Case Report: Diabetes Mellitus in a Yorkshire terrier.

One week after the onset of polyuria, polydipsia, lethargy and weight loss and a one-day history of anorexia and vomiting, a 3.9kg, middle aged, spayed female Yorkshire terrier was presented to the Veterinary Teaching Hospital. Clinical examination was unremarkable except for cranial abdominal pain. Based on blood analyses, radiographic findings, and urinalysis, a diagnosis of diabetes mellitus was made. Insulin therapy was initiated at the hospital and adjusted appropriately based on monitoring clinical signs and serial blood glucose determinations. Despite acheiving adequate glycaemic control in the hospital environment, this dog developed cataracts after two months of therapy at home, but was otherwise clinically normal.

Case Report: Diabetes Mellitus in a Yorkshire terrier.

One week after the onset of polyuria, polydipsia, lethargy and weight loss and a one-day history of anorexia and vomiting, a 3.9kg, middle aged, spayed female Yorkshire terrier was presented to the Veterinary Teaching Hospital. Clinical examination was unremarkable except for cranial abdominal pain. Based on blood analyses, radiographic findings, and urinalysis, a diagnosis of diabetes mellitus was made. Insulin therapy was initiated at the hospital and adjusted appropriately based on monitoring clinical signs and serial blood glucose determinations. Despite acheiving adequate glycaemic control in the hospital environment, this dog developed cataracts after two months of therapy at home, but was otherwise clinically normal.

Obesity, hyperglycaemia and hyperinsulinaemia in Jamaica [abstract]

Insulin resistance (IR), with its associated with higher circulating levels of insulin and glucose occurs in non-insulin-dependent diabetes (NIDDM) and obesity and is often present in hypertension (HTN). The prevalence of these diseases is high in Jamaica and this study sought to determine the relationship between several measures of obesity, hyperinsulinaemia and hyperglycaemia. Anthropometric and glycaemic status variables were assessed in 469 men and 704 women. Fasting C-peptide and insulin levels were measured in subjects from the top and bottom 15 percent of a Body Mass Index (BMI) frequency distribution curve. The glucose/insulin ratio (Glu/Ins) was used as a measure of IR and the C-peptide/insulin as a measure of hepatic extraction. The obese (BMI> 32kg/m2) group had higher levels of fasting (Fglu) and postchallenge (2hGlu) glucose, insulin, C-peptide and lower Glu/Ins than the thin group (BMI<20kg/m2), suggesting greater IR. Forty-six percent of the obese were hyperinsulinaemic compared to 25 percent of the thin. Obese normogloglycaemics had higher levels of Fglu and 2hGlu than the thin normoglycaemics. Levels of glucose and insulin correlated with waist-hip ratio (WHR), waist and conicity measurements but not with BMI in the obese. In the thin group, there was correlation between glucose levels and WHR, Hyperglycaemia was more common in women. The higher levels of Fglu and 2hGlu in obese normoglycaemics suggest that the mechanisms responsible for the association between obesity and hyperglycaemia may already be operating. The association between hyperglycaemia, WHR and conicity but no BMI, suggests that `central tendency' may be a more useful indicator of dysglycaemia. The higher levels of hepatic extraction in the obese group indicate that the observed hyperinsulinaemia is not due to low hepatic extraction. (AU)

The influence of persistent hyperglycaemia of hyperfibrinogenaemia and hyperviscosity in diabetes mellitus

The effect of hyperglycaemia on hyperfibrinogenaemia and its consequence on plasma viscosity was investigated in 69 diabetic patients during the course of hypoglycaemic treatment. Glycaemic control was assessed by measurement of glycosylated haemoglobin (HbA). Plasma fibrinogen concentration (PFC) was determined by a clot-weight method. The relative plasma viscosity (RPV) was measured by capillary viscometry. The mean PFC and RPV were significantly (p<0.001) elevated in the diabetic patients as compared with a non-diabetic control group. Both PFC and RPV showed a distinct, step-wise increase with progressively poorer glycaemic control. The data strongly indicate that persistent hyperglycaemia is associated with a frank hyperfibrinogenaemia and hyperviscous plasma in most of the diabetic patients studied. These abnormal haemorrheological changes could impact adversely on both the haemostatic process and circulation in diabetic patients(Au)

A survey of knowledge, attitude, practice and perception of diabetics on insulin therapy in St. Thomas, Jamaica

This cross-sectional survey of diabetics on insulin therapy sought to identify the level of knowledge of patients on insulin regarding diabetes and insulin therapy and to ascertain the perception, attitudinal and behavioural practices of these clients as it relates to insulin therapy and self administration in St. Thomas, Jamaica. A total of 107 clients were interviewed using a structured questionnaire which was administered as an interview schedule. Three focus group discussions were also conducted. Knowledge was high in the area of responses to whether or not insulin lowers the blood sugar, what is to be done if the respondents felt bad after taking insulin and also where insulin is injected. The highest percentage response to the question assessing knowledge was found in clients who used insulin between 5-9 years. There was poor knowledge in the questions addressing identification of insulin by type brand and in addition most persons felt it was alright to miss insulin for a day. This could influence the practices being carried out by the diabetics and quite likely place them at high risk for hypoglycaemia and hyperglycaemia. Most respondents had a fair attitude towards insulin therapy when compared to the length of use of insulin. Most persons also showed a fair attitude towards their treatment particularly those with over ten years of use. The role of health education and other types of support for diabetics on insulin therapy were identified among factors that could facilitate better practices. Keen attention should be paid to the socio economic environment as it impacts readily on these clients especially the elderly and the indigent in their ability to care for themselves.(Au)

The Trp64 A rg mutation of the B3- Adrenergic Receptor Is associated with hyperglycemia and current body mass index in Jamaican women

The Trp64Arg mutation the the beta3-adrenergic receptor (beta3-AR) has been linked to earlier onset of non-insulin-dependent diabetes mellitus (NIDDM), insulin resistance, abdominal obesity, and an increase capacity to gain weight in some European and Japanese populations. We studied the prevalence of the mutation and its association with NIDDM and obesity in our population, in which both rates are high, especially in women. The frequency of the homozygous mutation was 1.53 percent, and of the Arg allele, 10.5 percent. Rates were similar in men and women. Significantly higher body mass index (BMI), weight, hip circumference, and fasting and postchallenge 2 hour blood glucose concentrations were associated with the presence of the Arg allele in women but not in men. The association with weight and hip measurements and with hyperglycemia was present only in women aged less than 55 years. In multivariate analysis, the mutation was associated with the BMI and sex in a model that also included age. The variation in fasting and 2 hour blood glucose levels were predicted by beta3-AR, gender, age and BMI. These results suggest that the presence of the mutation contributes to obesity and hyperglycemia in our female population.(AU)

The hyperglycaemic effect of s-nitroso-glutathione via the release of nitric oxide - abstract

Recent evidence suggests that nitric oxide (NO) is an important factor in both inflammatory-induced and streptozotocin-induced diabetes. In this study we investigated the pharmacological activity of S-nitroso-glutathoine (GNSO), a carrier of NO, on blood glucose level in 10 mongrel dogs, and measured their plasma nitrate concentration after the administration of GSNO. S-nitroso-glutathoine elicited a dose-dependent increase in blood glucose level (15 - 102 percent) which was paralled with an increase in nitrate production. The blood glucose levels at 2.0 and 2.5 hrs in an Oral Glucose Tolerance Test were significantly higher in dogs administered with GNSO than those of the controls (p<0.05). There was also a significant increase in plasma nitrate on administration of GSNO (35 - 100 percent). The plasma nitrate concentrations from 0.5hr to 2.5hrs were significantly higher compared to the controls (p<0.05). The hyperglycaemic effect of GSNO was enhanced with the co-adminstration of ascorbic acid. This resulted in 5 - 30 percent increase in blood glucose concentration. The blood glucose levels at 2hrs in dogs after the co-administration of 35mg kg of GSNO (P<0.05). The data from this study showed that persistent hyperglycemia can be an unwanted side effect of GSNO administration and that the glucose concentration should be closely monitored when this drug is used to treat patients(AU)

Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad

Many middle-income countries are experiencing an increase in diabetes mellitus but patterns of morbidity and resource use from diabetes in developing countries have not been well described. We evaluated hospital admission with diabetes among different ethnic groups in Trinidad. We compiled a register of all patients with diabetes admitted to adult medical, general surgical, and ophthalmology wards at Port of Spain Hospital, Trinidad. During 26 weeks, 1447 patients with diabetes had 1722 admissions. Annual admission rates, standardized to the world population, for the catchment population aged 30-64 years were 1031 (95 percent CI 928 to 1134) per 100,000 in men and 1354 (1240 to 1468) per 100,000 in women. Compared with the total population, admission rates were 33 percent higher in the Indian origin population and 47 percent lower in those of mixed ethnicity. The age-standardized rate of amputation with diabetes in the general population aged 30-60 years was 54 (37 to 71) per 100,000. The hospital admission fatality rate was 8.9 percent (95 percent CI 7.6 percent to 10.2 percent). Mortality was associated with increasing age, admission with hyperglycaemia, elevated serum creatinine, cardiac failure or stroke and with lower-limb amputation during admission. Diabetes accounted for 13.6 percent of hospital admissions and 23 percent of hospital bed occupancy. Admissions associated with disorders of blood glucose control or foot problems accounted for 52 percent of diabetic hospital bed occupancy. The annual cost of admissions with diabetes was conservatively estimated at TT10.66 million (UK 1.24 million pounds). In this community diabetes admission rates were high and varied according to the prevalence of diabetes. Admissions, fatalities and resource use were associated with acute and chronic complications of diabetes. Investing in better quality preventive clinical care for diabetes might provide an economically advantageous policy for countries like Trinidad and Tobago. (AU)

Strategies for the use of oral agents and insulin in NIDDM

The goals of chronic treatment of NIDDM are to eliminate or minimize microvascular and neuropathic complications and reduce the incidence of macrovascular complications to that of the non-diabetic. The first goal can be achieved by appropriate glycaemic control while the therapeutic regimens necessary to attain the second goal have yet to be clearly elucidated. Ideal glycaemic regulation would be normal fasting and post-prandial blood glucoses and haemoglobin Alc. Inadequate data are available to ascertain what lesser levels of glycaemic control in NIDDM patients might be adequate to minimize microvascular and neuropathic complications. Since the rate of development and progression of the complications appears to be related to the magnitude and duration of hyperglycaemia, it would seem that, all other factors being equal, the better the chronic glycaemic control achieved in NIDDM patients, the more benefit can be expected. Thus, while one can strive for haemoglobin Alc in the normal range, attaining a level which is no higher than 15 to 20 per cent above the upper limit of normal may be a more practical target. Since hypertension accelerates microvascular disease, a secondary goal should be to maintain a mean arterial pressure < 100 mm of Hg. The strategies employed to achieve glycaemic control in NIDDM patients are dependent on the magnitude of impairment of insulin secretion and the degree of insulin resistance in the individual patient. The quantitative magnitude of the defects differs among NIDDM patients and changes with time in the individual patient. The therapeutic programme must be individually designed and periodically re-evaluated. Four classes of drugs are available for the management of hyperglycaemia in NIDDM patients: 1) Inhibitors of carbohydrate digestion such as alpha glucosidase inhibitors. These drugs lower post-prandial glucose rise. 2) Agents that decrease hepatic glucose production. This is the main action of intermediate acting insulin at bedtime. 3) Agents that increase insulin action on the liver and/or peripheral tissues. Metformin and thiazolidandiones are likely to act through this mechanism. 4) Drugs that stimulate insulin secretion. Sulfonylureas are the prototype of this class of drugs. Patients with mild modest fasting hyperglycaemia and significant post-prandial hyperglycaemia respond well to diet plus alpha glucosidase inhibitors. More severe hyperglycaemia usually indicates significant decrease in insulin secretory reserve and is better treated with metformin or sulfonylureas. As insulin secretory deficiency increases, sulfonylureas or sulfonylureas plus metformin are necessary. Progressive insulin secretory deficiency may require bedtime insulin and oral agents during daytime. When insulin secretion is severly impaired, multiple doses of insulin are likely to be needed. This stepwise approach to combination drugs therapy of NIDDM seems the most reasonable approach in 1995 (AU)

DCCT and intensive insulin therapy - abstract

In June 1993, the Diabetes Control and Complications Trial (DCCT) Group announced their long-awaited research findings to the world. In this landmark study in patients with insulin-dependent diabetes mellitus (IDDM), the question "Does control of hyperglycaemia lead to primary and secondary prevention of diabetic retinopathy, nephropathy and neuropathy?" was answered. The evidence presented clearly proved that the better the glycaemic control an IDDM patient had, the smaller was the risk of developing diabetic retinopathy, nephropathy and neuropathy (primary prevention). For those patients who already had these microanglopathies, the better the glycaemic control, the smaller was the risk of their progression (secondary prevention). There was a price to pay for this achievement - the tighter the glycaemic control, the greater was the risk of developing severe hypoglycaemia was about 3-fold in those patients who received intensive insulin therapy to attain tight glycaemic control compared with those who were on conventional insulin therapy whose glycaemia was not as well controlled. Intensive insulin therapy used to attained better glycaemia control consisted of multiple dose insulin injections or continuous subcutaneous insulin infusion. In humans, there are two components of insulin secretion - a "basal" component where insulin is secreted continuously 24 hours a day and a "bolus" component where extra insulin is secreted in response to meals. Intensive insulin therapy attempt to mimic this and, in so doing, improves glycaemic control when compared with conventional insulin therapy where two injections of mixed insulin are administered daily. Intensive insulin therapy is more than mimicking the physiological pattern of insulin secretion. Intensive insulin therapy is also enhancing adherence to therapy through goal setting, compassionate caring of, and regular communication with, the patients with IDDM. It is interdisciplinary team work, involving the Diabetes Health Care Team (physician, nurse educator, dietitian, etc.) and the patient(AU)

Characteristics of the pre-clinical state in type 11 diabetes mellitus - abstract

Preclinical type II diabetes was recognized by the U.S. National Diabetes Data Group and the World Health Organization in 1979 - 80. Their recognition of this condition was based on studies of people with varying degrees of post-challenging glucose tolerance who were followed prospectively for the development of complications of diabetes mellitus, primarily retinopathy. It was found that undiagnosed diabetic subjects whose 2-hour post-challenge glucose value was o11.1 mmol/l were at high-risk of developing diabetic complications. Subsequent studies have found that undiagnosed pre-clinical type II diabetes mellitus is very common in many countries. In the US population, it is found in 10 - 20 percent of persons aged 50 years and older, with even higher rates in Blacks, Mexican Americans, and American Indians. This is a significant proportion of the American population to have a disease that conveys increased morbidity and mortality and yet is totally untreated. There is significant fasting (Mean 7.5 mm01/1) and post-challenge (mean 14.4 - 15.0mm01/1) hyperglycaemia among subjects with preclinical type II diabetes mellitus in the USA. The levels of hyperglycaemia are not benign. Indeed, if patients with known diagnosed diabetes mellitus exhibited these values, their hyperglycaemia would surely not remain untreated. Certainly, at least dietary therapy would be instituted, if not oral hypoglycaemic agents. Nevertheless, all subjects with pre-clinical type II diabetes are undiagnosed and their hyperglycaemia remains untreated. When in the natural history of diabetes mellitus is type II diabetes diagnosed? Recent data show that retinopathy begins developing at least 7 years before clinical diagnosis of type II diabetes mellitus and that onset of type II diabetes mellitus probably occurs at least 5 years before that. During this entire 12-years period, hyperglycaemia in these undiagnosed cases is totally untreated and significant retinopathy is developing, indicating that widespread structural lesions related to diabetes mellitus are occurring. Other data confirm that pre-clinical type II diabetes mellitus is not a benign condition. Significant complications are present in patients at diagnosis. For example, 21 percent of newly diagnosed patients have retinopathy in US studies and prevalence of retinopathy was 29 percent among newly diagnosed patients enrolled in the UK Prospective Study of Type II diabetes mellitus. Prevalence of macrovascular disease in undiagnosed NIDDM is about equal to that found in diagnosed diabetes mellitus, and rates of coronary heart disease in both diagnosed and undiagnosed diabetes mellitus are about twice the rate found in non-diabetics. Mortality in undiagnosed diabetes mellitus is also equal to that of diagnosed and both are significantly higher than that in non-diabetics. Risk factors for micro- and Macro-vascular complications in pre-clinical Type II diabetes mellitus are very common and are as frequent as those found in diagnosed diabetics. The prevalence of treatable risk factors for subjects with undiagnosed diabetes mellitus in the U.S.A. includes 31 percent exceeding fasting plasma glucose of 7.8 mmol/l. Obesity is present in 67 percent, including 82 percent of women and 50 percent of men. Over 60 percent have hypertension, only half of which is controlled. Total cholesterol>240mg/dl is found in 49 percent and LDL-cholesterol > 160 mg/dl is found in 42 percent. Prevalence of hypertriglyceridaemia is 28 percent and 32 percent smoke cigarettes. Dietary fat intake>30 percent of calories occurs in 79 percent of subjects with undiagnosed diabetes mellitus, saturated fat>10 percent of calories occurs in 77 percent, and subjects with pre-clinical diabetes mellitus are thus at high risk for coronary heart disease. We have methods in our therapeutic armamentarium to deal with all of these risk factors, should we choose to find and diagnose the millions of people who have undiagnosed diabetes mellitus(AU)

Haemorrheological changes in diabetic neuropathies - abstract

Chronic hyperglycaemia leads to disturbances in metabolic pathways in nerves. However, the underlying mechanisms are still not fully understood. One of the theories of diabetic neuropathy has implicated a vascular factor, which we believe may be associated with abnormal haemorrheological changes. Persistent hyperglycaemia creates a "stressful" conditions which triggers increased production of the acute-phase-reactant protein, fibrinogen, causing the development of a hyperfibrinogenaemic state. Apart from the red cell concentration, fibrinogen is the next most important determinant of whole blood viscosity. Therefore, an hyper-viscosity syndrome is commonly seen in diabetic patients. The increased viscosity could be an important factor in the development of endothelial damage in the vaso nervorum, hence contributing to the pathogenesis of diabetic neuropathy. The present study examined changes in haemorrheological parameters, with particular emphasis on plasma fibrinogen concentration in diabetics with and without peripheral neuropathy. Forty-seven (47) diabetics, 39 females and 8 males, were selected randomly during routine attendance at the Diabetic Clinic at the Unversity Hospital of the West Indies. Patients underwent a comprehensive medical check and were screened for peripheral neuropathy. Twenty-one patients were classified as insulin-treated and 26 as non-insulin-treated. For the diabetic patients, the mean (ñ SD): Age = 53.71 ñ 15.22 years, duration of diabetes mellitus = 12.96 ñ 7.97 years, B.M.I. = 30.00 ñ 10.00, blood pressue = 162.58 ñ 33.91/91.78 ñ 11.65 mm Hg; HbA1 = 13.99 ñ 4.83 percent. Only 2 (4.35) of the patients smoked or drank alcohol. A sex and age-matched non-diabetic control group consisting of 30 subjects were also studied. Venous blood was analysed for plasma fibrinogen concentration (PFC), packed-cell volume (PCV), haemoglobin concentration (HB) and glycosylated haemoglobin (HbA1) levels. The prevalence of peripheral neuropathy in the diabetic patients was 73.87 percent. PFC was significantly (p < 0.001) elevated in diabetic group, 5.06 ñ 1.26 g/l, compared with non diabetic groups, 3.19 ñ 0.65 g/l. However there was no significant difference in PFC betwen diabetics with (4.19 ñ 1.36 g/l) and without (5.14 ñ 1.14 g/l) neuropathy. Both PCV and Hb values were significantly less (p<0.05) in diabetics than in non-diabetics. Neither PCV nor Hb showed any significant variation between deabetics with and without neuropathy (AU)

Diabetic neuropathy: the local experience - abstract

The prevalence of polyneuropathy in diabetic populations ranges from 0 to 93 percent depending on patient selection factors, criteria for diagnosing neuropathy and the sensitivity of the detection methods. Affected patients may be asymptomatic. Postural hypotension, gastric symptoms and hypoglycaemic unawareness are autonomic neuropathic indices of early death in diabetes mellitus. Long-term hyperglycaemia is the most important aetiologic factor. The recently published results of The Stockholm Diabetes Intervention Study and the Diabetes Control and Complications Trial confirm that control of hyperglycaemia can reduce the occurrence of clinical neuropathy and deterioration of nerve conduction velocity. Here at the Diabetes Clinic at the University Hospital of the West Indies a prevalence of 4 percent for neuropathy was noted, but that study did not include nerve conduction studies. In addition, many of these patients had had the disease for more than ten (10) years or were diabetics with complications or with poor metabolic control. This study was designed to determine the prevalence of diabetic neuropathy in a more representative group and to compare prevalence with metabolic control and other complications of diabetes mellitus. The patients were taken from the Clinics at the Diabetes Asssociation of Jamaica. This is a walk in clinic, centrally located in Kingston. The patients were questioned about symptoms of peripheral neuropathy and of autonomic neuropathy. A thorough neurological examination was performed and cardiac autonomic nerve testing done. Nerve conduction velocities were measured for the ulnar and radial nerves. Retinopathy was evaluated by findoscopy and nephropathy by 24-hr urine excertion of albumin and creatinine clearance. Serum cholesterol and triglycerides were measured. Metabolic control was assessed by random blood glucoes, fructosamine and glycosylated haemoglobin. The ages ranged from 25 years to over age 65 years. Symptoms of peripheral neuropathy were present in majority of patients. This was predominantly numbness and was so, regardless of age and duration of diabetes mellitus. Most have symptoms of bladder disfunction rather than bowel disfunction; 20 percent urinary incontinence and 10 percent involuntary faecal soiling. The majority had clinical neuropathy on examination, with the loss of ankle reflex followed by loss of vibration sense being the commonest manifestations. Unequivocal autonomic cardiac neuropathy was present in only a few patients. These patients were older than 55 years and had had diabetes melitus sor more than ten (10) years. Of those were symptomatic, the majority had poor blood glucose control. However, this was not so for those with autonomic neuropathy. Neuropathy and retinopathy were present in the majority of those with numbness but the presence of retinopathy correlated poorly with actual signs of nephropathy (AU)

The neurological complications of diabetes mellitus: a clinical classification - abstract

Diabetic neurological disorders affect a significant proportion of our diabetic population in the Caribbean and world-wide. With the increasing life expectancy of today's diabetic population so has the incidence of these neurological disorders increased. Even without this, however, with early diagnosis it has been found that neurological lesions can occur early in the disease and in some instances be the presenting manifestation of hyperglycaemia. Over the ensuring years an increasing numbers of neurological syndromes have been identified affecting both somatic and autonomic nervous systems. These classifications have used either anatomical location, symmetrical or asymmetrical involving, focal or generlaised, functional disturbances, and have even been based on possible aetiological factors, recognisable clinical syndromes, type of nerve fibre implicated, pathological, and clinical course of the disorder, etc. In clinics and institutions where investigative tools such as electromyography, nerve conduction studies and the more refined biochemical modulations are available, classification of the syndromes on an anatomical or aetiological basis can be defined, but in settings such as ours and in institutions not having access to sophisticated neuro-investigations, clinicians have to rely on their clinical knowledge to specify and identify these neurological syndromes. In order to better identify these neurological lesions, we at the University of the West Indies. (Drs. C. McIver, E. Morrison, D. Kelly and R. Richards) began an attempt to identify and describe the neurological lesions and their prevalence in the diabetic population attending the Diabetic Clinic at the University Hospital of the West Indies between 1967 and 1969. Based on these clinical assessment we were able to identify a number of clinical presentations of neurological disorders in our diabetic subjects. We found that diabetic neuropathy or neurological disorders were present in 69 percent of the diabetic population, with neuropathy being present in 59 percent of the male and 36 percent of the female population attending the clinic over the period of assessment. Again, it was found that 12 percent - 15 percent of patients presenting with a history of a few months to two years had clinical features of diabetic neuropathey which at times could be ameliorated by normalisation of their hyperglycaemia (AU)

Intermediate outcomes of primary care for diabetes mellitus: a comparison of public and private practice in three Caribbean countries - abstract

This study examined the quality of monitoring and control of obesity, hyperglycaemia and hypertension among 1661 attenders with diabetes mellitus at public health centres and private general practitioners in Trinidad and Tobago (791 (13 percent private)), Barbados (690 (24 percent private)) and Tortola (180 (31 percent private)). Weight was recorded in the preceding 12 months for 83 percent but heights were recorded only for 2 percent. Blood glucose was measured in the last 12 months for 93 percent in Tortola, 82 percent in Barbados and 36 percent in Trinidad. Blood pressure was measured in the preceding 12 months for 95 percent of patients. Compared with Barbados the proportion overweight (>72 kg female and >85 kg male) was higher for clinic attenders in Tortola (OR 1.44 (95 percent CI 1.02 - 2.04)) and less in Trinidad and Tobago (0.60 (0.48 - 0.76). The proportion with 'poor' blood glucose control (8 mmol/l fasting or 10 mmol/l random) was higher at clinics in Trinidad (1.61 (1.27 - 2.04) than in Barbados and lower in private than in public practice (10.57 (0.44 - 0.75)). The proportion with untreated hypertension (BP 160/95 mm Hg) was less for clinics in Tortola than in Barbados (0.13 (0.04 - 0.41) as was the proportion with treated but uncontrolled (BP > 140/90 mm Hg) hypertension (0.29 (0.18 - 0.47). Private practice attenders were more likely to have untreated hypertension (2.07 (1.42 - 3.03) or treated but uncontrolled hypertension (1.87 (1.23 - 2.83)) when compared to public practice. These variations in intermediate outcomes of diabetes care might be partly explained by differences in case mix but emphasise as priorities the control of obesity for clinics in Tortola, the control of hyperglycaemia for clinics in Trinidad and Tobago, and the control of hypertension in private GPs' offices when compared with health centres (AU)

Aetiology, treatment and prevention of diabetic nephropathy: an overview - abstract

In the studies of the aetiology, treatment and prevention of diabetic nephropathy, several end-points can be used, including death due to renal failure, uraemia, azotaemia, proteinuria, microalbuminuria and changes in glomerular and tubular functions. The two parameters commonly used, though not ideal, are glomerular filtration rate and protein excretion. Several factors contribute to the development and progression of diabetic nephropathy. These include hereditary factors, severity of hyperglycaemia, hypertension and hyperlipidaemia. Siblings of probands free of diabetic nephropathy have less evidence of renal disease than do siblings of probands with diabetic nephropathy. Several studies have also shown that individuals with high glycosylated haemoglobin concentrations (poor glycaemic control) are more likely to develop diabetic nephropathy. It is not clear, however, if this is a direct relationship (e.g. via glycosylation) or indirect (e.g. increased flux through the aldose reductase pathway, or alteration in vascular permeability). It is also unclear whether there is a direct relationship between glucose level and the development of diabetic nephropathy. The route of administration of insulin, e.g. into systemic circulation or into the portal system, may be important in the development of diabetic nephropathy. Specific inhibitors in the metabolic pathways (e.g. aldose reductase inhibitors, glycosylation inhibitors) may slow or prevent the development of diabetic nephropathy. Several studies have shown that increase in albumin excretion rate and decrease in glomerular filtration rate precede the development of hypertension and, once present, contribute to the rate of progression of diabetic nephropathy. Some, on the other hand, feel that hypertension reduces protein excretion, and a few studies have shown that it also preserves renal function and/or prevents azotaemia. It is also not clear at what level blood pressure should be treated, as urinary albumin excretion decreases when normotensive individuals are treated with angiotensin-converting enzyme inhibitors. Reduction of protein consumption in humans (to approximately 0.6 gm protein/kg body weight per day) can slow the rate of decline in glomerular filtration. Also influencing the rate of development of hyperlipidaemia, if necessary, with hypolipidaemic drugs is potentially beneficial in hypertensive diabetic patients. In summary, although definite data are lacking, an attempt should be made to optimize glycaemic control and hypertension should be treated early and vigorously. Hyperlipidaemia which persists in the presence of normoglycaemia should be treated with diet and hypolipidaemic drugs (AU)

Extraction of an hyperglycaemic principle from the annatto (Bixa orellana)

The red powdery extract from the seeds of the annatto, Bixa orellana, is a well known food colouring. In an oil suspension it is used as a folk remedy (bush tea) in the West Indies, for diabetes mellitus. Detailed investigations on this extract, yielded a methyl ester, trans-bixin, molecular weight 394 and molecular formula C24 H30 O4. This purified substance was demonstrated, in anaaesthetised mongrel dogs, to cause hyperglycaemia. Concomitant electron microscopy of tissues biopsies, revealed damage to mitochrondria and endoplasmic reticulum mainly in liver and pancreas. When dogs were fed on a diet fortified with riboflavin, there was neither demonstratable tissue damage nor associated hyperglycaemia. These findings point to: (i) the potential dangers of informal medications such as 'bush teas'; (ii) the possible role of plant extracts/food additives in the development of diabetes mellitus especially in the undernourished state. (AU)