Showing papers in "Diabetes Care in 1980"
TL;DR: Questions such as do diabetic individuals have a higher incidence of infection,Why are diabetic patients predisposed to infection, why is necrosis common in several of the infections, what is the course of asymptomatic bacteriuria, who do diabetic patients develop foot infections, and how should foot infections be prevented and treated should be topics of clinical investigation.
Abstract: Most physicians believe that diabetic individuals are predisposed to infections and that infection complicates the control of the diabetes. However, only bacteriuria can be documented to occur with increased frequency in diabetic compared with nondiabetic patients. Although most bacteriuric diabetic patients are asymptomatic, severe infections such as emphysematous pyelonephritis, papillary necrosis, perinephric abscess, and candida pyelonephritis may occur. Tuberculosis, once a proven threat to diabetic individuals, is a less serious problem now that effective screening and chemoprophylaxis programs have been initiated. Several unusual infections such as malignant external otitis, rhinocerebral mucormycosis, emphysematous pyelonephritis, and emphysematous cholecystitis occur also exclusively in diabetics. Foot infections are very important in diabetic patients; successful treatment requires accurate assessment of the extent and etiology of the infections and often involves surgery as well as broad antibiotic coverage. The important problem of infection in diabetic patients deserves careful evaluation. Questions such as do diabetic individuals have a higher incidence of infection, why are diabetic patients predisposed to infection, why is necrosis common in several of the infections, what is the course of asymptomatic bacteriuria, who do diabetic patients develop foot infections, and how should foot infections be prevented and treated should be topics of clinical investigation.
363 citations
TL;DR: Thirty insulin-treated diabetic individuals were interviewed in their homes 6–12 mo after having attended diabetic education classes at a community hospital to measure their patients' level of compliance with their insulin administration, urine testing, diet, hypoglycemia management, and foot care prescriptions.
Abstract: Thirty insulin-treated diabetic individuals were interviewed in their homes 6-12 mo after having attended diabetic education classes at a community hospital. Self-report as well as direct observation were used to measure these patients' level of compliance with their insulin administration, urine testing, diet, hypoglycemia management, and foot care prescriptions. All patients were complying with at least 59% of the points measured. Over one-half of the group indicated compliance with at least 70% of the 61 points measured. However, only 7% complied with every one of the 45 points considered to be necessary for good control of their disease. The group was most compliant with regard to insulin administration and least compliant regarding urine testing. The level of these patients' beliefs regarding their disease (severity and susceptibility, treatment benefits, and barriers) and cues to action were also measured. A correlation of 0.5 occurred between these patients' overall compliance levels and a composit of their level of health belief motivation. The highest levels of correlations between the areas of compliance and the motivators occurred with cues to action.
306 citations
TL;DR: A modified oral glucose tolerance test was done during the third trimester in 811 pregnancies in Pima Indian women over a 13-yr period, and maternal and fetal complications were documented, and the third-trimester glucose concentration was highly predictive of the subsequent incidence of diabetes.
Abstract: A modified oral glucose tolerance test was done during the third trimester in 811 pregnancies in Pima Indian women over a 13-yr period, and maternal and fetal complications were documented. Diabetes was known to be present in 51 pregnancies. Among those who were not previously known to have diabetes, rates of perinatal mortality, macrosomia, toxemia, and cesarean section varied directly with glucose concentration, but congenital malformation and prematurity rates did not. Rates of all of these complications were higher in known diabetic women than in the remainder of the population. In addition to glucose concentrations, maternal weight and age were predictive of macrosomia and toxemia. Third-trimester glucosuria was found to be of very limited value as a screening procedure for gestational diabetes. In 233 women followed for 4–8 yr, the third-trimester glucose concentration was highly predictive of the subsequent incidence of diabetes.
295 citations
TL;DR: Fructose ingestion results in markedly lower serum glucose and insulin responses and less glycosuria than either dextrose or sucrose, both when given alone or as a constituent in a test meal, however, as glucose tolerance worsens, an increasingly greater glycemic response to fructose is seen.
Abstract: We studied the acute effects of oral ingestion of 50-g loads of dextrose, sucrose, and fructose on post-prandial serum glucose, insulin, and plasma glucagon responses in 9 normal subjects, 10 subjects with impaired glucose tolerance, and 17 non-insulin-dependent diabetic subjects. The response to each carbohydrate was quantified when the respective carbohydrate was given alone in a drink or when given in combination with protein and fat in a test meal. The data demonstrate that (1) fructose ingestion resulted in significantly lower serum glucose and insulin responses than did sucrose or dextrose ingestion in all study groups, either when given alone or in the test meal; (2) although fructose ingestion always led to the least glycemic response compared with the other hexoses, the serum glucose response to fructose was increased the more glucose intolerant the subject; (3) urinary glucose excretion during the 3 h after carbohydrate ingestion was greatest after dextrose and least after fructose in all groups. In conclusion, fructose ingestion results in markedly lower serum glucose and insulin responses and less glycosuria than either dextrose or sucrose, both when given alone or as a constituent in a test meal. However, as glucose tolerance worsens, an increasingly greater glycemic response to fructose is seen.
163 citations
TL;DR: The findings indicate that gestational diabetes is attended by disturbances of varying degrees in all major classes of insulin-dependent foodstuffs and must be viewed as a disorder of multiple fuels.
Abstract: To assess the effects of gestational diabetes mellitus (GDM) on intermediary metabolism in late pregnancy, circulating levels of glucose, FFA, triglycerides, cholesterol, and individual amino acids were monitored for 24 h while subjects received a liquid formula diet (containing 2110 cal and 275 g carbohydrate) in three equal feedings at 0800, 1300, and 1800. Attempts were made to distinguish between varying degrees of severity of gestational diabetes by subdividing the population into those with fasting plasma glucose within the normal range for pregnancy, i.e., below 105 mg/dl (GDM
158 citations
TL;DR: Clinical peripheral vascular disease was studied in an incidence cohort of 1073 residents of Rochester, Minnesota, who were found to have diabetes mellitus in the period 1945–69, and the cumulative incidence of subsequent PVD was estimated to be 15%; at 10 yr and 45% at 20 yr after the diagnosis of diabetes.
Abstract: Clinical peripheral vascular disease (PVD) was studied in an incidence cohort of 1073 residents of Rochester, Minnesota, who were found to have diabetes mellitus in the period 1945-69. About 8% of patients already had clinical evidence of PVD at the time of diagnosis of diabetes. The proportion increased with the age at which diabetes was discovered. Among those unaffected initially, the incidence of subsequent PVD was slightly greater for men, 21.3 per 1000 person-years, than for women, 17.6 per 1000, and it increased both with age and duration of diabetes. The cumulative incidence of subsequent PVD was estimated to be 15% at 10 yr and 45% at 20 yr after the diagnosis of diabetes. The age-adjusted prevalence of residents with diabetes and a history of PVD was 3.3 per 1000 population 30 yr of age or over on 1 January 1970.
149 citations
TL;DR: The quality of metabolic control may play an important part in the development of this form of diabetic macroangiopathy and a relationship that was highly significant (P < 0.001) for the peripheral type (below the knee) of PVD.
Abstract: Data of 623 nonselected diabetic outpatients are presented who were screened for peripheral vascular disease (PVD) and for cardiovascular risk factors. PVD was diagnosed in 15.9% of the diabetic patients (14.4% women and 18.0% men). Nine percent of the patients had signs of marked mediasclerosis at the ankle level. Multivariate statistical analysis revealed that PVD was closely associated with systolic hypertension and also with the duration of diabetes, a relationship that was highly significant (P less than 0.001) for the peripheral type (below the knee) of PVD. Diabetic patients with arterial disease at the pelvic or femoral site exhibited a higher number of cardiovascular risk factors. In contrast, in patients with the peripheral type, significantly higher blood glucose values were found. Therefore, the quality of metabolic control may play an important part in the development of this form of diabetic macroangiopathy.
147 citations
TL;DR: Although CSII must remain a research tool, it is increasingly likely that the technique affords the conditions for testing the hypothesis that metabolic near-normalization of diabetes slows, arrests, or reverses the course of the microvascular disease associated with the syndrome.
Abstract: Low-volume, dual-rate, continuous subcutaneous insulin infusion (CSII) creates long periods of nearnormalization of blood glucose and major intermediary metabolites in most insulin-requiring diabetic patients. The technology and strategy of the system are discussed. We have observed encouraging clinical and fluorescein angiographic improvement in severe diabetic retinopathy after 3 mo of outpatient CSII; in the kidney, glomerular capillary permeability (microalbuminuria) is reduced or normalized in long-standing diabetic patients after a few days of CSII-induced strict control. Reduction in insulin dose during CSII treatment of newly diagnosed ketonuric diabetic patients may indicate improved B-cell function in this group. Although CSII must remain a research tool, undertaken only under close medical supervision, it is increasingly likely that the technique affords the conditions for testing the hypothesis that metabolic near-normalization of diabetes slows, arrests, or reverses the course of the microvascular disease associated with the syndrome.
142 citations
TL;DR: There is now sufficient evidence to justify a total screening program for carbohydrate intolerance in pregnancy, and the presumptive evidence, in conjunction with the studies of O'Sullivan, is sufficiently strong to justify screening all pregnant women for carbohydrateolerance in pregnancy.
Abstract: There is now sufficient evidence to justify a total screening program for carbohydrate intolerance in pregnancy. O'Sullivan, in a series of publications, has shown that the condition is associated with large babies and an increased perinatal mortality rate, which can be ameliorated by treatment aimed at normalizing the blood sugar concentration. He has also shown that a considerable number of women with relatively mild carbohydrate intolerance eventually develop overt diabetes. There is also the suggestion, from work in rats, that mild diabetes may be transmitted from one generation to the next. The mechanism by which this happens is not clear, but Aerts has suggested that pancreatic beta-cells in the developing fetus are damaged by maternal hyperglycemia, with the result that when the female offspring eventually reach maturity and become pregnant, they too develop subclinical diabetes. Whether this occurs in pregnant women with gestational diabetes has still to be shown, but the presumptive evidence, in conjunction with the studies of O'Sullivan, is sufficiently strong to justify screening all pregnant women for carbohydrate intolerance in pregnancy.
134 citations
TL;DR: Compliant and noncompliant obese, non-insulin-dependent diabetic subjects were assessed using a variety of demographic variables, the health locus of control scale (HLC), and the perception of severity of disease index based on the health belief model.
Abstract: Compliant and noncompliant obese, non-insulin-dependent diabetic subjects were assessed using a variety of demographic variables, the health locus of control scale (HLC), and the perception of severity of disease index based on the health belief model. The complaint subjects were significantly older and viewed their illness as significantly more severe than the noncompliant patients. Additionally, they tended to exhibit more of an internal locus of control that the noncompliant patients.
115 citations
TL;DR: The failure to restore glycemic patterns of diabetic to those of nondiabetic persons is largely due to the failure of subcutaneously administered insulin to mimic the pattern of insulinemia of healthy subjects.
Abstract: Glucose homeostasis in healthy subjects is characterized by postmeal glucose increases of about 40 mg/dl, peaks at about 45 min, decreases close to antecibal levels 1 h after the peak, and no spontaneous oscillations until the next meal. Diabetes is characterized by progressive loss of glucose homeostasis from stable to unstable, which is directly proportional to loss of insulin secretory reserve. Degree of instability of diabetes in ambulatory subjects within a 24-h period can be expressed as mean amplitude of glycemic excursion of M-value and between two successive 24-h periods as mean of daily differences of blood glucose. Stable diabetic persons have lower values, which are closest to those of nondiabetic persons, and unstable diabetic persons have higher values. The mean diurnal blood glucose level is a measure of glycemic control. The failure to restore glycemic patterns of diabetic to those of nondiabetic persons is largely due to the failure of subcutaneously administered insulin to mimic the pattern of insulinemia of healthy subjects.
TL;DR: Future studies of diabetes management will have much to gain from consideration of the role of the father and siblings in treatment, attention to the diabetic child's impact on family functioning, and recognition of sources of support and stress outside the family that affect adaptation to diabetes.
Abstract: Research on diabetes management and the family has been traditionally viewed within a linear model, in which parental attitudes toward diabetes are seen as the principal influence on the child's adjustment and metabolic control. Recently the focus of research has shifted to the broader family milieu, with an emphasis on patterns of cooperation and conflict among all family members in implementing the treatment regimen. As investigators have begun to study the entire family, the linear model of parental influences has been overshadowed by a systems model of family interaction, based on the concept of mutual influences among all individuals in the family. Several methodological problems have characterized research in this area, such as inadequate assessments of family functioning, unreliable indices of metabolic control, and insensitivity to differences in age and disease variables. Future studies of diabetes management will have much to gain from consideration of the role of the father and siblings in treatment, attention to the diabetic child's impact on family functioning, and recognition of sources of support and stress outside the family that affect adaptation to diabetes.
TL;DR: An intensive care program was offered to all insulin-dependent, pregnant diabetic women who presented to The New York Hospital Obstetrical Clinic in their eighth week or less of gestation to normalize their blood glucose and to teach the technique of self-monitored glucose determination, diet and exchange lists, and the method to titrate insulin according to the blood glucose determination.
Abstract: An intensive care program was offered to all insulin-dependent, pregnant diabetic women who presented to The New York Hospital Obstetrical Clinic in their eighth week or less of gestation. The patients were hospitalized for 1 wk to normalize their blood glucose and to teach the technique of self-monitored glucose determination, diet and exchange lists, and the method to titrate insulin according to the blood glucose determination. The mean blood glucose for the first 10 patients accepted to the program was 169 mg/dl at the start of the program with a mean hemoglobin A1c of 9.4% for the group (normal < 5.5%) and glucosuria up to 50 g/24 h. After discharge, mean glucose was 91 mg/dl, and urinary glucose excretion was 1.4 g/24 h. HbA1c fell into the normal range 5 wk after normoglycemia was achieved (3.4%) (nl < 5.5%). Normoglycemia was maintained as outpatients until 3 wk before delivery when the patients were readmitted for tests of fetal well-being. Mean weight gain for the mothers was 12.2 kg. Mean glucose at delivery was 87 mg/dl and HbA1c was 3%. Hormonal profiles (hCG, hPRL, estrogens, progesterone, hPL) normalized after normoglycemia was achieved and remained normal until delivery. Mean gestational age at time of delivery was 38.8 wk with a mean infant birth weight of 2988 g. No infant manifested hypoglycemia, hypocalcemia, erythremia, or respiratory disease. The use of self-monitored blood glucose allows for optimal care of the insulin-dependent, pregnant diabetic woman while she remains at home with her family.
TL;DR: The clinical course of myocardial infarction was compared between known diabetic (Ds) and nondiabetic (NDs) MI patients matched for age, sex, and hospital ward and found Ds with arrhythmias and/or conduction disorders had a particularly poor prognosis for surviving.
Abstract: The clinical course of myocardial infarction (MI) was compared between 154 known diabetic (Ds) and nondiabetic (NDs) MI patients matched for age, sex, and hospital ward. In both groups similar numbers of cases with cardiac rupture, shock, pulmonary edema, and clinically observed arrhythmias were found. In contrast, Ds patients had significantly more frequent A-V and intraventricular conduction disorders than NDs (P
TL;DR: Pregnant women attending the regular prenatal clinic at Los Angeles County (LAC)/Women's Hospital received a 3-h oral glucose tolerance test (GTT), finding that the perinatal mortality in uncomplicated Class A diabetic women is as low as in the general population.
Abstract: Pregnant women attending the regular prenatal clinic at Los Angeles County (LAC)/Women9s Hospital received a 3-h oral glucose tolerance test (GTT). Upper limits for the test are a fasting blood glucose of 100 mg/dl (serum glucose 110 mg/dl), 1 h 170 mg/dl (200 mg/dl), 2 h 130 mg/dl (150 mg/dl), and 3 h 120 mg/dl (130 mg/dl). The incidence of overt diabetes (fasting hyperglycemia) was 3.5% and of Class A diabetic women (abnormal test but normal fasting glucose value) it was 8.8%. The incidence of abnormal tests is greater in obese patients, potential diabetic patients (family history of diabetes or abnormal obstetrical history), and with increasing age. However, it was 3.4% in a group of patients below age 20 yr and without an abnormal medical or obstetrical history. The perinatal mortality in uncomplicated Class A diabetic women is as low as in the general population. Patients with Complicated Class A (previous stillbirth or who develop preeclampsia) and those patients who develop fasting hyperglycemia should have medical and obstetrical surveillance. Twenty-five percent of the infants of Class A diabetic mothers experience some morbidity. Long-term follow-up of mothers with abnormal tests in pregnancy is indicated, since the incidence of subsequent carbohydrate abnormality is 40%. As a screening procedure, pregnant women should have a 2-h serum glucose following the administration of 100 g of a glucose solution. In patients with a value of over 140 mg/dl, a GTT should be performed. In patients with a screening value of less than 140 mg/dl, it should be repeated by 34 wk gestation.
TL;DR: Smokers and nonsmokers were comparable regarding sex ratio, age at diabetic onset, duration of diabetes, residual beta-cell function, fasting hyperglycemia, and glycosuria.
Abstract: This study was performed in order to examine the influence of tobacco smoking on carbohydrate and lipid metabolism and microangiopathy in diabetic patients with normal serum creatinine. Among 163 adult insulin-treated patients 114 smoked daily (smokers). Compared with nonsmokers, smokers had on the average a 15--20% higher insulin requirement (P < 0.001) and serum triglyceride concentration (P < 0.05), increasing to a 30% rise in heavy smokers (P < 0.01). The degree of retinopathy was equal in the two groups, as was the average creatinine clearance [99 +/- 2 (mean +/- 1 SEM) versus 101 +/- 4 ml/min in smokers compared with nonsmokers]. Smokers and nonsmokers were comparable regarding sex ratio, age at diabetic onset, duration of diabetes, residual beta-cell function, fasting hyperglycemia, and glycosuria. Evidently, tobacco smoking represents a strain on both carbohydrate and lipid metabolism in insulin-treated diabetes mellitus.
TL;DR: Data is presented to show that even when remissions of gestational diabetes occur with the progression of pregnancy, the risk of subsequent diabetes remains unaltered and the dependence of prevalence rates for Gestational diabetes on the criteria selected and their substantial effect on assessment of screening methods is demonstrated.
Abstract: The general requirements for establishing diagnostic criteria with tests of glucose tolerance are discussed in relation to standards for gestational diabetes that are in current use. Data are presented to show that even when remissions of gestational diabetes occur with the progression of pregnancy, the risk of subsequent diabetes remains unaltered. The prognostic potential that fasting blood glucose levels has for the outcome of pregnancy is also considered. Finally the dependence of prevalence rates for gestational diabetes on the criteria selected and their substantial effect on assessment of screening methods is demonstrated.
TL;DR: Patients who took bran maintained metabolic improvement over the 3-mo treatment period, while those who stopped bran did not, and body weight decrease 0.8%.
Abstract: Thirty-eight patients (13 men and 25 women) with impaired glucose tolerance, aged 33–70 yr, underwent a dietary program adding 20 g of raw bran to their usual diet without changing their dietary habits. After 1 mo of treatment, the areas under the curves for glucose and insulin were reduced from 26,214 ± 5618 to 24,529 ± 5207 g/min ( P < 0.001) and from 15,893 ± 9714 to 12,440 ± 7377 mU/min ( P < 0.001), respectively, cholesterol was reduced from 234 ± 40 to 212 ± 29 mg/dl ( P < 0.001), and triglycerides were reduced from 108 ± 56 to 97 ± 50 mg/dl ( P < 0.05). Body weight (initially 128.44% relative body weight) decrease 0.8% ( P < 0.02). After the first month, 14 subjects were studied for a further 2 mo. Six patients continued bran feeding, and eight, who stopped bran, were used as controls. Patients who took bran maintained metabolic improvement over the 3-mo treatment period, while those who stopped bran did not.
TL;DR: It is concluded that fructose or sorbitol, given as part of a meal, results in lower glucose levels in both normal and diabetic subjects, but that the latter is not related to a difference in insulin release.
Abstract: Sucrose, sorbitol, and fructose (35 g) were fed to normal and diabetic subjects as a component of a 400-calorie breakfast. In both normal and diabetic subjects, the mean peak increment in plasma glucose was highest after the sucrose meals (44.0 mg/dl for normal subjects; 78.0 mg/dl for diabetic subjects); lowest after sorbitol meals (9.3 mg/dl for normal subjects; 32.3 mg/dl for diabetic subjects); and intermediate after the fructose meals (29.0 mg/dl for normal subjects; 48.0 mg/dl for diabetic subjects). In normal subjects, the mean peak increment of plasma immunoreactive insulin followed a similar pattern, but in diabetic subjects there was no significant difference between the three groups. We conclude that fructose or sorbitol, given as part of a meal, results in lower glucose levels in both normal and diabetic subjects, but that the latter is not related to a difference in insulin release.
TL;DR: The data show that low-dose insulin, with a slower rate of glucose decrease, is as effective as a high dose for the treatment of DKA in children with less incidence of hypokalemia and decreased potential for hypoglycemia.
Abstract: We studied the efficacy of low-dose (0.1 U/kg/h) and high-dose (1..0 U/kg/h) insulin, given randomly to children with diabetic ketoacidosis (DKA) by continuous intravenous infusion without a loading dose. Plasma glucose reached 250 mg/dl in 3.4 +/- 0.4 h with the high-dose insulin group compared with 5.4 +/- 0.5 h with the low-dose insulin group (P < 0.01). During the first 12 h of therapy, plasma glucose fell below 100 mg/dl in 2 of 16 in the low-dose compared with 12 of 16 in the high-dose patients. The decrement of ketone bodies, cortisol, and glucagon was similar in both groups. The number of hours required for HCO3(-) greater than or equal to meq/l and arterial blood pH greater than or equal to 7.30 were not significantly different in the two groups. Hypokalemia (K < 3.4 meq/L) occurred in 3 of 16 low-dose and 10 of 16 high-dose patients. The data show that low-dose insulin, with a slower rate of glucose decrease, is as effective as a high dose for the treatment of DKA in children with less incidence of hypokalemia and decreased potential for hypoglycemia.
TL;DR: A diabetic survey that was carried out in one of the few cassava-eating areas of Zambia, where blood sugar estimations were carried out and the frequency of diabetes was ascribed to malnutrition and the high carbohydrate diet.
Abstract: Although some time has passed since the interesting article by D. E. McMillan and P. J. Geevarghese (DIABETES CARE2: 202-208, 1979) was published, I thought that you might be interested in a diabetic survey that was carried out in one of the few cassava-eating areas of Zambia. The medical team went from house to house, where blood sugar estimations were carried out with an acceptance rate of 82%. A prevalence of 1% of diabetes was found. In addition, the diagnosis of diabetes was confirmed in 23 of the 69 patients who were registered at the small mission hospital. We were unable to trace the other 46 for blood sugar and clinical examination. This figure of 69 diabetic patients in a small hospital with an outpatient attendance of 67,000 must be compared with Lusaka Central Hospital with 250,000 outpatients and only 16 diabetic outpatients. At the same time as the diabetic survey was going on, an assessment of the nutritional status of the population was done by weight, height, and skinfold thickness. The average weight of 598 adults over 15 yr of age was 105.6 lb and average height was 59.4 in. Three-quarters of the men and almost half of the women were below the 60% standard skinfold thickness. A total daily calorie intake of 1439, 93% of which was cassava, was found by a dietary survey carried out at the same time. As diabetes was not a common disease in the large maizeeating parts of Zambia, we felt that the cassava with its cyanide might be involved. However, because of the lack of evidence of cyanide toxicity on the pancreas then, we ascribed the frequency of diabetes to malnutrition and the high carbohydrate diet.
TL;DR: Observations indicate that abnormalities of BMT and pulse volume recordings may be more labile measurements than previously thought and may be amenable to therapeutic intervention.
Abstract: Ten patients with type I diabetes mellitus were enrolled in a program of exercise and carbohydrate “control” using self-monitored glucose determinations and self-adjusted insulin. Glucose control was improved for the group, although normoglycemia was not uniformly achieved. Pulse volume measurements performed at the onset and after 8–10 mo documented a drop in systolic arm blood pressure with increases in the ankle-arm index (P < 0.001). Quadriceps biopsy was successfully performed at the beginning and after 8–10 mo for analysis of basement membrane thickening (BMT) in seven patients. Six patients showed a decrease in basement thickening on rebiopsy (P = 0.02). One patient showed increased BMT. This was the only patient to maintain a mean hemoglobin A1c of greater than 10% for the duration of the study. These observations indicate that abnormalities of BMT and pulse volume recordings may be more labile measurements than previously thought and may be amenable to therapeutic intervention. The relationship of these variables to the severe micro- and macrovascular sequelae of diabetes mellitus remains to be established.
TL;DR: The data suggest that a 2-h screening procedure for gestational diabetes is more efficient than a 1-h procedure in that fewer confirmatory glucose tolerance tests need to be performed in order to yield this rate of detection.
Abstract: A pilot community-based screening program for gestational diabetes has been in operation in Cleveland, Ohio, since April 1, 1977. A socioeconomic and racially heterogeneous group of pregnant women are being routinely tested at approximately 24-28 wk of gestation by a capillary whole blood glucose determination, 2-h after a 75-g oral challenge. The results of the first 2225 screenings are analyzed in terms of the variables of maternal race, age, and stage of gestation. The overall incidence of positive screenings (greater than or equal to 120 mg/dl) is shown to be 11.5%, with significantly more positive tests among the whites than the nonwhites. Follow-up oral glucose tolerance testing results in an overall detection rate for abnormal carbohydrate metabolism of 3.1%. The data suggest that a 2-h screening procedure is more efficient than a 1-h procedure in that fewer confirmatory glucose tolerance tests need to be performed in order to yield this rate of detection. It may soon be feasible to introduce such a program on a wider community basis in concert with regionalized perinatal care.
TL;DR: Beginning in 1963, fast-acting insulin in three daily injections up to the maximal tolerated dose was administered both to gestational and clinical diabetes without vascular complications, which can be defined as the highest quantity that can be given without bringing about hypoglycemic disturbances.
Abstract: Beginning in 1963 we have administered fast-acting insulin in three daily injections up to the maximal tolerated dose (M.T.D.), which can be defined as the highest quantity that can be given without bringing about hypoglycemic disturbances. This therapeutic criteria was applied both to gestational (280 pregnant women) and clinical (199 pregnant women) diabetes. M.T.D. was established on first admission to hospital and afterward controlled weekly in the outpatient clinic and during short periods of hospitalization (average of 53 days per patient). The average increase of the M.T.D. was 38 IU from 15 wk until delivery. As regards maternal blood sugar, at the M.T.D. average values at fasting and over the 24-h period were very close to the corresponding values of the control group (normal pregnancy). Total perinatal mortality (P.M.) was 2.9%; in the gestational diabetes group it was 2%. The incidence of congenital malformations (C.M.) (2.4%) increased with the severity of diabetes. No congenital defects were observed in 96 infants of patients treated before the 15th wk. Labor started spontaneously in 90.4% of the cases. The incidence of cesarean section was 21% in patients in White9s Classes Al and A2 (as recently redefined by Freinkel and Metzger 8 ) and 28% in other classes and that of forceps and vacuum extraction was 1% and 6%, respectively. The incidence of small-for-dates and overweight newborns from mothers with gestational and clinical diabetes without vascular complications is consistent with normal figures (macrosomia 3.4%). Small-for-dates newborns from pregnant diabetic women with vascular complications had a significant incidence. Respiratory distress syndrome (RDS) was 0.6% and hypoglycemia was 13.4%. No case of death was due to these two causes. Clinical results are discussed.
TL;DR: More open discussion of alcohol use with patients is needed to give them the know-how to alter their diets and to inform them of the necessary precautions.
Abstract: Newer concepts regarding the management of diabetes favor a diet that is more liberal in carbohydrate content and more personalized for the patient. Ideally, the end result will be improved glycemic control and fewer complications. Allowing more flexibility in the diet is a way of fostering better patient compliance. Alcohol, for example, which is frequently disallowed, can safely be included in the diet of many diabetic patients who desire a drink with meals, provided that certain guidelines are followed. Dietary substitutions can be made with relative ease. Although there are contraindications to its use by certain people, alcohol in moderation does not appear to compromise carbohydrate homeostasis in most individuals and, if early studies are confirmed, could possibly have some beneficial side-effects. More open discussion of alcohol use with patients is needed to give them the know-how to alter their diets and to inform them of the necessary precautions.
TL;DR: The peritoneum may be a rational alternative to both the intravenous and subcutaneous delivery sites for an implanted insulin delivery system, and may result in a reduction in meal-related glycemic excursions, compared with a similar quantity of NPH insulin delivered subcutaneously.
Abstract: The potential advantages of the peritoneum as an insulin delivery site for an implanted mechanical pancreas are reviewed. During embryogenesis in humans, the development of the pancreas and liver are closely related such that, in the adult, all endogenous insulin secreted by the pancreas passes directly to the liver before entering the peripheral circulation. This anatomic relationship permits the direct modulation of absorbed nutrients from the gut by both the liver and pancreatic hormones. Preliminary studies in the dog indicate that at least a portion of insulin infused into the peritoneal space enters the hepatic portal vein before entering the peripheral circulation, thereby simulating normal pancreatic insulin secretion. Infusion of insulin directly into the peritoneum in humans has demonstrated that (1) insulin absorption is rapid (within minutes), (2) it results in appropriate meal-related peaks in peripheral insulin concentration, and (3) the insulin has biologic activity in suppressing meal-induced hyperglycemia. Furthermore, analysis of the absorbed insulin pattern indicates that approximately 50% of the delivered insulin is removed before entering the peripheral circulation, compatible with hepatic insulin removal. In addition, insulin delivered into the peritoneum in diabetic individuals may result in a reduction in meal-related glycemic excursions, compared with a similar quantity of NPH insulin delivered subcutaneously. Thus, the peritoneum may be a rational alternative to both the intravenous and subcutaneous delivery sites for an implanted insulin delivery system,
TL;DR: The data suggest that insulinization of the liver, without peripheral hyperinsulinemia, may be a goal of artificial insulin delivery.
Abstract: Prehepatic insulin production can be determined from analysis of connecting-peptide behavior in the plasma. In the present study, we have determined prehepatic insulin production in six normal men throughout a day that included three typical 750-cal meals. Total insulin secretion for the 24 h was 45.4 ∪, secreted as 10.6 ∪ with breakfast, 13.4 ∪ with lunch, and 13.8 ∪ with dinner. The remaining 7.6 ∪ was secreted during the 9 h night at a rate of 0.85 ∪/h. At least 50% of the newly secreted insulin is known to be extracted by the liver during the initial transhepatic passage, so that total peripheral delivery can be estimated as approximately 22 ∪/day. Consequently, portal vein insulin levels are in excess of those seen in peripheral blood by at least 20 ± 8 μ∪/ml in the fasted state, and by as much as 115 ± 15 μ∪/ml in the 2-h postabsorptive state. The data suggest that insulinization of the liver, without peripheral hyperinsulinemia, may be a goal of artificial insulin delivery.
TL;DR: The data suggest that full-blood Aborigines from the Mowanjum Community, Derby, Western Australia have an abnormally high insulin response to glucose, which is ameliorated, but not normalized, by reverting to their traditional life-style.
Abstract: Recent epidemiologic studies have revealed a high prevalence of maturity-onset diabetes in certain populations that have undergone comparatively rapid urbanization. There is evidence suggesting that Australian Aborigines may respond to urbanization in this way. Thirteen full-blood Aborigines from the Mowanjum Community, Derby, Western Australia, cooperated in the present study. They spent 3 mo living in their traditional hunter-gatherer life-style, after which their insulin response to glucose was measured in a starch tolerance test. The findings were compared in follow-up studies conducted 3 mo after returning to their urban environment. Similar studies were conducted in Caucasians of comparable age and weight. Fasting glucose concentrations were lower in Aborigines than in Caucasians and were unaffected by life-style changes. Although basal insulin levels were similar in the three groups, there were striking intergroup differences in the insulin responses to glucose. The areas under the insulin curves in the first hour after starch ingestion were: urban Aborigines 4478 +/- 465 microU/ml-1/min, traditional Aborigines 2959 +/- 301 microU/ml-1/min, and Caucasians 2097 +/- 224 microU/ml-1/min. This appeared to reflect differences in the early rates of change of glucose concentrations. The data suggest that these Aborigines have an abnormally high insulin response to glucose, which is ameliorated, but not normalized, by reverting to their traditional life-style.
TL;DR: Study in juvenile-onset diabetes indicate that the liver is capable of altering its release of glucose in response to changes in blood glucose concentration when small, physiologic doses of insulin are infused, which may provide an explanation for the efficacy of preprogrammed insulin delivery systems in the treatment of diabetes.
Abstract: The liver has a unique role in regulation of blood glucose in the postabsorptive state, after ingestion of glucose-containing meals, and in circumstances of glucopenia. It is soley responsible for the delivery of glucose to the bloodstream in the fasted state, thereby maintaining blood glucose concentration for the ongoing needs of body tissues, particularly the brain. An equally important role is played by the liver in the maintenance of normal glucose tolerance in response to carbohydrate ingestion. The liver is the principal site of glucose deposition after glucose feeding, while muscle and adipose tissue represent relatively minor sites of disposal of ingested glucose. In addition, the rise in glucose and insulin caused by glucose ingestion inhibits endogenous hepatic glucose production, which serves to minimize postprandial elevations in blood glucose. When blood glucose is reduced by small increments in circulating insulin, a rebound increase in glucose output from the liver is the initial or principal mechanism counteracting the fall in blood glucose concentration. Studies in juvenile-onset diabetes indicate that the liver is capable of altering its release of glucose in response to changes in blood glucose concentration when small, physiologic doses of insulin are infused. These findings may provide an explanation for the efficacy of preprogrammed insulin delivery systems in the treatment of diabetes.