[National organization of health care in diabetes based on the "Croatian model"]. / Nacionalna organizacija zdravstvene zastite dijabeticnih bolesnika "Hrvatski model".

This review article shows the development and organization of the "Croatian Model" of organization of health care for diabetic patients from Professor Vuk Vrhovac to this day, and its inclusion in the St. Vincent Declaration-a group of recommendations agreed upon in 1989 with the aim to decrease the morbidity and mortality of diabetes and its complications. The Model is organized on primary, secondary and terciary levels of health care. After the administrative changes of 1993, specialized health care for diabetic patients is delivered through County and Regional Centres for Diabetes and the Diabetes Reference Centre (the Vuk Vrhovac Clinic for Diabetes, Endocrinology and Metabolic Diseases), a scientific and educational institution and a WHO Collaborating Centre. Mention is made of the Croatian Diabetes Registry and statistical data on the morbidity (the prevalence of diabetes in Croatia is 2.37%) and mortality of diabetes mellitus and its complications, of organization of health care for diabetic patients, their medical treatment and care in Croatia.

[Fatal "overwhelming" strongyloidiasis in an immunosuppressed patient]. / Smrtonosna "preplavljujuca" strongiloidoza u bolesnika sa suprimiranim imunitetom.

The increased use of immunosuppressants in the treatment of malignant and non-malignant diseases in today's medicine has significantly contributed to the increased interest in infections caused by opportunistic microorganisms and rare parasites. A fifty-eight-year old male patient, professor, born in Bosnia, was admitted to the Institute due to poor general condition and decompensated steroid diabetes. He had been under immunosuppressant therapy for the previous 5 weeks. Six months before, he noticed squamous and crusted changes on capilli, and afterwards on his body too. As these changes did not respond to local therapy he was admitted to the Department of Dermatovenereology, Zagreb University School of Medicine. Histologic analysis indicated pemphigus erythematosus. He was treated with immunosuppressants (methylprednisolone + azathioprine). Endoscopic examinations revealed duodenal ulcer, in addition to diabetes which could not be regulated by oral hypoglycemics. He received antiulcerative therapy for ulcer treatment. Several hours upon admission the patient became highly febrile, and vomited a sanguinolent content. In spite of intensive therapy, he became comatose and died 20 hours later. On autopsy, generalized strongyloidosis of the lungs, liver, duodenum and small intestine, and a bleeding duodenal ulcer due to strongyloidosis were found. This review should remind us that hyperinfestation with strongyloides is a rare and severe complication, and could be expected in immunocompromised patients.

Improvement of lipoprotein lipid composition in type II diabetic patients with concomitant hyperlipoproteinemia by acipimox treatment. Results of a multicenter trial.

OBJECTIVE: To study the tolerability and efficacy of acipimox on hyperlipidemia and diabetes compensation in patients with NIDDM under conditions of a routine clinical practice. RESEARCH DESIGN AND METHODS: We recruited 121 patients (60 men and 61 women) from 10 participating clinical centers. They were randomly divided into two groups and treated for 3 mo either with acipimox (250 mg three times a day) or placebo, using an open study design. RESULTS: Acipimox treatment led to a significant drop in fasting serum total triglyceride levels (by 28%) after 1 mo of drug administration. This decrease prevailed up to the end of the 3-mo study. Serum total cholesterol levels declined by 14%, and high-density lipoprotein tended to rise in acipimox-treated patients. These changes in lipid metabolism were not accompanied by any adverse effects of acipimox on glucose metabolism as judged by HbA1c measurements and the oral glucose tolerance test. Eight patients (out of 82 treated with acipimox) reported moderate adverse events of transient character, such as skin reactions and gastric disturbances. CONCLUSIONS: Acipimox seems to be a useful agent for treatment of diabetic dyslipidemia and does not deteriorate glycemic control.

Diabetes in time of armed conflict: the Croatian experience.

During the summer of 1991, armed conflict broke out in the Republic of Croatia. This resulted in many deaths and the displacement of many persons, with population loss in some communities and additional population burden in others. Registration of diabetic persons has been compulsory in Croatia since 1975 and from available statistics compiled by the Vuk Vrhovac Institute for Diabetes in Zagreb it was known that in 1991 there were 111,096 diabetic persons in Croatia, 16% requiring insulin, 46% treated with oral agents and 38% using dietary treatment only. This information helped to plan adequate supplies during the emergency. Contacts with international organizations and friends were of value in overcoming shortages, the most useful gifts being battery-operated blood glucose measuring devices. A study in Zagreb failed to demonstrate an association between the stress of displacement and metabolic control. Somewhat unexpectedly, diabetes and its complications did not present a major public health problem during the first 8 months of the armed conflict, but the long-term effects of these events remain to be seen.

Zinc and copper in the serum of diabetic patients.

The Zn/Cu ratio was examined in the serum of three groups of persons: healthy volunteers, diabetic patients on diabetic diet (NIDDM), and diabetic patients on diabetic diet and insulin (IDDM). Zinc, copper, the Zn/Cu serum ratio, and the blood glucose level were determined during fasting and 2 h after breakfast. Zn and Cu serum levels in NIDDM and IDDM patients were decreased. The Zn/Cu ratio was higher in both groups of diabetic patients. These changes in the Zn and Cu levels as well as in the Zn/Cu ratio were not related to chronic diabetic complications.

[Biopsy of the external ear in diabetology]. / Biopsija usne skoljke u dijabetologiji.

In the introductory part the authors pointed to the need for the application of the morphologic method which would make possible the estimation of the existence and degree of miocroangiopathic changes. Microangiopathic changes were observed on the material obtained by skin biopsy of the auricle and the reason for selecting this localization was explained. It was performed in the representative sample consisting of 441 patients with diabetes mellitus and 92 persons with disturbed glucose tolerance and the objective indicators for small blood vessel changes were confirmed by the analysis of the material obtained by the method described. The possibility of the quantification of the degree of these changes was at the same time presented and illustrated. Finally, the authors came to the conclusion that reproducibility of these quantifications was satisfactory. Thereby, they were of the opinion that in their further work they could compare described and quantificated changes in respect to individual vital characteristics of the investigated group, the existence of factors considered risky for the appearance of diabetes mellitus complications and the degree of their development.

The cytologic identification and quantification of testicular cell subtypes. Reproducibility and relation to histologic findings in the diagnosis of male infertility.

In testicular imprint smears from 100 infertile men (both testicles), stained using the Pappenheim and Papanicolaou methods, the cell forms (light and dark spermatogonia, primary and secondary spermatocytes, spermatids, spermatozoa and Sertoli cells) were identified and quantified by the counting of 500 consecutive cells. Identification of the cell types, which are described and illustrated, was consistent and reproducible; the advantages of the different stainings in their analysis is documented. The cell counts were tested for reproducibility and compared to the histologic diagnoses and sperm counts. Statistical analysis showed the highest reproducibility for cells frequently encountered in smears (0.99 for Sertoli cells and 0.98 for spermatozoa) and the lowest but still satisfactory reproducibility for rare or arbitrarily defined cell forms (0.71 for dark spermatogonia and 0.76 for secondary spermatocytes). The high reproducibility of the smear quantification permits the introduction of a number of indices, defining clinically useful relations between cell types that are indicative of various types of infertility. The data obtained by cytologic quantification showed reasonably good correlation with the histologic diagnoses of desquamation and focal fibrosis and excellent correlation with Sertoli cells only, arrested spermatogenesis and complete fibrosis. The cytologic quantification of testicular smears adds considerable information to the diagnosis of impaired fertility and should be instituted in properly equipped centers.

The effects of piretanide in patients with congestive heart failure and diabetes mellitus: a double-blind comparison with furosemide.

A double-blind parallel group study was carried out to compare the effects of piretanide on daily glucose profiles, symptoms of congestive heart failure and serum electrolytes with those of furosemide in 24 diabetic in-patients suffering from congestive heart failure. After a 3-day run-in period on placebo, patients were allocated at random to receive 10-days' treatment with either 6 mg piretanide or 40 mg furosemide once daily. The results showed that there were no differences between the glucose profiles between the first and the last day of treatment, nor were there any differences between the two treatments. Piretanide and furosemide both produced a significant reduction in the number of symptoms of congestive heart failure. There were no significant changes in biochemical variables within the groups, nor were there any differences between the groups, except for an increase in uric acid and decrease in total protein values after furosemide. Mean triglyceride values decreased significantly after piretanide treatment, and SGOT values decreased after both treatments, the latter change being of no clinical relevance. Side-effects were generally mild in both groups and did not require any counter-measures.

Nonenzymatic glucosylation of very-low density lipoprotein alters its metabolism in the rabbit.

In order to determine the metabolic consequences of lipoprotein glucosylation, the glucosylated 125I-VLDL turnover was analyzed in comparison to the native one. Autologous in vitro glucosylated VLDL, separated by affinity chromatography, was injected into a nondiabetic rabbit and the amount of the radioactivity distributed in all lipoprotein fractions measured. Glucosylated--125I-VLDL metabolism versus control--125I-VLDL after six hours were: glc-VLDL = 35 +/- 4.5%, control- VLDL = 35 +/- 4.9%, glc-IDL = 51 +/- 3.8% control-IDL = 31 +/- 4.3% p less than 0.01; glc-LDL = 9 +/- 2.2%, control-LDL = 12 +/- 2.6%; glc-HDL = 5 +/- 1.4%, control-HDL = 22 +/- 2.9% p less than 0.001. A retained turnover of glc-VLDL and prolonged retaining of the triglyceride-rich lipoproteins (VLDL, IDL) in the circulation were found. The results suggest that the incorporation of glucose into lipoproteins may influence the steric configuration of molecules by blocking the sites of the lipolytic action of lipoprotein lipase. The data presented provide strong support for the idea that there are factors other than reduced LPL activity which contribute to defective VLDL removal in diabetes mellitus.

Blood glucose and free insulin levels after the administration of insulin by conventional syringe or jet injector in insulin treated type 2 diabetics.

UNLABELLED: The levels of blood glucose and free insulin were compared in 20 diabetic subjects (type 2) receiving one dose of a combination of fast-acting and intermediary-acting insulins in the morning by means of a needle syringe or a jet injector (SICIM, Italy), using minimum possible injecting power. A shift to the left in the free insulin profile, consequential to different pharmacokinetic characteristics of insulin when administered by means of a jet injector, was observed, although no significant differences were seen for free insulin levels. Statistically significantly higher blood glucose values (P less than 0.05) were recorded 6 and 9 h after insulin administration by means of a jet injector, as well as statistically significant higher MBG values (P less than 0.05), thus indicating a faster and shorter effect achieved in comparison to that produced by the syringe injected insulin. CONCLUSIONS: 1. When switching the method of insulin administration in patients from needle syringe to jet injections the power of the jet injector should be increased (it can be set in three different levels). If that is not possible, because of patient skin characteristics then the dose of intermediary acting insulin should be slightly increased. 2. No local or general side-effects were registered using minimum injecting power of jet injector. 3. The results of the controlled poll have shown that this method of insulin administration is less painful and simpler for patients. The great majority of the patients would like to possess a jet injector.

Filter paper blood sampling for glycated haemoglobin determination and its use in the control of diabetes mellitus.

Blood sampling on filter paper was tested for determination of glycated haemoglobin. The method showed coefficients of variation of 3.4% and 4.1%, and linearity coefficients of 0.978 and 0.91 for the microchromatographic and colorimetric methods respectively. A blood sample on filter paper impregnated with 5% ethylene glycol solution remains stable for 8 days at room temperature. In a group of 30 diabetics educated in the filter paper blood sampling technique, no statistically significant differences were registered among the mean values of their blood glucose profiles, glycated haemoglobin levels determined at the hospital and those obtained at home 14 days after discharge. In conclusion, the use of blood spotted on filter paper seems a cheap and convenient method for collecting, storing and transporting samples for analysis of glycated haemoglobins. It is also a useful alternative for home monitoring of diabetics. Moreover, it could also be useful in epidemiological studies of diabetes.

Seminal plasma LDH-X in testosterone rebound therapy.

The changes in seminal plasma LDH-X isoenzyme were investigated in 27 oligozoospermic patients treated with large doses of testosterone. The increase in this isoenzyme, proven to occur prior to the sperm count elevation, might possibly serve as a predictor enabling the choice of an optimal term for affecting conception. A high percentage of responders has been found in patients with severe oligozoospermia (less than 0.1 x 10(6) spermatozoa/ml), but with a high initial relative percentage of seminal plasma LDH-X. The determination of this parameter could be one of the criteria for the selection of patients who will probably respond to the therapy.