO2 kinetics data, the clinical significance of exercise for people with type 2 diabetes is clear.
A quantitative scale of acanthosis nigricans.
Authors: Burke J P , Hale D E , Hazuda H P , Stern M P
Published: March 2007

OBJECTIVE: To develop and validate a scale for acanthosis nigricans (AN). RESEARCH DESIGN AND METHODS: Subjects were participants from the San Antonio Family Diabetes Study and the San Antonio Family Heart Study. A total of 406 subjects were independently examined for AN by at least two observers. Five locations were examined: the neck, axilla, elbows, knuckles, and knees. Interobserver concordance and kappa statistics were calculated to determine replicability of the scale. Comparisons of diabetes-related risk factors by AN score were also calculated. RESULTS: Only the neck had consistently high kappa statistics, and thus, other locations were excluded from further analyses. Elevated AN was strongly associated with elevated fasting insulin and BMI in both diabetic and nondiabetic subjects. Elevated AN was also strongly associated with elevated fasting glucose, systolic blood pressure, and diastolic blood pressure, and with decreased HDL in nondiabetic subjects. In diabetic subjects, elevated AN was associated with elevated total cholesterol. CONCLUSIONS: We have developed a scale for AN that is easy to use, has high interobserver reliability in Mexican Americans, and correlates well with fasting insulin and BMI. This scale will permit longitudinal and cross-sectional evaluation of AN and will permit the evaluation of AN as a trait in genetic studies.