The basal to total insulin ratio in outpatients with diabetes on basal-bolus regimen.

OBJECTIVE: To evaluate the basal/total ratio of daily insulin dose (b/T) in outpatients with diabetes type 1 (DM1) and type 2 (DM2) on basal-bolus regimen, by investigating whether there is a relationship with HbA1c and episodes of hypoglycemia. METHODS: Multicentric, observational, cross-sectional study in Italy. Adult DM1 (n = 476) and DM2 (n = 541) outpatients, with eGFR >30 mL/min/1.73 m2, on a basal-bolus regimen for at least six months, were recruited from 31 Italian Diabetes services between March and September 2016. Clinicaltrials.govID: NCT03489031. RESULTS: Total daily insulin dose was significantly higher in DM2 patients (52.3 ± 22.5 vs. 46 ± 20.9 U/day), but this difference disappeared when insulin doses were normalized for body weight. The b/T ratio was lower than 0.50 in both groups: 0.46 ± 0.14 in DM1 and 0.43 ± 0.15 in DM2 patients (p = 0.0011). The b/T was significantly higher in the patients taking metformin in both groups, and significantly different according to the type of basal insulin (Degludec, 0.48 in DM1 and 0.44 in DM2; Glargine, 0.44 in DM1 and 0.43 in DM2; Detemir, 0.45 in DM1 and 0.39 in DM2). The b/T ratio was not correlated in either group to HbA1c or incidence of hypoglycemia (<40 mg/dL, or requiring caregiver intervention, in the last three months). In the multivariate analysis, metformin use and age were independent predictors of the b/T ratio in both DM1 and DM2 patients, while the type of basal insulin was an independent predictor only in DM1. CONCLUSION: The b/T ratio was independent of glycemic control and incidence of hypoglycemia.

Correction to: The basal to total insulin ratio in outpatients with diabetes on basal-bolus regimen.

[This corrects the article DOI: 10.1007/s40200-018-0358-2.].

Healing of chronic necrobiosis lipoidica lesions in a type 1 diabetic patient after pancreas-kidney transplantation: a case report.

Necrobiosis lipoidica (NL) is a degenerative disease of dermal connective tissue of unknown etiology characterized by erythematous plaques preferentially localized to distal extremities. Skin lesions show a chronic relapsing nature. NL is often associated with diabetes mellitus and satisfactory treatment options are lacking. We describe the spontaneous healing of NL lesions after pancreas and kidney transplantation in a Type 1 diabetic patient with chronic NL recalcitrant to a variety of standard treatments. The 31-yr-old male patient had experienced NL lesions for more than 15 yr; despite various systemic and topical treatments, the skin lesions had pregressively enlarged. Because of end-stage renal disease, a simultaneous pancreas and kidney transplantation was performed and immunosuppressive therapy with tacrolimus (TAC), mycophenolate mofetil (MMF), and prednisone was started. Pancreatic transplantation maintained satisfactory metabolic control with no need of exogenous insulin. After transplantation, skin lesions slowly healed without any specific treatment, leaving residual areas of fibrotic scars. A skin biopsy confirmed the absence of typical NL lymphocytic and histiocytic inflammatory response. Clinical remission of NL lesions may probably be explained by the concomitant effect of multiple-drug regimen for immunosuppression (TAC, MMF, and prednisone) and improved skin microcirculation secondary to the good metabolic control provided by pancreas transplantation.

Effects of high glucose on insulin secretion by isolated rat islets and purified beta-cells and possible role of glycosylation.

We investigated the effect of 24 h of exposure to various glucose concentrations on insulin secretion by isolated rat pancreatic islets and purified rat beta-cells. Compared with islets cultured with standard medium (5.5 mM glucose), islets cultured with 16.7 mM glucose showed a higher basal insulin release (means +/- SE, 3.0 +/- 0.5 vs. 0.7 +/- 0.2%, n = 8, P less than .005) and reduced glucose-stimulated insulin secretion (2.4 +/- 0.3 vs. 5.8 +/- 0.4%, n = 8, P less than .005). Similar results were also obtained with purified beta-cells. The effect of high glucose was time dependent (present after 12 h, maximal after 24 h) and reversible: when islets cultured with high glucose were transferred to standard medium, normal responsiveness to glucose was restored within 8 h and normal basal release within 24 h. Mannitol, 3-O-methylglucose, and 2-deoxyglucose were not able to mimic the effects of glucose. Islets or purified beta-cells cultured in the presence of high glucose had a normal response when stimulated with glyburide, dibutyryl cyclic AMP, and isobutylmethylxanthine. Tunicamycin, an inhibitor of N-terminal glycosylation, prevented glucose-induced desensitization when added during 24 h of islet culture with 16.7 mM glucose. Swainsonine, another agent that influences glycosylation, had a similar effect. Our study indicates 1) that 24 h of exposure to high glucose induces a specific and reversible impairment of insulin secretion in response to glucose, 2) that this is a direct effect of glucose on beta-cells, and 3) that islet glucose metabolism and glycosylation processes may play a critical role in determining glucose desensitization.

Metformin and insulin receptors.

We evaluated the effect of metformin (N,N-dimethylbiguanide), a biguanide known to be less toxic than phenformin, on insulin binding to its receptors, both in vitro and in vivo. Specific 125I-insulin binding to cultured IM-9 human lymphocytes and MCF-7 human breast cancer cells was determined after preincubation with metformin. Specific 125I-insulin binding to circulating monocytes was also evaluated in six controls, eight obese subjects, and six obese type II diabetic patients before and after a short-term treatment with metformin (850 mg orally, b.i.d., for 4 days). Plasma insulin levels and blood glucose were also measured on both occasions. Metformin significantly increased insulin binding in vitro to both IM-9 lymphocytes and MCF-7 cells; the maximum increment was 47.1% and 38.0%, respectively. Metformin treatment significantly increased insulin binding in vivo to monocytes of obese subjects (+ 31%, P less than 0.05) and diabetic patients (+ 63%, P less than 0.01). Scatchard analysis indicated that the increased binding was mainly due to an increase in receptor capacity. Insulin binding to monocytes of normal controls was unchanged after metformin as were insulin levels in all groups; blood glucose was significantly reduced after metformin only in diabetic patients. These data indicate that metformin increases insulin binding to its receptors in vitro and in vivo. The effect in vivo is observed in obese subjects and in obese type II diabetic patients, paralleling the clinical effectiveness of this antidiabetic agent, and is not due to receptor regulation by circulating insulin, since no variation in insulin levels was recorded. By this mechanism, therefore, metformin may contribute to restoring insulin effectiveness in subjects with impaired insulin responsiveness.

Differences in nuclear triiodothyronine binding in rat brain cells suggest phylogenetic specialization of neuronal functions.

The central nervous system depends on thyroid hormones (TH) in regard to its development, maturation, and maintenance of normal functions. As there is much evidence to suggest that the effects of TH are mainly mediated through specific nuclear binding sites, we have studied the anatomical distribution of T3 nuclear receptors in different regions of adult rat brain, and the localization of receptors in the fractionated neuronal and glial nuclei of neocortex, paleocortex, and cerebellum. Purified nuclei from the various brain regions were prepared by ultracentrifugation in 2.2 M sucrose. Purified neuronal and glial fractions were obtained by discontinuous sucrose gradient centrifugation in 2.2 and 2.4 M sucrose. The washed nuclear fractions were used for T3 binding assay at 37 C for 30 min and the data analyzed by least squares nonlinear regression analysis. Nonfractionated nuclei from all regions studied were found to have similar dissociation constant (Kd) values (1.04-1.38 nM) and Eadie-Hofstee plots indicated the presence of an apparently ubiquitous single class of high affinity, low capacity binding sites. The increase in binding from cerebellum (54 +/- 24 fmol/mg DNA; mean +/- SE) to neocortex (666 +/- 89 fmol/mg DNA) showed a caudo-cranial pattern. In fractionated neuronal nuclei, the same trend was observed, only to a greater degree (1628 +/- 266, 994 +/- 76 and 212 +/- 29 fmol/mg DNA in neocortex, paleocortex, and cerebellum, respectively); the difference between corresponding values for glial nuclei of neocortex and paleocortex (357 +/- 139 and 250 +/- 92 fmol/mg DNA, respectively) was not statistically significant, and no specific T3 binding was found in cerebellar glial nuclei. These data suggest that TH may have an important role in neurons from phylogenetically newer regions, concerned with higher mental functions. The caudo-rostral distribution pattern may also indicate a gradient of TH actions in central nervous system regions.

The effect of 3,5,3'-triiodothyronine on leucine uptake and incorporation into protein in cultured neurons and subcellular fractions of rat central nervous system.

Previous studies have shown that nuclear thyroid hormone receptors in rat brain are preferentially localized within neurons. These cells also synthesize protein at a high rate, and the aim of the present study was to investigate any relationship between these two characteristics. In this paper we have shown that T3 stimulates leucine uptake and incorporation into protein in primary cell cultures of neurons. Stimulation was apparent with concentrations of hormone as low as 1.25 nM and increased in a dose-dependent manner up to 10 nM T3. However, the rapidity of the effect (evident at 25 min, and significant at 40 min) suggests that protein synthesis is stimulated at the level of translation, rather than transcription. More detailed study with 5 nM T3, revealed that incorporation into both soluble (cytoplasmic) and insoluble (membrane-associated) protein fractions was stimulated to similar degrees, and therefore the effect on protein synthesis was general. Furthermore, T3-mediated stimulation of leucine uptake into neurons was completely abolished in the presence of the protein synthesis inhibitors, actinomycin D and cycloheximide, and therefore the effect on leucine uptake was attributed to an increased requirement for the amino acid in protein synthesis (pleiotrophic effect). Parallel studies conducted with synaptosomes and mitochondria isolated from the central nervous system of adult euthyroid animals revealed that 5 nM T3 was without effect on leucine uptake and incorporation into protein. Possible reasons for this lack of effect are discussed.

Triiodothyronine binding in adult rat brain: compartmentation of receptor populations in purified neuronal and glial nuclei.

In order to investigate the localization of nuclear T3 receptors in adult rat brain, we have developed a technique for separating neuronal and glial nuclei, and compared nuclear T3 binding in both fractions. Glial and neuronal nuclear populations were prepared by homogenization of the whole brain except the cerebellum, followed by discontinuous density gradient centrifugation in 2.4 and 2.2 M sucrose. For purposes of comparison, liver nuclei were prepared by centrifugation in 2.4 M sucrose. Microscopic examination of the nuclei confirmed the purity of the two nuclear fractions to be above 90% with minimal extranuclear contamination. T3 binding studies were performed on the washed nuclear fractions using saturation analysis techniques. Maximum binding (Bmax) and dissociation constant (Kd) were obtained by nonlinear least-squares regression analysis. After 30 min incubation at 37 C, Bmax in neuronal nuclei was 1203 +/- 118 fmol/mg DNA (mean +/- SE) (n = 6), in comparison with 196 +/- 14 fmol/mg DNA in glial nuclei (n = 7). The corrected value for Bmax in glial nuclei, assuming 8% neuronal nuclear contamination, was 100 fmol/mg DNA. Bmax in liver nuclei was contamination, was 100 fmol/mg DNA. Bmax in liver nuclei was 299 +/- 38 fmol/mg DNA (n = 6). The Kd values were 0.38 +/- 0.04 nM, 0.34 +/- 0.05 nM, and 0.33 +/- 0.04 nM in neuronal, glial, and liver nuclei, respectively. The specificity of T3 binding to the nuclear receptor in both neuronal and glial nuclei was studied in competition studies, and revealed closely similar relative binding affinities (T3 greater than T4 greater than rT3) in both. We conclude that the higher T3 binding capacity of neuronal nuclei may be related to their higher protein synthetic ability, suggesting that T3 may be of importance in a rapid structural turnover in these cells. The effect of T3 on myelination in glial cells may be mediated through the nucleus.

Metformin normalizes insulin binding to monocytes from obese nondiabetic subjects and obese type II diabetic patients.

In order to evaluate the in vivo effects of biguanides on the insulin receptor, we have studied insulin binding to circulating monocytes of six normal controls, eight obese nondiabetic subjects, and six obese type II diabetic patients, both before and after 4 days of treatment with the biguanide metformin (850 mg twice daily orally). Before drug administration, 125I-insulin binding to monocytes was decreased in obese subjects and diabetic patients. After metformin administration, an increase in insulin binding to peripheral monocytes was observed in seven of eight obese nondiabetic subjects (3.57 +/- 0.43 to 4.69 +/- 0.59% bound at 10(7) monocytes, mean +/- SEM, P less than 0.01) and in all diabetic patients (3.21 +/- 0.21 to 5.22 +/- 0.34, P less than 0.01). Scatchard plots indicated that the increased binding was due to an increase in the receptor number. In contrast, no significant change in insulin binding was found in normal controls after metformin administration (5.31 +/- 0.14 and 4.70 +/- 0.12). These studies indicate that metformin normalizes the binding of insulin to its receptor in obese subjects and diabetic patients. It is suggested, therefore, that the action of metformin on the insulin receptor may be one of the mechanisms of the antidiabetic effect of this drug.

Insulin internalization into monocytes is decreased in patients with type II diabetes mellitus.

We studied the internalization of [125I]insulin into circulating human monocytes, a cell type widely used for insulin binding studies. The internalization of [125I]insulin was assessed by both an acid extraction technique, which removes surface-bound insulin but not intracellular insulin, and by a trypsinization technique, which removes cell surface-bound hormone. After 5 h of incubation at 22 C, over 40% of the total cell-associated [125I]insulin was internalized into monocytes of normal subjects. This internalization was temperature dependent; the fraction of internalized hormone was progressively decreased when the incubation temperature was reduced from 37 to 4 C. Treatment of monocytes with increasing concentrations of 2,4-dinitrophenol also decreased [125I]insulin internalization, whereas dansylcadaverine, an inhibitor of transglutaminase, had no effect. Analysis by gel filtration of the internalized labeled hormone after 4 h of incubation at 22 C indicated that 50-60% of the label was degraded insulin, but detectable intact insulin was still present. Internalization of insulin was then studied in monocytes from eight obese patients (161% of ideal body weight) with type II diabetes mellitus. After 4 h of incubation at 22 C, the specific total monocyte-associated [125I]insulin was decreased compared to that in cells from 7 normal subjects [6.02 +/- 0.38% (+/- SE) vs. 3.91 +/- 0.31% of the total; P less than 0.001]. Moreover, the percentage of hormone that was internalized was also decreased from 41.4 +/- 1.2% of the total to 28.9 +/- 1.8% (P less than 0.001). In 20 nondiabetic obese subjects, specific cell-associated [125I]insulin was reduced to 3.9 +/- 0.3% (P less than 0.001). However, compared to that in normal subjects, the percentage of hormone that was internalized was not decreased (39.7 +/- 3.51% of the total). The present findings indicate that human circulating monocytes internalize [125I]insulin; this process is temperature and energy dependent; and monocytes from obese type II diabetic patients have a significantly decreased ability to internalize insulin. This decreased internalization may play a role in the cellular resistance to insulin that occurs in these patients.

Nuclear tri-iodothyronine (T3) binding in neonatal rat brain suggests a direct glial requirement for T3 during development.

Tri-iodothyronine (T3) binding studies were performed on neuronal and glial nuclei prepared from developing rats brain by discontinuous sucrose gradient centrifugation. Maximum binding capacities (MBC) and dissociation constants (Kd) were obtained from Eadie-Hofstee plots of transformed data. An ontogenic study on nuclei prepared from whole brain revealed that on day 5 after birth, glial nuclear MBC was 1774 +/- 201 (S.E.M.) fmol/mg DNA compared with 974 +/- 117 fmol/mg DNA for the neurones (P less than 0.01). Although diminishing to 667 +/- 112 fmol/mg DNA by day 21, alterations in neuronal MBC over the neonatal period were not statistically significant, whereas glial MBC diminished steadily to 557 +/- 133 fmol/mg DNA in glial nuclei (P less than 0.05). Over the same period, a significant reduction in Kd was noted only in the glia, from 3.17 +/- 0.40 to 1.83 +/- 0.34 nmol/l (P less than 0.03). Ligand specificity of the receptor in both nuclear types on day 21 was tri-iodoacetic acid greater than T3 greater than thyroxine greater than 3,3',5'-T3, but this was less clearly demonstrated at day 5. Regional studies on days 15 and 21 demonstrated that for both neuronal and glial nuclei, receptors are concentrated in the cerebral cortex and diminish in a cranio-caudal direction. Cerebral glial MBC on day 21 was 2215 +/- 147 fmol/mg DNA, at this stage still exceeding the cerebral neuronal capacity of 1111 +/- 207 fmol/mg DNA. The results indicate that neonatal glia may respond directly to thyroid hormones via nuclear receptor binding, and that receptors are predominantly located in the cortex.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct effects of biguanides on glucose utilization in vitro.

The effect of the biguanides metformin and phenformin on glucose utilization in isolated cells was studied with IM-9 human lymphocytes. Both agents stimulated glucose consumption from the incubation media. Detectable effects of metformin were seen at 33 mumol/L and detectable effects of phenformin were seen at 1.7 mumol/L. Both agents, at similar concentrations, also stimulated [3H] 2-deoxy-D-glucose uptake. Studies with phenformin indicated that biguanides increase the Vmax of uptake without changing the Km. In contrast to the biguanides, IM-9 cells insulin did not influence either glucose consumption or [3H] 2-deoxy-D-glucose uptake. These data provide evidence, therefore, that biguanides may directly influence the cellular utilization of glucose.

[Physiopathology of the autonomous thyroid nodule]. / Fisiopatologia del nodulo "autonomo" della tiroide.

"Autonomous" thyroid nodule is a localized nodular lesion of the thyroid gland characterized by growth, iodine uptake and function, all independent from TSH control. These nodules represent a heterogeneous anatomic and clinical entity. The clinical diagnosis is based upon a negative suppression of nodule iodine uptake and scan imaging by T3 administration. The nodule function is determined by high serum thyroid hormone levels and/or low TSH (measured by ultrasensitive assay). Etiology and pathogenesis of these nodules is not yet completely clarified. Both genetic and environmental factors determine nodule growth and function: thyroid cells, in fact, are genetically heterogeneous and may have intrinsic (congenital) characteristics that may promote the growth of cellular clones having mitotic and functional activity that is partially independent of TSH. In these particular cell clones, environmental factors like iodine deficiency or other goitrogens may favour the growth of autonomous nodules and also, by activating their function, may induce toxicity. The autonomous thyroid nodules need to be treated only when they become toxic: in this case both surgical excision or radioiodine may be used.

Effects of three experimental conditions on preschool children's ability to coordinate visual perspectives.

60 3-, 4-, and 5-yr.-old children were asked to coordinate visual perspectives in three conditions: (1) Piaget and Inhelder's "Three Mountain Task," (2) identify objects a doll could see against the side of two intersecting walls, and (3) choose a picture which represented which objects the doll could see. Both condition and age effects were significant. For all age groups there were significant differences between the "Three Mountain Task" and the other two tasks, with significantly more children responding correctly on the two object-identification conditions. No significant differences between the two object-identification conditions were found. While 5-yr.-olds performed significantly better on both object-identification conditions, no differences were found between the 3- and 4-yr.-olds on these tasks. No age effect was found on the "Three Mountain Task." Children of all groups found this task too difficult. 3-, 4-, and 5-yr.-olds seem better at coordinating visual perspectives than suggested earlier. Greater success on present tasks may be due to the reduced number of visual cues that represented alternate visual perspectives. Differences in cognitive demands of each condition were analyzed.

The resistant ovary syndrome la sindrome da ovaio resistente.

After briefly recapitulating present-day knowledge on this recently identified syndrome with its polymorphic clinical and laboratory pattern, the authors describe three cases that have come to their attention. The most interesting was case III which was successfully treated on the basis of analogous reports found in the literature, with large doses of HMG-HCG in spite of the apparent "physiological absurdity" of this treatment. The authors stress the discrepancy frequently observed between functional diagnosis and histological findings; they suggest some possible explanations but stress the need for further research in order to clarify the nature of the functional damage in these patients and the level at which it is situated.

Hysteroscopic patterns in women receiving replacement estrogen therapy.

There is general agreement that unopposed estrogen therapy can cause cystic hyperplasia of the endometrial mucosa, and it is also possible a progression of this lesion towards borderline forms of hyperplasia and adenocarcinoma in patients where there is a predisposition. The Authors report their experience of a combined, hysteroscopic and histological, study made on a group of patients who had undergone cyclic therapy with conjugated estrogens. In this group the more complex forms of hyperplasia were found in those patients treated with the higher dose of estrogens. The Authors emphasize that cyclic therapy of small doses of estrogens associated with 7-12 days of progestins every month can prevent or correct endometrial cystic hyperplasia. The microhysteroscope is a new instrument very simple to use; because of its accuracy, it makes the gynecologist able to perform an immediate endo-uterine diagnosis, thus avoiding some of the other techniques used in the examination of the uterine cavity; in the Authors experience this very interesting endoscopic method has proved to be extremely useful in the controls of patients receiving replacement hormone treatment for menopausal troubles.