Showing papers in "Diabetic Medicine in 1987"
TL;DR: Increased diene conjugation suggesting increased free radical activity is associated with microangiopathy and this may have pathogenetic implications is suggested.
Abstract: Free radicals are highly reactive unstable chemical species which have been implicated in the vascular damage associated with several disease states. Diene conjugates, probable products of free radical activity on lipids, were measured spectrophotometrically in 26 diabetic patients with microangiopathy, 36 uncomplicated diabetic patients, and 36 healthy controls. Total diene conjugates and diene conjugate to triglyceride ratios were significantly elevated in diabetic patients with microangiopathy (0.57 +/- 0.08 and 0.31 +/- 0.14 OD units/ml respectively; mean +/- SD) when compared with patients without complications (0.32 +/- 0.10, p less than 0.001, and 0.17 +/- 0.06, OD units/ml, p less than 0.011). There was no difference in total diene conjugation and their ratio to triglycerides between healthy controls and uncomplicated diabetic patients and the results were not influenced by the type of diabetes or level of diabetic control. Diene conjugate ratios repeated in 14 patients on two occasions, 6 weeks apart, with stable metabolic control were consistent. Increased diene conjugation suggesting increased free radical activity is associated with microangiopathy and this may have pathogenetic implications.
179 citations
TL;DR: It is concluded that abnormalities of foot pressure occur in early sensory neuropathy and may precede clinical abnormalities and assessment of the toe‐loading ratio may provide a sensitive measure of motor dysfunction in early diabetic neuropathy.
Abstract: Dynamic foot pressure has been studied in 44 diabetic subjects of mean age 52 years with no clinical evidence of neuropathy and in an age and sex matched non-diabetic control group. Vibration perception threshold (VPT), sensory (SCV), and motor conduction velocities (MCV) were also measured in the diabetic subjects. Sixteen diabetic subjects (Group A) had abnormally high pressures under the metatarsal heads (>10 kg/cm2), whereas the remaining 28 diabetic subjects had normal results (Group B). The ratio of toe to metatarsal head loading (normal 0.112) was significantly reduced in Group A (0.077) compared to Group B (0.127: p<0.05). VPT and sural nerve SCV were also significantly abnormal in Group A subjects compared with Group B (p<0.005 and p<0.02, respectively), though there were no differences in MCV. A significant inverse correlation was obtained between toe loading and VPT. It is concluded that abnormalities of foot pressure occur in early sensory neuropathy and may precede clinical abnormalities. Assessment of the toe-loading ratio may provide a sensitive measure of motor dysfunction in early diabetic neuropathy.
130 citations
TL;DR: The results confirm that there has been a change in the male to female sex ratio and suggest that there are about 500 000 diagnosed diabetics in England and Wales including about 190 000 insulin‐treated patients.
Abstract: A prevalence survey for known diabetes was conducted in a geographically defined population of nearly 40,100 in Oxford in April 1982. The age-adjusted prevalence rate was 10.4/1000 which did not differ significantly from age-adjusted rates of 9.5/1000 in Poole and 10.5/1000 in Southall. The prevalence increased with age and was higher in men than women over the age of 30 years. Our results confirm that there has been a change in the male to female sex ratio and suggest that there are about 500,000 diagnosed diabetics in England and Wales including about 190,000 insulin-treated patients. These findings are consistent with a secular increase in the prevalence of diagnosed diabetes over the last two decades which has important implications for the planning and provision of resources for care.
123 citations
TL;DR: The prevalence of unrecognized hyperglycaemia as a risk factor for acute stroke is greater than previously reported in the UK and admission blood glucose concentration is of greatest importance in predicting early mortality and morbidity.
Abstract: In a prospective study of 86 patients with acute stroke, blood glucose and HbA1 were estimated within 72 h of onset The prevalence of previously diagnosed diabetes mellitus was 8% whereas 28% could be assumed to have had unrecognized hyperglycaemia preceeding the acute event as identified by a stable HbA1 raised more than two SD above the mean reference value Complete functional recovery of the limbs within 4 weeks of the stroke was confined to those patients with a normal admission blood glucose None of the patients with a raised admission blood glucose regained full functional recovery within 4 weeks Cumulative mortality at 4 weeks was significantly raised in patients with an elevated blood glucose value irrespective of their HbA1 values (p less than 005) The prevalence of unrecognized hyperglycaemia as a risk factor for acute stroke is greater than previously reported in the UK and admission blood glucose concentration is of greatest importance in predicting early mortality and morbidity
116 citations
TL;DR: Overnight as well as morning urine collections can be used when diagnosing microalbuminuria in insulin‐dependent diabetics and the results show that the albumin to creatinine ratio in morning urine is a reliable estimate of 24 h AER and better than measurement of the album in concentration alone.
Abstract: With the aim of comparing different urine collection periods in the assessment of micro-albuminuria, urinary albumin excretion rates (AERs) were measured in samples from 24 h, overnight, and morning urine collections in 54 patients aged 17 to 62 years with insulin-dependent diabetes mellitus with a mean duration of 15 years. The AER in overnight urine was found to be reduced by 25% compared to the rate in 24 h and morning urine. Assessing the ability to predict a 24 h AER within the microalbuminuric range (20-200 micrograms/min) we found a sensitivity of 90% and a specificity of 88% for both overnight and morning urine samples. These values were slightly improved by relating AER to the excretion of creatinine and it is concluded that overnight as well as morning urine collections can be used when diagnosing microalbuminuria in insulin-dependent diabetics. Furthermore the results show that the albumin to creatinine ratio in morning urine is a reliable estimate of 24 h AER and better than measurement of the albumin concentration alone.
103 citations
TL;DR: Whether a patient's risk status is influenced by the degree of variation of albumin excretion rate around a risk level, or whether the classification of risk is improved by multiple collections, awaits testing in prospective subjects.
Abstract: The variability of overnight urinary albumin excretion rate (AER) and albumin to creatinine ratio was assessed in eight normal subjects and two groups of insulin-dependent diabetic patients divided on the basis of an initial overnight urinary albumin excretion rate below (n = 15) or above (n = 12) 30 micrograms/min. The latter group is known to be at risk of developing clinical diabetic nephropathy. An albumin to creatinine ratio of 2.6 and above identified all patients with an initial albumin excretion rate greater than 30 micrograms/min. The mean of the coefficients of variation, calculated from five successive overnight urine collections, for all subjects was 38% for albumin excretion rate and 37% for albumin to creatinine ratio. There was no significant difference in the variation of albumin excretion rate and albumin to creatinine ratio within or between the groups. Subsequent AERs from diabetics with an initial rate greater than 30 micrograms/min changed category more often (chi 2 = 11.9, p less than 0.001) than those from diabetics with lower initial rates and normal subjects. This was due to four subjects with initial values close to the cut-off level, whose subsequent values varied around it. Albumin excretion rates in normal subjects never exceeded 11 micrograms/min. Whether a patient's risk status is influenced by the degree of variation of albumin excretion rate around a risk level, or whether the classification of risk is improved by multiple collections, awaits testing in prospective subjects.
93 citations
TL;DR: In an attempt to identify factors of prognostic importance, patients dying within 35 years of the onset of diabetes with patients surviving for 40 years or more are compared.
Abstract: All 906 patients with insulin-dependent diabetes mellitus (IDDM) diagnosed before the age of 31 years, prior to 1943, and admitted to the Steno Memorial Hospital were followed until death or until 1 January 1984. In an attempt to identify factors of prognostic importance, we compared patients dying within 35 years of the onset of diabetes with patients surviving for 40 years or more. Three hundred and seventy-seven patients survived for 40 years or more; of these 224 were still alive and invited to a re-examination, in which 184 participated. After 40 years of diabetes, the most frequent complications were impaired vision (due to diabetic retinopathy) and persistent proteinuria. However, 53% had no major complications despite 40 years with IDDM. The 184 re-examined patients (median age 60 years, median diabetes duration 47 years) were all genuine IDDM patients, as defined by stimulated C-peptide levels. Proliferative retinopathy or visual impairment was found in 56% of the 184 patients, abnormal ECG or amputations in 26%, and elevated urinary albumin excretion rate (AER) greater than or equal to 30 mg/24 h) in 45%. Twenty-five per cent had none of these complications. Proliferative retinopathy was associated with elevated AER and raised systolic blood pressure, macroangiopathy with the use of antihypertensive drugs, and proteinuria with low age at diagnosis, large increase in systolic blood pressure, smoking, and insulin-binding antibodies. Sex, age and diabetes duration were not associated with any of these three late diabetic complications.
91 citations
TL;DR: In type 2 diabetic patients who continue to have fasting hyperglycaemia on maximal sulphonylurea therapy, fasting normoglycaemia can be achieved easily, without minimal changes in diet or lifestyle, by means of a basal insulin supplement.
Abstract: Many diabetic patients continue to have hyperglycaemia on maximal sulphonylurea therapy. Five different therapeutic options, with the prime aim of achieving normal fasting plasma glucose concentrations, have been compared in 15 asymptomatic, sulphonylurea-treated type 2 diabetic patients in a randomized crossover study of 8-week periods. In 24 h metabolic profiles the overnight mean (+/- 1SD) basal plasma glucose level on sulphonylurea therapy was 8.9 +/- 4.2 mmol/l. This was slightly improved with added metformin therapy (7.3 +/- 4.3 mmol/l, p = 0.013), but reduced to normal by added ultralente insulin (5.2 +/- 3.2 mmol/l, p less than 0.001), ultralente insulin alone (5.1 +/- 1.6 mmol/l, p = 0.005) or by ultralente and soluble insulin (4.7 +/- 1.4 mmol/l, p = 0.003). The mean glycosylated haemoglobin concentration was reduced significantly only by the treatments which included insulin. None of the patients had severe or incapacitating hypoglycaemia and only when on additional soluble insulin did patients show a significant gain in weight. Combining sulphonylurea therapy with ultralente insulin did not significantly improve overall glucose control over treatment with ultralente alone, although the insulin dose required to restore fasting normoglycaemia was significantly lower (median (interquartile range), 25 (12-41) versus 40 (27-80) U/day, p = 0.001). In type 2 diabetic patients who continue to have fasting hyperglycaemia on maximal sulphonylurea therapy, fasting normoglycaemia can be achieved easily, without minimal changes in diet or lifestyle, by means of a basal insulin supplement.
76 citations
TL;DR: Glycosylated haemoglobin is a more sensitive and specific test for diabetes in patients with AMI than admission hyperglycaemia, and it is found that Undiagnosed diabetes was found in 4.3% of subjects with AMi who contributed 9.6% of hospital mortality.
Abstract: We studied 397 patients admitted to hospital with acute myocardial infarction (AMI) to validate an admission level of haemoglobin A1c (HbA1c) diagnostic for previously unknown diabetes mellitus by assessing glucose tolerance after 3 months. In 38% of survivors clearly abnormal HbA1c level (greater than 7.8) was 100% sensitive and 99% specific for diabetes with fasting hyperglycaemia, although the sensitivity fell to 67% when three diabetic subjects without fasting hyperglycaemia were included. Admission hyperglycaemia (plasma glucose greater than or equal to 11 mmol/l) was present in 20% of patients with AMI, of whom only one in five had levels of HbA1c indicating prior diabetes. Glycosylated haemoglobin is a more sensitive and specific test for diabetes in patients with AMI than admission hyperglycaemia. Undiagnosed diabetes was found in 4.3% of subjects with AMI who contributed 9.6% of hospital mortality.
75 citations
TL;DR: Guar ingestion reduced postprandial insulin and enteroglucagon responses, the latter significantly so, but had no apparent effect on gastric inhibitory polypeptide, pancreatic glucagon, gastrin, and pancreatic polypePTide.
Abstract: The effects of guar granules sprinkled over food on carbohydrate and lipid metabolism were studied in a double-blind cross-over trial in 18 patients with non-insulin-dependent diabetes mellitus (mean +/- SEM age 61.3 +/- 2.5 years). Five-gram guar granules (Guarem, Rybar Laboratories, Amersham, Bucks) were sprinkled over food at each main meal for 4 weeks, and during a 4-week placebo period (separated by a 2-week 'wash-out' period), 5 g wheat bran was taken in the same way. Diabetic treatment was not changed during the study. Mean fasting plasma glucose (FPG) concentration and glycosylated haemoglobin (HbA1) concentration after treatment were significantly lower than after the placebo period (FPG 8.29 +/- 0.47 vs 8.78 +/- 0.53 mmol/l, p less than 0.05; HbA1: 8.70 +/- 0.39 vs 9.09 +/- 0.39%, p less than 0.05). There was a 50% reduction in the incremental area under the postprandial glycaemic curve when guar was eaten with a standardized test meal. Total plasma cholesterol decreased from 5.79 +/- 0.29 to 5.19 +/- 0.22 mmol/l (p less than 0.05) after the guar treatment period. Guar ingestion reduced postprandial insulin and enteroglucagon responses, the latter significantly so, but had no apparent effect on gastric inhibitory polypeptide, pancreatic glucagon, gastrin, and pancreatic polypeptide.
73 citations
TL;DR: Over the last 30 years evidence has accumulated to suggest that autoimmune mechanisms are involved in the remarkably cell specific destruction of pancreatic s-cells preceding the clinical onset of insulin-dependent diabetes mellitus, IDDM, in man.
Abstract: Over the last 30 years evidence has accumulated to suggest that autoimmune mechanisms are involved in the remarkably cell specific destruction of pancreatic s-cells preceding the clinical onset of insulin-dependent diabetes mellitus, IDDM, in man.
TL;DR: Neutrophil killing of Candida albicans in the presence of increased concentrations of glucose and galactose is examined to suggest the existence of aldose reductase activity in neutrophils and using gas chromatography it is demonstrated that sorbitol is present in extracts of diabetic neutrophil.
Abstract: The mechanism whereby hyperglycaemia inhibits neutrophil function is unclear We have examined neutrophil killing of Candida albicans in the presence of increased concentrations of glucose and galactose Killing was abolished in 50 mmol/l glucose and 10 and 50 mmol/l galactose The oxidative phase of killing was examined using lucigenin-enhanced chemiluminescence An increase in glucose concentration from 5 to 50 mmol/l produced a fall in chemiluminescence output from 1285 +/- 168 (mean +/- SE) to 822 +/- 98 mV min (a reduction of 36%) These data suggest the existence of aldose reductase activity in neutrophils and using gas chromatography we have demonstrated the presence of sorbitol in extracts of diabetic neutrophils As oxidative killing and sorbitol production are both NADPH-dependent the inhibition of killing is likely to be due to competition for this electron donor This abnormality of neutrophil function may aggravate various infections in the patient with diabetes
TL;DR: Blood glucose 2 h after an oral glucose load and glycohaemoglobin and GHb levels were used as screening tests in a general practice diabetic screening programme and the diagnosis of diabetes (DM) was based on a separate oral glucose tolerance test (OGTT) in 223 of 1040 screened subjects.
Abstract: Blood glucose 2 h after an oral glucose load (2hBG) and glycohaemoglobin (GHb) (Corning agar-gel electrophoresis) levels were used as screening tests in a general practice diabetic screening programme. The diagnosis of diabetes (DM) was based on a separate oral glucose tolerance test (OGTT) in 223 of 1040 screened subjects, selected as a stratified sample biased towards higher levels of 2hBG and GHb. The GHb assay was also repeated at the recall examination and urine was tested for glycosuria before and after glucose administration.
At a cut-off level of 8.1%, the screening GHb assay correctly identified 90% of all probable diabetics with a specificity of 85.3% (95% CI 83.3–87.3%) and a positive predictive value of 14.0% (9.0–19.0%). The specificity of the screening GHb assay as a screening test for true DM was 45.8% (39.0–52.4%) at 90% sensitivity, and that of the recall GHb assay was 64.5% (57.9–71.1%). The screening 2hBG was 93.3% (88.9–97.7%) specific at 90% sensitivity as a screening test for true DM diagnosed by OGTT at recall. The test characteristics for fasting glycosuria were: sensitivity 16.7% (0–37.8%) and specificity 98.0% (96.0–100.0%). Equivalent values for the post-glucose test for glycosuria were: 72.7% (46.4–99.0%) and 77.4% (70.1–84.7%), respectively.
While GHb assay is a poorer screening test for DM than the 2hBG at the single cut-off level quoted, comparison of the accuracy of the two tests shows that the GHb assay is only marginally less accurate. It is superior to testing for glycosuria as a screening test for DM and can be performed on any random blood sample, facilitating its use in population screening.
TL;DR: The prevalence of hyperglycaemia and the determinants of blood glucose level on patients with AM1 are examined to assess whether the relationship between hyperglyCAemia and poor outcome might be causative, and thereby potentially amenable to intervention.
Abstract: As many as one-quarter of all patients admitted to hospital after acute myocardial infarction (AMI) may have an elevated blood glucose concentration. Moreover hyperglycaemia in this context is associated with a poor prognosis. In this article we examine the prevalence of hyperglycaemia and the determinants of blood glucose level on patients with AM1 to assess whether the relationship between hyperglycaemia and poor outcome might be causative, and thereby potentially amenable to intervention.
TL;DR: This review will attempt to delineate how the diabetic state disturbs normal microvascular function and progresses to the stage of clinically evident diabetic microangiopathy.
Abstract: Despite the recognition that failure of the microcirculation may be implicated in the pathogenesis of the long-term complications of diabetes' and that microangiopathy represents the major cause of death and disability in insulin-dependent diabetes,* understanding of the pathophysiology of microvascular damage is confused and lamentably incomplete. Modern diabetic management is founded on the precept that good metabolic control minimizes the risk of microangiopathy, but every diabetologist can recall patients who only fleetingly experience normoglycaemia and yet remain complication-free after many years of diabetes, and the converse where complications develop despite 'good' diabetic control. Such exceptions raise the possibility of susceptible subgroups of patients at particular risk of developing microvascular damage, but attempts to define such groups on the basis of genetic characteristics have produced contentious results. 3-6 We are left therefore with the need to know what are the earliest, preclinical functional changes in the microcirculation that presage clinical microangiopathy, in order that logical treatment strategies might be applied at a reversible stage of the condition. Our ignorance of these earliest functional changes attests to the difficulty of studying something that is both inaccessible and minute without disturbing the system that is being examined. Recent technological developments have provided us with the tools to surmount some of these difficulties and a clearer picture of microvascular structure, function, and physiological behaviour is emerging. This review will attempt to delineate how the diabetic state disturbs normal microvascular function and progresses to the stage of clinically evident diabetic microangiopathy.
TL;DR: It is concluded that a lower than convential dose of Guar can be effective and palatable and the incorporation of guar into food increases its metabolic benefits and palatability.
Abstract: Sixteen non-insulin-dependent diabetic patients, mean age 60 years (range 47-69 years) and duration of diabetes 9 years (2-20 years), completed a randomized cross-over study of three 6-week periods separated by 2-week intervals to minimize carry-over effects, in which their usual bread was replaced by either control bread, guar bread (100 g guar/kg wheat flour), or control bread plus a guar granulate. The mean (+/- SEM) intake of guar taken in bread was 7.6 +/- 0.7 g/day (range 3.1-14.3 g/day). The granulate was taken in a dose of 5 g twice daily which provided 8.3 g guar/day. Significant reductions were found in glycosylated haemoglobin after guar bread (11.5 +/- 0.8% to 10.7 +/- 0.8%; p less than 0.02) and after guar granulate (11.2 +/- 0.8% to 10.6 +/- 0.7%; p less than 0.05) compared with control bread. Total cholesterol was also reduced significantly after both guar bread and guar granulate (p less than 0.01, p less than 0.02), the changes being due to LDL-cholesterol. Dietary intakes and body weight did not change. No significant side-effects were reported; 14 subjects found guar bread more palatable than guar granulate but 8 preferred the granulate for its convenience. We conclude that a lower than convential dose of guar can be effective and palatable. The incorporation of guar into food increases its metabolic benefits and palatability.
TL;DR: While 19 out of 20 control subjects responded appropriately to hypercapnia with an increase in flow, eight of the diabetic patients failed to respond normally, this difference being significant (p = 0.03).
Abstract: Cerebral blood flow was measured both under conditions of normocapnia and hypercapnia in 22 diabetic patients and 20 normal control subjects, using either the intravenous 133Xe method or the closely comparable 133Xe inhalation method. While 19 out of 20 control subjects responded appropriately to hypercapnia with an increase in flow, eight of the diabetic patients failed to respond normally, this difference being significant (p = 0.03). Those manifesting an abnormal response included young, insulin-dependent patients with a short duration of diabetes and no clinical evidence of complications.
TL;DR: It is shown that metformin effectively lowers plasma glucose without hyperinsulinism or significant rise in fasting blood lactate and other gluconeogenic precursors.
Abstract: Fourteen non-insulin-dependent diabetics (9 female, 5 male), aged 46 to 64 years, uncontrolled by diet (fasting plasma glucose greater than or equal to 8 mmol/l), were treated with metformin, 1-3 g daily, and followed prospectively at 1 week, then at 2-weekly intervals for 6 months. The fasting plasma glucose fell significantly (p less than 0.01) after 1 week of therapy and HbA1 showed a significant reduction, 13.4 +/- 2.5% (mean +/- SD) to 10.7 +/- 1.8% (normal range 5.1-9.3%) at 8 weeks (p less than 0.001). There was no significant change in body weight, plasma insulin, serum cholesterol or triglycerides, blood lactate, pyruvate, glycerol, alanine, 3-hydroxybutyrate or acetoacetate concentration. Systolic, diastolic, and mean arterial blood pressures, along with resting heart rate remained unchanged. This study shows that metformin effectively lowers plasma glucose without hyperinsulinism or significant rise in fasting blood lactate and other gluconeogenic precursors.
TL;DR: There was evidence of increased in vivo platelet aggregation in the diabetic group v controls shown by raised values of beta‐thromboglobulin, platelet factor 4, and platelet micro‐aggregates, but there was no significant difference in fibrinogen andfibrinopeptide A levels, nor in ‘in vitro’ tests of platelets aggregation between the groups.
Abstract: Abnormalities of platelet aggregation and coagulation have been reported in insulin dependent diabetes mellitus (IDDM), although there is controversy concerning their relationship to microangiopathy. We have studied platelet function and haemostasis in 55 patients with IDDM, 23 without, 14 with mild (background retinopathy) and 18 with severe (proliferative retinopathy, or background retinopathy plus proteinuria) complications. Studies were done on 2 occasions 8 weeks apart and the results compared with 28 control subjects. There was evidence of increased in vivo platelet aggregation in the diabetic group v controls shown by raised values of beta-thromboglobulin (61 ± 42, mean ± SD, v 18 ± 14 μg/ml, p<0.001), platelet factor 4 (62 ± 76 v 14 ± 11 μg/ml, p<0.01), and platelet micro-aggregates (20 ± 16 v 12 ± 11%, p<0.01). There was no significant difference in fibrinogen and fibrinopeptide A levels, nor in ‘in vitro’ tests of platelet aggregation between the groups. Dilute whole blood clot lysis time was increased in the diabetic group v controls (6.4 ± 2.6 v 4.8 ± 0.5 hours, respectively, p<0.001). Subjects with severe complications had significantly increased platelet micro-aggregates when compared to those without complications (23 ± 16 v 16 ± 11%, p<0.05) and increased dilute whole blood clot lysis time (7.0 ± 2.8 v 6.0 ± 2.5 hours, p<0.05).
We conclude that patients with IDDM show increased intravascular platelet aggregation which is more severe in those with microangiopathy.
TL;DR: The prevalence of insulin‐dependent diabetes mellitus (IDDM) using a central register maintained for the changeover to U‐100 insulin, diabetic health visitor index cards, hospital admissions of diabetic children, and individual registers maintained by us was 0.54 for Asian and 0.99 for White Caucasians.
Abstract: A survey was conducted in 1984–85, within Leicester City boundaries, which contains 64 535 children below the age of 15 years (20 267 Asian and 44 268 White Caucasian) to ascertain the prevalence of insulin-dependent diabetes mellitus (IDDM) using a central register maintained for the changeover to U-100 insulin, diabetic health visitor index cards, hospital admissions of diabetic children, and individual registers maintained by us. Overall prevalence per thousand for children aged 0–15 years was 0.54 for Asian and 0.99 for White Caucasians; for ages 10–15 years they were 0.97 and 1.87, and for ages 0–9 years, 0.31 and 0.18, respectively. This was not statistically different at the 5% level.
Ours is the first population based study of its kind in Asian children, and challenges the view that there is a large difference in the prevalence of IDDM between Asians and White Caucasians. A wider analysis of this observation incorporating a large population base is suggested.
TL;DR: Although blood glucose control at some individual daytime points appeared lower on CSII, overall diabetic control was similar on the two regimens, and there was a significant positive correlation between glycosylated haemoglobin levels on each regimen with an inverse correlation between fasting blood glucose values and glycosymoglobin on injection but not pump treatment.
Abstract: Twelve C-peptide negative insulin-dependent diabetic patients participated in a randomized cross-over study of 6 months treatment with twice or thrice daily insulin injection therapy and continuous subcutaneous insulin infusion (CSII). Standard, non-intensified management conditions were maintained throughout. Glycosylated haemoglobin levels were similar on both regimens (9.2 +/- 0.5% versus 9.0 +/- 0.4%; CSII vs injection therapy; (mean +/- SEM). Capillary blood glucose concentrations before breakfast (5.2 +/- 0.4 mmol/l vs 9.1 +/- 0.8 mmol/l), after lunch (6.5 mmol/l +/- 0.8 vs 7.9 +/- 1.0 mmol/l) and before the evening meal (5.0 +/- 0.7 mmol/l vs 7.7 +/- 0.7 mmol/l) were lower on CSII, as were 24-hour urine glucose excretion and total insulin dose (39.3 +/- 2.2 vs 49.8 +/- 4.0 U/day). There was a significant positive correlation between fasting blood glucose values and glycosylated haemoglobin on injection but not pump treatment. Thus although blood glucose control at some individual daytime points appeared lower on CSII, overall diabetic control was similar on the two regimens.
TL;DR: The data suggest that the factors underlying the development of retinal and renal microangiopathy might be of different origin, and patients in the retinopathy group showed a higher frequency of detectable nephropathy and were more often treated with antihypertensive drugs.
Abstract: The association between retinopathy and nephropathy was investigated in a retrospective study of 52 insulin-dependent diabetics with preproliferative or proliferative retinopathy and in 48 patients without or with background retinopathy. The duration of diabetes was 23.2 +/- 1.0 years (mean +/- SEM) and 22.0 +/- 1.2 years in the two groups. Patients in the retinopathy group showed a higher frequency of detectable nephropathy and were more often treated with antihypertensive drugs. However, a high proportion (35%) of patients with proliferative retinopathy did not show any detectable signs of nephropathy. Furthermore, nephropathy did not seem to develop in patients with retinopathy during an observation period of up to 9 years. The data suggest that the factors underlying the development of retinal and renal microangiopathy might be of different origin.
TL;DR: Investigation of the effects of a high fructose diet on the control of blood glucose and serum lipids in non‐insulin‐dependent diabetic patients found that incorporation of fructose into the diabetic diet may lower post‐prandial glucose levels without disturbing serumlipids.
Abstract: The effects of a high fructose diet on the control of blood glucose and serum lipids were studied in 10 non-insulin-dependent diabetic patients (mean age 64.4 years, mean duration of diabetes 5.6 years). Comparison was made following 28 days on the usual diabetic diet and 28 days during which 25% of the usual carbohydrate was substituted with fructose. There was no change in mean (+/- SEM) fasting plasma glucose (on usual diet 9.2 +/- 0.5 mmol/l, on fructose diet, 9.1 +/- 0.4 mmol/l), but there was a fall in mean plasma glucose levels at 30, 60, and 120 min in a 75 g OGTT following the fructose diet. There was no significant change in fasting lipids: on usual diet mean serum cholesterol 5.8 +/- 0.2 mmol/l, on fructose diet 5.6 +/- 0.2 mmol/l; serum triglyceride, on usual diet 1.3 +/- 0.1 mmol/l, on fructose diet 1.3 +/- 0.1 mmol/l; HDL cholesterol on usual diet 1.4 +/- 0.1 mmol/l, on fructose diet 1.4 +/- 0.1 mmol/l. Mean body weight did not vary significantly between the two diets. Incorporation of fructose into the diabetic diet may lower post-prandial glucose levels without disturbing serum lipids.
TL;DR: It was concluded that small intestinal permeability was abnormal in some patients with DD and that this might be a factor in the aetiology of the diarrhoea.
Abstract: Small intestinal permeability to mannitol and lactulose was studied in 12 patients aged 36-70 (mean 56) years with diabetic diarrhoea (DD). Ten uncomplicated diabetics aged 24-56 (mean 37) years and 25 normal subjects aged 22-60 (mean 37) years served as controls. Permeability was assessed by measuring urinary recovery of the test substances after oral ingestion. Mean lactulose excretion in patients with DD was significantly lower than in normal controls but was not significantly different from the uncomplicated diabetics. Mean lactulose excretion was not significantly different in the three groups. However, lactulose to mannitol excretion ratios (LMER) were significantly higher in patients with DD compared to the controls or the uncomplicated diabetics. LMER in seven patients with DD were outside the normal range. LMER in patients with DD did not correlate with blood urea, small intestinal transit time, faecal fat excretion, small intestinal bacterial overgrowth, duration of diabetes or duration of diarrhoea. Jejunal morphology was normal in all patients with DD. It was concluded that small intestinal permeability was abnormal in some patients with DD and that this might be a factor in the aetiology of the diarrhoea.
TL;DR: The role of simple sugars in the aetiology of diabetes and the extent to which their elimination is important in the management of diabetes are considered.
Abstract: Avoiding simple sugars has been one of the few almost universally accepted principles of treatment in diabetes. Lay people, as well as some doctors throughout the world, regard a high intake of sucrose and other refined carbohydrates as being a major aetiological factor in diabetes. This review considers the role of simple sugars in the aetiology of diabetes and the extent to which their elimination is important in the management of diabetes.
TL;DR: Random blood glucose measurement is not a sufficiently sensitive method for detecting gestational diabetes as presently defined and the majority of those with impaired glucose tolerance would be missed.
Abstract: It has been suggested that a single random blood glucose measurement, timed in relation to food, can be used to determine those women needing a formal oral glucose tolerance test for the detection of gestational diabetes. One hundred and ten pregnancies have been screened to compare the results of a formal oral glucose tolerance test with timed venous plasma glucose measurements taken throughout the day. At the suggested thresholds of 6.1 mmol/l (within 2 h of eating) and 5.6 mmol/l (at greater than 2 h of food), random blood glucose testing is specific and excludes most normal women. However, the sensitivity of the test is low, and the majority of those with impaired glucose tolerance would be missed. Random blood glucose measurement is not a sufficiently sensitive method for detecting gestational diabetes as presently defined.
TL;DR: Sixteen adults patients with insulin‐dependent diabetes mellitus and 16 healthy controls, matched for sex and age, were asked to collect their urine during the night and during the day at rest, at weekly intervals on four occasions.
Abstract: Sixteen adults patients with insulin-dependent diabetes mellitus and 16 healthy controls, matched for sex and age, were asked to collect their urine during the night and during the day at rest, at weekly intervals on four occasions. Subjects with heart failure, kidney disease, hypertension, abnormal urinanalysis (Albustix positive) or poorly controlled diabetes prior to entry in the study, were excluded.
A high variability in the albumin excretion rates (AER) was observed in both diabetic and control groups but the variance was significantly greater in diabetics. Moreover the variance in AER was higher in daytime as compared to overnight urine collections in both groups. Overnight urine collections are more precise than daytime urine collections for the determination of AER.
TL;DR: It is concluded that long‐term survival with IDDM may be determined by factors susceptible to intervention such as metabolic regulation and patient attitude to their disease.
Abstract: Forty per cent of all Danish insulin-dependent diabetic (IDDM) patients survive for at least 40 years after diagnosis In an attempt to identify factors influencing the probability of surviving for 40 years or more, we followed all IDDM patients diagnosed before 1943 and admitted to the Steno Memorial Hospital Patients surviving greater than or equal to 40 years were compared with patients dying within 35 years of diabetes diagnosis Patients dying within 35 years were characterized by male preponderance (p less than 001), poor metabolic control (p less than 005), and by less frequent attendance at a specialized care unit (p less than 00001) Death due to uraemia/diabetic nephropathy was also characterized by male preponderance, poor metabolic control, and few contacts with a specialized care unit but in patients dying from cardiovascular disease (CVD), no effect of sex was found, indicating that the protection from CVD found in the female non-diabetic population is absent in IDDM patients We conclude that long-term survival with IDDM may be determined by factors susceptible to intervention such as metabolic regulation and patient attitude to their disease
TL;DR: Lesions in areas of callus were more likely to have healed by the end of the study period, but average time to healing was significantly longer than other lesions and there was no difference in quality of diabetic control, or smoking habit.
Abstract: During a 32-month period 94 foot ulcers in 54 diabetic patients aged 38-90 years (mean 64 years) were managed in a specialist foot clinic. Fifty-six percent were men, and they were significantly younger than women; 46% were taking insulin. Mean duration of diabetes was 13.4 years. Comparison with controls revealed a higher prevalence (p less than 0.01) of retinopathy (60% vs 23%), neuropathy (89% vs 31%), vasculopathy (71% vs 34%), arterial calcification (31% vs 20%) and previous lesions (54% vs 4%). There was no difference in quality of diabetic control, or smoking habit. A simple classification of lesions was used. All types yielded mixed cultures of microorganisms (average 2.1 per swab); the flora obtained was affected by systemic antibiotics. Abnormal pressure was judged to have contributed to all lesions occurring in areas of callus. In addition definable trauma precipitated the event in up to 60% of all other types. Lesions in areas of callus were more likely to have healed by the end of the study period, but average time to healing was significantly longer than other lesions. Despite intensive outpatient support, 33 patients spent a total of 1188 days in hospital during the 974 day period, an average of 36 days per patient and 1.2 beds per day. Further research is urgently required to define optimal methods of prevention and treatment of diabetic foot ulcers.
TL;DR: Serum fructosamine, albumin and plasma glucose were studied in patients during recovery from diabetic ketoacidosis, and in eight patients with “decompensated” diabetes without acidosis to find out whether changes in serum fructsamine were accompanied by decreases in serum albumin.
Abstract: Serum fructosamine, albumin and plasma glucose were studied in eight patients during recovery from diabetic ketoacidosis, and in eight patients with “decompensated” diabetes without acidosis. In the ketoacidotic group, serum fructosamine had fallen significantly by a mean of 12% by 8h, and fell further during the remainder of the study. A smaller but significant fall in fructosamine (mean 6.1%) was seen in the decompensated group after only 18h, with again a further fall thereafter. These changes in serum fructosamine were accompanied by decreases in serum albumin. However, when fructosamine was corrected by calculating a fructosamine/albumin index (FAI) (fructosamine × 100/albumin), the FAI did not change significantly in either group until a small reduction was noted in the ketoacidotic group at 5 days, which might reasonably be expected as an index of intermediate-term glycaemia.
Therefore minor fluctuations in albumin levels seen in diabetic patients can affect fructosamine, and correction may be be advisable for the test to be a valid measure of glycosylated serum proteins.